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A THEORETICAL 




AND 



PEACTICAL TREATISE 



DISEASES OF THE SKIN, 



BY 






P. RAYER, M.D., 



PHYSICIAN TO LA CHARITE HOSPITAL, MEMBER OF THE ROYAL ACADEMY OF MEDICINE, CONSULTING PHYSICIAN TO THE KING. &C, &C. 



FROM THE SECOND EDITION, ENTIRELY REMODELLED. 



WITH NOTES AND OTHER ADDITIONS, 



BY 



JOHN BELL, M.D., 



FELLOW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA ; MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY, AND OF THE GEORGIFILI SOCIETY OF FLORENCE. 
AND JOINT AUTHOR OF " BELL AND STOKEs's LECTURES ON THE THEORY AND PRACTICE OF PHYSIC." 



iUttl) jTorti) Skautifulhj (Holourci* J)laU0, 

CONTAINING FOUR HUNDRED SEPARATE ILLUSTRATIONS, 

CAREFULLY COLOURED FROM NATURE. 




PHILADELPHIA: 

CAREY AND HART, 126 CHESTNUT STREET, 

FOR G. N. LOOMIS. 

1845. 



\NR 






Entered, according to the Act of Congress, in the year 1845, hy 

CAREY AND HART, 

in the Clerk's Office of the District Court for the Eastern District of Pennsylvania. 



T. K. & P. G. COLLINS, PRIN 
No. 1 Lodge Alley. 



PREFACE 



r 



BY THE AUTHOR. 



In this new edition, as in the first, the Diseases of the 
Skin are classed according to their general pathological 
characters, and the orders are established on the basis of 
the method pursued by Willan. Several changes have 
been made in the distribution of that part of the work 
which treats of the malformations and alterations in the 
structure of the skin, of the diseases of the follicles, and of 
those of the nails and hair. 

I have recast the whole of the descriptions, and endea- 
voured to make them more accurate and more complete 
than they were before. I have added considerably to the 
therapeutical considerations, as well by reverting to the 
facts and cases published before the first edition of this 
work appeared, as by taking note of all with which science 
has since been enriched. I have not confined myself to 
pointing out the therapeutical means whose effects were 
familiar to me in consequence of having tested them my- 
self, but have signalized a variety of other remedies which 
have been recommended by different practitioners. 

Important additions have been made to the history of 
several diseases, particularly that of the variolous and vac- 
cinal eruptions, of scabies, of the syphilides or cutaneous 
eruptions consequent on a venereal taint of the system, of 
purpura, lupus, cutaneous scrofula, and the inflammations 
of the skin excited by artificial or accidental means gene- 
rally. I have also given a more ample account of those 
diseases of the skin which are peculiar to different coun- 
tries, and of several diseases of the lower animals susceptible 
of transmission to the human species. 

In a brief historical notice I have referred to the earliest 
observations extant on each disease discussed, to the series 
of inquiries which successively rendered its history more 
complete, and to the best monographies in which these 
various accounts have been collected, and their sum and 
substance exhibited in connection. 



To conclude, I have thought it well, in a practical work, 
to support and illustrate, general principles by a constant 
reference to particular instances, which should exhibit the 
individualities as it were, of the different forms of cutaneous 
diseases, which should show the application of the various 
therapeutical measures recommended, or which should 
make the reader acquainted with forms not yet described, 
or with rare complications, that could hardly have found a 
place in a general description : -with this view, I have 
selected and given the details of two hundred cases of every 
interesting form and variety of affection of the skin, the 
whole of which were written under my own eye by the 
pupils successively attached to me as physician to the 
Hopital Saint Antoine and the Hopital de la Charite. 

Paris, March the 8th, 1835. 



NOTE BY THE TRANSLATOR. 

This English Edition is in all respects similar to the French one. Very 
little room was found for addition of any kind, and to have retrenched from 
the text, would have been to do the author injustice. The work is there- 
fore given complete, and little beyond an explanation of the various thera- 
peutical means and formula? recommended is added in foot notes. The 
sense of one passage only has been intentionally changed ; this stands at 
the bottom of page 177, and in the original gives us to know that the 
Eliaats, a nomadic Asiatic tribe, had from time immemorial been in the 
habit of inoculating coiv-pox, with a view to prevent the attacks of small- 
pox, — the suggestion which has made the name of Edward Jenner immor- 
tal. The startling assertion, however, comes from the author having mis- 
quoted a passage from the Bombay Transactions. On referring to the 
original, it was found stated that the Eliaats were familiar with the pre- 
servative pouters of coio-pox against small-pox, just as the peasantry of 
Gloucestershire were. The reading is consequently restored to its proper 
signification. 

R. WILLIS, M.D. 



PREFACE 



TO THE AMERICAN EDITION. 



The magnitude and copiousness of the great work of 
M. Rayer on Diseases of the Skin, while precluding the 
hope of successful rivalry on this side of the Atlantic, would 
seem, for these very considerations, to render the task of 
addition and comment comparatively light and easy, and to 
exonerate him from the charge of presumption who might 
be persuaded to perform this humble duty. Whether well 
founded or not, it was under such a belief that the Editor 
was induced to accede to the wish of the publishers, that he 
would superintend this first American edition. 

Although it so happens, that his contributions have been 
much more various and extensive than he had at first con- 
templated, the Editor has constantly endeavoured to adhere 
closely to the course pursued by the distinguished author 
himself; in his giving a preference for the practical over 
the speculative, and in illustrating general principles by 
particular cases. Free use has been made of the works of 
Plumbe and Mr. E. Wilson; the more rightfully, as their 
pages are continually enriched by the observations derived 
from M. Rayer's volume. Contemporary French authors 
have not been overlooked ; but to the pages of the different 
Medical Journals, which contain so much valuable matter 
on the pathology and treatment of many cutaneous diseases, 
is the Editor under the greatest obligations. From these 
sources are derived many of his chief additions, as, for 
example, on variola, vaccinia, syphilida, molluscum and 
glanders. 

2 



The notes of the translator, Dr. Willis, have been re- 
tained : they are in small type and accompanied with the 
initials, R. W. The contributions of the American Editor 
in the same type with that of the text, are given at the foot 
of the page, and are always indicated by the letter (a) or (b), 
&c. prefixed. In one instance alone, " Outlines of the Pa- 
thology and Remedial Treatment of Diseases of the Skin," 
he has introduced his observations into the body of the work. 

The Editor was fain to avail himself of the option kindly 
allowed him by the publishers, to undertake or decline, as 
he might deem convenient, the supervision of the engraving 
and colouring of the plates which give so much interest and 
value to the present work, and which will constitute, in 
the eyes of many, its most attractive feature. His exist- 
ing engagements not allowing him to execute this duty 
in a manner satisfactory to himself, the services of Dr. 
Goddard were enlisted by the publishers for the purpose. On 
him, also, devolved the translation of the letter-press explana- 
tions that accompany the plates. The result is such as might 
have been expected from the well known artistical taste and 
practised eye of this gentleman; and it is believed, that the 
coloured engravings in the American edition, which are of 
the same number and size as in the French and English 
editions, will bear a scrutinizing comparison with these latter 
in their style and finish of execution, and exhibit in favour- 
able relief the merits of the Philadelphia artists engaged 
in the work. 



SYNOPTICAL 



TABLE OF CONTENTS. 



INTRODUCTION. 

Connection between diseases of the general system and cutaneous 

eruptions - - - ... 

Authors on cutaneous diseases - 
Classification ------- 

FIRST DIVISION OF THE DISEASES OF THE SKIN. 

CHAPTER I. 

Inflammatory Affections. 
Preliminary considerations - 

Forms of cutaneous inflammation - 

1st. Having a single elementary form ... 

2d. Having several elementary forms ... 

Effects of Inflammation of the Skin. 
Ulcers -------- 

Scabs and crusts ------ 

Local symptoms ------ 

General symptoms ------ 

Complications ------- 

Normal and pathological anatomy of the skin - . - 

Etiology of inflammatory affections of the skin - 

Diagnosis ........ 

Prognosis ....... 

Influence of inflammatory affections of the skin — their evolution and 
repercussion — on the general health - - - - 

Treatment of the inflammatory affections of the skin 

of the acute affections .... 

of the chronic affections - 

Effects of various therapeutic means and agents - 



Page 

13 
14 
21 



22 

ib. 
ib. 
ib. 



23 

ib. 
ib. 
ib. 
24 
25 
20 
29 
ib. 

30 
31 
ib. 
32 
33 



Outlines of the Pathology and Remedial Treatment of Diseases of 
the Skin, by the American Editor. 

Structure of the skin ------ 45 

General anatomy of ------ 40 

Analogy of function between the skin and mucous membranes - ib. 

Etiology ------.47 

Classification of cutaneous diseases - - - - ib. 

That of Dr. Crai^ir ------ jk # 

That of Mr. E. Wilson - - - - - -54 

General resemblance between acute and chronic diseases of the 

skin ------- 55 

Indications of treatment ------ 50 

Sect. I. Inflammations having a single Elementary Form. 

EXANTHEMATA 58 

Erythema ------ .go 

Erythema intertrigo ------ ib. 



Erythema paratrimma 

a punctura - 

papulatum - 

tuberculatum 

nodosum 

marginatum 



circmatum 
fua:ax 



Chronic erythema - - - - 

■ of the feet, with chapping of the skin - 

of the lips - - - - 

■ of the nipple ... 

of the abdomen in pregnancy 

of the anus - 

— of the prepuce ... 

of the vulva - - - - 

Fiery spots of the face - 

Diagnosis of erythema ... 

Prognosis ----- 

Treatment ----- 
Historical notices and particular cases of erythema 

Erysipelas - 

Causes - 

Symptoms ..... 

Simple erysipelas .... 

Erysipelas miliaris - 

phlyctenodes ... 

— erratica .... 



metastatica ... 

Phlegmonous erysipelas ... 

Erysipelas gangrenosa ... 

cedematosa ... 

Erysipelas of the face ... 

■ of the scalp ... 

■ of the mamma ... 

of the umbilical region 

1 of the groin ... 

of the scrotum and prepuce 

of the limbs ... 

General erysipelas .... 
Anatomical observations ... 
Diagnosis ..... 
Prognosis ..... 
Treatment ..... 
Historical notices and particular cases of erysipelas 
Rubeola, measles .... 
Rubeola vulgaris .... 
sine catarrho - 

without eruption (febris morbillosa) 

anomalous - - . . 

Diseases consecutive to measles 



Page 
00 
ib. 
ib. 
ib. 
ib. 
01 
ib. 
ib. 
ib. 
ib. 
ib. 
ib. 
ib. 
ib. 
ib. 
ib. 
ib. 
ib. 
02 
ib. 
03 

05 

ib. 
ib. 
ib. 
00 
ib. 
ib. 
ib. 
ib. 
ib. 
ib. 
ib. 
ib. 
07 
ib. 
ib. 
ib. 
ib. 
ib. 
ib. 
08 
ib. 
ib. 
70 

71 

ib. 
ib. 
ib. 
72 

ib. 
ib. 



via 



CONTENTS. 



Anatomical observations 
C*Oi 

nosis 
Prognosis 
ment 
1 1 torical notices and cases 

>( uu \ I IN \ 

latina simplex 

• anginosa 

maligna 

■ sine exanthemate 

mdary diseases 
Structural changes 
Causes 

- 
Prognosis 
Treatment 
Prophylaxis 

II torical ootices and cases 
Roseola 

Roseola estiva 

autumnalis 

annulata 

infantilis 

■ variolosa 



vaccina 

miliaria 

febrilis 

rheumatica 

cholerica 



Historical notices and cases 

I H in \l;l \ 

Urticaria;)' 

f 

al) ingestis 

(c) from poisonous 



fish 



— pei - 

— chronica 

— evanida 
- 

— tuberoi a 



Causes 
Diagnosis 

- 
Treatment 

Historical notices and cases 
Artificial exanthemata 



BULLAE 



PSHPHIOUS ....... 

Pemphigus acutus, (febris bull ynocha cum vesiculis, 

fell. | . solitarius) - 

Pemphigus chronicus (pompholyx diutinus) 
Structural changes ------ 

Causes ....... 

Diagnosis ------- 

Prognosis ------- 

Treatment ------- 

Historical notices and particular cases - 

IvllMV -------- 

Rupia simpli \ ------ 

prominens ------ 

escharotica ------ 

Causes ------- 

Diagnosis ------- 

Prognosis ------- 

ment ------- 

I [istorical notices and particular cases - 

Artificial Bi i i 

Ampulla ------- 

Blister - - - - - - 

Historical notices and cases - - - - - 



yesicul^: 



Herpes 

Herpes Zoster 



Page 
78 

73 

ih. 
74 

ib. 
76 

77 

ib. 
78 
ib. 
ib. 
7!) 
ib. 
ib. 
80 
ib. 
81 
82 
ib. 
84 
ib. 
ib. 
ib. 
ib. 
ib. 
85 
ib. 
ib. 
ib. 
86 
ib. 
87 

ib. 
ib. 
ib. 
88 
ib. 
ib. 
ib. 
ib. 
ib. 
ib. 
ib. 
80 
ib. 
90 

91 

ib. 

ib. 
92 
93 

ib. 
ib. 
ib. 
ib. 
94 
98 
ib. 
ib. 
ib. 
99 
ib. 
ib. 
ib. 
ib. 
100 
ib. 
101 
ib. 

103 

ib. 
104 



. .KM 

1 



(a) Phlyctcnoid group 

(a) Circinate group 

Alterations of structure 

Causes 

Diagnosis 

Prognosis 

Treatment 

Historical notices and cases 

1 [erpes phlyctenodes - 

Causes 

Diagnosis 

Prognosis and treatment 

Historical notices and cases 

Herpes circinatus 

Historical notices 

Herpes labialis 

Historical notices 

Herpes prasputialis 

Historical notices and cases 

Herpes vulvaris 

auricularis 

palpebralis,&c. 

iris 

Historical notices and cases - - - - 

Eczema. ------ 

Eczema simplex ----- 

rubrum ----- 

impetiginodes - 

Chronic eczema .----■ 

of the scalp - 

of the face - 

of the ear .-■--■ 

of the nipple - - - 

of the umbilicus - 

of the thighs, scrotum, anus, &c, in the male 

of the thighs, vulva, anus, &c, in the female 

of the extremities - 

of the bend of the arm, axilla?, and hams 

of the hands - - - - • 

nplications of Eczema - - - - ■ 

Alterations of structure ..-'■-■ 

uses --...-. 

aosis ---.... 

nosis ---..-. 

Treatment ---.»--. 

Historical notices and cases - 

(«) Cases showing the arsenical treatment 
Hydrargyria ---.... 

mitis --.... 

febrilis ----.. 

— — maligna --.--. 

Causes ---.... 

nosis ----... 
gnosis ---..-. 

Treatment ----... 

Historical notices and cases - - 

Scabi ---.... 

Causes ----... 

Acarus scabiei - 

Diagnosis -----.. 

Prognosis -----.. 

Treatment ----... 

Historical notices and cases - 
Miliaris Sudatoria vel Sudor Miliaris - 

Alterations of structure. - 

Causes ------ i 

Diagnosis ■---_. 

Prognosis "■----. 

Treatment ----.. 

Historical notices and cases - 
Sddahina ---.,. 

Causes and symptoms - 

I 'i ignoeis ------ 

Prognosis ---..,, 

Historical notices - 

Artificial Vesicular Eruptions - 



Tage 
104 

ib. 
106 

ib. 

ib. 

ib. 
107 
108 
109 

ib. 

ib. 

ib. 
110 

ib. 
Ill 

ib. 
112 

ib. 

ib. 

118 

ib. 

ib. 
114 

ib. 
115 

ib. 

ib. 
110 

ib. 
117 

ib. 

ib. 

ib. 
118 

ib. 

ib. 

ib. 

ib. 
119 

ib. 

ib. 
120 
121 
122 
129 
1:30 

ib. 

ib. 

ib. 
132 

ib. 
133 

ib. 
134 
135 

ib. 
136 
137 
138 

ib. 
139 

ib. 
140 

ib. 

ib. 
141 

ib. 

ib. 
144 

ib. 

ib. 

ib. 

ib. 
145 



CONTENTS. 



IX 



PUSTULE 

Variola or Variolous Eruptions 

(a) Suppurative inflammation of the dermis 
Variola, small-pox ... 

Symptoms and periods 

(a) Description of - 

Variola discreta ... 

per insitionem (inoculated) 

sine variolis ... 

anomalous - 

Alterations of structure 

Causes .... 

Diagnosis .... 

Prognosis .... 

Treatment .... 

local ... 

Complications ... 

Historical notices and cases 

(a) Cases by the American Editor 
Varicella (Variola Spuria) 

umbilicated pustular (Varioloid) 

(a) Identity of origin with variola 

Diagnosis .... 

Historical notices and cases 

Varicella, conoidal pustular 

Historical notices and case 

Varicella, globose pustular 

Historical notices and case 

Varicella, papular ... 

Historical notices ... 

Varicella, vesicular (chicken-pox) 

Causes .... 

Diagnosis - 

Treatment .... 

Historical notices and cases 

Varicella, sine varicellis 
Vaccinia .... 

Inoculation of cow-pox 

Diagnosis .... 

Prognosis .... 

Treatment .... 

(a) Protective value of vaccination 

Historical notices and cases 
Vaccinella .... 

Historical notices - 

Acne - - - - - 

Alterations of structure 

Diagnosis .... 

Prognosis and treatment 

Historical notices ... 

Rosacea .... 

Causes .... 

Diagnosis .... 

Prognosis and treatment 

Historical notices and cases 
Sycosis (Mentagra) 

Causes .... 

Diagnosis .... 

Prognosis .... 

Treatment .... 

Historical notices and cases 
Impetigo .... 

figurata ... 

sparsa - - - - 

Causes .... 

Diagnosis .... 

Prognosis .... 

Treatment .... 

Historical notices and cases 
Favus ----- 

disperses (porrigo lupinosa, Wil.) 

confertus (porrigo scutulata, Wil.) 

Alterations of structure 

Causes .... 

Diagnosis .... 
Prognosis and treatment 
3 



Page 
146 

ib. 
147 
149 

ib. 
151 
152 

ib. 

ib. 
153 

ib. 
155 

ib. 

ib. 
156 
157 
158 
159 
162 
163 
164 
165 
166 
167 
169 

ib. 

ib. 

ib. 
170 

ib. 

ib. 
171 

ib. 

ib. 
172 

ib. 

ib. 

ib. 
174 

ib. 

ib. 
176 
177 
178 
179 
180 
181 

ib. 
182 

ib. 

ib. 
183 

ib. 

ib. 
184 
185 
186 

ib. 
187 

ib. 
188 
189 

ib. 
190 
191 

ib. 

ib. 

ib. 
193 
195 
196 
197 
198 
199 

ib. 

ib. 



Historical notices and cases 
Ecthyma 

acutum 

chronicum 

Causes 

Diagnosis 

Prognosis 

Treatment 

Historical notices and cases 
Artificial Pustules 



FURUNCULI 



FuRUNCULUS 

Causes 

Diagnosis 

Prognosis 

Treatment 

Historical notices and cases 
Hordeolum 

Causes 

Diagnosis and Prognosis 

Historical notices 
Anthrax 

Diagnosis 

Prognosis 

Treatment 

Historical notices and case 



GANGRENE 



Anthracion 

Alterations of structure 

Diagnosis 

Prognosis 

Treatment 

Historical notices and cases 



PAPULA 



Lichen - - - 

simplex 

pilaris 

circumscriptus 

agrius 

urticatus 

lividus 

tropicus - 

local varieties of 

Causes 

Diagnosis 

Prognosis 

Treatment 

Historical notices and cases 
Strophulus 

intertinctus 

• albidus 

confertus 

Diagnosis 

Prognosis 

Treatment 

Historical notices and cases 
Prurigo 



mitis 



— formicans 

— senilis - 

— podicis 

— scroti 
plantaris 



Causes 
Diagnosis 
Prognosis 
Treatment 

Historical notices and cases 
Artificial papulae 



Lepra - 

Observations on structure 



SQUAMA 



Page 
201 
205 

ib. 

ib. 
206 

ib. 

ib. 

ib. 

ib. 
209 

210 

ib. 

ib. 

ib. 
211 

ib. 

ib. 

ib. 

ib. 

ib. 
212 

ib. 
213 

ib. 

ib. 
214 

ib. 

ib. 
216 

ib. 

ib. 

ib. 
217 

220 

ib. 

ib. 
221 

ib. 

ib. 

ib. 

ib. 

ib. 
222 

ib. 

ib. 
223 

ib. 
224 
226 

ib. 

ib. 

ib. 

ib. 

ib. 
227 

ib. 

ib. 

ib. 
228 

ib. 

ib. 

ib. 
229 

ib. 

ib. 

ib. 
230 
231 
232 

233 

ib. 
234 



CONTENTS. 



- 

- 
ment 

II • a I eases 

Psoriasis - 

ata) 

conflttens (diffusa) 

(«) infantilis 

m\ I 



calp 

of tin 

of the trunk, scrotum, prepuce 

palmaris 

palmaris centrifuga 

- 

I i. ... 

Treatment 

I I storical notices aud cases 

Pityriasis - 

general 

local - 

capitis 



— palpebrarum - 

— labrum 

— palmaris et plantaris 

— oris 
praputii, &c. 



Causes 
Diagnosis - 

Prognosis - 
Treatment - 
Historical notices and cases 
Artificial squamous inflammations 



TUBERCULA 



Lupus - 

cxedens - 

non exedens 

Causes « 

Diagnosis • 

Prognosis • 

Treatment ... 
Historical notices and cases 

Scrofula - 

Causes - 

Diagnosis • 

Proi;e - 

Treatment 

i ical notices and cases 

Cancer - - 
vulgaris 

melanic (Anthracine) 

leucoid - - - 



mollusciform 

ohimney sweepers' 

local varieties of 

((/) general divisions of - 

- 
Diagnosis - 

Prognosis - 

ment 

rical notices and cases 

Elephantiasis [Graecorum) 
.itomical r. ■ 
Ca' 

- 
ment 
] 1 -■ rical notices and cases 
Artificial n brrcular inflammations 



234 
235 

ih. 

ib. 

893 

210 

ib. 
211 

ib. 
212 

ib. 

ib. 

ib. 

ib. 

ib. 

ib. 
243 

ib. 

ib. 
214 

217 

ib. 

ib. 
218 

ib. 
219 

ib. 

ib. 

ib. 

ib. 

ib. 

ib. 
250 

ib. 
253 



ib. 

ib. 

ib. 
255 

ib. 
256 

ib. 

ib. 
258 

261 
262 

ib. 

ib. 

ib. 

2G3 

205 

ib. 

266 

267 

ib. 

ib. 

ib. 

ib. 
268 

ib. 

ib. 
269 

ib. 

ib. 

273 

275 
ib. 

270 
ib. 

277 

281 



Page 



BrcT. II. Inflammations having a varif.ty of i li mini auv forms. 
SYPHILIDA (Syphilids) 

Primary symptoms cf SYrmi.is - 

(a) Different poisons produce gonorrhoea and chancre 

Gonorrhoea ".."""" 

Chancre and its varieties 

Simple venereal sore - - - - 

Indurated sore (the Hunterian chancre) 

Phagedenic sore - 

Gangrenous sore 

Degenerated sore 

Bubo - 
Secondary symptoms 

SYPHILIDA - - "iii" 

the exanthematons syphihde - 

macula? syphilitica? 

the bullous syphilide - 

the vesicular - 

the psydracious pustular 

the phylzacious pustular 

syphilitic rupia 

the papular 

the squamous ... 

the tubercular - 

, . the serpiginous syphilide 

Subcutaneous syphilitic tubercles (gummata) - 
Syphilitic ulcers of the mucous membranes 

i — excrescences - 

■ — alopecia ...-.- 

onychia 



Complications with syphilides 
Diagnosis 
Prognosis 
Treatment 

Historical notices and cases 
Ambustio, burn - 

the erythematous 

vesicated or bullous 

eancrenous 



Diagnosis 
Prognosis 
Treatment 

Historical notices and cases 
Pernio, chilblain 

erythematous 

bullous - 

gangrenous 

Causes 
I diagnosis 
Prognosis 
Treatment 
Historical notices 



S8S 

ih. 
283 

ib. 
284 
285 
286 

ih. 
2>7 
288 

ih. 
2110 

ib. 
291 
292 

ib. 

ib. 
293 

ib. 
291 
295 

ib. 
297 
299 

ib. 
300 
301 
302 

ib. 
303 
301 
306 

ib. 
313 
318 

ib. 

ib. 

ib. 
319 

ib. 

ib. 
321 

ib. 

ib. 

ib. 

ib. 
322 

ib. 

ib. 

ib. 

ib. 



Sect. III. Peculiar states of the skin not referable to inflamma- 
tion. 



ANEMIA 
SANGUINEOUS CONGESTIONS 



HiEMORRHAGIiE 



Purpura 



sine febre 



— simplex 

— urticans 

— hemorrhagica - 

— febrilis 



senilis 

Anatomical observations 

Causes 

Diagnosis 

Prognosis 

Treatment 

Historical notices and cases 



322 
323 

ib. 

ib. 

ib. 

ib. 
324 

ib. 
326 

ib. 
327 

ib. 

ib. 
328 

ib. 

ib 



v 



CONTENTS. 



Morbid states of the secreting functions of the skin 



PERSPIRATION 



El'HIDROSIS 



EPIDERMIS 



Neuroses of the skin 
Anesthesia 

Historical notices and cases 
Hyperesthesia 



Page 
333 

334 

ib. 
ib. 

335 

ib. 

ib. 

336 



Faulty structure or unusual states of one or other of the elements 
of the skin. 



ALTERATIONS OF ITS COLOUR 

Leucopathia seu Albinismus - 

Historical notices and cases - 
Nigrities ..---■ 

Cases - - - - " ■ 

Ephelis _.---. 

Lentigo ....... 

Chloasma or liver-spot . - - 

Causes _-----• 

Diagnosis - 

Treatment . - - - - 

Historical notices and cases - 
Melasma - 

Pigmentary nevi - 

Blue colour of the skin . - - 

Yellow colour of the skin - - - 

Artificial or accidental discoloration of the skin 

Slate colour from the internal use of nitrate of silver 
Staining of the skin - 



HYPERTROPHIC 

Hypertrophy of the papillae and epidermis ... 
Ichthyosis _ . - - - 

Anatomical observations - - 

Causes ------ 

Diagnosis - - - - - 

Prognosis and treatment - 

Historical notices and cases - - - - - 

Verruce, Warts - 

Historical notices ------ 

Verrucous nevus _._-•- 

Horny productions - - - - 

Historical notices and cases - - - - 

Corns, Tylosis ------ 

Historical notices - - - - - 

Hypertrophy of the vascular elements of the skin - 
Phlebectasia - - - - - 

Capillary angiectasia - - - - 

Nevus araneus ------ 

Nevus flammeus - 

Vascular growths or excrescences -.--'- 

Cutaneous vascular nevus - 

Subcutaneous vascular nevus 

Congenital cutaneous and subcutaneous vascular tumours - 

Of erectile tissue ------ 

Of dilated veins - 

(«) Nevus or erectile tumour 

Causes """."" 

Diagnosis - 

Prognosis - 

Treatment - 

Historical notices and cases - - - - 

Cheloid tumour - 

Causes - 

Diagnosis - 

Prognosis and treatment 

Historical notices and cases . - - - 

Hypertrophy of the corion - 
Hypertrophy of the subcutaneous cellular and adipose tissues 



DEGENERATIONS 



Fibrous degenerations 
Melanosis 

Historical notices 
Tubercular matter 



337 

ib. 
338 
339 
340 
341 
342 

ib. 

ib. 

ib. 

ib. 
343 

ib. 
344 
345 

ib. 
346 

ib. 
347 

348 

ib. 

ib. 

ib. 

350 

ib. 

ib. 

351 

352 

353 

ib. 

ib. 
355 

ib. 
356 

ib. 

ib. 

ib. 

ib. 

ib. 
357 

ib. 

ib. 
358 

ib. 

ib. 

ib. 
359 

ib. 

ib. 

ib. 

ib. 
360 
361 

ib. 

ib. 

ib. 
362 
363 



Increased secretion - 
Causes - 

Diagnosis _ - - 

Prognosis and treatment 
Historical notices and cases 
(a) Sebaceous ichthyosis 
Worms or grubs of the skin 
Follicular elevations - 
(a) Molluscum - 

« contagiosum 

" cases of 

» treatment and literature of 

Follicular tumours - 

Calculi of the follicles - 



SPECIAL DISEASES OF THE PILIFEROUS FOLLICLES 
AND ALTERATIONS OF THE HAIR 

Atrophy - 

Congenital deficiency of the hair - 

Supernumerary tufts of hair - - - - 

Unusual growth of the hair - - - - 

Felting of the hair - 

Changes of colour of the hair - - - - 

canities - 

Historical notices - 

Alopecia, baldness - 
(a) Remote causes of - 
Alopecia, (porrigo decalvans, W.) - - - - 

(tinea tondans, Mali.) . - - - 

Treatment ---"." 

Historical notices and cases - - - - - 

SPECIAL DISEASES OF THE UNGUEAL MATRICES 
AND ALTERATIONS OF THE NAILS 



Onychia 



from an outward cause 



from the nail growing into the flesh 

treatment ... - 

from an internal cause - 

eczematosa ... - 

syphilitica ... - 

maligna - 

Historical notices and cases - - - 

Subungueal ecchymopes . - - 

Faulty conformation and texture of the nails 

Loss of the nails (alopecia unguialis) - 

Anomalous growth - 

Anomalous situation (misplaced) 

Ficus unguium - 

Anomalous form - 

Defcedatio, degeneratio unguium 

Accidental reproduction and production 
Gangrene of the skin - 
Cicatrices of the skin - - - - 

Anomalous formation of the skin 

Congenital deficiency - 

Remarkable extension - 



Page 
364 

ib. 
365 
366 

ib. 



SPECIAL DISEASES OF THE SEBACEOUS FOLLICLES 367 



ib. 
368 

ib. 

ib. 

ib. 

ib. 
370 
371 

ib. 

ib. 
372 
374 
375 
376 



ib. 

ib. 

ib. 

ib. 
377 

ib. 
378 

ib. 
379 

ib. 

ib. 
380 

ib. 
381 

ib. 



382 

ib. 

ib. 

ib. 

ib. 
383 

ib. 
384 

ib. 
385 

ib. 

ib. 

ib. 
386 

ib. 

ib. 

ib. 

ib. 
387 

ib. 
388 

ib. 

ib. 

389 



PARALLEL BETWEEN THE DISEASES OF THE SKIN 
AND THOSE OF THE MUCOUS MEMBRANES - 



Inflammation 



exanthematous 
bullous 
vesicular 
■ pustular 



ib. 

ib. 
ib. 
390 
ib. 
ib. 



xu 



( ONTENTS. 



[nflammadon, furancular 

papular 

■ tubercular 



igrenoua 

— ulcers 

— bemorrhe 

— dyschromata 

— bypertropbis 

— cicatrices 



APPENDIX. 

LIVING CREATURES INFESTING THE SKIN - 
reside vegetable structures - 

ulus -..--.- 

Phthiriasis seu morbus pedicularis - 

Pulex 

irritans ....... 

penetrans (acarus Americanus) 

ins scabiei -----.- 
Filiaria Medinensis or Guinea-worm .... 

(a) Locality and subjects of 
(Estrus --..---- 

I. Group. 

INTUMESCENTLE: DISEASES ORIGINALLY FOREIGN 
TO THE SKIN, BUT IMPLICATING IT AT LENGTH 

Elepbantiasis Arabica ------ 

Anatomical investigations - 

(«) Brazilian variety ------ 

Causes ....... 

(a) Geographical distribution of 

Diagnosis ------- 

Prognosis ....... 

Treatment ....... 

1 1 istorieal notices and cases - 
Barbadoes leg ....... 

Andrum and Perical: Endemic hydrocele and pedarthorace 
Senki ........ 

Mouth canker ------- 

II. Group. 
ENDEMIC TUMOURS 

ppo pustule ------- 

Tara of Siberia ------- 

III. Group. 
ELEPHANTOID DISEASES. MODIFICATIONS OF THE 

TUBERCULAR ELEPHANTIASIS OF THE MIDDLE 
AGES 

M a 1 rouge de Cayenne ----.. 

Kadi ....... 

Lepra of Holstein (Spedalsked) - - - * - 

Lepra Taurica (Lepra Crimea}) - 

Lepra anssstbesica Indorum ..... 

Jewish leprosy (Saraat) ..... 

Malum mortuum ...... 

IV. Group. 

SYPHILOID DISEASES. EPIDEMIC SYPHILITIC AND 

ANALOGOUS DISEASES 
Disease of the District of Chavanne-Lure (France) 

if the Bay of St. Paul (Canada) 
Disease of Fiume or of Scherlievo (Italy) ... 

aldine (Tyrol) ...... 

Disease of Brunn (Moravia) . . . - - 

Tophi amboinc n 

Bib -nd) ...... 

Pian de Nerac (France) ..... 

Framboesia, yaws Wesl Indies) .... 

(a) Diagnosis between sibbens and yaws . . - 

V. Group. 
PELLAGRA AND CERTAIN SQUAMOUS DISEASES 
Pellagra (Milanese) ...... 



ib. 
ib. 
ib. 
ib. 
ib. 
ib. 
392 
ib. 



393 

ib. 
395 
390 

ib. 

ib. 

ib. 
397 
398 

ib. 
400 



401 

ib. 
402 
406 
407 

ib. 

ib. 

ib. 
408 

ib. 
410 

ib. 

ib. 

ib. 



411 

ib. 
ib. 



412 

ib. 

ib. 
413 

ib. 

ib. 

ib. 
414 



ib. 

ib. 
415 

ib. 
416 

ib. 

ib. 
417 

ib. 

ib. 
418 

419 
420 



Pellagra, severe ---..-- 
Anatomical researches ------ 

( lauses --....-- 

1 diagnosis ------- 

Prognosis ------- 

Treatment ------- 

Historical notices ------ 

Mai de la rosa (Spain) ------ 

Acrodynia (France) ------ 

Disease of Melada (Gulf of Venice) - - - - 

VI. Group. 

ENDEMIC BLANCHING AND DISCOLORATION OF THE 

SKIN 

Cerate (New-Grenada) ------ 

Pinta (Mexico) ------- 



VII. Group. 
ENDEMIC ACUTE ERUPTIONS - 



Lichen tropicus, prickly-heat 
Itch of the Illinois (N. America) 



VIII. Group. 
EPIDEMIC GANGRENOUS DISEASES 



Nome (Sweden) ------- 

Ignis sacer of the middle ages - - - - - 

IX. Group. 

CONTAGIOUS DISEASES WITH PSEUDO-MEMBRANOUS 
FORMATIONS - 

Diphtheritis of the skin ------ 

X. Group. 

TRICHOMATOUS AFFECTIONS 



Plica 



XL Group. 



VARIOUS DISEASES NO LONGER MET WITH IN THE 
PRESENT DAY - 

Sudor Anglicus (sweating sickness) - 

Epinyctis ...... 

Mentagra of the Latins ------ 

Waxen of Westphalia ---... 

XII. Group. 
CERTAIN DISEASES OF ANIMALS CAPABLE OF BEING 

COMMUNICATED TO THE HUMAN SUBJECT - 
Cow-pox -----.. 

(a) Anatomical structure ---.__ 

•■ Vaccination of the cow - 

" Retro-vaccination ----.. 

" Cow-pox from variolous matter .... 

" False or spurious cow-pox - 

" Varieties of - 
Grease ------ 

Carbo (charbon) ---... 
Scabies ---... 
Eruption contracted from a lioness ... 

Glanders - 

(a) Writers on - 

" Connection between and farcy in the horse - - . 

" Anatomical lesions from, in this animal 

li Symptoms and progress in - 

" Etiology - 

" Glanders in the human subject \ 

" Treatment - 

" Chronic glanders .... 

" Chronic farcy - - - . 

" Treatment of chronic glanders and farcy 

•• Cases by Dr. Graves - 

" Other cases -...__ 
Formulary ---... 



Pagfl 
120 
421 

ib. 

ib. 

ib. 

ib. 
128 
424 

ib. 



425 

ib. 
ib. 



ib. 

426 

ib. 



427 

ib. 

ib. 
ib. 



428 

ib. 
429 
430 

ib. 



430 

ib. 

ib. 
431 

ib. 
432 
433 
434 

ib. 

ib. 
435 

ib. 

ib. 
437 

ib. 

ib. 

ib. 
498 
439 

ib. 
410 

ib. 

ib. 
441 
444 
1 15 



INTRODUCTION. 



It is long since the study and description of those diseases which 
appear on the exterior of the body with characteristic symptoms, were 
detached from general pathology ; and it is impossible to deny that 
the history of these diseases has been more fully and satisfactorily 
given by the writers who have made them objects of their peculiar 
consideration. Nevertheless, it must be allowed, that many serious 
inconveniences would arise from completely abstracting this study 
from that of the other morbid conditions of the economy. It would, 
above all, be a grave error to separate certain cutaneous eruptions 
from lesions of other systems, when both derive their origin from the 
same cause : to attempt to isolate the venereal eruptions, for example, 
from the other symptoms of syphilitic infection — exostoses, perios- 
toses, nocturnal pains in the bones and joints, &c, would evidently 
be arbitrarily to disconnect the different orders of symptoms of one 
and the same disease. These venereal eruptions have farther so 
intimate a relationship with the primary symptoms to which they gene- 
rally succeed, that it even becomes imperative on us to include both 
under the same general head of investigation. 

Certain diseases, such as the eruptive fevers, produced by infection 
of the whole system, although they indeed exhibit themselves on the 
exterior of the body at determinate periods in peculiar and character- 
istic symptoms, are, to all intents and purposes, general diseases, the 
effects of which are occasionally felt with far greater violence by other 
systems, than by the skin. In some cases, indeed, in variola, rubeola, 
scarlatina, &c, no eruption ever makes its appearance, and the skin 
then continues entirely a stranger to the effects of the contagion. 
Who does not know, moreover, that these diseases impress or modify 
the constitution so deeply, that it generally becomes forever after 
unsusceptible of being influenced, by the cause which produces 
them ? 

In some diseases which are entitled cutaneous, the affection of the 
skin, so important in a diagnostic point of view when it occurs, is so 
completely secondary in the question of their nature, that this altera- 
tion, which sometimes only shows itself at an advanced stage of the 
disease, may disappear when the general symptoms acquire greater 
intensity, and only reappear when these decline ; the severity, like the 
nature of the disease, being linked to morbid conditions of the eco- 
nomy other than those of the skin, as is abundantly evident in purpura, 
measles, &c. 

If in the eruptive fevers and the syphilides, the evidences of a 
general constitutional affection appear in a multitude of phenomena, 
the connection of several other alterations of the skin with a par- 
ticular state of the constitution is no less evident ; it is very striking 
in scrofulous tubercles and ulcers, which are always preceded or 
accompanied with other symptoms of a strumous nature. 

Besides these cases of general infection, and of original or heredi- 
tary disposition of the constitution, which are transmitted to the skin, 
or manifest themselves there in the shape of eruptions of divers forms, 
the principal phenomena of several morbid states of the system at 
large, and of certain derangements of important organs, are peculiar 
affections of the skin. Erysipelas is occasionally seen supervening 
periodically, every month, or every two months, at the usual menstrual 
periods, when the catameniafail or are deficient in quantity; strophu- 
lus is one of the most usual morbid phenomena at the time of teeth- 



ing ; urticaria and lichen urticatus frequently succeed derangement of 
the digestive functions, &c. Outward symptoms of complex morbid 
states, these eruptions then possess characters very distinct from those 
that are proper to them, when they arise under other circumstances. 

There are very many cases in which, without being able to dem- 
onstrate such a thing rigorously, the existence of a connection of the 
above kind, or of certain relations of various affections of the skin 
with particular states of the constitution, cannot be called in question. 
Who is not aware that many of the diseases generally designated as 
tettery in their nature, or as scall, such as eczema, lichen, psoriasis, 
&c, are frequently hereditary, and that they occur among individuals 
of the same family, even when placed in very different social positions ? 
A point that is not less incontestable is, that it is impossible in an im- 
mense number of cases, to ascribe to any outward cause the develop- 
ment or spontaneous disappearance of a great variety of herpetic affec- 
tions; and, when the slowness of their progress, and the frequency 
of their recurrence, are contrasted with the facility and the prompti- 
tude with which artificial or accidental eruptions of almost all kinds 
are cured, we are naturally led to conclude, that the former are de- 
pendent upon peculiar states of the constitution, states which several 
authors and the vulgar have designated collectively under the title of 
tettery, scorbutic, fyc. 

We should even have a very imperfect notion of the variable nature 
of certain cutaneous affections, did we not take note of their relations 
in the chain of cause and effect with a variety of other diseases. 
There is so intimate a connection betwixt gout and gravel, that the 
gouty are frequently liable to alternate attacks of these two affections, 
and when one of them has influenced the constitution deeply, the 
other is often long of showing itself. Without being either so con- 
stant or so striking, alternate attacks of gout, lichen, agrius, chronic 
eczema and psoriasis are still so frequently observed in the upper 
walks of life, that there does actually appear in some cases to be a 
kind of consanguinity between these affections despite of the dissimi- 
larity of their appearances. 

On the other hand, there is always this wide difference between the 
diseases, which, to make use of an old expression, have their roots in 
the interior, and the eruptions produced by the action of external 
stimulants upon the skin, which I have denominated artificial erup- 
tions, even when both appear with the same elementary forms, that 
they always belong to two distinct orders of diseases. 

Not only is the nature of the several affections of the skin independ- 
ent of their external appearances, but every circumstance in these 
diseases, their beneficial or noxious influence upon the system, their 
amenableness or rebelliousness to curative means, all, even to their 
very nature, is modified by different states of the general system, — 
by the influence of age, the tear and wear of the constitution, &c. 
The impetiginous eczema of infants, crusta lactea, was long ago 
recognized as an affection which was frequently beneficial rather than 
injurious to the general health, and one which got well spontaneously, 
after the lapse of a certain time, without the necessity of having re- 
course to remedial measures of any kind. Who, on the contrary, is 
not aware of the fact when an eruption of this kind makes its appear- 
ance about the age of puberty, and when the menstrual function is 
irregular, that cures obtained by every means, often by the use of 



11 



INTRODUCTION. 



ription, are frequently followed by 
. md that recover) is never either complete or attended 
with beneficial efl is a function of so much consequence 

in the female economy remains deranged? Almost all the eruptions 
thai appear about the critical age, it matters not what their form may 
i !nfl\ rebellious; considered in tin- light of supplementary 
excretions, ;is they are by some pathologists, or as critical and elimi- 
- by others, it is always dillicull, and occasionally 
ttempl to cure them. The more we study the deve- 
lopment and tendency of the greater number of the diseases of the 
skin which invade independently of any outward appreciable cause, 
we become convinced of their connection with the state of 
nstitution, and of the necessity there is for considering them 
under this point of view before we think of undertaking their cure, 
Oi i\ en of interfering with them so as to modify their progress. 

The field of observation, and the difficulties that surround it, in- 
ni extent and magnitude in relation to the acute diseases upon 
winch certain epidemic constitutions impress a character of mildness 
or of malignity that proves a remarkable feature, and gives a similarity 
to the whole of the individual cases; this has been particularly ob- 
served in almost all the epidemic variolas, scarlatinas, &c, that have 
ever prevailed. The principles of prognosis and treatment in such 
rencies are rather to be sought for in the histories of analogous 
epidemics, than in the general descriptions we possess of the disease 
occurring under ordinary circumstances. In the same way we know 
tain seasons, and during certain medical constitutions the 
character of an eruptive fever is occasionally so uniform, that the 
same mode of treatment proves applicable in the plurality of the cases 
encountered, without much regard being paid to individual peculi- 
arities or conditions. The influence of seasons and prevailing medical 
(institutions, however, is much less evident than that of epidemic 
constitutions. 

A small number of diseases — cancer and melanosis particularly, 
when they appear upon the skin, are most commonly the outward 
manifestation of a diathesis, the effects of which either are already, or 
speedily will be, felt by one or other of the internal organs; it very 
rarely happens that the action of these diseases is limited to the point 
or points of the skin upon which they seem to fasten themselves. 

Certain affections of the skin, such as eczema and lichen, are oc- 
casionally seen to occur in the course of an internal malady, and 
their evolution to be followed by a favourable solution of the disease. 
On the other hand, it is by no means unfrequent to observe the more 
or less complete disappearance of a variety of cutaneous eruptions, 
not only on the invasion or during the course of an acute disease, but 
also on the attack and at any period in the continuance of a chronic 
affection of an internal organ. It is more particularly between the 
es of t!i;' mucous membranes and those of the skin that these 
are observed, which prove prejudicial or salutary, accord- 
ing as the disease is diverted to the interior or exterior of the body. 
I:i air, ease in which these alterations have been observed, the 
affection of the skin once apparent must not be meddled with; the 
object of the practitioner must rather be to fix it, to bring it back, 
in the event of its having disappeared, and afterwards to favour 
,olution, in the hope of ultimately guiding it to a fortunate 

In a word, every day's observation proves more and more satisfac- 
torily, that the study of the diseases of the skin cannot be detached 
from that of general pathology, and of the multifarious morbid con- 
ditions with which they have such numerous and varied relations. 
A knowledge of these diseases, in fact, implies familiarity with gene- 
ral infections, hereditary predispositions, the effects of regimen, mode 
of life, ice; it concludes acquaintance with the maladies which have 
led them, knowledge of the internal lesions which accompany 
them, appreciation of the organic changes which follow certain erup- 
tions, prescience of the affections which are apt to supervene on their 
That such general views may acquire practical 
."hat they may be advantageously applied to the treat- 
if the skin, the extent of these relations and influ- 
me cases, contested or altogether inappreciable 
in othi be studied and estimated, as much as may be, 

. and even in the morbid individualities of each 



particular case, the whole of the circumstances and every one of the 

elements being taken into account. 

Hippocrates' remarked that the same eruptions occurred under two 
different aspects, according as thej existed by themselves, or as they 
were the depositaries of a morbid state (aTtooTaaitsy. These solutions 
of disease by the skin J he says, are announced by tubercles, tumours, 
pustules, ulcers, alopecia, &c, in proportion to the rapidity of the 
development of which is that of the solution itself in any given case. 
When the solution of the disease does not happen bj the formation 
of tubercles, or ulcers of the skin, or in some other evident way, 
relapses are frequent and follow rapidly. This relation between 
cutaneous eruptions and diseases generally, is mentioned in several 
other passages, in which the father of physic appears rather to en- 
quire into the significance of these eruptions, than to describe or study 
them in themselves. ^ Yet he does consider them elsewhere, under 
other points of view, namely, those of their nature and treatment/ 
their relations with different ages," and even with the seasons. 7 The 
strumous affections of childhood, the eruptions that accompany teeth- 
ing, the occurrence of cancer among individuals of mature years, and 
of prurigo among the aged, had all attracted his observation. 

Hippocrates describes erysipelas, and the ill consequences of its 
retrocession; 3 he mentions phlyctenae and a great many eruptions, 
the names of which are still preserved in our medical nomenclature, 
such as eczema, ecthyma, phlyzacia, psydracia ; he makes several 
remarks on the summer hydrcea, lepra, psoriasis, lichen, pityriasis,' 
on the pruriginous excoriations of the pudenda, 10 on the varieties of 
ephelis and their treatment ;" he describes cancer ; 12 he distinguishes 
different kinds of ulcers; 13 he mentions certain serious gangrenous 

'Hippocratis Opera, interprete Foesio, in fol. Francofurti, 1621. — Qlconomia Hip- 
pocratis, authore Foesio, in fol. Francofurti, 1588. — I have referred to this edition 
throughout, it being esteemed one of the most correct. I must remark, however, that 
in the translation of Foesius, as in all the others, into the Latin tongue, there are many 
expressions in the nomenclature rendered by words which, in the present day, have a 
very different signification; lichen, for instance, is translated impetigo, exanthemata is 
pwitukr, alpha* is vitiligo, &c. To prevent any mistake from this cause, I have fre- 
quently placed the Greek word behind the Latin title of the translator. 

2 Impetigines (taip^rif) et lepra, albicantesque vililigines (xal xouxal) si juvenibus 
qnidem aut pueris horum aliquid conlingat ant, sensim se prodens, diuturniate tem- 
poris augetur; in iis quidem, ex pustulae abscessus esse minime existimandae sunt, 
sed marbi. A quibus ex his aliquid subito multumque contingit, id certi abscessus 
(iwoVTaa-it) dici possit. Oriuntur autem albicantes vililigines ex maxime quidem 
leihalibus morbis, velet quae morbus phamicaeus (4> 3l nx«y) dicitur. Lepra vero et 
impetigines ex iis qui ab atrabile fiunt. (Hippocratis Op. Pncdictorum, lib. ii. p. 114.) 

3 Quineliam quae in cu lem abscedunt, foras erumpentia tubercula {qipaTa.) : velut 
putrescents et purulenti quidam tumores, aut ulcus, aut reliquae hujusce generis in 
cute efflorescenles pustulae (^avA^ara) desquamatio, glabratio et capillorum deflu- 
vium, vitiligines (i).<pk) scabies (xsirfw) aliaque hujusce modi, qua;, conferto et repen- 
tino quodam confluxu, non autem dimidiato, et semi repente abscedunt et quoecumque 
alia dicta sunt, etsi non indigne morbi excretione respondeant. (Hippocratis, De 
morb. vulgaribus, lib. ii. p. 1002.) 

♦ Qua: erumpere et febres decernere nata sunt ulcera ac tubercula, si non afiuerint 
judicationem ipsam tollunt. Quibus vero intro subsistunt certissimas et celerrimas 
morborum recidivas afTerunt. (De morb. vulgar., lib. ii. p. 1009.)— Lepra, prurigo, 
scabies U*f*), impetigines (xe.^isc), vitiligo (i^i,), et alopecia ex pituita oriuntur.' 
Sunt autem ista feeditas potius qnam morbi; favus tjnifi'ov), struma-, phyethia, furun- 
culi et carbunculus, ex pituita oriuntur (De affectionibus, p. 525).— Quibus per febres 
assiduas pustulae {<p\h{a) toto corpore enascuntur, lethale est nisi quid purulentum 
abscedat. In his ver6 pracipuo adnasci ad aures tubercula solent (Coaca: pranc- 
tiones, p. 133).— Quibus ad articulos prarubra pustulae superficiales enatae sunt ac 
subinde rigent us, velut ex acceptis plagis cum dolore venter et inguina rubescunt et 
pereunt (Coaca; pranot.,p. 195).— Pustularum eruptiones (ifa&^ara) velut sumrna 
cuteleviter lacerata aut velhcata, totius habitus tabem et corruptionem denuntianl 
(Coacx pranot.,p. 189).— Eos (dolores) juvari spes est, si abscessus aliquis erunent 
aut pustulae toto corpore pullulannt. (Pradictorum, lib. ii. p. 109 ) " 

5 Cum fauces a-grotant, aut tubercula in corpore exoriuntur, excretiones in cons, 
derationem adhibendae. Si namque biliosae sint, corpus simul aegrotat At si sano 
rum similes extitennt, secure corpus nutrias. (Aphorism., sect, if— aDh 15 spc vii 
lib. ii. p. 12-14.) ' sec> V1K 

« Pradictorum, lib. ii. p. 95. — Aphorism., sect. iii. aph. 31 

- Vere...., lepra impetigines, vililigmes et pustular ulcerosa plunmac, et tubercula 
et articuloruin dolores (Aphonsmi, lib. in. sect, vii.— aph. sect, iii aph 20 d 1248 \ 

—-Estate et oris exulcerationes, genu alium putredines et sudamina fAnh Z'J 

iii. aph. 21. p. 1248.)-Hyeme viris-Pustute mul.x nocturnae, eLycti«les dicia,-' 

(De acre, locis et aquis, p. 281.) ' ^" n > cu(le s dictaa . 

s Pradictorum, lib. ii. p. 45. — Aphorismi, sect. vi. aph. 25. 

9 Praedictorum, lib. ii. p. 109. 

io Si ulcera in pudendis innascantur, et pruritus corripiat, olea;, heder.r ruhi P t 
mali punici dulcis folia trita, vino veten macerato, deinde carnetn recenie'm f I f" 
obductam in subdititio opposito, et per noctem teneat. (De nat. muliebri 582 1 

ii De morbis mulierum, lib. ii. p. 667. ' '' 

12 De morb. mulier., lib. ii. p. 648. 

w At vero ulcera quatuor progrediendi modos mihi habere videntur. L'num 1 
in profundum, cujusmodi sunt fistulosa, cicatrice obducia.et intuscava. Alter 11 " ^ 



INTRODUCTION. 



15 



affections under the title of Noma ; x lastly, he speaks of an epidemic 
fever 2 in which an eruption (dii-Oposetj) similar to that produced by 
burns, was observed, a disease which has been regarded as small-pox 
by some commentators, and with more reason by others as a bullous 
fever. 

Several particular cases in the Hippocratic collection, are remarka- 
ble either from inculcating the doctrine of desposits (drfoorourif) or from 
the vigour and variety of the descriptions ; such is the case of a wet 
nurse, the whole of whose body became covered with ecthymata when 
she gave over nursing; 3 such is that of Silene, labouring under severe 
fever, whose body became covered on the eighth day with red spots, 
and who died on the eleventh ;" such is that of Thasus, who was 
attacked with a gangrenous affection of the foot, &c. 5 

Celsus 6 does not, like Hippocrates, study the cutaneous eruptions 
with reference to their origin and the crises they consummate. He 
remarks, however, that phlegmon sometimes appears after fever, that 
certain eruptions occur during the .spring and summer seasons, and 
that others are most frequent among children, but he dwells little 
upon these relations. On the other hand, the ideas he conveys to us 
of these diseases are in general much more complete than those of 
Hippocrates ; his description of furunculus, and hordeolum, of the 
callous ulcer, of chilblains, of erysipelas, especially the gangrenous 
species of the disease, of circumscribed lichen (first species oi papula), 
of lichen agrius (second species of papulae), of sycosis, psoriasis (third 
species of impetigo), of psoriasis guttata, and especially of Greek 
elephantiasis, cancer, malignant pustule (carbunculus), and a variety 
of diseases of the organs of generation and of the matrices of the nails, 
are not only remarkable for their accuracy, but farther for the excellent 
therapeutical precepts with which they are conjoined. Celsus farther 
describes various kinds of alopecia (area ophiasis) and sundry diseases 
of the hairy scalp (porrigo, cerion) ; it is more difficult to fix upon the 
precise diseases he mentions under the name of ignis sacer, epinyctis, 
scabies, impetigo of different kinds, &c. 

Pliny 7 describes no disease particularly, but he mentions a host of 
simple and compound medicines for the cure of all that were known, 
those of the skin among the number. His nomenclature is the same 
as that of the Greek physicians. He gives the names of several erup- 
tions of which Celsus makes no mention, of the lichen of children, of 
the prurigo of the aged, of prurigo pudendi, of furfures faciei, &c. 
He also names several diseases which were new, or confined to cer- 
tain countries, the contagious mentagra, and the gemursa of Italy, the 
carbunculus (anfhracion) peculiar to Gallia Narbonnensis, and ele- 
phantiasis very common in Egypt. This writer also makes mention 
of several very active medicines against diseases of the skin, such as 
cantharides and elaterium internally, as well as the external use of 
vinegar, lime and alum.. He even speaks of baths of the mineral 
waters, as often employed successfully in the treatment of ulcers and 
several other affections of the skin. (De differentia aquarum, medi- 
cinis, et observationibus.) 

Galen 3 gives the details of several cases of herpes and elephan- 
tiasis; he has a long list of remedies against erysipelas, lichen, varus, 

aJ superiora tendunt, velutque super excrescentem carnem habent. Tertium in latum, 
qualia quae serpentia dicunt. Quartus modus est, qui solus secundum naturam motus 
videtur. (De medico liber, p. 21.) — (De ulceribus, p. 869.) 

' Nomas ver&maximaesunt lethales.quoe putredines altissimedescendentes habent, 
suntque nigerrimae et siccissimae. Vitiosae quoque et in periculum pracipitant, quae 
saniem nigram reddunt. (Preedictor, lib. ii. p. 98.) 

2 Cranone carbunculi aeslate grassabantur. Per magnos aestus affatim et conti- 
nenter compluit, idque ab Austromagis. Sanies quidem plurimacuti subnascebatur, 
qua; intro conclusa dum incalesc'eret, pruriginem excitabat. Deinde verd in pustulas 
erumpebat iis affines, quae in ambustis fieri solent. Tantus inerat sub cute ardoris 
sensus, ut uri viderentur. (De morb.vulg., lib. ii. p. 994). 

Aristophontisfiliam febris tertio et quinto die prehendit.sicca plurimum permansit, 
alvus tamen huic conturbata est, difficilis judicatio fait, supra triginta dies cessavit. 
Pustulce, (<f>xuxTai»ai) quidem ex laboribus non vehementibus, ad diem septimam per- 
veniunt, aliquantulum lividos (De morb. vulg., lib. iv. p. 1329). 

a Lactanti pustulos (!x0y>aTa) per totum corpus eruperunt, qute ad sestatem conse- 
derunt, ubi lactare desiisset (De morb. vulg., lib. ii. p. 1013). 

* Octavo sudor frigidus per omnia membra diffusus est, cum pustulis (i^Mfxara) 
rubentibus, rotundis, parvis, varis non absimilibus, quae permanebant neque absces- 
sum faciebant (De morb. vulg., lib. i. p. 970.) 

6 De morb. vulg., p. 985. 

6 Celsus. Deremedica. Ed. Fouquier et Ratier, 12mo. Paris, 1823, 

7 Plinii secundii. Historiae mundi, lib. xxxvii. Venet. 1569. 

s Galeni Opera, folio. Basileae, 1562.— Novus index in omnia quoe extant Galeni 
opera, fol. Basileae, 1562. 



sycosis, &c. 5 But his theory of the humours constantly renders his 
descriptions obscure, and leads him away into numerous digressions, 
defects which the precision and purity of the painting of Celsus render 
still more striking. Although he studied sweating and the other 
critical phenomena particularly, and observes that ulcers of the skin 
are frequently an indication of a bad state of the constitution, 10 Galen 
does not insist to the same extent as Hippocrates, on the relation 
between cutaneous eruptions, and the solutions and the dTtoataais ot 
diseases. 

The distinction of the cutaneous diseases into those which attack 
the skin of the whole body, and those which are confined to the head 
or to a few regions, is expressly mentioned by Galen in his Isagoge, 11 
where he also notices the connection of several of these affections 
with gout and rheumatism. Under the title of a^ P and of x^iov 
(favus of the Latin writers) 12 he clearly indicates the humid eczema of 
the scalp (tinea mucosa), and acute impetigo of the same part (porrigo 
favosa Willan). 

Caalius Aurelianus 13 has left a number of details on the treatment 
of phthiriasis and elephantiasis, of which Aretaeus presents us with a 
picture that is both more complete and more animated. 14 

iEtius 15 treats of several diseases of the skin after Archigenes, and 
of the affections of the genital parts after Leonidas. He describes 
with particular care a number of diseases of the skin, to which infants 
at the breast are liable, and he gives good precepts in regard to milk 
diet, on the use of baths, on that of cold water, on ablution in fever, 
and a great variety of other therapeutic means. Scribonius Largus 10 
gives the characters of zona, which had already been mentioned by 
Pliny. 

Alexander Trallianus 17 merely repeats the observations of the Greek 
medical writers, on the external diseases of the head. 

Paulus iEgineta distinguishes lepra from psoriasis, and gives an 
excellent description of onychia maligna, under the name ofpterygion. 
He recommends us not to interfere with the eruptions of infancy save 
in their decline, and dwells upon the influence of regimen, and of the 
milk of the nurse. 18 

The Arabian writers 19 have not only reproduced the observations of 
Hippocrates, Galen, Rufus Ephesius, Oribasius, Paulus iEgineta, &c, 
on the diseases of the skin, but were the first who described variola, 
rubeola and the elephantiasis, since entitled from them, of the Arabians. 
Avicenna 20 has given a particularly good account of anthracian and 

9 Galeni Opera, u.s. De compositione pharmacorum, secundum locos. CI. v. p. 323. 
10 Magna tamen ex parte cutis, quoniam in hanc excrementa, quae in habitum cor- 
poris colliguntur, natura expellit, multis et assiduis ulceribus afficitur quippe cancri, 
phagedaenae, herpetes erodentes, carbunculi, et quae Chironia et Telephaea vocantur. 
milleque alias ulcerum generationes ab ejusmodi cacochymia nascuntur. (De tern- 
peramentis, lib. iii. CI. i. p. 45.) 

ii Culem totiusque corporis partes exagitant lepra, psora, alphos albus,alphos niger. 
leuce, impetigo simplex, impetigo agrestis, dracontiasis, achrocordones, thymi, myr- 
meciae, clavi calli. Quaedam horum ex podagra et articulari morbo, quaedem ex sese 

oriuntur Achores, pityriasis, meliceres, atheroma, et favus. Porro earn partem, qua- 

capillo tegitur, et mentum occupant, alopecia, ophiasis, calvities, et madarotes. Pili 
omnes fluunt, extenuantur, quassantur, scindunter, squalescunt,in pulverem redigun- 
tur, subflavescunt, canescunt. (De exterioribus capitis afiectionibus. Introductio 
seu medicus, 117.) 

' 2 Ax^psf, id est manantia ulcera, cutis capitis vitium sunt, ab ipso sic dicta affectu. 
quad cutem tenuissimis foraminibus perforent, ex quibus glutinosa euluit sanies. Huic 
vitio affine est, quod xnp;ov dicunt Graeci (nos favum), in quo foramina sunt, quam in 
illis majora, melleum continentia humorem. (Galeni De remediis paratu facflibus. 
—7. Classis, t. iii. p. 300.) Aetius (Tetrabibl. cap. 68, lib. ii.) describes impetigo of 
the scalp under the name of /usXixupic. M. Alibert has described that of the face under 
the name of melitagre. 

i3 Caelius Aurelianus. De morbis acutts et chronicis, 4to. Amstelodami, 1755. 

m Aretaeus. De causis et signis acutorum, et diuturnorum morborum, folio. Lugd. 
Batav.,1735,p. 67. 

'5 Aetii Amidenicontractaeexveteribus medicine tetrabiblos, hocestxvi. sermones. 
Basil., 1542 folio. 

is Scribonius largus. De compositione medicamentoram. 

" Alexandri (Tralliani) libri duodecim, grace et latine, multo quam antea aucti 
ores et integriores. Basil, 1594, 8vo. 

13 Pustulis qua; puero per cutem erumpunt, primum san6 nullum facessere nego- 
tium oportet; ubi verd probe decreverint, tunc jum curare tentabimus balneis opti- 
mum verd est nutricem dulciori victu uti. (Pauli ^Eginetae Opus de re medica. Lib. 
i. p. 7. Parisiis, 1532.) 

■9 Rhazes. In medicinali disciplina, ch. xxvi. fol. Venitiis, 1542. 

20 Avicenna (In res medicas omnes, &c.) (Venetiis, fol. 1564. lib. iv. fen. i. tract, 
vi. p. 71, 72 and 73) has well distinguished rubeola from variola: " Variola vero in 
principio apparitionis est eminentia et altitudo ; et morbillus est minor variolis et 

minus accedet oculo quam variolae Lacrymre in co sunt plures...et dolor dorxi 

minor." 



1(J 



INTRODUCTION. 



. pruna et ignipenico); bis description de 

■ applicable to pemphigus and rupia, and 

ilia! ; his safati corresponds with our impetiginous 

■ ad and other regions of the body, and his bothor 

hrris to 1 \\iccnna appears farther to have distinguished 

between scabies and prurigo.- Avenzoar speaks of the acarus seal/it /.'' 

The Arabian physicians, greal advocates for blood-letting, have 

enriched the .Materia Medica with a variety of new medicines, 

and advanced therapeutics by their novel applications of many of 

se that were already known. They studied the action of baths, 

icularby of the sulphureous mineral waters, in diseases of the skin. 

The writers who come next in order after the Arabian physicians, 

have left us ample details with regard to the two most remarkable 

epidemics, that have ever occurred whether the extent of their ravages 

or the length of time during which they continued be considered. 

l'lieodoricus 4 and Gilbertus Anglicus 5 were the first who described 

the lepra of the middle ages; Torella, 6 Manardus, 7 Massa, 8 Fracas- 

;iid many others, make us acquainted with the various forms 

of syphilis. 

On occasion of these two memorable epidemics, and with a view 
the better to fix their characters, Aquilanus, 10 Leoniceus, 11 and some 
other writers quoted in the Aphrodisiacus of Luisinus, such as Mon- 
tesaurus, Scanaroli and Cataneo, gave more attention than had yet 
been done to a comparative study of the descriptions of lepra, ele- 
phantiasis, alphos and leuce, left by the Greek writers, and of elephan- 
tiasis and several other diseases of the skin, handed down by the 
Arabians. These authors remind us of the fact that the translators 
of Rhazes and Avicenna make use of the word lepra to designate the 
disease entitled elephantiasis by the Greeks; that the lepra of the 
Greeks was a squamous disease, and that the elephantiasis of the 
Arabians is distinct from both the lepra and elephantiasis of the Greeks. 
One of the most celebrated surgeons of the period when letters 
and the sciences began to revive, Guido de Gauliaco or Guy de 
Chauliac, 1 * distinguished five species of tinea, which correspond 
exactly with impetigo, eczema, sycosis and favus of the scalp; he 
characterizes anthracion perfectly, and is the first who speaks of the 
contagion of scabies. 

Vidus Vidius or Guido" mentions the vesicular varicella or chicken 
pox. 

Fracastorius, in his treatise de morbis contagiosis , u endeavours to 
determine which of the diseases of the skin were contagious, and 
which were not ; he has also distinguished very accurately between 
anthrax, plnjma and proper carbuncle [anthracion?]. 

Fernelius" describes lentigo, and the redness of the skin, the 
pustules and indurations or tubercles of rosacea; he also gives a 
particular account of sundry forms of syphilitic eruption ; he indicates 
purpura, or at least spontaneous ecchymosis of the skin ; he unites 
into a single group impetigo, the whole of the papular and squamous 
eruptions, and describes eczema of the scalp under the name of tinea. 
Forestus, 16 a learned observer, has published a number of particular 

1 Spanruniur super nasum el super poma maxillarum bothor (pustulse) albae.quasi 
ipsa sint puncta laciis. 

2 Et scabies quidem differt a pruritu in hoc quod cum pruritu non sunt bothor 
(.pnstulae) sicut sunt in scabia; et pruritus quidern senilis parum obedit curationi. 

3 Avenzoar. De rectincatione et faciliatione medicationis et regiminis. Venetiis, 
fbl. 1649. 

* Theodorici Ohirurgia secundum medicationemHugonis de lue venerea,1519, folio. 
5 Gilbertus. Laurea anglicana seu compendium totius medicinae. Lugdon, 4to. 

1510. 

« Torellae De pudendagra tractatus. Consilia qutedam, etc. Aphrodisiacus, p. 491, 
U.l. Lngdoni llatavorum, 1728. 

I Manardi Medicidales epistolae, etc. Ferrarse, 4to. 1521. 
' Ma^sa. De morbo gallico. Aphrodisiacus, p. 39. 

• Fracastorius. Syphilis, sive de morbo gallico Libri tres. Veronae, 1535, 4to. 

\quilanus (Sebastianus). De morbo gallico. Aphrodisiacus, p. 1. 

II I.eoniccni. De epidemia quam Iiali morbum gallicum vocant. — Aphrodisiacus, 
p. 17. 

I iy de Chauliac. Chirurgine tractatus, folio, 1570. 
13 Vidus Vulius. Ars univers. medicine, 1. ii. cap. vi. De variolis el morbilis. 
H Fracastor. De morbis contagiosis. lib. ii. cap. xv.; de distinctione infectionum 
cutanea™ m. — Ibid. Phvma verd furunculo simile pene est; sed planius est.et rotun- 
dius, valgus impropne Carbonem vocat, multum differens ab eo, qui proprie Carbun- 
lieitur. 
1 Kernelii I'niversa medicina, fol. Colonise Allobrogum, 1679. 

-ervationum et curat, medic, etc. — De exterioribus vitiis capitis, 
de maculis faciei, de pruritu ani, de phlyctsnis. 



cases, among which there occurs one of pemphigus infantilis, one oi 
COntagioUS scabies, which he distinguishes from B variety oi other 
diseases, all alike designated in his time by the title of scabies, one 

of psoriasis palmaris, one of lepra vulgaris, tVc. These cases are 
accompanied with scholia, in which Forestus examines and discusses 
the observations of preceding writers relative to cases of a corre- 
sponding description. 

Schenkius, 17 a laborious and erudite compiler, has brought together 
a great number of cases of alterations of the hair, of congenital and 
accidental homy productions, of diseases of the hairy scalp, of sycosis 
or mentagra, of lichen, &c. 

Sennertus 18 describes many of the changes in colour which the 
skin undergoes, particularly those which are entitled liver-spots 
(chloasma); as also fetid ephidroses of the feet, axilla? and body at 
large. He gives a detailed account of the diseases of the hair-follicles 
and of plica, after Starnigel and other observers. 

Ballonius or Baillou 19 revives and comments upon the Hippocratic 
doctrine of the diseases of the skin, considered now as existing per 
seipsis, now as drtbtrrosHs or depositaries or emunctories, and again as 
vitia loci. 

The essays of Joubertus 20 and Compolongo 21 scarcely deserve to be 
mentioned. 

Mercuriali 22 introduced into his descriptions the observations of the 
writers who preceded him. Like Galen, he divided the special dis- 
eases of the skin into two sections : as they -were peculiar to the head, 
or as they were liable to appear on all parts of the body. The latter 
he subdivided into two special groups : as they altered, first, the 
colour of the skin (leuce, alphos, &c.) ; secondly, as they rendered 
its surface rough and uneven (impetigo or lichen, pruritus, scabies, 
or psora, lepra,) to which he added a variety of tumours, without, 
however, condescending on the description of any. Under the name 
of tinea he gives the characteristic symptoms of favus (tinea favosa; 
porrigo lupinosa Willan) with great clearness, — its bright yellow and 
dry crusts, its transmission by contagion, and its influence in causing 
the loss of the hair. He detaches completely and with justice, the 
disease from achores and favi, [impetiginous eczema, and impetigo?] 
the influence of which upon the constitution and anterior diseases, he 
carefully notes. 

Joannes Riolanus, 23 after alluding to this division of Mercuriali, 
proposes another of his own, based upon the appearances presented 
by the diseases of the skin, without regard to their seat. The dis- 
eases of the skin, says he, maybe divided, first, into pustules (prurigo, 
scabies, psora, lepra, impetigo, psydracia, ambustio ;) secondly, into 
deformities (macular, morbid discolorations, loss of the hair, phthiria- 
sis;) thirdly, into tubercles (warts, excrescences, condylomata.) 

Hafenreffer 24 describes the diseases of the skin very briefly, and often 
after the ancient or cotemporary authors, without appearing to have 
been guided by any general views in their distribution. He includes 
variola, rubeola, the venereal eruptions, and the primary symptoms 
of syphilis in the study of the diseases of the skin. There is, in fact, 
nothing remarkable in his work, especially in comparison with that 
of Mercuriali, beyond his description of the syphilides or syphilitic 
eruptions, of dysenteric variola?, and his history of the pediculi of the 
human body, of which he reckons four species, one of which evidently 
corresponds to the acarus scabiei. He farther attempts to construct a 
table of synonyms, in which the Greek, Latin, Arabian, and German 
names of the diseases of the skin are included ; but, he has here com- 
mitted a considerable number of errors, and has frequently assimilated 

" Schenkii Observat. medic, rariror., libri vii. fol. Lngduni 1694 
ParSS ^L™* '' " L ^ V ' *™ lert ' a ' De CUl ' S ' ca P illolu,n et unguium vitiis. 

» Ballonii (Gail.) Opera omnia. Epidem. et Ephemer, lib. i. t. i. p 49 4to. 
Oenevae, 1762. r ' 

*> Joubertus (Laurent). De affectibus pilorum et cutis, 12mo. Geneva; 1572 
*' Compolongo (Emil.). De morbis cutaneis, lib. iv. tract, iii. Parisiis 1634 "' 
" Accardius (Paulus) Tractationem de morbis cutaneis et omnibus hnmani cor 
pons excrements ex ore Hieronymi Mercurialis excepit et in quinque libros di»M«it 
acedidit. Venetns, 1572, 4to. Basil, 1756, 8vo. Venetiis, 1601, folio. Ibid IBM 
4to. See also the book of Merculiari: De decoratione, in which he treats of the ilV 
eases of the nails, and of several other affections of the skin. 

^Riolani (Joanuis) Opera Omnia. De morbis cutaneis, p. 547, fol. 1610. 
2< Hafenreffer (Samuel). n**ioyh<» i.u\itt<n» in quo cutis eique adher-rentum n in i„ m 
affectus etc., traduntur. 12mo. Tubing*, 1630.— Ulmi, 1660, Svo. "Ionium 



INTRODUCTION. 



17 



many very imperfect descriptions, which, nevertheless, refer evidently 
to diseases widely different. 

After a short review of the structure of the skin, Willis 1 divides 
the diseases to which it is liable, into two sections, as they show 
themselves v el cum, vel sine tumore. The affections cum twmore are 
farther general or particular. Of the former several invade with 
fever, variola, rubeola, the exanthemata and efflorescentiae of infants ; 
others without fever, prurigo, and the impetiginous and leprous affec- 
tions^ The diseases sine tumour include the whole of the macula?, 
ephelis, liver-spot, &c. These divisions were natural enough. 

Bonetus 2 has gathered together into his useful collection a considera- 
ble number of rare cases of cutaneous disease, the greater number of 
which are taken from the Ephemerides natures curiosorum, 3 or the 
Acta regies societatis medico. Hafniensis. 4 Imitating the example thus 
set, Magnetus in his Bibliotheca medico-practica, 5 has given a reprint 
of the work of Willis, quoted above, and by adding many interest- 
ing cases of cutaneous disease published by Blandini, Raymondus, J. 
Forti, B. Sylvaticus, Hagedorn, Rhazes, Schulz, Wedel, A. Saporta, 
Helwig, and others, has contributed to spread abroad information of 
much practical value. 

Many observers have assisted the progress of cutaneous pathology, 
by the publication of particular cases, in the Journals or periodical 
Collections, with a view to demonstrate the utility of divers modes of 
treatment, or to make known certain rare forms of affections of the 
skin. As depositaries of this kind, I must mention the Centurea of 
Laz. Riverius, 6 the Observations of M. A. Severinus, 7 particularly 
with reference to Arabian elephantiasis of different parts of the body, 
and the collections of Zacutus Lusitanus ; 8 Stalpartus van der Wiei, 9 
Felix Platerus, 10 Dodonnreus, Benevenius, 11 Borellus, 12 Hagedorn, 13 
Philip Hechstetter, 14 &c. More recently, several observers, Duncan, 15 

1 Willis. De affectibus cutaneis, eorumque morbis. De medicamentorum opera- 
tionibus, sect. iii. cap. v. p. 279. Opera omnia. Amstelodami, 4to. 1682. 

2 Bonetus (Th.) Medicinae septentrionalis collatitia. Genevas, 1684 et 1686, vol. 
ii. folio. 

3 This collection contains a very considerable number of cases that deserve to be 
consulted. Vide Index universalis Ephemeridum, &c. 4to. Norimbergce, 1739, Art. 
Scabies, Gutta rosacea, etc. 

* Acta regiae societatis medicae Hafniensis. — Interesting cases are also to be found 
in several other collections, particularly in the Collection academique des Memoirs, 
des actes,des societes litter aires etrangeres, 4to. Paris, 1775. 

5 Mangeti (J. J.). Bibliotheca medico-practica: Cutis morbi, t. i. p. 803, et seq. fol. 
Genevae, 1645. 

6 Riverii (Laz.). Observationes medicae, et Obs. com municatae, 4to. Parisiis, 1645. 
In the works of Riverius I find notices of a gangrene of the skin, occasioned by the 
application of a blister thickly sprinkled over with powdered cantharides ; of a case 
of retrocession of tubercles of the face, which was followed by fatal continued fever; 
of the use of an ointment of white precipitate in a case of impetiginous eczema (impe- 
tigo fera); of a salve of red precipitate in fungous onychia; of a case of erysipelatous 
eczema, under the name of scabies pruriginosa ',',• of several instances of syphilitic 
eruptions in new-born infants or children; of a case of general squamous eruption, 
attended with excessive pruritus, which seems to be referable to general pityriasis, &c. 

i Severinus (Marc Aurel.) De recondita abscessuum natura, 8vo. Neap., 1632. In 
this work we find a case of elephantiasis of the scrotum, with a figure (De abscessi- 
bus muco-carneis); a case of elephantiasis of the leg with a fig. (utriformis cruris 
abscess us); a case of subcutaneous tumour of the skin, with fig.; and some rather 
interesting inquiries on epinyctis (De epinyctidis et roseolis liber). 

8 Zacuti Lusitani Opera, fol. 2 vol. 1649. — t. ii.p. 140. — Inveterata tinea, oleo bom- 
bacino curata. — De praxi medica admiranda, lib. iii. (obs. 136.) Ulcera manantia 
diuturna in universa corporis mole exorta, a case of eczema treated successfully by 
local and general bleeding, aluminous baths, diluents and purgatives, and cured at 
length by means of issues. Zacutus gives (lib. i.) a case of furfuraceous eczema of 
the scalp, cured by bathing the part with urine (obs. iii.); of phthiriasis of the eyelids 
(obs. Ixv.); of rosacea cured by leeching (obs. lxxv.); of wart of the tongue, cured by 
the leaves of the chelidoneum majus (obs. lxxix.); of pruritus of the genital organs 
(obs. xcii.); of variola in a pregnant woman (obs. xlvii.); of fetid sweating (lib. iii. 
obs. Ixxiv.); of bloody sweat (lib. iii. obs. xli.), &c. * 

9 Stalpartus van der Weil, in his Obs. rar. med. Centur. 12mo. Leidas, 1727, gives 
a case of ichthyosis with a figure ; several cases of nrevi ; a case of anaesthesia, &c. 

10 Platerus (Felix). (Obs. Hbri tres, 12mo. 1660). Agreat number of cases of cuta- 
neous disease. (In superficici corporis dolore observ. ; In discoloratione obs.), but 
often badly characterized, and the details overlaid with formulae. 

11 Dodonneus (Remb.) (Medicinal, observ. exemp. rar. 12mo. Harderovici). Ele- 
phantiasis Arabica ; syphilitic eruptions; lepra; horny productions. 

i* Borellus (Pet). (Hist, et obs. medico-physic, centur. 12mo. Castris, 1653). Fun- 
gous tubercles after variola; accidental hairy and horny productions; purpura 
hemorrhagica. 

i3 Hagedorn (L.) (Obs. med.-pract. cent. iii. 12mo. Francof. ad Viadr.). Variola; 
variola in the fectus; measles, and its secondary diseases; prurigo, &c. 

14 Hechstetter (Ph.). (Rar. obs. med. decad., iii. 12mo. Aug. Vindel.) Purpura: 
exanthemata with hemorrhage; elephantiasis scroti. 

13 Duncan (And.). Medical cases, 8vo. Edin. On Corrosive sublimate in several 
diseases of the skin; tinea; purpura. 

5 



Reil, 16 De Haen, 17 Gilibert, 13 &c, have published in their Clinical R»- 
ports, a very considerable number of cases and practical remarks, on 
the pathology and treatment of cutaneous diseases. 

The great merit of the work of Turner 19 is its positive and practical 
character. In support of the doctrine he advances, he generally quotes 
one or more cases which he has either met with in his own practice, 
or which he borrows from the writings of others. He was the first 
who gave a good description of the various species of herpes (herp. 
circinatus, herp. phlycteenodes, herp. zoster), which he detaches deii- 
nitely from herpes exedens vel depascens, i. e. lupus; he distinguishes 
the furuncular anthrax from true carbuncle; he gives a curious case 
after Willis, of the absence of perspiration (anhydrosis) ; he insists 
on the danger of suppressing copious or fetid ephidroses ; he describes 
coloured or pigmentary na?vi, vascular navi, and degenerated nsvi, 
and speaks of their treatment by means of the ligature, excision, and 
the application of escharotics ; he relates after Job a Meekren a re- 
markable case of extensibility of the skin of the neck and breast. 

The work of Lorry 20 is distinguished for its general views, and the 
broad manner in which the author there regards the study of the dis- 
eases of the skin. In these particulars, Lorry is undoubtedly supe- 
rior to all the writers who preceded, and to the greater number of those 
who have followed him. He begins by studying the general organi- 
zation and particular structure of the healthy skin; he compares its 
elements in the different regions of the body, and, after a rapid glance 
at its functions, he considers its relations with the other systems and 
organs of the economy. He next passes briefly in review the various 
modifications which the skin experiences under the influence of exter- 
nal agents — the air, varied temperatures, climates, and applications 
of all kinds; he then takes note of the effects of the ingesta, food 
and drink ; of rest and exercise ; of sleep and watching ; of the affec- 
tions of the mind, &c. He next specifies the influence of whatever 
is internal or organic, such as of the strumous constitution, of suck- 
ling, of the variolous, venereal, morbillary virus, &c, and insists on 
the necessity of a careful inquiry into the probable causes of each 
affection. The prognosis he studies comparatively in children, adults, 
and the aged ; he insists strongly upon the danger of repelling cu- 
taneous eruptions, and he revives and develops the Hippocratic di- 
vision of the diseases of the skin, into those which are determined 
thither by internal affections, and into those which are produced by a 
merely local morbid process. 

His general views of the treatment of cutaneous diseases are of the 
very highest interest; he makes us sensible of the necessary and im- 
portant modifications that must be made in the treatment, according 
as the eruptions have arisen under circumstances in which they must 
be considered as critical, depurative, or dangerous to cure ; accord- 
ing as they indicate a slow or speedy solution of internal maladies ; 
and lastly, as they are entirely local, and capable of being combated 
by external or topical means. Lorry's work, so rich in these practical 
views, is, however, very deficient in particular descriptions of indi- 
vidual diseases ; here we constantly feel the want of precision in the 
determination of species, which are often imperfectly described, in 
several chapters, and under different names. 

Cotemporary with Lorry, Plenck 21 arranged the diseases of the skin 
into classes, in the hope of facilitating the study of this branch of 
pathology, and rendering the diagnosis of the individual affections 
more certain. This classification is founded on the external appear- 
ances of the diseases themselves, consequently on their most recog- 
nizable characters. Plenck formed fourteen classes of cutaneous 
diseases: lmo. Maculae; 2do. Pustulee ; 3io. Vesiculce ; 4to. Bulla-. 
5to. Papules; 6to. Crustce ; 7mo. Squama; 8vo. Callositates ; 9mo. 
Excrescentice cutanea ; lOmo. Ulcera cutanea ; 11 mo. Vulnera cutanea ; 
12mo. Insecta cutanea; 13mo. Morbi unguium; 14to. Morbi pilorum. 

is Reil (J. C). (Memorab. clinic, faciculi, 8vo. Halre, 1739-91-92.) Hemonl. ..■;■ 
petechialis ; pemphigus; diseases consecutive to measles and small-pox. 

" De Haen (A.) (Ratio Medendi. Vienna? et Paris.) Variola ; inoculation : 
rubeola; scarlatina; critical and non-critical sweats. 

is Gilibert (J. E.) (Adversarie medico-practica, 8vo. Lugd., 1791.) Cancer of the 
skin; scabies; ulcers; variola; pemphigus, syphilis, &c. 

"Turner (D.). A treatise of diseases incident to the.skin, 8vo. Lond. 1714; itrum 
1726, &c. Trad. Franc, 12mo. Paris, 1743. 

*° Lorry. Tractatus de morbis culaneis, 4to. Parisiis, 1777. 

21 Plenck (Joan. Jacob.) Doctrinade morbis cutaneis, qua hi insuas classes, genera 
el species rediguntttr. Vienna;, 1776, 8vo. Ibid. 1783, 8vo. Lovani, 1796. 






IM'KCDI CTION. 



to facilitate 
to convey information in 
. which is no! always in relation with their out- 
artificial method of arriving 
the knowledge of species, without which, 
ml no conclusions can be held 
I that Plenck had no intention of giving 

the skin according to their nature ; i; 
is therefore unfair to reproach him with the diversity of the elements 
which i I nt imperfections which 

particularly from his not having always stuck with 
sufficient cl what were in fact the most striking external 

tea which he has arranged together in each of his 
nt groups. 
Willan, 1 i tern of classification, starts essentially from the 

' nek; but instead of attaching himself, like the Ger- 
man author, to the most striking feature of the diseases of the skin, 
period in their progress, he assumes the character 
their highest pitch of development — at their 
//it, and before they have undergone any consecutive alte- 
ment of his distribution. In the majority of cases, 
es of the skin are much more strikingly characterized at this 
lither before or afterwards, by the appearances 
which or follow them, and which are frequently common to 

1 affections. Willan has, in conformity with this view, sup- 
es of ulcers, crusts, &.c. His groups are better ordered 
than those of Plenck. He never mingles, as the latter does constantly, 
symptoms with diseases ; and a much more accurate knowledge of the 
eruptions themselves than Plenck possessed, enabled Willan to judge 
more precisely of their proper places in his different groups. Several 
even extremely natural, such as the papulce, the squama, 
and even fjie exanthemata, if purpura be struck out of it; 
"ii the other hand, the ti&ercula includes diseases of the most dissimi- 
lar descriptions. The great characteristics of Willan's writin 

ipress they bear of the scientific spirit that guided him in his 
at precision, and the purity of his descriptions; 
irticular pains he takes to select well, and to use judiciously, his 
technical expressions; lastly, the taste and the sound judgment he 
lys in his interpretation of the ancients. If there be aught with 
which he is chargeable in the way of omission, it is with having paid 
too little attention to the relations of the diseases of the skin to the 
f the constitution, to anterior diseases, and to those affections 
which are attributed to their repercussion. His therapeia is in gene- 
: his practice, his writings, and the works which have issued 
from I , contributed powerfully to extend the free use of pur- 

mal employment of a variety of powerful medi- 
cines, such as the tincture of cantharides, the mineral acids, and the 
preparations both of antimony and arsenic in the treatment of cutaneous 
ions. 
man, by completing the works of Willan, and reproducing 
them in an ! nt form, 2 contributed greatly to extend 

a knowledge of the diseases of the skin. Bateman also in his edition 
of the atlas, commenced by Willan, gave figures of a considerable 
number of diseases of the skin. 3 

works of these celebrated pathologists were recast by Gomez, 4 

and published in the shape of a synoptical table of the diseases of the 

skin; bv Em, Szalay 5 in his inaugural dissertation, in the form of a 

I; and by Bertrand 6 and Ab. Hanemann and Sprengel, 7 who 

spread a knowledge of them over France and Germany. 

;n ^Robert). Description and treatment of cutaneous diseases, 4to. London, 

- 14, with plai on the diseases of Lond., 12mo. 1801. 

- Bateman (Thos.) A Practical Synopsis of Cutaneous Diseases, 8vo. Lond., 

819; 7th edit., 1829. 

Delineations of cutaneous diseases, 4to» London, 1817. Reports on the diseases 

don, 1819. Dr. Anth. Todd Thomson published in 1829 an ab- 

. with the addition of several original figures. 
Ensaio dermosographioo, o succinta e systematica descripcao das 
aidicaraodos respectivos remedios aconselhados. 4to. Lis- 

!meric). Diss, inau::. sistms synopsin morborum cutis secundum 

;uisiiorum. Vindobonce, 1818. 
ratique des maladies de la peau, etc., par Thomas Bateman, traduit de 
ir la 5ih edition, 8vo. Paris, 1829. 
Darstellung der Hautkrankheiten nach Willan's System bearbeitet 



The little work entific chw 

it is simply a . and of • M 'l v ''' i;,; 

having for the most part a practical end. It includes ins 
cheloid tumour, oi strumous tetter, of eruptions about tfa 
organs of men and women, and a variety of observations on the con- 
stitution, and on the physical and moral character of individ 
habitually subject to herpetic affections. The author speaks ol 
influence which diseases of the skin of the lace exert on the ts 
and habits of females of a certain age; he mentions the relation 
the diseases of the skin to gout and the affections of the uril 
is; he dwells on the difficulties almost always connected \ 
the treatment of cutaneous diseases, and the frequency of relaj 
among individuals who will not consent to follow the course pre- 
scribed, whether it be medicinal or dietetic, in every the most minute 
particular. 

At a time when almost all the chronic diseases of the skin of 
face, trunk and extremities, were designated in France under the 
name of dartres, which corresponds to the English word tetter, 
was interpreted by the Latin term herpes, the college of medicine 
Lyons proposed as the subject of a prize: To determine the vafi 
species of tetter, their causes, their symptoms, and the diseases I 
depend on them. The prize was awarded to the dissertation of H. 
J. A. de Roussel. 9 Sauvages 10 had admitted nine species of /.< 
(independently of psydracia, hydrcea, epinyctis, rosacea, ephelis and 
vitiligo); comprising, 1st, furfuraceous tetter; 2d, crusted tetter; 
3d, miliary tetter; 4th, eating letter; 5th, syphilitic tetter; 6th, 
garter-like tetter; 7th, collar-like tetter; 8th, pustular tetter (Da 
boutonnee) ; and 9th, zona. The species admitted by Roussel are in 
general better characterized, and bear greater affinity to those which 
are still described at the present day under other names. Under the 
head of herpes furfuraceous, he evidently includes the papular and 
squamous affections ; in his squamous running tetter or dartre vive, we 
recognize the characters of excoriated eczema, and his crusted tetter 
corresponding to our impetigo. Roussel endeavoured to discover 
and to point out the signs by means of which we may ascertain 
whether a cutaneous eruption is the depositary, as it were, the crisis 
or the solution of an internal disease, or exists per se ; and this foi 
one of the striking characteristics of his work, which is further remark- 
able for the efforts the author makes to approximate and bring into 
harmony the imperfect descriptions of his predecessors, rendered - 
more obscure by the diversity of nomenclature universally employed. 

The small treatise of Poupart 11 has no interest otherwise than as it 
contains several observations on the repercussion and on the metas- 

s of chronic diseases of the skin, and even the greater numbei 
his facts are derived from the writings of Ballonius, Mead, Sauvages, 
Raymond, Tissot, &c. The instances he gives are dysurise, leuct - 
rhceas and affections of the brain and lungs, supervening on the c 
of cutaneous eruptions. Poupart also studied the action of the ane- 
mone pulsatilis in cases of tettery eruption, and quotes several in- 
stances of its efficacy in their cure. 

Jackson 12 has treated at: great length of the causes and of the natun 
the diseases of the skin ; which he nevertheless only considers in a \ 
vague and general manner. He divides them into three groups; 1st. 
Morbid secretions of the subaceous glands; 2d. Morbid states of 
bulbs of the hair ; 3d. Morbid conditions of the cutaneous vessels. 

Chiarugi 13 limits his researches to the chronic and crusted (sor» 
diseases of the skin. He divides them into three orders: 1st crus 
papular diseases (impetigo, herpes); 2d, crusted phlycten'oid d - 
eases (achor, rogna); 3d, crusted pustular diseases (gotta rosea, lep 
tinea). Under the name of Impetigo, in the first group, he descril 
lichen pretty accurately, and gives a good definition of the disease • 
and, under the name of herpes, he includes the same diseases as 

von Th. Bateman, aus dem Englischen nbersetzt von Abraham Hanemann, mil V, r- 
rede und Anmerkungen von Kurt Sprengel, 8vo. Halle 1815 ' 

8 Reiz. Des maladies de la peau et de celles de l'esp'rit, sVo. 2d edit L79J 
. De Roussel (H. F. A.) Diss, de ranis Herpetun, s'peciebus, 8vo Cadomi 1 ' 
"> Sauvages (Boissierde) ISosologiaMethodica, 2 vols.4to. Amstelod., 1768, 

11 Poupart. Traitedes dartres, 12mo. Paris, 1 
'2 Jackson (Seguin Heori.) Dermatopath. Londres, 179] 

'3 Chiarugi (Vincenzio) Delle malattie cutanee sordiHe in genere e 'in snerin 
tato teonco-prattico, 2 vol. 2nda edizione.— Firenze, 2 vol. 1 - 



INTRODUCTION. 



19 



ancients {herpes miliaris, herpes zoster, herpes esthiomenes). In the 
second group he describes, under the name of achor, eczema and 
impetigo of the face and hairy scalp, and scabies under the title of 
rogna. The third group comprises rosa, or rosacea ; scabia, which 
appears to be eczema ; lepra, that is to say lepra grcecorum and ele- 
phantiasis and tigna, the account of which corresponds to the furfu- 
raceous, crusted and humid states of eczema and impetigo of the 
scalp. In a word, the work of Chiarugi, although posterior in point 
of time, is immeasurably inferior to that of Willan. 

Wilson 1 divided the diseases of the skin into, 1st. Febrile eruptions 
(urticaria, miliary eruption, varicella, variola, vaccina, pemphigus, 
rubeola, scarlatina). 2d. Simple inflammations (excoriations, burns, 
chilblains, &c). 3d. Constitutional inflammations (erysipelas, efflores- 
centia;, rednesses of the face, &c). 4th. Papular eruptions. 5th. 
Vesicular eruptions (scabies, eczema, zona, herpes, aphthae). 6th. 
Pustular eruptions (pustular scabies, impetigo, porrigo, crusta lactea). 
7th. Infantile eruptions (strophulus). 8th. Squamous eruptions (lepra, 
psoriasis, pityriasis, syphilitic blotches, elephantiasis). 9th. Tumours 
(acne, follicular enlargements, furuncles). 10th. Excrescences (corns, 
warts). 11th. Spots (lentigo, ephelis, purpura?, naevi). 12. Wounds. 
1 3th. Ulcers (simple ulcer, depressed ulcer, callous ulcer, fungous 
ulcer, syphilitic ulcer, scorbutic ulcer, scrofulous ulcer). In an 
appendix he makes a number of remarks on the spontaneous dis- 
appearance of certain cutaneous eruptions which was followed by 
various nervous symptoms. One of the inherent vices of this classifi- 
cation is its want of unity ; this, however, is a reproach that may be 
made to almost all the systems of classification of the diseases of the 
skin that have yet been proposed. In the formation of his groups, 
the author has attended at once to the nature of the diseases, to their 
relations with the constitution, and to their outward appearances. A 
more serious objection may be raised to the mode in which some of 
his groups are composed ; though we must still allow that the first 
group, were erysipelas added to it, would be extremely natural. 

Mr. Plumbe 2 not very long ago published a new distribution of 
the diseases of the skin. The first section includes those diseases 
which derive their distinguishing characters from local peculiarities 
of the skin (acne, sycosis, porrigo) ; the second section comprises 
such diseases as depend on a debilitated state of the constitution, and, 
consequently, on a diminution of tone in the vessels of the skin (purpura, 
pemphigus, ecthyma, rupia). Sundry diseases, generally beneficial in 
their influence, symptomatic of derangement of the digestive organs, 
and characterized by active inflammation, form a third section (porrigo 
favosa, porrigo larvalis, lichen, urticaria, herpes, furuncle). A fourth 
section or group is characterized by a chronic inflammation of the ves- 
sels which secrete the epidermis (lepra, psoriasis, pityriasis, pellagra, 
ichthyosis, warts). A fifth and concluding section, comprises a host 
of diseases of the most dissimilar character (scabies, eczema, elephan- 
tiasis, erythema, &c). There is unquestionably considerable inge- 
nuity in several parts of this arrangement ; but it is inferior to that of 
Willan. Mr. Plumbe's work, in other respects, is distinguished for 
its practical character, and for the importance which the author at- 
taches to the connection of diseases of the skin with morbid states of 
the constitution. 

M. Derien 3 divided the diseases of the skin into acute and chronic, 
and, as grounds of a subdivision, proposed their distinction into 
essential and symptomatic. Both Peter Frank 4 and Joseph Frank 5 
adopted the division of the diseases of the skin into acute (exanthe- 
mata) and chronic (impetigines). But this system, rigorously applied, 
frequently and necessarily leads to the discussion of one and the same 
disease in two different sections, according as it happens to be evolved 
slowly or speedily, and to run its course tardily or rapidly. We 
consequently find acute urticaria placed by Joseph Frank in a first 
class under the usual title, urticaria, and the chronic affection in a 

' Wilson (John). A familiar treatise on cutaneous diseases, 8vo. London, 2d 
edition, 1814. 

2 Plumbe (Samuel). A practical treatise on diseases of the skin, 8vo. London, 
18-24. Philadelphia, 1837. 

3 Derien (Jaqucs). Essai d'une table yynoptique des maladies de la peau, 4to. 
Paris, 1806. 

4 Franck (Joan. Petr.). De curandis hominum morbis epitome. Mannheim et 
Vienne, 1792. 

' 1'ianck (Joseph). Praxeos medical universal prsccepta, 8vo. Taurini, 1821. — 
Vol. iii. iv. De morbis cutis. 



second, under the name of urtica/io. Acute pemphigus is described 
in one. section under the name of bullce, and the chronic disease In 
another, under that of pemphigus. Against this view of Jos. Frank, 
it may also be shown that erythema, strophulus, herpes, ecthyma, 
mucifluent tinea, &c, are by no means uniformly chronic diseases, 
and that furuncle is not always acute. J. Peter Frank divides the 
exanthemata into naked and scabrous, and the impetigines into such 
are confined to the superficies of the skin, and such as penetrate more 
deeply. Joseph Frank has described, almost without order, the 
various cutaneous affections arranged by J. P. Frank, in these two 
divisions. The secondary division which he has adopted of cutaneous 
affections into idiopathic and symptomatic is inapplicable in any 
system of classification as a basis for the formation of sub-orders ; the 
distinction, however, is in itself of real value when applied to each 
disease in particular. 

M. Alibert, 6 whose works have obtained so much celebrity, has 
attempted to connect the diseases of the skin into families. 1st. 
Teignes (T. faveuse, T. granulee, T. furfuracee, T. amiantacee, T. 
muqueuse). — 2d. Pliques (P. multiforme, P. solitaire, P. en masse). 
— 3d. Dartres (D. furfuracee, D. squameuse, D. crustacee, D. ron- 
geante, D. pustuleuse, D. phlyctenoide, D.erythemoide). — 4th. Ephe- 
lides (E. lentiforme, E. hepatique, E. scorbutique). — 5th. Concroide 
ou keloi'de. — 6th. Lepre (L. squameuse, L. crustacee, L. tubercu- 
leuse). — 7th. Pians (P. ruboi'de, P. fongoi'de). — 8th. Ichthyonses (I. 
nacree, I. cornee, I. pellagre). — 9th. Syphilides (S. pustuleuse, S. 
vegetante, S. ulceree). — 10th. Scrofules (S. vulgaire, S. endemique). 
— 11th. Psorides (P. pustuleuse purulente, P. pustuleuse vesiculeuse, 
P. papuleuse, P. crustacee). No writer has seized with greater acute- 
ness than M. Alibert, the various aspects of these diseases, nor lias 
any one painted their principal characters in happier colours. His 
description of the teigneyhyetise(favus), of the dartre rongeante (lupus), 
of the keloi'de, of the dartre squameuse humide (discharging eczema), 
of scrofula, of the different syphilitic eruptions, &c, deserve to be 
particularly enumerated for their excellence. The work of this writer 
recommends itself to us farther, by the remarks and practical views, 
replete with interest, and the vast number of particular cases it con- 
tains, calculated to exhibit rare appearances presented by different 
forms of cutaneous disease, to demonstrate the efficacy of a variety of 
therapeutic means, and to show the salutary influences occasionally 
exerted by cutaneous eruptions on the general health, or to prove the 
dangers which attend on their repercussion. Still more recently, M. 
Alibert has published another and a more complete work, 7 in which 
he proposes a new classification of the diseases of the skin. The first. 
(dermatoses eczemateuses ) , comprises the inflammatory diseases ; the 
second (dermatoses exanthimateuses ) , consists of febrile eruptions ; the 
third (dermatoses teigneuses), is formed of the affections of the hairy 
scalp ; the four succeeding groups include constitutional affections, to 
wit, the fourth (dermatoses dartreuses), chronic eruptions, common to 
every part of the integuments; the fifth (dermatoses cancereuses ) , can- 
cerous affections; the sixth (dermatoses lepreuses), the squamous dis- 
eases; the seventh (dermatoses varioleuses), the variolous eruptions; 
the eighth (dermatoses strumeuses), the scrofulous affections; the ninth 
(dermatoses scabieuses), is distinguished by the general character of the 
diseases it includes to cause pruritus over the surface of the skin ; the 
tenth (dermatoses hemateuses), includes petechia? and purpura ; the 
eleventh (dermatoses dyschromateuses ), comprises changes in the colour 
of the skin ; the twelfth (dermatoses heleramorphcs), takes in various 
alterations not assigned or unassignable to any of the other classes. 
This classification 8 is deficient in unity of principle. The groups are 
evidently formed, now after the inflammatory character of the diseases, 

6 Alibert. Precis fheorique et pratique sur les maladies de la peau, in 8vo. 2 vol. 
premiere edit. Paris, 1810. 2nde edit. Paris, 1822. Description des maladies de la 
peau observees a l'hopital Saint Louis. Paris, 1825, fig. fol. 

7 Alibert. Monographie des Dermatoses, 2 vols. 8vo. Paris, 1832. 

8 Dr. Paget, in an essay on the advantages of the natural, compared with the arti- 
ficial, method of classification in the study of the diseases of the skin, (in the Edinb. 
Med. and Surg. Journal, vol. xxxix. 1633, p. 255,) has endeavoured to prove that the 
classification of Alibert was natural. This opinion has been successfully combated 
by M. Ch. Martins, in his dissertation entitled, Les preceptes de la mefhode naturelle 
appliques a la classification des maladies de la peau, 4to. Paris, 1834, who ought, 
however, at the same time to have acknowledged that the arrangement of Willan was 
artificial ; he might still have demonstrated its superiority. M. Baumes, in his Lettre 
d'un Medecin de Province aux dermatophytes des Hupitaux de Paris, 1834, has over- 






[NTR0D1 CTION. 



dow after their f< . in, hum their n, from 

- ,\ ••. 1 

titles of the difierenl ncluded in the • 

if the beterogeneousness of the elements 

of them ; an inconvenience which is not made 

up lor, as in the classification of Wilkin, by the accrual of real ad- 

the diagnosis. These groups, moreover, with 

11 of the two comprising the syphilitic and the strumous 

affections, have little value in a practical point of view. 

Mes! I ive and Schedel 1 have adopted the classification of 

Wilkin, but without assigning any place in the system to lupus, pel- 
■ ruptians, purpura, elephantiasis arabica and the 
(keloid formation. Their work is constructed on the same plan as 
i man, and like his, contains a very good summary of 

the principal diseases of tke skin.- It is enriched with the observa- 
: M. Biett on lupus and the syphilitic eruptions, which are 
bed with particular care. It also contains the results of 
this practitioner's experiments with the iodurcts of mercury and sul- 
phur, the action of which on the economy, and the circumstances 
under which they may be advantageously used, he was the first to 
study. Like tke English pathologists and M. Biett, the Messrs. Ca- 
and Schedel are bold in their recommendation internally of 
many v. ry active medicines, such as the tincture of cantharides and 
the preparations of arsenic, in the treatment of the more inveterate 
and rebellious chronic diseases of the skin. 

The work of M. Gilbert 3 has a greater show of erudition than that 
1 ist mentioned, and contains several concise but well chosen cases, 
and intesspersed remarks of a practical character on the diseases of 
the skin, considered in their relations with the constitution and the 
various morbid slates it exhibits. His classification, in conformity 
with that of Will an, has its inherent advantages and inconveniences. 

In a systematic synopsis Strove* has specified almost every known 
variety of disease of the skin. Mr. Wilkinson 5 has made several 
pertinent remarks on the treatment of the diseases of the skin ; the 
tract of .Mr. kelson" is without interest. 

M. S. Grimaud 7 has divided the diseases of the skin into five 
orders; 1st, diseases of the corpus reticulare ; 2d, diseases of the 
papillae ; 3d, diseases of the infundibuliform cavities ; 4th, disease of 
the follicles. 

Baker has proposed to divide the diseases of the skin into two 
classes, one of which, the epidermic diseases, includes the squamous, 
vesicular and bullous affections, and the other, — the diseases of the 
dermis, embraces our papula?, tubercula and pustula?. Dr. Craigie 8 
has likewise given a distribution of the diseases of the skin upon 
anatomical grounds which corresponds very nearly with that of Wilkin. 
Mr. Dendy" has attempted a classification of cutaneous diseases, 

looked the advantages of Willan's classification, erroneously disputed the utility of 

. and gratuitously supposed that those who adopted the grounds of 

this arrangement took no heed of the other appearances of the diseases of the skin, 

in exposing their characters and establishing their diagnostic features. Otherwise, 

he insists with reason on the importance of the study of the causes, and of the various 

conditions which precede or accompany the development and progress of diseases of 

kin. 

1 Cazenave et Schedel. Abrege pratique des Maladies de la Peau. 8vo. Paris, 

2me edit. ib. 1833. English translation, Philadelphia, 1829. 

- The work of these gentlemen is indeed all that Dr. Raver says it is. But let us 

here do Dr. Raver the justice which he has not done himself. The Abrege Pratique 

nave and Schedel, is an abridgment of the first edition of this, his own work, 

with the additions and alterations he indicates. There is another work published 

and so recently that Dr. Haver could not be aware of its existence, which owes 

much to the same source whence Cazenave and Schedel drew. Asa manual it is 

perior to the Synopsis of Bateman, and has the advantage over the 

Abrege Pratique in having been written by an individual intimately acquainted with 

ject. This is "A practical compendiumof the Diseases of the Skin, by J. Green, 

M. 1).. is:."). R. W. 

' Gilbert. Manuel des maladies speciales de la peau, 12mo. 1834. 

« Struve (T.ud. Aug.). Synopsas morborum cutaneorum, fol. fig. Berlin, 1829. 

« Wilkinson (J. H.). Remarks on cutaneous diseases, 8vo. London, 1822. 

• Kelson (T. If.). A few hints relative to cutaneous complaints. London, 1820. 

ncette Francaise, 1831,p. 

.ugie. Elements of general and pathological anatomy, 8vo. Lond. 1828. 

* Dendv (Walter). Treatise of '.lie cir.aneous diseases incidental to childhood, 



utility of which is more especially apparenl when children an 
r subjects. His distribution comprises the following classes : 1st, 



the 

theii ins uisuriDunon compr. 

diseases symptomatic of derangement in the alimentary canal ; 2d, 
diseases symptomatic of disorders in the functions of assimilation ; 
3d', diseases symptomatic of external excitement or stimulation, and 
of particular idiosyncrasy; 4th, diseases produced by specific conta- 
gions; and 5th, local diseases withoul constitutional derangement. 

M. Ch. Billard 10 has also made some obsen at ions on the cutaneous 
diseases of children, which he distributes after the classification of 
Willan. 

Messrs. linger 11 and J. L. Schonlein u have imagined that they could 
discover certain relations between the diseases of the skin and what 
they entitle the exanthemata of plants. 

J. Fantonetti 13 has made important additions to the subject of pella- 
gra in the translation which he has given of the 1st edition of m\ 
work, which has also been rendered into English by Mr. Dickinson" 
with the suppression of the particular cases, with a view to making it 
more elementary. 

To complete this review of the works of those who have con- 
tributed by general observations, the publication of particular facts, 
by their special studies, and treatises ex prqfesso, lastly, by their criti- 
cal and learned investigations and their elementary works to illustrate 
or render more easy the study of the diseases of the skin, 15 I ought 
still to mention a great number of monographs on almost every one 
of these diseases individually, and a variety of memoirs containing 
therapeutical experiments. But as the value of these references will 
be greatly increased by being given in connection, either with the 
general and preliminary considerations on the treatment of the acute 
and chronic inflammatory affections of the skin, or in the Historical 
Notices that will be found at the end of the description of each par- 
ticular disease, I shall reserve them for these places. Let me in this 
place, however, mention the researches of Dazille 16 on the diseases of 
the skin in the negro ; those of Wilson 17 on the same class of affections 
among the Hindoos, and the admirable observations of Adams 13 on 
morbid poisons (a). 

(a) To the above we may add A short Treatise on the External 
Characters, Nature and Treatment of the different forms of Porrigo or 
Scalled Head and Ringworm. By Walter Dick., d. 1838. Nou- 
velle Dermatoloqie, ou Precis theorique et pratique sur les Maladies de 
Id peau, &c. Times deux, 1842. Par P. Baumes. Manual of Dis- 
eases of the Skin. From the French of MM. Cazenave and Schedel. 
With notes and additions by Thomas H. Burgess, M. D., 1842. A 
Practical and Theoretical Treatise on the Diagnosis, Pathology, and 
Treatment of Diseases of the Skin, &c. By Erasmus W r ilson. London, 
1842. Philadelphia, 1843. 

"> Billard (Ch.). Traite des maladies des enfans nouveau-nes et a lamamelle, 8vo. 
Paris, 1828; 2e edition, avec notes, Paris, 1833. Svo. 

11 Unger. Die Exantheme de Pflanzen pathogenetisch und nosorgraphisch darges- 
tellt. Wien, 1833. 

12 Schonlein's Allgemeine und specielle Pathologie and Therapie. Wilrzbur" 8vo. 
1832. ' ° 

13 Fantonetti (G. B.). Trattato teorico e pratico dei mali della pelle. Milano, 1830. 
'« Dickinson (Will.). Treatise on diseases of the skin, 8vo. London, 1833. 

15 I here give the titles of several works which I have not been able to consult: 
Atsbury. Diss, de morbis cutaneis. Edinb. 1787._Boncursius,Barthol. Opusculumed 
mahs exterms. Bonon. 165G, 8vo.— Cartheuser. Diss, de morbis cutaneis.— Francof. 
ad Viadrum, 1760.— Dimsdale. Diss, de morbis cutaneis. Edinburgh, 1773.— A'Dob- 
scha. F. de cute et de morbis cutaneis. Jense, 1805.— Hartmann. Diss, de cutis exte- 
nons morbis. Regiom. 1736.— Jessenius, J. De cute et cutaneis affectibus. Pi. 
1611.— Jenftlamn. Diss.de morbis cutaneis. Erlangee, 1771.— Nebel. Diss, antiquilates 
morborum cutaneorum sistens. Giessse, 1793.— Schulze. Diss, de cutis exteriotis 
morbis. Halac, 1740. 

'« Dazille. Obs. sur les maladies des negres, 2 vols. 8vo. Paris 1782 




The insects were very small but still visible to the naked eve 
18 Adams on morbid poisons, 4to. Lond. 1807. 



A TREATISE 



ON THE 



DISEASES OF THE SKIN. 



CLASSIFICATION. 

1. In this work I comprise, under the general title of Diseases of 
the Skin, every morbid condition which shows itself on the exterior 
of the body by some distinguishing character. Many of these affections 
are preceded, accompanied or followed, by lesions of one or more of 
the other tissues, and occasionally by modification of the general cir- 
culating fluid ; the alteration of the skin, which is assumed as cha- 
racterizing them, is, in fact, only one of their more evident features. 

2. The study of the diseases of the skin demands, as a preliminary, 
a knowledge of its general conformation, of its intimate structure, and 
of its functions. Diseases of the integuments at large naturally fall 
under two grand divisions — as they affect the skin itself, or the parts 
which are connected with it. 

3. The skin may be the subject of wounds, of acute and chronic 
inflammation of different kinds, of anemia, hemorrhage and conges- 
tion, of neuralgic pain, of accidental blanching and discoloration, of 
original faulty conformation, and of changes of texture from the effects 
of disease. The parts dependent on the skin — the nails and hair — 
occasionally also present unnatural appearances, consequent on mor- 
bid alterations in the structures that prepare them. Moreover, several 
insects are found living and reproducing their kind on the surface 
and in the substance of the integuments. 

4. The following table presents, at one view, the names of the 
principal alterations of the skin and its dependencies, and the order 
in which they will be successively described. Wounds, being within 
the domain of pure surgery, will not be noticed in this work. I 
should also have abstained from speaking of certain other affections, 
entirely foreign, in their commencement at least, to the skin, had their 
true seats been more generally known, and had I not hoped to throw 
some light on their nature and treatment. I have not, however, 
thought it advisable to introduce into the table the titles of several 
diseases which are still but little understood, such as the Aleppo 
pustule, Radesyge, Frambcesia, &c, the description of which I have 
inserted in the appendix that will be found at the end of the work. 



TABLE. 



■ s of the 
Skin. 



Chapter I. 



Inflammatory af- i men 
lections, distri- / form 
t.nted according \ 
to the number ] 
and form oftheir 
elementary le- 
sions. 



Section I. 

Having a 
single ele- 
mentary 



/ 1. Exanthemata. — Erythema, ery- 

' sipelas, rubeola, roseola, scarlatina, 

urticaria ; artificial exanthemata. 

2. Bullc— Pemphigus, rupia ; artifi- 
cial bullce — blisters, ampullar. 

3. Vesiculc — Herpes, eczema, hy- 
drargyria, scabies, miliaria sudato- 
ria, (s'uette miliaire,) sudamina; arti- 
ficial vesicles. 

4. Pustulc — Variola, varicella, vac- 
cinia, vaccinella, acne, rosacea, 
sycosis, impetigo, favus, ecthyma ; 
artificial pustules. 

5. Furunculi. — Hordeolum, furuncu- 
lis, anthrax. 

6. Gangrene. — Anthracion vel pus- 
tula maligna, anthrax pestis. 

7. Papul.e.— Strophulus, lichen, pru- 
rigo ; artificial papulae. 

8. Squamje. — Pityriasis, psoriasis, le- 
pra, pellagra; artificial squama?. 

9. Tubercula. — Lupus, scrofula, can- 
cer i elephautiusisGracorum; arti- 

s ficial tubercles. 



Diseases of the 
skin. 



Section II. fl. Syphilis. 



Having 
vera! 



Chapter II. 

Peculiar statesof fANEMLS. 
the skin not re- Congestus Sanguinei. 



ferable to ii: 
flammation. 

Chatter III. 
Morbid states of 
the secreting 
functions of the 
skin. 

Chapter IV. 
Neuroses of the 

skin. 



Chapter V. 

Faulty structure, 
or unusual states 
of one or other 
of the elements 
of the skin. 



I HEMORRHAGIC. 

L 



f Exanthematica, bullo- 
| sa, vesiculosa, pus- 
-{ tulosa, squamosa, pu- 
| pulosa, tuberculosa, 
( vegetativa. 
f Exanthematica. 
-? Bullosa. 
(.Gangrenosa. 
c Exanthematica. 
-< Bullosa. 
(.Gangrenosa. 



r Purpura (Petechias, Vi- 
J. bices, Ecchymoses, 
(_ Dermatorrhagia). 



Perspirationis. Ephidrosis. 
Epldkrmidis. Exfoliatio. 



Anaesthesia, Hyperesthesia. 



Pigmenti (Achromata j 
Dyschromata). 



(Albinismus seu Leuco- 
pathia,Nigrities, Ephe- 
lis, Lentigo, Chloasma, 
Melasma, Naevus pig- 
mentarius, Color cotm- 
leos. Color sub flavus; 
artificial discolorations. 



Hypertrophic 



DIVISION II. 

Alterations of 
the dependen- 
cies of the skin. 



DIVISION III. 

Foreign bodies 
on the surface, 
under, or in the 
substance of the 
skin. 



Chapter VI 
\Degenerations 

/ Chapter I. 
Special diseases 
of the Sebaceous 
Follicles. 

Chapter II. 
Special diseases 
of the piliferous 
follicles. 
Chapter III. 
Special diseases 
of the ungueal 
matrices and al- 
terations of the 
1 nails. 

( Parasitic insects 
J infesting the 
( skin of man. 



Gangrena sim- 
plex. 

Cicatrices. / Corii, Mem- 

Defectus con- \ branae Cel- 
genitus cutis. ] lularis sub- 
Extensio vel / cutana?, et ( 
relaxatio in- I telos adipo- 
solita cutis. \ sae. 

\ 

( Degenerationes Fibrose. 

< Melanosis. 

(.Degenerationes Tuberculosa. 



Papillarum (Ichthyosis, Verruca, 
etepider- \ Producta cornea, Ty- 
mis. ( losis. 

< Phlebectasia,angiecta 
Vasorum I sia capillaris, Naevus 
cutis. ] araneus, flammeus, 

L&c. Tumor vascularis. 



Cheloidea, Tumores 
variij Elephantiasis 
arabica, Andrum et 
Pedarthorae Barba- 
does Leg, &c. 



\ Secretio aucta, Vermes sebacii, Levatio follicularis, 
C Tumor follicularis, Calculi folliculorum. 

"} Atrophia, defeutus congenitus pilorum. Pili supernu- 
> merarii; Incremenlum insolitum Pilorum, Coactio, 
J pilorum, Alopecia, Canities, Plica. 

1 Onychia, Vicia conformationis et structarce unguium; 

I Ecchymosis subunguealis : Incrementum insolitum 

} Unguium ; Situs insolitus ; Ficus ; Defaedatio, dege- 

1 neratio; Productio et Reproductio, &c. 



Pediculi; Pulices; Acarus Scabici : Filiaria medi- 
nensis ; CEstrus. 



5. All the diseases specified in these different groups show them- 
selves on the external surface of the integuments by distinguishing 
characters. In all, the skin is affected in a greater or less degree ; 
but some of them are also preceded or accompanied by febrile symp- 
toms, and by other functional organic lesions. Lastly, a great many 
of them, independently of the alterations of the skin, by which they 
are outwardly proclaimed, are evidently connected with morbid con- 
ditions of the blood, of the nervous system, or of some internal organ 
or system of organs. Diseases of the skin require, therefore, to be 
studied more deeply than in their mere external appearances. 



FIRST DIVISION. 



DISEASES OF THE SKIN. 



CHAPTER I. 

INFLAMMATORY AFFECTIONS OF THE SKIN. 



PRELIMINARY CONSIDERATIONS. 

6. I comprehend, under the generic title of Inflammation of the 
Skin, all those diseases which are characterized, externally, by the 
accumulation of blood in a point, a district, or the whole of the 
surface of this membrane, become the seat of morbid sensations : a 
phenomenon which is followed by resolution, desquamation, adventi- 
tious secretion or ulceration. 

7. These diseases, as numerous as they are various, studied gene- 
rally in their external characters, — those characters, namely, which 
are at once the most easily appreciated, — present themselves, when 
at their height, under aspects that are reducible to eight principal 
forms : 

1°. Exanthemata, distinguished by a generally diffused red tint of 
the skin; or by red, or reddish distinct blotches, scattered over its 
surface, and terminating by resolution, delitescence or recession and 
desquamation. 

2 . Bulla, or small, aqueous, and generally transparent vesications, 
formed by an effusion of serum or coagulable lymph beneath the 
raised epidermis. 

3°. Vesicles, or small serous, transparent elevations, differing from 
bulla* in their inferior size, and formed by a small quantity of serum, 
with or without coagulable lymph, deposited under the epidermis. 
This serum, or lymph, may be again absorbed, or by the rupture of 
the vesicles, be effused upon the surface of the skin. Vesicles are 
followed by desquamation, by superficial excoriations, or by small, 
thin and laminated scabs or crusts. 

* 4°. Pustule';, or elevations formed by pus, or a morbid matter 
differing from serum, deposited either in a follicle under the epi- 
dermis, or in the texture of the true skin. Pustules commonly dry 
off" into hard, thick scabs, which occasionally conceal excoriations 
or ulcers of variable depth. 

5°. Papula, or hard and solid elevations, almost always attended 

by itching. They end in resolution or desquamation, when their 

.ire not picked off" by the nails, in scratching. 

Squama, formed by lamina 1 of the epidermis, altered and 

dried, which are continually detached from the surface of the inflamed 

skin. 

or small solid, circumscribed, and enduring tumours, 
larger than papule. They terminate in resolution, induration, partial 
suppuration or ulceration. 

. or solid tumours, larger than tubercles, developed 
- subcutaneous cellular tissue, and in the interspaces of the 



skin. They terminate by suppuration with the expulsion of a core 
or sloughy substance. 

8. These various forms cannot be regarded as degrees of one mode 
of irritation ; for they are not all seen changing the one into the 
other, under the influence of artificial and graduated forms of irri- 
tation. Many of them are developed in distinct elements of the skin, 
and constantly display the same characters when they return, after 
having disappeared during a longer or shorter space of time. The 
special cause, under the influence of which an inflammation of the 
skin appears and produces a vesicle, rather than a pimple or a scale, 
is as yet unknown. 

9. All inflammatory affections of the skin, except those that are 
designated gangrenous, and whose elementary form varies and is 
little known, may be easily referred, during the period they remain 
at their height, to one or to several of these forms, the characters of 
which are definite and readily appreciable. 



eorms of cutaneous inflammation. 

§ 1. Having a single elementary form. 

(a) Exanthematous, diffuse or spreading inflammations — Erythema, 
erysipelas, rubeola, roseola, scarlatina, urticaria, artificial exanthemata. 

(b) Bullous, or effusive inflammation. — Pemphigus, rupia, phlyc- 
tense, artificial bulla 1 , blisters, ampullae. 

(c) Vesicular inflammations. — Herpes, sudamina, eczema, hydrar- 
gyria, scabies, miliaria sudans, artificial vesicles. 

(d) Pustular inflammations. — The variolous eruptions^ — variola, 
varicella ; the vaccine eruptions, — vaccinia, vaccinella ; gutta rosea, 
acne, sycosis, impetigo, favus, ecthyma, artijficial pustules. 

(e) Furunculous inflammations. — Hordeolum, furunculus, anthrax. 

(f) Gangrenous inflammations. — Anthracion, malignant pustule or 
Persian fire ; gangrenous carbuncle, typhoid inflammatory gangrene. 

(g) Papular inflammations. — Strophulus or gum, lichen or sunrash, 
prurigo or itchy-rash, artificial papulae. 

(h) Squamous inflammations. — Pityriasis or dandriff, psoriasis or 
scaly tetter, lepra or scaly leprosy, pellagra, artificial scaly inflamma- 
tions. 

(i) Tubercular inflammations.— Lupus, elephantiasis, scirrho-carci- 
noma or cancer, artificial tubercles. 

§ 2. Having several elementary forms. 

(a) Burns.— Exposure to excessive temperature is followed by 
exanthematous, bullous, or gangrenous inflammation. 

(b) Frost-bite.— Exposure to very low temperature is, also, suc- 
ceeded by exanthematous, bullous, or gangrenous inflammation. 

(c) Syphilitic affections produce exanthematous, vesicular, bullous, 
pustular, papular, scaly, tubercular, and forms of inflammation attend- 
ed with morbid growths. 

10. I have already noticed the chief defects of this classification. 



PRELIMINARY CONSIDERATIONS. 



23 



The most important, undoubtedly, is that of uniting, under several 
particular groups, affections which are foreign to each other in their 
progress, their tendency, and their mode of treatment ; and of sepa- 
rating others, such as the eruptive fevers, which have so striking an 
analogy with each other. These serious inconveniences, which I 
wish not to conceal, are counterbalanced, however, by the facility 
and precision of the diagnosis we are enabled to establish by means 
of the artificial arrangement adopted: and this, on reflection, appears 
to be the principal, and perhaps the only advantage to be expected, 
in the present state of knowledge, from nosological classification 1 

11. Ulcers. — In the above enumeration of the inflammatory affec- 
tions of the skin, I have made no mention of ulcers. These, in fact, 
constitute no primary alteration, or initiatory form of cutaneous dis- 
ease. They are always consequent on subcutaneous abscesses, or on 
vesicular, pustular, tubercular, or some other form of inflammation. 
Moreover, the description of ulcers cannot be detached from the dis- 
cussion of the various inflammations that produce them. I have, for 
the same reason, connected the description of chaps and fissures with 
the account of the diseases that occasion them, — erythema, eczema, 
lichen, psoriasis, syphilitic affections, &c. 

12. Scabs and crusts. — Neither can these, which are formed by 
matters deposited and dried on the surface of the skin, whether ulce- 
rated or not, be assumed as the distinguishing character of a genus. 
Independently of this, that, before being encrusted, diseases are vesi- 
cular, pustular, bullous, &c, a group formed after such a circumstance, 
would have been more vague than any of those we have adopted. 
Studied, however, as secondary phenomena, these crusts, in their 
mode of formation, their dimensions, their colour, their adherence, &c, 
present particulars calculated to characterize certain species — favus, 
rupia, &c. 

13. The chemical analysis of the morbid liquid or dried secretions, 
poured out by the diseased skin, can only furnish characters of a very 
secondary interest ; and yet the analyses that have been made of the 
vaccine lymph, of the true or modified variolous matter, of the matter 
of favus, of melanosis, &c, prove incontestably that no mode of in- 
vestigation whatever is to be contemned. 

14. The same remark is applicable to several other consecutive 
alterations. Thus, the dark stains formed by the deposit of a larger 
quantity of blood than natural in the tissue of the skin ; the bran-like 
desquamation of the epidermis, caused by certain papular or vesicular 
inflammations; the cicatrices which variola, zona, rupia, vaccinia, 
lupus, ulcerated syphilitic eruptions, &c, leave, all present characters 
that immediately proclaim their origin to the practised eye. 

15. When inflammation extends from the skin to the mucous mem- 
branes, they sometimes distinctly present the same forms of phlegma- 
siae as the skin itself. The difference of structure, however, of these 
two grand divisions of the cutaneous system, necessarily introduces 
modifications into the mode of development, and the appearance of 
the various forms of inflammation affecting their surface. Farther, 
the symptoms peculiar to each of these different forms, though easily 
appreciated in the skin, are much more obscure in the mucous mem- 
branes. 

16. Local symptoms. — Some, among the inflammations of the skin, 
are constantly either acute or chronic in their progress; others, again, 
according as the exciting cause is permanent or temporary, present 
themselves in the one or in the other of these forms. 

17. The most constant local phenomena of inflammation, redness, 
pain, heat, and swelling, exhibit a multitude of shades and varieties 
in the cutaneous phlegmasia?, which I shall discuss in detail, when I 
give the history of each individually. 

18. Redness is a constant phenomenon, whether it constitute the 
most evident character of the inflammation, as in the exanthemata, or 
is not readily to be appreciated, except before the formation, or after 
the rupture of vesicles, of bullae, and of pustules, or after the fall of 
scabs and scales. The distinguishing character of this redness, slight 
and fleeting in roseola, bright and flushing in scarlatina, is, that it 
disappears on pressure, but quickly returns when the pressure is re- 

1 One of the latest classifications of the diseases of the skin, is to be found in the 
work of the excellent and very learned writer, Dr. Craigie, entitled, Elements of 
General and Pathological Anatomy. 8vo., Edinburgh, 1328. It is alluded to by Dr. 
Rayer in the note under page 17. — R. W. 



moved. It is only in some cases, forming exceptions, but which occur 
more frequently than is generally imagined, that the redness does not 
entirely disappear. A certain quantity of blood has then been eflused 
beneath the skin, which, when the redness goes off, leaves behind it 
especially in vesicular, pustular, and bullous inflammation, brownish 
or yellowish stains, which are obliterated in the course of time. 

19. Itching, heat, scalding, burning, tension, gnawing, &c, are so 
many forms under which the pain of the inflamed skin may show itself. 
To each of them belong a number of shades, which are characteristic 
of several varieties of disease ; the pruritus, for instance, has particular 
characters in itch, prurigo, eczema, and urticaria ; the sense ot heat, 
sharp in erysipelas, hot and burning in scarlatina, is still more trouble- 
some in hydrargyria. Lastly, if several cutaneous phlegmasia? are 
accompanied by violent and intolerable pruritus, others do not com- 
monly excite the slightest sensation of itching ; amongst these are the 
syphilitic eruptions. 

20. The inflamed skin no longer communicates the soft and moist 
sensation of warmth, which is peculiar to the healthy state. An in- 
crease of heat is appreciable by the thermometer, in the greater number 
of acute inflammations, especially in scarlatina and hydrargyria ; but 
is not perceptible in chronic inflammations. With regard to the 
sensations of the patient, the heat, to him, appears slight, intense, 
gentle, or pungent and biting, and often much greater than it is in 
fact. 

21. The tumefaction of the skin, very conspicuous in some acute 
inflammations,— as erysipelas, urticaria, variola, erythema nodosum, 
anthrax, &c, is little appreciable in others,— as roseola, pityriasis, &c. 
The apparent tumefaction of the skin, in the greater number of cases, 
is owing, at least in part, to that of the corresponding subjacent cellu- 
lar tissue. , 

22. The 'functions of the skin are always more or less implicated 
in acute inflammations of its substance. The cutaneous perspiration' 
maybe diminished or suspended,— as in the height of the eruption of 
scarlatina ; or augmented, as in the sweating miliaria, (suette miliaire); 
or modified in its sensible and chemical properties. The secretion of 
the oily fluid, 3 which, in health, is poured out upon the surface of the 
skin, is entirely suspended in the parts affected with squamous inflam- 
mation. This want of secretion is especially remarkable in the pityri- 
asis of the hairy scalp, and in the scaly patches of lepra and psoriasis 
inveterata. The secretion of the sebaceous matter is likewise inter- 
rupted, under the same conditions ; but it is evidently increased in 
one variety of acne, viz., the punctata ; it is, farther, modified in 
certain impetiginous affections, in which the matter, having more the 
appearance of honey, or of a thick solution of gum, than of proper 
pus, distils from the follicles. Lastly, the secretion of the sebaceous 
substance evidently becomes of a contagious nature in favus. 

23. The formation of the epidermis is itself more or less modified 
in almost all the inflammations, and especially in those that are desig- 
nated as scaly; serous or purulent fluids, following vesicular and pus- 
tular inflammations, are sometimes deposited between this membrane 
and the corion, or in the cavities of the follicles. 

The production of the nails and hair may also present remarkable 
modifications, which I shall explain when treating of the morbid alte- 
rations of these structures. 

24. The absorbing powers of the skin," and its faculty of disen- 
gaging gaseous fluids, 5 as phenomena in health and disease, admitted 
by some observers and denied by others, call for further investigation. 

25. General Symptoms. — Every acute form of inflammation of 
the skin, that is intense and of some extent, is accompanied by fever, 
more or less violent in its character ; often, too, this fever precedes 
the heat of surface, and even any alteration in the appearance of the 
integuments. 

2 Cruikshank (William). Experiments on the insensible perspiration of the human 
body, showing its affinity to respiration, 8vo. 2d edit. Lond., 1795.— Roth (C.-H.-G.). 
Diss, de transpiratione cutanea, ajquilibrii caloris animalis humani conservation! 
inserviente, etc. Halee, 1793. — Stahl (G.-E.). Diss, de transpiratione impedita, in-4. 
Hake, 1707'. •' : ' 

3 Ludwi CT et Grutzmacher. De humore cutem inungente,tn-4. LipsiK, 1784. 

" Westrumb. Sur la faculte absorbante de la peau. (Journ. hebdomad., t.i. p. 290. 
and Bulletin des sciences medic, de Ferrussac, t. xix. p. 20.) — Larpent. Devi cutis 
absorbente. (Bull, des sciences med. de Ferr., t. xvii., p. 334.) 

s Collard de Martigny. Exhalations gazeuses de la peau. (Bull, des sciences rr.ed 
de Ferr., t. xxiii., p. 9.) 



24 



DISEASES OF THE SKIN. 



irkable in certain acute in- 

s, denominated eruptive fevers by a great many authors, 

eella, variola, miliaria, &c.' In these 

and general symptoms precede, by many days, 

. I>ul a))|«< . the skin, which, in the interval, is neither 

painful nor apparently changed in its principal functions. Some au- 

even think thai these febrile symptoms constitute such eruptive 

ttthi eruption itself ; and examples are quoted 

of variolous, miliary, and other levers occurring without any eruption. 
This much, at least, is certain ; that the general disturbance of the 
functions is to be taken into very particular consideration, in appreci- 
the phenomena of these diseases, and in adopting rules for their 
treatment. \\ e also observe attacks of erysipelas and urticaria come 
"ii without any appreciable cause, after a day or two of fever. The 
denominations, erysipelatous lever, miliary fever, &c, used by some 
authors, indicate certain presumed analogies between these diseases 
and the eruptive levers. The lever sometimes ceases, and always 
declines, with the appearance of the eruption. Several internal in- 
fill ations, and particularly anginae of different kinds, are developed 

in the same manner, after general febrile disturbances of the system. 

Lastly, several cutaneous affections are preceded by symptoms which 

are not febrile in their nature: these are pains more or less acute; 

ccur particularly in herpes zoster and herpes phlyctenodes, and 

i continue long after the disappearance of the eruption. 

26. The time that elapses between the action of the specific causes 
of variola, scarlatina, rubeola, varicella, and sweating miliaria, and 
the appearance of the first appreciable phenomena in these, diseases, 
baa been entitled the period of incubation. Its duration varies with 
each specie's of disease. In chronic affections, capable of being 
transmitted by inoculation, the length of this period varies, not only 

ding to the kind of disease, but also according to the individual 
infected. I shall have occasion to recur to this fact, when treating of 
scabies, favus, syphilis, &c. 

27. As to the general symptoms which acute inflammations of the 
skin most usually present, at their acme or characteristic condition, 
Mi< \ arise from the affection of one or more organs, and sometimes 
from that of a particular system according to the species, as is demon- 

d by the comparative study of variola, rubeola, scarlatina, &c. 
The number and severity of these symptoms are not always in the 
ratio of the intensity of the cutaneous inflammation. This, indeed, 
in a vast number of cases, is but one among the elements of these 
diseases, and, very often, one of the very least importance. 

The inverse ratio that exists between the urinary secretion and the 
cutaneous exhalation, is very conspicuous in some inflammations of 
the skm. Graefe maintains, that the particular odours which in variola 
and miliaria are disengaged from the skin, coincide with changes in 
the state of the urine. 

28. Chronic inflammations of the skin often supervene without 
being preceded by the slightest disturbance of the principal functions. 

These complaints, however, often give rise to a degree of nervous 
irritability during the day, and to sleeplessness through the night. 

i'he irritation caused by prurigo has been seen to induce, not only 
sleeplessness, but even gradual emaciation of the frame and, finally, 
death. Several chronic inflammations of the skin, especially those 
that occur in the genital organs, may excite unwonted venereal desires, 2 
and evCn a sort of satyriasis. 3 This connection of the integuments 
with the generative functions, observed under other circumstances, 4 
urs only in a very small number of cutaneous diseases. 

29. Complications. — Other diseases, — amenorrheea, d vsmenorrhcea, 
fltc., are occasionally combined with the invasion of acute and chronic 
inflammatory affections of the skin. These last may be either the 
effect or the cause of the first; and it is often difficult to determine 
which is primitive, which consecutive. 

1 8wu Morbornm exanthematicornm descriptionis, labularum forma 

ordinal tmslelod. — Chanel (C. f.c). An in exanthemale acuio 

ac febnli morbus sil loins in inflammalione cutis? In-4. Paris, 1829. — Eichhorn (H.). 

Haiulbuch fiber die Behandlung nnd Verh&tnng der Coniaaio-s-fieberhafien Exan- 

Berlin, 18 I.— (Analyzed in Gaz. med., 1833, in-4.. p. 298.) 

uo priiniu ad cms inter scalpendum in viro sexagenario, 
oipeui semen exi!i>se." (Lorry. De morbis eulaneis, p. 28.) 

Diss. Mir le satyriasis, in-8. Pans. an. xii. 
bomias. be usu flagrorum in re venerea. Leid;e, 1G29, in-12. 



In a certain number of cases, both primary and secondary affections 
appear to be the consequence of one, and often of the same specific 
cause, — as in rubeola, scarlatina, &c. 

When treating particularly of each form of inflammation of the 

skin, I shall point out the diseases that ofteitesl appear accidentally 
in its course: I may here cite, as examples o( these frequent compli- 
cations, that of scabies with prurigo, of ecthyma with rupia and boils, 
of eczyma with impetigo, of scarlatina with Budamina, >\e. 

30. When eruptive fevers are complicated together, instead of run- 
ning through their usual periods, they present remarkable peculiarities. 
Sometimes one of them suspends its progress, to resume it at the 
period of convalescence from the other, which follows its course : 
sometimes, on the contrary, the stages of the intervening affection 
appear to be accelerated. Certain eruptions are modified in their 
development and in their appearance, when they are contracted nearly 
at the same time, as has been seen in some closely approximated or 
simultaneous cases of inoculation of small-pox and cow-pox in the 
same individual. 

31. To the present time, but a small number of anatomical investi- 
gations have been instituted into the diseases of which individuals, 
attacked with chronic inflammatory affections of the skin, have died. 
After death, lesions of the lungs, of the organs of digestion, of the 
uterus, &c, have been observed, in proportions which do not seem 
to differ from the relative frequency of these morbid alterations, ob- 
served under other circumstances and in other subjects. These results 
will have no real utility, nor ever become the basis of practical infer- 
ence, until the internal lesions that coincide more frequently with such 
and such a form of inflammation of the skin than with such another, 
shall have been ascertained by the examination of an immense num- 
ber of bodies. It is already ascertained that rupia and lupus often 
occur along with scrofula ; that the impetiginous eczema of the face 
and hairy scalp is frequently complicated in infants with chronic 
inflammations of the caecum and colon, and of the mesenteric and 
lymphatic glands of the abdomen ; that rosacea often coincides with 
gastro-intestinal inflammatory diseases, &c. 

32. I shall bring forward no instance of inflammations of the skin 
complicated with biliary, mucous, or adynamic fever, the existence 
of which, as a distinct morbid condition, has not been demonstrated 
to me by any fact : I shall give a few cases of these phlegmasia; com- 
plicated with dothinenteritis or furuncular affection of the bowels, and 
with intermittent fever, which I have long been accustomed to separate 
from continued fevers. 4 

33. Intervening diseases may modify cutaneous eruptions in their 
progress, their colour, their termination, &c. Under the influence of 
some accidental internal irritation, an eruption that has lasted for 
several months is sometimes seen fading and entirely disappearing, 
to be slowly reproduced as soon as convalescence is established. 
These disappearances of the inflammatory affections of the skin as 
effects, are much more frequent than the same phenomena regarded 
as causes. A patient under my care at La Charite, for a syphilitic 
affection, having been attacked with pneumonia, the eruption vanished 
almost immediately, and as quickly showed itself again when the 
inflammation of the lungs was subdued. 

34. Not only may disease of the skin be preceded or accompa- 
nied by various other affections, but, among the inflammations of 
the integuments, several are even very commonly followed by other 
particular diseases. These consecutive affections, extremely com- 
mon, and sometimes of great severity after eruptive fevers, are very 
rare after chronic diseases of the skin. The distension of 'the veins 
of the face, in hypertrophy of the nose following rosacea ; the bald- 
ness consequent on favus; the ugly cicatrices produced by burns; 
the spots and cicatrices of syphilitic spots,— are all effects of primary, 
and not of secondary affections. 

35. Certain diseases of the skin may alternate 6 with alterations of 

5 Vide Diet, de Medecine, Art. Intermittent, t. xii. 

« Novi hominem cui quolies herpetes conquiescunt, toties hjemorrhoides erumnunt 
a n° lmbr f, flue " ,es el cruc.atibus distinguendi. (Lorry. De morb . cutan n 30S ' 
-Duo tantnm h,c notare sufiecent exempla. Alteram nobilisS* Sulieris 2 
scirrhoso tumore ipsum uterum depascente laborare videbatur Ain.l n ' 
fodalo per fluemium ulcerum herpeticorum sordi.iem sanabatJr- ciff'' VU " U 
repercussacons.lio.rursuus in hepar decumbebant, diende vert 'in uter ,,m * pessim ° 
eadem si ingenuous vuareturmenstrualibus haemorragiis autfluore albo mucosae? 



PRELIMINARY CONSIDERATIONS. 



25 



the viscera or of their membranes; a circumstance that has led to 
the belief that the former are converted into obstructions or infrac- 
tions. A young man, of twenty, had been ill for two years: at 
first he suffered with colicky pains and diarrhoea. The pains soon 
changed their seat, and settled in the stomach. From this time 
forward, he had great sensibility of the epigastric region, which was 
increased by the presence of food in the stomach ; he had attacks of 
vomiting which, though they occurred but rarely at first, became at 
length so incessant, that the patient was reduced to the lowest state 
of marasmus and debility. After two years of suffering, and the 
fruitless employment of a variety of remedies, the patient came to 
Paris to consult Professor Bourdier. His condition was now deplora- 
ble ; emaciated in the extreme, his strength gone, and the stomach 
unable to bear even the smallest quantity of broth. M. Bourdier 
learned from the patient : first, that he had had a considerable boil 
on the inside of the right thigh, the progress of which was very 
slow ; 2dly, that the colic and diarrhoea had supervened shortly 
after the cicatrization of this boil ; 3dly, that he had been relieved 
as often as a number of small ulcers had appeared between the toes 
of each foot; 4thly, that the vomiting had, on the contrary, increased 
when these healed up. Acting on this information, M. Bourdier 
ordered a blister to be put on the seat of the old boil, and flour of 
mustard to be placed between the toes. Twelve hours after the appli- 
cation of these remedies, the vomiting ceased, and the appetite had 
returned, The blister was kept open, and two months scarcely 
elapsed before the patient completely recovered. 

When any internal inflammation, which has been long s-tationary, 
is accidentally increased in intensity, it often causes, or is followed 
by, the disappearance of cutaneous eruptions, should there happen to 
be any on the surface at the time. 

36. Anatomy of the Skin. 2 — The human skin, when studied ana- 
tomically, from within outwards, presents, 1st. the corion, dermis, or 
true sfcin, the outer surface of which exhibits a vascular net-work 
and papilke ; 2d, a deep epidermic layer; 3d, a pigment, deposited 
partly in this membrane, and partly in the epidermis ; 4th, the 
epidermis; to these must be added the sebaceous follicles, the nails, 
and the piliferous bulbs . (a) These elementary parts and appendages 

(a) To these several parts should be added, to complete the struc- 
ture of the skin, the sudorific organs and their ducts, or the sudorifer- 
ous glands. They lie deeper in the substance of the dermis than the 
sebaceous glands, and extend more plentifully beyond into the adipose 
tissue. They are small, oblong bodies, composed of one or more 
convoluted tubule, or of a congeries of globular sacs, which open into a 
common efferent duct, and the latter ascends through the structure 
of the dermis and epidermis, to terminate by a funnel-shaped and 
oblique aperture or pore upon the surface of the latter. In most cases 
they are colourless or almost transparent. These vessels, in the 
number of their windings, and in their direction through the skin, vary 
in different parts of the bady. In the right hand these spiral tubes are 
bent from left to right, and on the contrary direction in the left hand. 

In anticipation of what may be said of the diseases of the different 
elements of the skin, it will be sufficient in this place to remark that 
our knowledge of the morbid states of the apparatus consisting of the 
sudoriparous glands so recently discovered, must be necessarily very 
restricted. So far, opportunity has not been allowed to observe posi- 
tive lesions of tissue ; and we can only speak of their deranged func- 
tions under the heads of augmented, diminished, and altered secre- 
tion. M. Wilson (Diseases of the Skin) describes augmentation of 
secretion under the heads of sudatoria simplex, and sudatoria maligna. 

petuo, horumce malornm neutrum experiebatur. (Lorry. De morb. cutan., p. 58.) — 
Lorry, also, speaks of a youth, labouring under scirrhous obstruction of the spleen, 
and rosacea of the nose, in whom the cutaneous affection extended as often as, by 
appropriate remedies, the splenic tumour was lessened. Remedies, however, being 
laid aside, the spleen regained its former size, and the gutta rosea declined notably, 
both in intensity and extent.— Op. cit., p. 648. 

' Bouchard. Essai sur 1' emploi des derivatifs externes,&c.,p.56, in-4. Paris, 1816. 

2 Galen has left some remarks on the structure of the skin. The anonymous author 
of the Introductio Anatomica, and, subsequently, Avicenna, first speak of the panni- 
culus curnosus. Jul. Casserius observed, that the skin was continued into the nostrils 
and mouth, and gave a figure of the epidermis, separated from the dermis. Fabricius 
Hildanus has carefully described the dependencies of the skin in man and animals. 
Bichat investigated, with wider views, the properties of the skin, epidermis and hair. 
7 



of the skin all undergo numerous primary or secondary alterations, 
in consequence of inflammation. 

I shall give the anatomical characters of the exanthemata, of 
vesicles, of bullae or blebs, of pustules, of tubercles, &c, among the 
general observations placed at the head of the several orders, or 
whilst tracing the history of the particular species they include. I 
restrict myself, here, to some preliminary remarks on the degree in 
which the different elements of the skin are affected in the various 
inflammatory diseases to which it is subject. 

37. In the major number of cutaneous phlegmasia?, the corion, or 
at least its deep and fibrous layer, is but little affected. The vascular 
net-work and the papillae on its external surface, with the sebaceoum 
follicles and hair-bulbs, are the seat of almost all these diseases, it 
we except furuncle, sty and anthrax, which are developed in the 
subcutaneous cellular membrane, and interstitial tissue of the corion. 
Pus is sometimes found in the cellules of this tissue after burns, and 
those chronic and intense inflammations occasioned by the applica- 
tion of cantharides. 

Hypertrophy of the corion may be the consequence of several 
chronic forms of inflammation, — of lichen, of lepra, &c. This change 
is more particularly remarkable in Arabian elephantiasis, and the 
first stage of scirrhus. The corion becomes softened in some deep- 
seated species of cutaneous inflammation ; and this alteration, which 
is altogether different from gangrene, precedes perforations of the 
skin whenever these take place. 

38. The morbid injection of the vascular rete of the external 
surface of the corion, is the principal anatomical character of one 
group of cutaneous inflammatory affections — the exanthemata. — This 
injected state, also, occurs in a remarkable manner, beneath the 
epidermis when it is raised by an effusion of serum or pus, in vesi- 
cular, bullous and pustular inflammations, and even under the scales 
of squamous inflammations. It is no less remarkable, also, in tuber- 
cular inflammations. 

The veins of the rete are sometimes permanently enlarged in old 
cases of rosacea, in eczema of the lower limbs of aged people, and 
particularly in some species of bloody naevi. 

The frequency of erysipelatous inflammation of the face, has been 
attributed to the predominance of the rete there ; but other parts, 
whose vascular net-work is very conspicuous, as the glans and the 
labia pudendi, are rarely attacked by erysipelas. The frequency of 
this disease in the face must, therefore, be owing to other circum- 
stances. 

39. The papillce 3 of the outer surface of the dermis, appear to be 
especially affected in squamous inflammations. The papillae of the 
skin sometimes attain an extraordinary size on the surface of blisters 

— (Anatomie generale, vol. 4, p. 640, 8vo., Paris.) Gaultier studied analytically, the 
elements of the skin, which can easily be followed in the integument of the neat's- 
tongue, and in the human skin hypertrophied (Systeme cutane de l'homme, 4to. Paris, 
1809-1311). Blainville has given a beautiful exposition of the tegumentary appara- 
tus, considered as an organ of defence, of absorption, of secretion, and of sensation, in 
the different classes of animals (Principes d'anatomie comparee, in-8. Paris, 1822. 
— Cours de physiologie generale et comparee, 15e et 16e livraison,in-8. Paris, 1829). 
Chevalier, (Lectures on the general structure of the human body, and on the anatomy 
and functions of the skin; 8vo. London, 1823;) C. M. Andree, (De cute humani 
externa, Lips., 1805;) J. B. Wilbrand, (Das Hautsystem in alien seinen Verzweigun- 
gen ; Giessen, 1813, in-12 ;) Van der Busch, (De integumentis communibus ; Leidae, 
in-4., 1814;) Joan. Carol. Graeffe, (De cute humana, in-4., Leip., 1824;) Langston 
Parker, (Mechanism of the skin, Lond. Med. Gaz., vol. vii., p. 353;) and W. Wood, 
(an Essay on the structure and functions of the skin, 8vo., Edin., 1832;) have made 
many interesting remarks on the structure and functions of the skin. Schroeter has 
endeavoured to represent its texture (Das menschliche Gefiihl-Organ des Getastes, 
etc. folio, Leip., 1814). Voigtel (Handbuch der pathologischen Anatomie; 8vo.. 
Halle, 1804; list. Band., p. 65), has made some remarks on the alterations of the 
dermis, of the epidermis, of the sub-cutaneous adipose layer, and of the follicles. 
Craigie (Elements of general and pathological anatomy, 8vo., Edinb., 1828), has added 
several anatomical observations on classification. Lastly, to Gendrin (Histoire ana- 
tomique des inflammations, in-8., Paris, 1826, t. i., Anat. path, de la peau enflammee, 
p. 397), we owe many interesting investigations on several forms of inflammation of 
the skin. 

3 The papillae discovered by Malpighi. (De Lingua, exercit. in Epist. — De externo 
tactus organo in Epist. Op. Omn., t. ii.,) have been admitted and described by Ruysch, 
who has figured those of the nipple of the female, of the teat of the whale, and of the 
tongue of man, (Thesaurus, anat. ii., tab. iv., fig. 1, 4, 6, 7, 8, 9,) by Albinus, (Acad, 
annot., lib. iii.,cap. ix. et xii.,) by Hintze, (De papillis cutis tactui inservinetibus, Lngd. 
Bat., 1747.) by Gaultier, (Rech. anat. sur ('organisation de la peau de l'homme, in-4, 
Paris, 1811,) and by Dutrochet in his Observations sur la structure et la regeneration 
des plumes, avec des considerations sur la composition de la peau des animaux vei- 
tebres. (Journ. de phys., Mai, 1819.— Journ. compl. des sc. med., t. v., p. 366.) 






DISEASES OF THE SKIN. 



I suppuration ; bul this is above 
all in the Arabian elephantiasis, in syphilitic affections accompanied 
with morbid growths, in some nari, in ichthyosis, and in one variety 
especially of this dia rved in individuals who have been 

. thai the elongation of the papilla becomes 
Some pathologists have supposed that 
j rurigO was caused In inflammation of the papilla'; but this assump- 
tion h D supported b\ any anatomical tacts. The disease 
imonly on the outer parts of the thighs or arms, and 
in the shoulders, situations in which the eve does not detect nume- 
rous papilla?, and is never seen attacking the cushions of the lingers, 
■ S, or where they are very conspicuous. 

The foep-seated epidermic layer (couche albide prqfonde, Gard- 
ner), which cannot usually be perceived in the human skin, I have 
-■en very distinctly in some cases of Arabian elephantiasis. It is 

ly like the external epidermis. I am not aware whether it 
undergoes any modification in other cutaneous affections or not. 
1 1 . Thi' piffiru at or n te-mucosum 1 is altered in the greater number 

menus inllammations; for a certain quantity of blood is almost 
always deposited beneath the epidermis, in the epidermic layer of the 
papillae when it exists, on the surface, or in the substance of the der- 

veii the exanthemata sometimes exhibit these bloody suffusions. 
From the quantity of blood deposited, and the amount of its elements 
imbibed by the skin, result spots or stains of a brown, livid, coppery, 
or yellowish-gray colour, &.C., which continue for a longer or shorter 
space of time according to the age and the constitution of the indi- 
vidual affected, the nature of the disease, and the means of cure 
employed. 

42. The epidermis 3 undergoes numerous alterations at the decline 
or during the course of many inflammations of the skin ; it becomes 
dry and brittle, and then it chaps and splits, or is detached from the 
true skin in the form of bran, scales, or plates, and sometimes in large 
flaps from regions where it is thicker or stronger, as it is on the soles 
of the feet, the palms of the hands, the knees, the elbows, &c. Its 
detachment is rarely followed by the fall of the nails, but most com- 
monly by that of the hair. 

The colour of the epidermis may undergo several modifications. — 
It grows yellowish in some syphilitic affections, black in one variety 

yriasis, of a dull wliite in lepra, and of a pearly hue in some 
pityriases of the hairy scalp. The increase or diminution in the thick- 

iii the transparency, and in the tenacity of the epidermis all 
furnish important characters in the determination of species. 

13. The sebaceous follicles 3 are attacked by diseases peculiar to 
themselves. '' They become altered in many affections which were pri- 
marily unconnected with them. The parts of the skin most frequently 
inflamed are also those that are most amply provided with follicles. 
The history of eczema, of impetigo, of favus, of acne, of rosacea, 
&C., demonstrates how frequently inllammations of the follicles occur, 
and how various these diseases are in their characters. The follicles 
of the chin in man are subject to a very intractable species of pustular 
inflammation — sycosis menti. The follicles of the pubes are more 
rarely affected than those of any other region of the body. 

1 B. S. Albinus. De sede et causa colorisjEthiopum et coeteroruro hominum. Lugd, 
ltaiav., 1737, et Annot acad., lib. L, cap. li. — Soemmering. Ueber die kccperliche Ver- 
-chiedenheit des Negers vom Europaer. — Everard Home. On the black colour of the 
rete mucosum, (Phil. Trans., 18.) — Heusinger. Recherches sur la production acci- 
ilentelle da pigment et du carbone dans le corps humain (in German). Eisenach, 
I 833. — An extract will be found in the Archives gen. de medecine, t. v., p. 290. — Marx. 
Sur le pigruentum de la peau des negres (Bullet, des sciences medicales de Ferrus- 
sac, t. xvii.. p. 322.) — Leidenfrost. Diss, de statu prceternaiurali succi retis Malpigh- 
.•ani. Dnisburg, 1771. 

- 11. Pabricius. De totius animalis integumentis. ac primo de cuticula, et iis qua? 

■■upra cuiicuUiin sum; inOpcr. omn. — Ludwig. De cuticula: Leipsicc, 1739. — Meckel. 

i l'cpiderme (Mem. de l'academie royale des sciences de Berlin, annee 

1757).— Monro. De cuticula humana; in his Works, Edinburgh, 1781.— J.-Th. Klin- 

i Hermann. De veia naturi cuticula?, ejusque reseneratione. Pragoe, 1775. 

— I!. Mojun. SulP epidermide, etc. Genoa, 1815.— Chiaje (S.) Osservrazioni sulla 
struttara della epidermide umana. Napoli, 1827. 

• J. Ch. Rensa (presid. Autenrieih). De glandulis sebaceis. Diss. Tubinga>, 1807. 

— Weber. Sur les follicules sebaces (Journ. coropl., I. xxix., p. 138).— Eichhorn, Sur 

de la peau et sur lea roies par lesquelles elles s'operent, (Bulletin des 

stcience* de Ferussac. t. xi., p. 15,) has maintained that the sebaceous fol- 

ive no existence as peculiar organs, and that the sebaceous matter of the skin 

by the hairy follicles; we see, however, that the follicles of the glans, 

i.nd those of ihe skin generally, of many animals, never produce hair. 

' Ka De fuUkaloram sebaeeorum morbis, in-8, Rovtock, 1828. 



•It. The. fttjfta-willbelasl described. 

To the diseases generally known to affect these minute organs, favus 

must be added. 

The hair-bulbs of the genital parts and axilla' are more randy dis- 
eased than those of the face and sea!]). In the axilla, especially, the 
hair-follicles are deeper and larger than anywhere else, and their 
inllammations are always more than usually severe and rebellious m 
their nature. 

45. I shall, by and by, describe those alterations which the nails 
experience when the skin which they cover is attacked by lepra, eczema, 
psoriasis, syphilis, &c. 

46. The relative frequency with which cutaneous inllammations 
occur on the right and on the'left side of the body, is a subject which, 
if not very useful, is at least curious. When I treat of zona, icterus, 
&C., I shall present the remarks of Mehlis on this subject, 5 and point 
out certain errors into which he has fallen, his calculations not having 
been made on data sufficiently extensive. 

47. Some forms of inflammation are set up indiscriminately on every 
part of the surface: — such are erythema, ecthyma, and others ; but 
many of the same class of maladies affect certain regions especially: 
eczema shows itself on the hairy scalp, on the cars, and on the margin 
of the anus; prurigo affects, in preference, the outer parts of the 
limbs; lupus attacks the cheeks and ala? of the nose ; rosacea, sycosis, 
and acne, regarded as modifications of the same disease, invade the 
face, the chin, and the integuments of the trunk ; others, again, con- 
stantly occupy the whole, or almost the whole, surface of the body at 
once ; such are measles, scarlatina, &c. 

48. The etiology or doctrine of the causes of cutaneous inflamma- 
tion, has been the subject of much research. The roots, to use an 
old and characteristic expression, of certain local diseases of the skin, 
such as warts, follicular tumours, horny appendages, &c, were dis- 
tinguished at a very early period to be internal. To approach as nearly 
as possible to a true knowledge of the causes of cutaneous disease in 
general, it has been found necessary to study not only the nature and 
the effects of external stimuli on the skin, but, further, the relations 
of the skin to the principal organs of the economy, 6 and the influence 
of diseases on affections of the integuments. 

49. Thus studied and compared in their causes, their progress, 
their termination, their treatment, and their nature or mode of exist- 
ence, inflammations of the skin fall naturally under two categories. 
Those of the one, essentially local, and produced by external evident 
causes, are easily and promptly cured ; those of the other, developed 
without any appreciable outward cause, appear linked to morbid 
states of the system, — to more or less complex conditions of the 
organization, of which they are only, so to speak, symptomatic 
expressions; thus we say scrofulous lupus, purpura hemorrhagica, cic. 

50. Natural excretions, or other matters, deposited on the surface 
of the skin, — the scurf of the hairy scalp, in pityriasis capitis, for 
example, the matter of the perspiration in intertrigo aurium, the mu- 
cous discharge in the same disease of the thighs, the contact and fric- 
tion of the dress, garters, corsets, &c., 7 and a multitude of irritating 
substances, such as mustard, cantharides, tartrate of antimony, Bur- 
gundy pitch, croton oil, &c, excite particular inflammations, which 
appear under various forms, — exanthematous, vesicular, or pustular. 

51. Many chronic inflammations are caused by want of cleanliness. 
It was partly to this cause that Willan attributed the great number of 
cutaneous diseases, observed in London, among the iower classes of 
society. The frequency of skin complaints, or of itch, at least, among 
the inhabitants of lower Brittany, is due to the state of filth in which 
they live, and to the ease with which this disease is communicated. 
It seems certain that prurigo, and several artificial forms of inflam- 
mation, would be less common among the poorer classes, were they 
not compelled, by necessity, to neglect the use of baths and other 
similar means of preserving health, which their laborious occupations 
often render more particularly necessary. 

5 Mehlis (C. F. Ed.). Comment, de morbis hominis dexlri et sinistri; 8, 1817. (J. 
Frank. Delectus opusculorum, vol. i., Novocomi, 1827.) — Cartereau (E.F. » 
la symmetric dans le corps de l'homme, these, in-4. Paris, 1823. 

c Lorry. De morbis cutaneu — Art. vi. Desensu cutis ad alias partes rclativo- seu 
cutis cum aliis partibus consensus. — p. 25. 

' Sauvages numerat erysipelas in eule nascens a rollarium ecclesiasticorn 
(Lorry. De morbis cutan., p. Of ) 



PRELIMINARY CONSIDERATIONS. 



27 



The subject of cosmetics, 1 their uses and abuses, &c, ought to be 
resumed in another spirit, and presented in a more scientific shape, 
and in better keeping with the present state of knowledge, than lias 
hitherto been done. 

52. Too high a temperature of the atmosphere is the evident cause 
of several forms of inflammation of the skin ; the eczema solare, and 
lichen tropicus, may be cited as examples. The same cause often 
aggravates chronic inflammations, such as rosacea and lichen facialis, 
or increases the itching occasioned by some others, as lichen simplex, 
scabies, &c. Moisture and cold combined, cause a particular inflam- 
mation of the skin of the hands and feet, called chilblain. 

Exposure to cold hastens the formation of the wheals in urticaria, 
and favours the development of the Arabian elephantiasis in Egypt 
and Barbadoes. 

53. The influence of electricity is little known ; all we are certain 
of is that the electric spark will produce indelible stains of the skin. 

54. Certain inflammations occasionally act as direct causes of 
some others. It is thus that small-pox and measles cause the deve- 
lopment of the boils and ecthyma so often observed in convalescence 
from these diseases. 

55. Many particular modifications and affections of the digestive 
functions exert an influence, badly defined indeed, and certainly exag- 
gerated, yet established by incontestable facts, on the development of 
certain diseases of the skin. 2 Who has not seen the brow, nose, 
cheeks and eyelids of young people, habitually temperate, become 
covered with spots and pimples, after two or three days of indulg- 
ence in the pleasures of the table ? Let but habitual irregularity of 
life follow such accidental excesses, and a chronic inflammation of 
some sort will almost certainly be established in the face or some 
other region of the body. It is also known that drunkards are so 
much the more subject to gutta rosea, as their favourite beverage is 
more strongly charged with spirit. 

56. The influence of salted and highly seasoned food on the deve- 
lopment of chronic inflammation of the skin, has long been known, 
and never disputed. Rice, oysters, mussels, lobsters, shrimps, &c, 
and different kinds offish, sometimes also cause exanthematous erup- 
tions. 3 

57. Lorry has mentioned a similar effect produced by certain medi- 
cines. " Every time," says he, " that I have had occasion to pre- 
scribe acrid or volatile spirits (esprits acres ou volatiles) to some of 
my patients, small itchy non-critical rashes, occasionally containing 
scrum, have come out on their skin." I have, myself, seen eruptions 
produced by the essential oil of turpentine, by cubebs, pepper, bella- 
donna, &c. Fourcroy gives, as one of the signs of poisoning by 
nitric acid, an eruption of pustules analogous to those of the small- 
pox. Hemlock taken into the stomach sometimes causes stains of 
Ihe skin, especially of the legs and thighs. 

The process of dentition in children often gives rise to the deve- 
lopment of erythema and strophulus, vulgarly called tooth or teeth- 
ing rashes. Lastly, many cutaneous inflammations are preceded by 
inappetence, bitter taste of the mouth, nausea, sometimes by actual 
vomiting, and other functional disorders of the digestive organs. 

58. From Galen downwards, a great number of writers have re- 
garded the major part of the chronic affections of the integuments 
as bilious. 4 The frequency of skin diseases in infancy, seemed to be 

1 Mercurialis, lib. de coratione, in-4. Venet., 1623. — Fallopius De decoratione; in 
Oper. — Banneau, histoire naturelle de la peau et de ses rapports avec la sante et la 
beaute du corps, in-8. Paris, 1803. — Trommsdorff, Kalopistria, oder die Kunst der 
Toilette fi'ir die elegante Welt. Erfurt, 1804. — Chaals-des-ctangs. Considerat. anat. 
et physiol. sur la peau, suiv-ies d'un precis sur les cosmetiques, in-4. Paris, 1816. 

-' Lorry. De morbis cutaneis, p. 39. — Genesin effloreseentiarum in sordibus syste- 
inatis gastrici qureri fere, semper debere, multorum atque etiara nostris observationibus 
convictum videtur (Stoll. Rat. Med., in-8. part i., p. 28). — Welti. Exanthematum fons 
abdominalis, in-4. Goetting. — De Neufville. Versuch und Grundriss einer pract. 
Abhandl. von d. Sympathie des Verdauungsystems. Goettingen, 1788. — Tissol; CEu- 
vres, t. xii., p. 71. — Lorry has seen: Stupendos in cute tumores assurgere nobili 
feminae, qnoties ilia vel tantillum oryzae assumeret (De morb. cutan., p. 27). — Ency- 
clopedic methodique, Art. acide nitrique. — Alibert. Therapeutiqne, 5e edit., torn, ii., 
p. 427. 

3 I know a family, one member of which suffers certainly from nettle-rash, if he 
touches any of the lobster tribe, or vinegar, or acid fruits ; another suffers sadly from 
opium, and the tinctures of the druggists' shops; the smallestquantity of any of these 
causes the skin to tingle, and to throw out an abundant crop of papulae, the itching 
from which is unbearable. — P. W. 

* The Royal Society of Medicine of Paris proposed this as the subject of a prize in 



explained by the remarkable development of the liver. Pujol quotes 
the case of a dropsical old maid, who had suffered from obstruction 
of this organ during ten years, and to which there succeeded a hu- 
mid and crusted tetter on the thighs and arms. A sister-in-law of 
Pujol, who was attacked with a humid tetter of the ears, suffered 
afterwards from an hepatic affection. Lieutaud assures us anatomical 
investigation has satisfied him that obstinate eruptions of the skin, as 
well as other chronic diseases, have often been owing to some de- 
rangement of the liver ; Lorry maintains that altered bile produces 
pruriginous pustules, carbuncles, &c. : lastly, according to Pujol, we 
are to conclude that a disease of the skin depends on a change of the 
bile, whenever the malady has come on in a bilious subject without 
evident cause, or when it has been preceded by the suppression of an 
hemorrhoidal flux, by a bilious fever, by jaundice, by hepatic colic, 
by obstinate intermittent fever, or when it has originated under the 
prolonged influence of a stimulating or heating regimen. Darwin 
holds that acne is connected with derangement of the prima? viae ; and 
Mr. Plumbe has grouped together several diseases which he conceives 
to be generally symptomatic of a deranged condition of the digestive 
organs. Barbette has, with good reason, denied that the liver and 
the bile exert so great an influence on the production of chronic in- 
flammation of the skin : and, in fact, I have myself, repeatedly, seen 
not only diseases of the biliary apparatus without any eruption on the 
surface of the body, but in a multitude of cases of cutaneous affections, 
I haA r e found it impossible, with all my care, to discover any trace 
either of antecedent or concomitant lesion of the liver or of the parts 
connected with it. Lastly, in warm countries, where disorders of the 
biliary apparatus are so frequent, the coincidence of diseases of the 
skin with affections of the liver, has never been particularly dwelt 
upon by authors. 

59. A few imperfectly recorded cases have also led some to be- 
lieve that diseases of the spleen were occasionally reflected upon the 
integuments. 5 The results of my own researches, more numerous 
and more conclusive than those of Yalli, are at variance with this 
assertion. 

60. In individuals attacked with chronic inflammation of the skin, 
the digestive apparatus is very commonly perfectly healthy ; and were 
it even shown that affections of the stomach, of the liver, or of the 
spleen, were generally found accompanying skin complaints, it would 
not be, on that account, quite fair to infer that the latter were sympto- 
matic of the former, for they might both be effects of the same cause. 

To conclude this subject, then, it is undeniable that certain articles 
of food and of medicine taken into the stomach, and some gastro- 
intestinal affections, do cause eruptions of various kinds on the 
skin: but it is not less certain, that the Galenists of old, and, in later 
days, the disciples of the physiological school, 6 have exaggerated the 
importance of these causes ; the former in attributing to changes in 
the bile, the latter to irritation in the stomach and bowels, results over 
which it is impossible to prove that the biliary or digestive apparatus 
habitually exercises any influence. 

61. A great number of cutaneous inflammations may be produced 
by mental labour, by excessive watching, by rooted sorrow or by any 
other act or circumstance that modifies the state of the nervous system. 7 
The misery and gloom that pervade the northern parts of Italy, have 
been assigned as a cause of the pellagra so common there. Of five 
hundred insane patients in the hospital at Milan, Dr. Holland reck- 
oned that two-thirds were affected with pellagra. Numerous cases 
of meladermia, eczema, zona, pemphigus, erysipelas, and urticaria, 
which I have collected, prove that the influence of the nervous sys- 

1783. The memoir of Pujol, which was held the best of those submitted, is truly poor 
in facts, and contains a mass of ill-supported notions. — Diss, sur les maladies de ia 
peau relativement a l'etat du foie, in (Euvres de Pujol, torn, ii., p. 99. Paris, 1823.— 
Galen. Methodus medendi, lib. iv., c. 17 (Herpetes biliosus procreat succus). De 
tumoribus praternaturalibus, cap. ix. (Herpes). — Ludwig. Adversar. med. pract.. v. 
i., p. 202.— Lieutaud, Precis de medecine pratique, t. ii., p. 282.— Lorry. De morbis 
cutaneis, pp. 51 and 52. — Barbette Opera omnia, cap. De herpete. 

s Valli. Saggio sopra diverse malathie cutanee. 

s The school of Broussais. 

7 Cum inter aquae purissimae potores viderim non unum qui diluta slomacha'.i 
saburra, sese pustulis ad frontem indignabatur inter vini immoderatos bibaces recer- 
seri, quorum in numero juniorem monachum studiis deditum.meri potu sanatum vidi; 
medicumquenimiopere meditationi indulgentem.qui aquaardorem laboribus innatum 
temperare ddm studet, faciem fcedis pustulis deturpntam habebat, hunc remiss 
diis, et meri potu nitorem cutis recuperasse vidi. (Lorry. De morb. cutaneis, p. 64. 






DISEASES OF THE SKIN. 



table. It is well 
known Ct to cutaneous eruptions and to 

erysipi 

itic muscular exertions* on the 

- been observed by Lorry. 

habitual rest ami inaction is often accompanied by great 

. ,ni(l whit dtin ; and 1 have ascertained the beneficial 

influence which i 1 by the relaxation of the muscular system 

on the progress of diseases of the skin among the labourers and 

handicraftsmen received into our hospital. 

The opinion very generally diffused among persons labouring 
chronic affections of the skin, of their diseases being kept 
up by some alterations of the blood, 2 by some morbid state of the 
humours, is strengthened by sundry observations. I have noticed 
thai the! blood was bully in a great many of these cases, even when 
was no fever, and no appreciable disorder in any of the prin- 
cipal functions. In anthracion or malignant pustule, in small-pox 
and measles, the blood is certainly charged with some principle of 
ion. Pujol assures us that the serum of the blood is bilious in 
;l cutaneous diseases. It is very probable that certain agents 
only evert their influence on the integuments after having been carried 
into the torrent of the circulation. The inflammation of the skin in 
the mercurial disease, and the leaden hue that follows the long-con- 
tinued internal use of the nitrate of silver, are examples of the effects 
of such absorptions. As to the alterations of the lymph, and the 
acrimony of the serum, the mucus and the humours, which used to 
be universally admitted, almost all that has been written and taught 
on the subject, is hypothetical. I except those experiments that have 
been made on the contagious qualities of the fluids or matters of cow- 
pox, small-pox, scabies, of the nasal mucus in measles, &c. The 
appearance of many of these affections without appreciable cause, 
tbeir hereditary properties, their frequent recurrence and so forth, 
are so many circumstances which the alteration of the blood, were it 
demonstrated, would render less obscure. 

64. The state of general plethora, observed in individuals of a 
sanguine temperament, whose skin is habitually ruddy, is more rarely 
the cause of cutaneous inflammation than the local plethora, produced 
by the stasis, or habitual or accidental afflux of a certain quantity of 
blood to any particular region of the surface of the body. 

()."). The relations between the skin and the organs of respiration, 
have been well obseryed by Meckel. 3 Our knowledge, however, of 
the influence exerted by diseases of the organs of respiration on those 
of the skin, is confined to a very scanty number of facts. Alibert 
lias related two cases of eczema alternating with paroxysms of asthma. 
Hooping-cough is known to be occasionally followed by cutaneous 
eruptions, and phthisis often causes exhausting ephidrosis, and occa- 
sionally severe sudamina. 

tit). I have seen some chronic inflammations of the skin appearing 
only during pregnancy, such as eczema impetiginodes and prurigo, 
and others ceasing, or at all events, declining sensibly in their vio- 
lence during menstruation, pregnancy and nursing. In these cases, 
however, the diseases showed themselves anew on occasion of the 
suppression of the menses, or at the natural period of the cessation of 
this flux. I have observed eczema, and other chronic inflammations 
of the skin unexpectedly invading females who had been compelled 
by the death of their child or nursling, to give up nursing suddenly; 
these are the milk eruptions (dartres laiteuses) of certain writers. 
Similar cases have long been familiar in practice. 4 

67. Some authors tell us that the abuse of the sexual propensity 
may induce eruptions on the skin :(a) Lorry thinks they are more fre- 

(a) They are a common effect of masturbation. 

' I'm'.e qui nimio motui, prosertim ante cetatem maturam indulgent, vultu varicoso 
ei pustulosA facie incedunt notabiles.si pracsertim latet intus acre superfluum (Lorry. 
De morb. cutan., p. 43). 

* J. F. Dieffenbach. Recherches physiolosjiques sur la transfusion du sang d'un 
chat Itpreux, du sang d'un cheval atteint de farcin, etc. (Journ. compl. des sc. med., 
lom. xxxiv., p. 1 13.] — Vide the art. rubeola, variola, icterus, anthracion, purpura, etc. 
■ ckel. Diss. Pulmonum cum cute commercium illustrans. Halae, 1789. 

. pract, p. 26-7 (."Suppressio menstrnarum herpetum causa). — 

" Unde fit ii mensiiuis deliiescentibus dimidia feminarum pars morbis afficiatnr cuta- 

kfi cutis ipsis magis antea nituent (Lorry. De morb. 



quently the effeel of an opposite cause. "Certe," says he, "utn- 
usque sexiis evolutione fact!, m castam instituerint vitaro erumprt 
vulgo ingens pustularum conglomerata congeries." 1 Noting girls 
who suffer from these eruptions, and particularly from acne, are yen 
ittacked with rosacea at a later period of life. 
08. Lorry informs us that pruriginous eruptions are sometimes 
seen to break out in individuals attacked with nephritis." Although 
my attention has been particularly turned to diseases of the kidneys 
for some years, I have not met with any case confirmatory of this 
assertion. 

69. Not only do certain diatheses modify the characters of some 
cutaneous diseases, but they eminently predispose to the develop- 
ment of several of them. I have observed that scrofulous children, 
with thick lips, and heads of the shape of a calabash, were often 
affected with eczema impetiginodes of the face and hairy scalp, during 
the course of the first dentition. They are sometimes attacked with 
phagedenic affections (dartres rongewntes) of a very obstinate cha- 
racter, at the age of seven years, and about the period of puberty. 

70. Among the causes of skin diseases, Galen mentions the arthritic 
virus; Ludwig 7 points to the same source, and Lorry tells us that 
in families where the gout was hereditary, those individuals who 
escaped the disease, were subject to tettery eruptions. Pouteau, 
also, speaks of the influence of rheumatism in the development of 
cutaneous diseases. I am, myself, satisfied of the frequent alliance 
of diseases of the skin (dartres) with gout and rheumatism ; I have 
seen these affections disappear suddenly, without any obvious cause, 
and the patients become the victims of the most violent pains in the 
articulations. 

71. The hereditary nature of a great number of diseases, and 
particularly of many cutaneous affections, is one of the best established 
facts in pathology. It often follows the law of resemblance, and 
sometimes that of sex. 

72. Some individuals, free from hereditary diseases, and apparently 
of a good constitution, are yet so subject to certain kinds of cutaneous 
inflammation, that Hufeland 8 has seen fit to designate this condition 
by the title of Constitutio psorica, a denomination for which Jos. 
Frank has substituted that of Constitutio impetiginosa. I have myself 
given my advice to a great many persons in whom eczema, psoriasis, 
lichen, &c, appeared to be the effect of a constitutional predisposi- 
tion which was very difficult of removal, and which tended con- 
tinually to recur, independently of any accidental or other appreciable 
cause. 

73. Several inflammatory affections of the skin may be congenital 
(erysipelas, variola, phemphigus) ; others appear especially in infancy 
(strophulus, pemphigus infantilis, roseola infantilis, measles, favus, 
&c), and others again are more commonly met with in old age 
(prurigo senilis, pemphigus pruriginosus , and so forth.) 

74. According to Alibert, scavengers, and those who live habitually 
in air loaded with sulphurous vapours, are rarely affected with chronic 
inflammations of the skin. 9 Some have also fancied that workers in 
charcoal, and those employed in preparing plumbago or black-lead 
were cured of the cutaneous diseases with which they happened to 
become affected, by the mere influence of their occupations. I have 
myself met with too many exceptions to these notions to have any 
doubts of their inaccuracy. Artificial vesicular and papular eruptions 
have been described under the name of grocer's itch, and baker's itch, 
which are either the consequences of local stimulants, or true eczemas 
happening in persons exercising these trades. Hydrargyria has been 
observed among the labourers in quicksilver mines. The trades that 
demand great muscular exertion and require the person to be exposed 
to high temperatures, render those that exercise them liable to sudden 
relapses of such complaints as eczema, lichen, rosacea, &c, a few 
days after apparent recovery from these affections. 

cut., p. 71.)— Dantur etiam mulieres quibus, dum tardias ernmpnnt mense* forfnra 
eminent simiha, cessantia simul ac copiosius ilii effluxerint." (Lorrv n 9* \ 



Lorry. De morb. cutan., p. 45. 



(Lorry, p. 98.) 



s Nee novum et inobservatum in nephritide, quoties calculus pundit renes et ore 
terum substantiam, pustulae prurientes ad cuiern orianiur. (Lorry Op en n fi<5 \ 

7 Ludwig. Advers. de morb. arthrit. evolut., t. iii., p. 25.,-Lorry. De morb cutan 
p. 64.— Pouteau. CEuvres posthumes. cutan., 

8 Hufeland. Journal der praktischen Heilkunde. 21. B. 4 St. S. 14. 

» Lorry was of a different opinion: "Ssepe. herpelibus ant sordibus cutis morbos !i 
producendis fuit satis vicinia latrinarum. (Lorry. De raorb. cutan., p 86} 



PRELIMINARY CONSIDERATIONS. 



29 



75. The influences of local situation, of climate and of season, more 
remarkable than those exerted by trades or professions, cause varieties 
in cutaneous affections which call for attention, and so modify the 
bodily organization, as to render it more obnoxious, or less liable to 
be attacked by one or another of these diseases. A multitude of 
denominations, such as pemphigus of India, of the Brazils, and of 
Switzerland; tropical lichen, lepra of the Arabians, lepra of the 
Greeks, and lepra of the Jews ; sweating disease of Picardy ; malignant 
pustule of Burgundy and Persian fire ; summer roseola, autumnal 
roseola, &c, show that this influence had been noted, and, perhaps, 
even exaggerated by pathologists. Several diseases are, indeed, 
observed almost exclusively in certain countries — pellagra in the 
Milanese, the Aleppo pustule in Syria, plica in Poland, and so on. 

It would be both a curious and an interesting subject of investiga- 
tion to determine the relative degrees of frequency of inflammatory 
affections of the skin, and of their different species according to cli- 
mate and local situation. Observations on this subject at the present 
time are too scanty to form the basis of any comparative inquiry of 
the least importance. 1 The most contradictory conclusions would 
evidently follow from inquiries commenced with insufficient data. 

76. With this study of the influence of local situation and climate, 
that of endemical cutaneous affections, such as sweating miliaria, 
anthracion or malignant pustule, plica, pellagra, &c, is naturally con- 
nected. I have myself proved that sweating miliaria was endemical 
in moist and shady places : and statistical accounts of several other 
diseases of the skin have been begun, and ought by all means to be 
continued. 

77. As to those cutaneous diseases which were formerly epidemical, 
but which are now no longer so, such as Greek elephantiasis in the 
middle ages, and syphilitic affections towards the end of the 15th 
and the beginning of the 16th centuries, their mode of attack and the 
causes of their evolution, are as unknown to us as those of the small- 
pox, measles, scarlatina and other epidemics which we, in our own 
day, see attacking communities at frequently recurring intervals. It 
is impossible to say why some diseases, after having had the epidemic 
character at one time, should have lost it at another, whilst certain 
others have constantly preserved this feature. 

78. The history of medical constitutions, as regards inflammatory 
affections of the skin, is exceedingly incomplete. It seems demon- 
strated, however, that erysipelas frequently requires particular methods 
of treatment according to the prevaling epidemic constitution; that 
roseola, rubeola, scarlatina, &c, have occasionally a character of 
mildness, or of malignancy, which becomes a distinguishing feature 
in different ' epidemic invasions of these diseases. It is wrong to 
question the accuracy of these circumstances ; but it is no less erro- 
neous to attempt to see throughout each year, and even each quarter 
of the year, a common character in the cause and progress, of many 
diseases that are essentially different ; and it is with less reason still, 
that only one mode of treatment for the whole of these various affec- 
tions has been recommended. 

79. Several acute inflammations (variola, vaccinia, &c), and some 
chronic forms of skin disease (scabies, favus, &c), are contagious. 
These affections are transmitted by means of particular agents, known 
under the name of virus, miasm, &c. The human subject is in gene- 
ral only once affected with small-pox, measles, and scarlet fever. 
But one attack of scabies, of favus, or of syphilis does not give 
security against a second. Scabies, which is especially contagious 
by contact, cannot be communicated by inoculation ; the vaccine 
pock, transmissible by inoculation, is not so by simple contact, nor by 
its matter being rubbed upon the skin. The number of diseases of 
the skin, capable of being transmitted by one or other of these modes 
of contagion, is not yet satisfactorily ascertained. 2 " I once saw," 

1 Willan and Bateraan on the diseases of the skin in London. (Willan. Reports 
on diseases in London, in-12, 1801. — Bateman. Reports on the diseases of London, 
in-8. London, 1819.) — On diseases of the skin in Dublin. (Med. and Surg. Journ., 
Edinb., xxxiv., p. 99.) — Segond. Maladies de la peau a Cayenne (Journ. hebd. 2e 
serie, t. iv., p. 434). — According to Lorry : " Obnoxii sunt morbis cutaneis, Britones, 
Picardi, Flandri, Batavi." (De morb. cut., p. 34.) M. Richerand, on the contrary, 
thinks that the Dutch (Bataves) are very subject to diseases of the urinary organs, 
and suffer but rarely from affections of the skin. — Nouv. elem. de physiol., lOe ed. 
Paris, 1833, torn, ii., p. 152. 

2 Adams. Observations on morbid poisons, chronic and acute, 4to. London, 1807. 

8 



says Pujol, " a dentist labouring under a violent eruption (eczema?), 
of the right hand, infect, in one day, the faces of a great number of 
pupils in the royal military school of S&reze. The eruption appeared 
on the faces of the boys four or five days after the contact of the 
dentist's hand." 

80. Diagnosis. Inflammatory affections of the skin, generally con- 
sidered, are distinct from hemorrhagic affections of the same tissue. 
In these last, the attendant redness does not disappear on pressure, 
neither is it accompanied by heat, and it is most commonly free from 
all morbid sensations. Moreover, desquamation of the cuticle or 
some accidental secretion is an almost invariable consequence of in- 
flammation ; neither of which circumstances is perceived in hemor- 
rhagic affections, the red spots of these passing successively through 
shades of a greenish and brightish yellow as they disappear. 

Whenever there is a production of squamae or of furfurse, or any 
accidental secretion, inflammation is no longer liable to be confounded 
with simple congestion. There is never any real difficulty "except 
when the point to be determined is, whether certain congestions with 
morbid heat, sometimes observed after violent emotions of the mind, 
or at the period of menstruation in women in whom this function is 
performed with difficulty, are the first appearances of an erysipelas or 
not. And we observe in fact, that if the congestion but continue, 
inflammation will very speedily take its place. 

81. The determination of species seldom presents any serious diffi- 
culty when the disease possesses its essential characters, when it has 
reached its acme, or has passed through one or more of its stages. 

Various acute inflammations, and eruptive fevers in particular, 
sometimes exhibit, on their invasion, none but equivocal characters, 
— nothingbeyond general and ill-defined disturbance : at a later period, 
and towards their decline, these diseases only exhibit features more 
or less modified, and occasionally so much altered, that these afford 
us no assistance in our diagnosis, unless compared and contrasted with 
antecedent phenomena. 

In a given case, it is necessary first to inquire what the cause of 
the disease may have been ; then, by attentive examination, to ascer- 
tain the form to which the eruption belongs ; that is to say, whether it 
be exanthematous, bullous, vesicular, pustular, and so on. There 
remains no more to be done but to compare the symptoms and the 
progress of the species under review, with those of the phlegmasia?, 
which present themselves under the same generic aspect. 

82. The diagnosis may be rendered difficult in a greater or less 
degree, according as the primitive form of the inflammation remains 
unchanged or is much altered, as it is destroyed or replaced by new 
and consecutive alterations ; lastly, as the disease is simple, or com- 
plicated with other inflammations of the skin of the same, or of dif- 
ferent elementary forms. An attentive examination of consecutive 
alterations (scabs, ulcers, scales, cicatrices), sometimes of itself, and 
without any other hint, leads to a knowledge of the nature of the 
primary lesions, which are, moreover, often to be discovered with all 
their peculiar characters in the immediate vicinity of those points of 
the skin which were first affected. When it happens that several 
forms are conjoined in the same situation, or in the same individual, 
there is always found one predominating, to which the others, deter- 
mined by way of analysis, must be attached as adventitious, and be 
held as constituting complications. 

83. Inflammatory affections of the skin being sometimes associated 
with diseases of the mucous membranes of the viscera, or of the 
parts connected with them, the presence or absence of such affections, 
together with the apparent causes of their origin, require to be noted 
in order to render the diagnosis complete. 

84. Prognosis. There are no grounds upon which the prognosis 
can be founded save a precise knowledge of the natural progress and 
terminations of acute and chronic inflammations of the skin, the de- 
gree of efficacy of the means employed in their treatment, the circum- 
stances that may hasten and complete, or that may oppose and prevent 
their cure, such as the appearance of the menstrual flux in young 
women arrived at puberty, its near cessation in females who are 
approaching the critical period, &c. 

In the majority of acute characteristic inflammatory affections, 
especially in simple eruptive fevers, the advance, the periods, the 
phenomena, the duration of the disease, — all may be calculated and 






DISEASES OF THE SKIN. 



I with : in acute inflammations, how- 

. ami complicated with other affi 
ature, there is no longer any rule for their 
i, nor i for the calculation of their issues. 

ilsobe modified according to the b 
ibject. In old people chronic inflammations of the skin that 
are in eternal causes oughl often to be respected ; they 

mes be moderated, they ought seldom to be cured. In 
ss reserve is necessary, and the prognosis is more 
favourable. In childhood, the greater number of chronic inllamma- 
fthe skin, except favus, lupus, and the itch, run their course, 
.ind i^et well spontaneously, after a longer or shorter lapse of time ; 
.it this period of life, skin complaints appear often to be the very 
of prejudicial. 

V.S to hereditary affections, those especially that depend on the 
ilous or arthritic diathesis, are necessarily obstinate and more 
difficult to cure than the same diseases occurring under other cir- 
istances. 

Every form of artificial inflammation whatever is easily, speedily, 
and often spontaneously cured. 

Acute and chronic inflammations of the skin are sometimes 
salutary. The appearance of an exanthematous eruption may put an 
end to angina, 1 and abdominal infarctions (engorgements), to pulmo- 
nary inflammations, and wandering pains; many diseases of the skin 
itself have been seen arrested and cured by an attack of erysipelas. 2 
This form of exanthema, occurring on the thorax of a woman attacked 
with very severe puerperal peritonitis, caused the cessation of this 
serious disease. I have often remarked an eruption of furuncles in 
adults, and of eczema impetiginodes in children, happen at the time 
all the symptoms of an internal inflammatory affection disappeared. 
I have also seen eruptions of ecthyma occur during convalescence 
from several acute diseases. Boils are often critical in insanity. 3 
Pujol has seen hypochondria vanish with the appearance of furfura- 
eruptions over the whole body. A child of a year old, after 
baring exhibited all the symptoms of meningitis, sank into coma, the 
sutures separated, and the head became deformed. Dr. Gall, who 
saw this infant, decided that she had hydrocephalus, and pronounced 
an unfavourable prognosis. Derivatives to the intestinal canal had 
been unavailing; the size of the head was increasing; the child was 
pale and weak; the extremities were infiltrated, when a general 
scabby eruption appeared, and decided its fate; the fever ceased; 
the colour, which had been that of yellow wax, came again, and the 
child by degrees recovered a state of perfect health. 4 The head, 
h still somewhat' misshapen, is much less disproportioned than 
:! wa^ The child, now ten years of age, is robust, and possessed of 
all the physical powers of the strongest children at this age; but the 
intellect appears to be extremely moderate. P. Frank quotes a case 
of inflammation of the brain, favourably terminated by an attack of 
erysipelas. 5 Rosen and Mead give instances of intermitting fevers 
i by the appearance of small-pox. Prof. Andral cites a%ase of 
eery severe, and almost desperate pneumonia, the symptoms of which 
\ anished as by enchantment on the appearance of a variolous eruption. 
M. Brachet has seen a case of phthisis arrested by the intervention of 
small-pox." 1 have myself seen, in the person of a voun<v maoistrate 
a bronchial affection, which I regarded as complicated with tubercles' 
happily terminate after the spontaneous eruption of an eczema on both 
forearms. A mass of observations on the good effects of the vaccine 
pustule in a great number of diseases has been laid before the public- 
and whilst it must be allowed that these results are not without a tino-e 
rion, it appears certain that this eruption has several times 
i the means of giving a favourable modification to the progress 
ain chronic atfections. It is on this account that every form of 
cutaneous inflammation supervening in the course, or during the 
decline of an internal disease, ought, in general, to be respected, if 

-. de angina exanthematum eruptione solvenda. Hals.. 1763. 

- ir divers points de 1'art de guerir, in-4. Paris, 1621. 
pete, in-4. Paris, 1823. 
.nirol. Art. Folic, Diet, des sciences medicates. 

rol., Ire edit., torn, xi., p. 313. 
iii., p. 15;;. 
IS, ir.-l.. p. 274. 



not too intense, and if the internal malady ad vanee towards its termi- 
nation, or become less severe in proportion as the disease ot the 
integuments increases in extent, or runs through its periods. 

The utility of those artificial inflammations'' which tin- prac- 
titioner is every day in the habit of exciting and keeping up, o\cr 
certain regions of the body, is based on these and similar observations; 
they were successfully employed by Foucquet in angina (fauciumr), 
by Goodwin, in angina pectoris, by Jenner, in various forms of 
pulmonary catarrh, and there is, perhaps, no affection, either acute or 
chronic, in which I have not myself tried them with various measures 
of advantage. 

89. Analogous observations have led others to inoculate scabies, 
and other contagious diseases of the skin. 8 Dr. Lhomme recovered 
a child which had fallen into a state of emaciation, after an attack of 
enteritis, by inoculating it with tinea. In such cases it has always 
appeared to me preferable to have recourse to some artificial eruption, 
than to the inoculation of a disease disgusting in itself, and very often 
difficult of cure. 

90. In other circumstances, far from being salutary, the occurrence 
of any form of cutaneous inflammation is prejudicial. Measles some- 
times hasten the progress of tubercles of the lungs; repeated attacks 
of erysipelas aggravate the Arabian elephantiasis; eczema of the legs 
induces the ulceration of varices, &c. There are cases again in 
which it is impossible to determine whether an eruption shall be 
advantageous or hurtful. M. Calmeil, who has paid particular 
attention to the development of diseases of the skin among the insane, 
was unable to come to any conclusion in regard to the measure in 
which he conceived they might prove beneficial, or the contrary. 9 

91. The repulsion of acute inflammations of the skin is more 
commonly attended by grave consequences in measles and scarlet 
fever than in any of the other eruptive diseases. Not only is it 
necessary for us to be on our guard against the fatal effects of such 
retrocessions of these eruptive fevers, but farther to provide against 
those which proceed from the sudden disappearance of certain chronic 
inflammations, as of lichen, eczema, and impetigo. I shall have 
occasion to quote instances, in illustration, in regard to each of these 
diseases. 

92. The number of cases that have been witnessed, in which the 
disappearance of cutaneous affections coincided with the development, 
or accelerated progress of an internalinflammatorydisea.se, have made 
many afraid to attempt their treatment, or to desire their cure. 10 
When there exists at the same time, in the same individual, two 
all'ections, one of which is internal, the other external, it seems 
improper to attempt to combat the latter by any active means. 

In academical collections, instances may be found recorded of 
diseases of the digestive organs following the disappearance of tetters 
or tineas (dartres ou teignes). These cases, however, rarely occur, 
and seem often little conclusive. The numerous inquiries that have 
been instituted in later times in regard to diseases of the stomach, of 
the intestinal canal, and of the parts connected with these, have 
added but little to the earlier observations we possess; their causes 
have too frequently been overlooked, or passed by in silence. Never- 
theless, the case related by M. Bouchard deserved to be quoted (35.). 

93. Several cases tend to show that the suppression of an eruption 
or of a scabies may occasion epilepsy, 11 insanity, and other cerebral 
aflections. In the year 1785, at Bassenheim, on the left bank of the 
Rhine, a corporal, about 21 years of age, of a spare and bilious 
temperament labouring under a severe tettery affection (une dartre 
vive), about four inches in diameter, situated on the fore and upper 
part of the right thigh, was received into hospital. The disease 
extended over a small part of the scrotum, and caused violent itching 

doi.llaT' 0ntheinfluenceof ^ f '^l eruptions in certain leases, &c. 4to. Lon- 

AiV St ? rr 'T,^ isS " d u e efficacia scabiei in sravioribusquibusdarn morbis 'Pnh 17R1 
Alibert. Precis th. et pr. sur les maladies He i, „„„., 




rnond. Des maladies qu'il est dangereux de gnerir, ta-8., NImH^m' mT^ 
delapeau qu .1 conv.ent d'en.retenir, ihes. Paris, an rUL-Philip™ fil Ma ' ad,e " 
sitions de medecine et de chirurgie. Paris, 1825, pp. U and l r > ,Jo Kr- Propo- 

" Schenk, lib. i. De Epilepsia, Obs. 1C— Hocbard (Journal de \u** n - 
46.. Esqnirol. Art. Folie, Diet, des 8c medic.-G.lhen. Advert tt^ L XXV " * 
-Ephem. nat. cur. Dec. ij., Obs. 69.-Ann. v. Obs. 224. ACversar - P rac "c pr.,p.l9S. 



PRELIMINARY CONSIDERATIONS. 



31 



'.here. M. Bouillaud, chief surgeon of the hospital, employed a pallia- 
tive and cautious treatment in the first instance; but, by and by, 
yielding to the importunities of the patient, who complained of the 
intolerable pruritus of the affected part which prevented all sleep, he 
gave his consent to the. application of compresses, dipped in vinegar 
and water, to the seat of the disease. His surprise was great when 
the next day he found this man in a deplorable condition. The 
eruption had disappeared from the limb, but a state of somnolence, 
attended with stertorous breathing and complete absence of sensation 
and voluntary motion, supervened immediately afterwards. Every 
means was tried to bring back the disease ; blisters were applied to 
the spot first affected, and measures calculated to subdue this apo- 
plectic metastasis were exhausted in vain. The cerebral disease 
continued to advance unchecked, and the patient died on the third 
day. No examination was made of the body. 1 

Amaurosis 2 and convulsions, 3 especially in young children, have 
also sometimes been produced by the suppression of acute or chronic 
inflammatory affections of the skin. It is very possible, certainly, 
I hat effects have been ascribed to the repercussion of skin diseases, 
of which they were totally innocent ; but when such accidents occur, 
as in the preceding case, almost simultaneously with the disappear- 
ance of the skin disease, they give rise to serious questions of patho- 
geny and therapeutics. 

Pulmonary consumption has been seen following the cure of herpetic 
affections. 4 Lentin, Loder, Pederit and Portal have given cases of 
phthisis which were ascribed to the suppression of the perspiration 
from the soles of the feet. A young man whom I had cured of an 
eczema of the legs, was attacked almost immediately after with a 
pleurisy, for which he put himself anew under my care, and from 
which he was relieved without any return of the eruption. I have 
seen bronchitis follow the cure of rupia in a scrofulous subject; and 
I have collected several analogous instances of pulmonary inflamma- 
tions following the methodic cure of eczema, of various species of 
lichen and of psoriasis. 

95. Diseases of the heart and of its membranse, 5 have also been 
observed to follow the suppression of various forms of cutaneous 
inflammation. 

96. Admitting always that these facts are deserving of much 
attention, I yet affirm that the mischiefs attributed to the removal of 
tetters and tineas {dartres et teignes) are much rarer than is generally 
imagined. The most common consequences of these retrocessions 
observed are ophthalmic affections, inflammations of the glands of 
the neck, otitis, deafness, and now and then hydrocephalus acutus 
in infancy; pulmonary catarrh, phthisis and other affections of the 
thoracic viscera in young people ; affections of the liver, ascites, 
cystitis, &c, in riper years, and in old age. The following case is 
an instance as rare as it is curious of these metastases. 

A wine merchant consulted M. Petit for a discharge from the 
urethra, which had made its appearance some days before. The 
pain he suffered was severe ; the matter discharged was precisely 
similar to that of gonorrhoea, so that Petit thought he had to do with 
this disease in fact, but the patient declared on his honour that he 
had run no risk of infection, and that his wife was in the enjoyment 
of perfect health. It was requisite, however, to find some cause for 
the appearance of this inflammation ; and Petit discovered it when 
he learned that the patient had for a long time laboured under an 
eruption on the skin of the fore arm, which had suddenly disappeared 
a few days before the discharge came on. Petit ordered the appli- 
cation of a blister to the place where the eruption had previously 
existed, and all the symptoms of the presumed clap speedily disap- 
peared. 6 

97. Treatment. An infinity of remedies and of different curative 
plans have been recommended in acute and chronic inflammatory 
affections of the skin, in a manner so general as to render the study 

1 J. B. Campet. Sur l'apoplexie. An xiv., (1805,) p. 18. 

2 Hoffmann. Med. rat. syst. p. i. s. I.e. 8, obs. 1 (Morbili suppressi).— Klein. Ir.- 
terpr. clinic, tit. amaurosis (ex repulsis varis faciei). 

3 Gilibert. Advers. pract. primar., p. 197 (Phoenigmus per plumbea repercussus). 
* Unde dira nee rara tamen est phthyseon historia qua: a retropulsis nascautur 

herpetibus. (Lorry. De morbis cutan., p. 27.) 

b Pressavin. Nouv. trails de vapeurs, p. 174, 12mo. Lyons, 1796 

« Bouchard. Essai sur l'emploi des derivatifs externes, p. 50, 4to. Paris, 18 10. 



of their principal applications, from the same point of view, a subject 
of positive utility. This first glance will also recall to our notice 
certain therapeutical investigations, which it would be well to repeat 
at the present day, and under better ascertained conditions. Farther 
on in this work, in the history of each particular inflammatory affec- 
tion of the skin, I shall hold myself bound to specify the doses and 
mode of administering the remedies proper for them at their different 
periods, and the modifications that may require to be introduced into 
the remedial plan, when the causes of the disease, the constitution of 
the patient, and the influence of any accidental or intervening lesion, 
are ascertained. 

98. Treatment of the acute inflammatory affections. There are a 
certain number of acute inflammations of the skin, the conditions of 
whose existence are such that nothing can advantageously arrest their 
progress ; the various phenomena that accompany these diseases are 
as little to be opposed as the natural actions of the economy. The 
part of the physician is then to regulate the evolution of the disease, 
and to endeavour to limit its effects. 

This expectant method is applicable to simple erysipelas, to common 
measles, to uncomplicated scarlatina, and to all artificial inflamma- 
tions of little intensity. With a few exceptions it ought also to be 
regarded as the proper method of treatment in all cases of unmixed 
eruptive fevers. 

Thus, therefore, many acute inflammations are to be confined 
within moderate bounds by regimen — by abstinence and. diluents : 
the disease exhausts itself, and the cure is accomplished naturally. 
But whenever these inflammatory affections appear inclined to spread 
to a large extent of the surface, to invade the subcutaneous cellular 
tissue, or other organs, or when they are accompanied by very violent 
febrile symptoms, we are to interpose, by means more or less energetic, 
according to circumstances, — provided always that no critical phe- 
nomenon proclaims these diseases as having a natural tendency to 
a speedy termination. It must not be overlooked, moreover, that 
these inflammations have most commonly a certain number of periods 
to pass through, and that we cannot, without danger to our patient, 
seek to cut them short at their outset. 

99. The degree of warmth 7 proper to be kept up in the chambers 
of patients and around affected parts, is a point upon which we are 
often consulted in the treatment of acute inflammations of the skin, 
and especially in that of eruptive fevers. In measles, a somewhat 
elevated temperature has appeared to me, in general, advantageous. 
This would be very painful, and probably very prejudicial in scarla- 
tina. It would add to the swelling and to the headache in erysipelas 
of the face. 

100. The febrile symptoms accompanying acute and uncontagious 
inflammations of the skin, are moderated by the abstraction of a 
quantity of blood, when the constitution of the patient admits of the 
practice ; the progress of the eruption is then milder and more regular. 
I must, however, again remark, that there are a number of cases in 
which the spontaneous and natural termination of the diseases is so 

'evident an event that it is well to abstain entirely from bleeding, 
which in this case would have the effect of needlessly reducing and 
weakening the patient. Of late, the local abstraction of blood has 
certainly been abused in the treatment of eruptive fevers. Recalling 
an erroneous opinion of M. La Metrie, it has even been proposed to 
cut them short by means of repeated bleedings. This mistake pointed 
out, it must still be allowed that the abstraction of blood is impera- 
tively called for in the treatment of those intervening inflammations 
which the disappearance of eruptions often gives rise to. Expe- 
rience has amply confirmed, in my own hands, the advantages of this 
practice approved and established of old. 8 

Local bleedings are generally useful in phlegmonous erysipelas, 
in scarlatina anginosa, in variola accompanied with obstinate vomiting, 
in measles complicated with intense bronchitis, or with pneumonia. 
In children this mode of abstracting blood requires particular care ; 
without it the bleeding is seldom effected in due measure, being 
almost always either insufficient or excessive ; leech bites in them 
bleed either too little or too much. 

7 Pohl. Pr. de regimine caloris et frigoris in morbis exanthematicis. Leips., 1707. 
s Kortum. Diss.de exanthematis febrium acutarum retrogressis per venresectionetn 
restituendis. Hsele, 1741. 



82 



DISEASES OF THE SKIN. 



101. When tb ' ' ,llt,r sina11 m ( l uan 

3 us that it can be excited or 

ck by the tartarized antimony exhibited in emetic doses, 

am l ti ed from great jeopardy. In certain epi- 

i mended as preferable 
to the nod and to blood-letting. 1 Generally recom- 

mended by P. Frank and Cullen in the beginning of acute diseases 
in winch the skin appears more or less affected with inilammation, 
tartrate of antimony is at the present time confined in its application 
t number of cases. Often useful in erysipelas, owing to 
an outward cause, in urticaria occasioned by eating muscles, &c, 
tartrate of antimony and ipecacuanha have been too generally pre- 
scribed in the commencement of measles to favour the throwing out 
of the eruption, which may be impeded by morbid conditions of the 
most dissimilar kinds, such as convulsions, pneumonia, difficult den- 
tition, &.c. &c. Lastly, according to M. Fontaneilles, 2 a solution of 
a drachm of the tartrate of antimony to a pound of water, by way of 
ration, is an excellent antiphlogistic in erysipelas and various 
other acute cutaneous phlegmasia. 

102. Purgatives, recommended with justice by Hamilton in scarla- 
tina, are no less beneficial in hydrargyria, and in some cases of va- 
riola, of erysipelas, and other diseases. Halle informs us that several 
bold or rather rash attempts have proved that small-pox might some- 
times yield through all its stages to the evacuating plan of treatment. 
I have not myself repeated this experiment. 

103. Diaphoretic drinks, 3 particularly tepid infusions of borage and 
of sambucus nigra, may generally be advantageously prescribed to 
allay the thirst of the patients and determine to the skin during the 
two first periods of the eruptive fevers. Recourse is also sometimes 
had to the tepid bath in the treatment of phlegmonous erysipelas of 
the limbs, of ecthyma, of papular erythema, of the small-pox, &c. 
The same means are sometimes employed w T ith a view to recall the 
eruption in measles when it has disappeared suddenly. The vapour 
bath is occasionally used with similar intentions. 

104. Liniments of cream, of oil, or of grease diminish the heat 
and dryness of the skin in erysipelas, variola, and scarlatina ; those 
of cream give great relief in the confluent small-pox of the face. 

105. Wright, Currie, Martius, and others, conceive that the reac- 
tion which follows the affusion of cold water over the surface of the 
body, is often useful in certain cases of scarlatina and rubeola, at- 
tended with a dry and burning heat of the skin, or with a tendency 
to meningitis. I have never tried this method, against which there 
prevails a general prejudice in France. 

Cold water, plain or acidulated, has been used with success as a 
lotion or a bath in the treatment of burns of various degrees of inten- 
sity, as also of ulcers, and in cases where the skin has been affected 
with heat and itching. Water in abundance as a diluent has been 
extolled by Hancock and many others in the treatment as well of 
general fever as of scarlatina, measles, and small-pox. 

106. Harris relates several instances of the good effects of the 
application of alcohol in erysipelas ; 4 ether is also sometimes used to 
burns ; and James 5 tells us he has often tested the efficacy of this 
remedy in the painful inflammation that occasionally follows the use 
of blisters. 

107. Urtication, or stinging with nettles has been imagined to 
restore the eruption of fevers, in which it had receded too rapidly. 
I have often replaced this means by the use of sinapisms, and of 
mustard baths in the cases of children. 

108. Blisters are often successfully used to fix erysipelas of an 
erratic nature, to bring the inflammation to the exterior in phlegmo- 
nous erysipelas, and to restore it in case of its retrocession in erup- 
tive fevers. Stoll 7 conceives that their application, in miliary fevers, 

' Stoll. Ann. Med., i., pp. 15-58. 

* Bullet, de la Soc. med. d'emulation. Octob., 1823. 

» Jauhert. Determiner quelles sont. dans les fievres exanthematiques, les circon- 
stances dans lesqoelles le regime rafraichissant est preferable 4 celui qui est echauf- 
fant, et celles dans lesquelles on doit employer une methode conlraire. (Mem. de la 
ale de med., in-4., t 1, 1776, p. 529.) 

* Harris (G.). Diss. med. et chir., 8o Lond., 1725. 

< James (R.). Medical Dictionary, in fol., vol. i., p. 699. 
« Schwarz (Hufeland. Journal der prakt. Heilkunde., v B. 2 St. p. 153). 
.. Rat. Med., t. n.. | 



ought to be preceded by the use of purgatives ; a precept which seems 
too general. 

109. The nitrate of silver in substance or in a concentrated solution, 
has of late been recommended as a cautery to check the progress of 
certain acute diseases of the skin, and to prevent the mischiefs that 
sometimes complicate them. This plan which has been styled the 
ectrotic has been put in practice in the case of small-pox, of erysipelas 
of the face, of zona, and of several other varieties of herpes. 

1 10. Experiments to a certain extent demonstrate that mercurial pre- 
parations do really exercise a remarkable influence over the evolution 
of acute cutaneous inflammations. Recommended in erysipelas by M. 
Ricord, they had previously been used as preservatives against variola 
and scarlatina. According to Wedekind, small-pox pustules are not 
evolved in those situations that have been covered with a mercurial 
plaster, and the effects of inoculation are prevented by washing the 
punctures with a solution of corrosive sublimate and sal ammoniac. 

Dessessart has extolled calomel as giving immunity from small-pox. 8 
Sacco and Selig say that mercury destroys the specific properties of 
vaccine matter, and weakens or interrupts the progress of the pustule 
already formed. Hoffman, Baglivi, Lettsom, Lentin, Andry, Reil, 
Hufeland, Hildebrant, Cotugno, and others have pushed mercury to 
salivation in the very beginning of small-pox, in order to mitigate its 
violence. Huxham, Bailey, Douglas, Kreysig, Hufeland and others 
have also recommended it in this disease, and Loesecke, Mueller, 
and Hamilton have reaped great advantages from the medicine in 
measles. I have repeated several of their experiments, and in the 
proper place will make known the results of my inquiries. 

111. As to preservative methods, I can only quote the efficacy of the 
vaccine pustule against small-pox, and the demonstrated usefufness of 
belladonna in epidemic scarlet fever. The property ascribed to cam- 
phor of destroying the infection of measles is much less than certain. 
Intermittent erythema and urticaria are to be treated like febrile 
accessions. As to periodic inflammations dependent on amenorrhea, 
on dysmenorrhoca, or the suppression of an habitual evacuation, their 
recurrence is prevented by reinstating these evacuations or finding 
substitutes for them in blood-letting, and the use of purgatives. 

112. Treatment of chronic inflammations. The treatment of chronic 
diseases of the skin is held with justice to be one of the most difficult 
matters in the healing art. Besides getting occasionally well under 
the influence of the most dissimilar remedies, the choice and applica- 
tion, and occasion to make use of which are beset with numerous 
difficulties and much uncertainty, we cannot conceal from ourselves 
something of a secret disinclination to attack many of these affections, 
the disappearance of which may be succeeded by more or less serious 
symptoms. 

113. Vegetable diet, white meats, &c, are available in a great 
many chronic inflammations of the skin appearing in young subjects, 
or in people of mature years, but of sound constitutions. A sober 
and regular life, habitual cleanliness, a diet composed of white meats, 
fresh vegetables, and ripe and watery fruits, contribute essentially to 
the effects of the therapeutic agents employed. Living on white 
meats (diete blanche), fish, chicken, &c, has been held by some as the 
only efficient remedy against chronic inflammations of the skin. 

Milk diet 9 perseveringly employed, has accomplished cures where 
pharmaceutical preparations, directed with the best views, had totally 
failed. This regimen, however, is injurious to elderly people ; under 
its influence I have seen several fall into a state of anemia, which a 
recurrence to more nutritious food caused to disappear. 

Some individuals digest milk with difficulty ; almost all, however, 
at length become accustomed to it, as Pujol well observes. The sto- 
mach is sometimes brought to bear this article of diet by the use from 
time to time of lime water. Some digest asses' milk more readily 
than any other ; some again find goats' milk, either alone or mixed 
with barely-water, sit most lightly on their stomachs. 

114. Veal or chicken broth may be recommended to those who 
have a distaste to the habitual use of milk ; particular advantages have 
been presumed, by some, to be possessed by broths made from the 

8 Mem. de l'lnstitut. Sc. phys., t. iii. 

» " Lac in omnibus eulaneorum morborum curationibus aded celebre est ut multi 
illi soli rite applicato omnem omnin& fiduciam addant, reliquis neelerti* «•' i 

victu eo utaniur." (Lorry, de morb. cut., p. 339.) b ' S1 P ro sol ° 



PRELIMINARY CONSIDERATIONS. 



33 



sea-turtle, from the lizard 1 and the viper; 2 and the numerous cases 
detailed of their good effects in Italy, Germany, France and England 
in cases of cancer, lepra, elephantiasis, syphilitic eruptions, &c, should 
induce us without prejudice to repeat these experiments. 

115. Fasting, or the use of a quantity of food less than the appetite 
demands (cura /amis), has been recommended in various forms of 
chronic inflammation of the skin, and particularly in syphilitic affec- 
tions. I have myself often obtained great and permanent advantages 
by reducing the quantity and changing the quality of the aliment. 
Lorry gives instances of this kind. 3 But few patients have the firm- 
ness to restrict themselves to a severe regimen and to endure the 
privations it implies. Females submit more readily than males. A 
celebrated accoucheuse of Paris, otherwise of a good constitution, 
suffered under a phagedenic tetter of the cheeks; she gave up her 
usual mode of living which was very nutritious and recherche, and 
confined herself to vegetables dressed with a small quantity of butter 
and seasoned with salt: she recovered, and ten years afterwards had 
had no relapse. 

Under the influence of these severe fasts, the constitution is so 
much weakened, that though the skin diseases get well, the strict 
regimen has often to be abandoned ; and then the eruptions reappear, 
in the same measure as the general health improves under the stimulus 
of better diet. 

116. Circumstances depending on age, on temperament, on ante- 
rior or concomitant affections, and on the particular situations in which 
patients are placed, sometimes require the tonic and strengthening 
plan to be substituted for the fasting and the antiphlogistic treatment, 
which, however, is generally much more extensively applicable. — 
See particularly under the heads rupia, lupus and impetigo. 

117. If the advantages of an appropriate regimen are well proved, 
the mischiefs arising from imprudences and irregularities in the mode 
of living, from the abuse of coffee, 4 of strong drink, of salt and 
highly-seasoned, food, &c, are not less apparent. It is enough, in a 
great number of cases, for patients in the way of recovery, or actually 
well, to abandon for a moment the strict system they had followed, 
to suffer an increase or a recurrence of their disease. Sometimes, 
too, these relapses happen after such an interval as seemed to warrant 
some remission of the severe watch that had been previously kept 
over the kinds and quantities of food employed. 

118. Rest, and the absence or diminution of muscular exertion of 
every kind, have a marked influence on the progress of chronic 
inflammations of the skin. I have seen individuals attacked with 
severe psoriasis, completely cured by remaining patiently for a month 
in bed ; and the effects of the same endurance are not less remark- 
able upon eczema and impetigo. A plan of life the very opposite of 
this — hardship and fatigue — has been recommended by Van Swieten 
against syphilis. The results of my own experience are not favour- 
able to this counsel, as I have always seen active exertion of body 
aggravate syphilitic affections and impede their cure. 

119. Daily observation demonstrates the utility of external remedies 
in the treatment of chronic inflammations of the skin. The ancients 
often made use of them, but it was almost always only after the 
exhibition of one or two cathartics. Lorry has restricted their em- 
ployment to too narrow a circle, and repudiated a number of topical 
applications of undeniable worth. Bell again has extolled them too 
highly ; because, if the necessity of acting directly on the organ 
affected be demonstrated in a great number of cases, it must also 
be owned that in a multitude of chronic inflammations of the skin 

1 Roemer (J. J.). Ueber den Nutzen and Gebrauch der Eide.xen in Krebsschaden, 
der Lustseuche und verschiedenen Hautkrankheiien. Leipsik, 1788. — Ancien journ. 
de medec, torn. Ixxx. p. 144. — Med. Comment, of Edinb., vol. ix., p. 257. — Oarminati, 
Opusc. therapeut., 4, torn, i., 1788. 

8 Home (F.). Clinic, researches. — Dehaen. Rat. Med. P. ix., c. 6, sec. 3.— Carmi- 
nati, xii., c. 6, sec. 2. — Colombier, Code de med. milit., t. v. p. 279. 

3 " Certd valentissimum novi hominen exercitio et animi et corporis apprime 
deditum, qui misere herpetibus, et ad faciem et ad artus laborabat, prurientibus illis, 
et noctu dieque vexantibus. Quoniam vini fortioris usui moderato addicium noveram, 
sola, vini mutatione in oligophorum et tenue sanatum fuisse testor. Alium vidi quem 
aquae potus omnino liberum fecit ab hujusmodi vitiis." (Lorry. De morb. cutan., 
p. 40.) 

4 M. Vattain attended a lady, in 1747, for a violent eruption on the arms. All the 
remedies employed failed to touch the complaint till she was persuaded to abandon a 
cup of coffee which she was in the habit of taking regularly morning and evening. 
(Saucerotte, Hygiene chirurgicale. Prix de l'Acad. de Chirurg., t. v., p. 40.) 

9 



(eczema, lichen, lupus, psoriasis, lepra, pityriasis, Greek elephan- 
tiasis, &c), the local affection of the integuments is nothing more 
than one of the conditions of the disease, and that recoveries after 
simple local treatment are commonly incomplete. 

120. Some external remedies, such as the acids, the nitrate of 
silver, actual cautery, &c, have a mere local effect, whilst the others 
are followed quickly or at a later period by phenomena which result 
from the absorption of the substances applied to the surface of the 
body. The salivation that follows the inunction of mercury ; the 
emaciation observed after the protracted use of iodated baths or 
unguents ; the increase of muscular strength from the sulphureous 
bath ; the colic and paralysis that result from the application of the 
salts of lead to abraded surfaces ; the pains of the bladder, occasioned 
by blisters, &c. ; bear witness to these secondary effects, and to their 
importance. 

121. When we reflect that so many diseases of the skin are owing 
to the neglect of proper cleanliness, and that the greater number are 
accompanied with an increased heat of surface, or by morbid secre- 
tions, we cannot be surprised at the excellent effects obtained from 
the use of simple baths, whether as soothing inflammation actually 
existing, or preventing its return. The advantages of baths of the 
decoction of bran, of emollient, gelatinous and oily baths, and those 
prepared with starch, marsh-mallows and lettuce, are no less evident. 
These are all preferable to the ordinary tepid bath. We know that 
fish-glue, and the glue prepared from bullocks' hides, in the isle of 
Rhodes, were used dissolved in water by the old Greeks in the 
treatment of burns, psoriasis, ecthyma, &c. These gelatinous baths 
ought in general to be administered at a very moderate degree of 
heat, as prolonged and repeated hot baths are rarely endurable when 
the skin is in a high state of inflammation. 

122. Cold baths, and bathing in running streams in particular, 
are serviceable in a great number of chronic inflammations, which 
from their nature, their form, or -their long continuance, have become 
fixed to particular places. I have made a number of experiments 
on the administration of narcotic cold baths in the treatment of chronic 
and painful inflammations of the integuments, the results of which 
were highly satisfactory to me. 

123. Soothing fomentations, such as those prepared with decoction 
of marsh-mallows, of althea, of the acanthus spurius, of lactuca 
sativa, of beet root, of the herb pellitory, and other mucilaginous 
plants, as also those esteemed of a sedative nature, that are prepared 
with poppy-heads, with elder-flowers, with olibanum, with melilotus 
officinalis, with euphrasia, veronica chamsedris, the leaves and stems 
of the plantago, &c. ; likewise cataplasms of crum of bread, rice 
flour, potato starch, &c, applied of a gentle warmth to circumscribed 
inflamed surfaces are generally useful. 

124. By anointing the body with oil, or grease of any kind, the 
skin is made softer and more pliant, and pain, heat and itching are 
sometimes allayed. It was long thought that each variety of greasy 
substance employed had peculiar curative virtues, and M. ChevreuP 
has, in fact, ascertained that these bodies not only vary in the relative 
amounts of their constituent elements, but also by the presence or 
absence of certain accessory principles, which posssibly may be not 
without influence in a therapeutic point of view. If lard be more 
generally employed than any thing else, it is only on account of the 
readiness with which it is everywhere to be procured. 

Hufeland 6 has recommended frictions with olive oil, or with nut 
oil in tetters (dartre). Linseed oil is familiarly used in the treatment 
of burns ; and Delpech has proposed the employment of oils generally 
in scabies. 

125. The advantages of blood-letting are less obvious in chronic 
than in active inflammatory diseases of the skin. Yet general as 
well as local bleedings by means of leeches and cupping-glasses have, 
under my own eyes, had the happiest effects in many chronic cases. 
I have derived the greatest advantage from this practice in eczema, 
impetigo of the face and hairy scalp, psoriasis, lichen, local prurigo, 
herpes phlyctenodes and other forms of chronic affection. It is 
generally proper to repeat the local abstraction of blood in youn^ 

6 Chevreul. Recherches chimiques sur les corps gras d'origine anima'e, in-8o. 
Paris. 
6 Journal der prak. Heilkunde, X. B. 4 St., p. 143— xii) B 4 St., p. 179. 



I 



DISEASES OF THE SKIN. 



be inflammation shows .1 disposition to extend, 
, rable pain. I have even put this practice 
in force in •; I elderly people of hale constitutions, with great 

advanl 

126, 1 f sulphur h&vt long and deservedly enjoyed 

: .illation in the treatment of chronic diseases of the 
skin, and especially of scabies. 

Siil r iters taken internally during one or several seasons 

mod if) the constitution materially, and perhaps accomplish a greater 
- than any other means. In France, the natural sul- 
phureous mineral waters of Aix (Provence), of Bagneres, 1 of Bagneres 
I bon, of Billazai (Deux Sevres), of Bareges, 3 of Cauterets, of 
Enghien, of Greoulx (Basses Alpes), of Bagnols (Loyere), of Aix 
;e), and of Saint Ainand (Nord), are justly celebrated; in 
iny, those of Aix-la-Chapelle, of Wisbaden, and of Nenndorf : 
\i\ and of Saint (iervais, in Savoy; of Baden, of Lapey- 
f Schinznack, and of Louesche, in Switzerland ; ! of Guitra 
a), of Argui, in Piedmont; of Alhama, and of Hardeles in 
Spain ; those of Naples ; those of Baden (Lower Austria), of Baden 
(Swabia); those of Harrowgate, Leamington and Bath, in England, 
iiy salutary. After having been drunk for several days, 
some of these waters, particularly those of Louesche, occasion a 
particular eruption, characterized by small acuminated and itchy 
and red blotches which appear first on the limbs, but, by and 
by, extend over nearly the whole surface of the body: a febrile 
paroxysm, accompanied by anorexia and great thirst sets in, the sleep 
is disturbed, and the urine is turbid and high coloured. All these 
symptoms abate within eight or ten days in the order of their appear- 
the epidermis is thrown off in flakes, and the pruritus is soon 
the only symptom that remains for some little time longer. This 
eruption appears to be one evidence of the beneficial operation of 
the waters, and ought not to cause a suspension of their use. The 
baths of Baden (Argovie), the waters and baths of Saint Amand 
sometimes, but by no means so generally, occasion symptoms analogous 
to those produced by the waters of Louesche. 

There are many other mineral waters found over the face of different 
countries of Europe which are also familiarly used internally in skin 
complaints. 

127. I have had ample opportunity at La Charite and elsewhere 
oi satisfying myself of the virtues of artificial sulphureous baths ; but 
to secure their good effects, it is certainly necessary to regulate the 
temperature and the dura/ ion of these baths, not only by their manifest 
effects on the skin, but by their influence on the constitution. In a 

1 eat number of cases I have found that there were immense 
ad\ antageS to be derived from gradually increasing the time of remain- 
ing in the bath to the amount of even five or six hours. This practice, 
so commonly followed at the natural springs, is by no means to be 
neglected in our establishments of artificial mineral waters, as some 
have proposed. I have attended children who have been brought 
to remain in the bath during three whole hours; and adults and 
persons further advanced in life, have at length been induced to stay 
four or five hours without exhaustion in the artificial sulphureous- 
water bath. The chief obstacle to this practice arises from the 
patients themselves, who, living in large towns and not duly appre- 
ciating its importance, will rarely consent to sacrifice so many hours 
to the care of their health. It is by this means, nevertheless, that 
those constitutions which make individuals subject to skin complaints 
are most certainlv modified, and that the relapses so frequent after 
every mode of treatment, are most surely prevented. 

The hot air bath and dry sulphureous fumigations, tried in the 
treatment of skin complaints by Glauber 1 anil Lalouette, 5 and brought 
forward anew with convenient modifications by M. Gales, 6 are now 

1 Lorry. Op. cit.. p. 33*. — Ganderax. Recherch. sur les proprietes phys. chimiq. 
el medic des eaux bin. de Bagnieres de Bigorre, in-8o. Paris, 1827. 

- Bordeu (Th.1. L'usage do- eaux de Bareges et du mercure dans les ecrouelles. 

. 11-18. 

B-(J.). F.->ai sur les eaux minerales ihermales de Louesche. Paris, 1828, 

* Glauber (Joan. Rudolphe). Furnei novi philosophici, sive descriptio artis distil- 
. in-12. Anistelodami, 1661. 
;ieue (P.). Nouvelle methode de trailer les maladies vene'riennes par les 
fumigations. Pans, 1771;. 

» Gales. Memoire et rapport sur les fumigations sulfureuses appliquees au traite- 
meni des affections catanees, in-8. Paris, 1816. 



rendered easih and safe!) applicable by means of the improved 

apparatus of M. Daivet.' Messrs. Clarke'' and Wallace' have seve- 
rally published interesting remarks on their effects, which to me, 
however, seem to be not without a tinge of exaggeration. The same 
thing may be said of the observations of Decairo, of \ ienna. 10 Sul- 
phureous fumigations are undeniably often serviceable in chronic 
eczema, but they arc rarely available against pityriasis, lepra and 
impetigo. They certainly weaken the patients more than sulphure- 
ous-water baths; they also modify the constitution in a less durable 
manner, and more rarely accomplish perfect cures. These fumiga- 
tions, too, sometimes irritate the skin further ; they have been known 
to occasion syncope, a sense of suffocation, &c. It would be imprudent 
to attempt their use without great discretion among children, pregnant 
women, asthmatic persons, or in cases where there was any suspicion 
of tubercles in the lungs. 

The vapour of sulphur administered by the process of M. Balland is 
much less irritating than fumigations with sulphureous acid gas, in lieu 
of which it may often be substituted with advantage. 

Lotions and ointments of sulphur have the same effects as the baths ; 
their activity may be increased by the addition of different substances ; 
such as iodine and mercury, which are more or less energetic in their 
actions, or diminished by others that seem to have little or no sensible 
effect on the economy, such as charcoal and sulphuret of antimony. 
These tropical applications do not modify the constitution, and are 
generally less useful than the prolonged employment of sulphureou.v 
water baths. 

129. The sulphuret ofpotassa, of soda, and of lime are made use 
of, not only for the composition of artificial baths, but in solution inter- 
nally, in the dose of five or six grains to the pint of water as a drink, or in 
the same quantity mixed with some vegetable extract. Pure sulphur 
is also prescribed internally in the dose of from twelve to twenty 
grains, especially by the vulgar, as a purgative, or in the idea that it 
may be absorbed and thus affect the constitution generally. 

130. Baths of sea-water, cold or hot, 11 and those of the mother- 
waters of our salt-mines 12 are very efficacious in many forms of chronic 
inflammation of the skin, especially in scrofulous subjects. Russel 
advises the internal use of sea-water before beginning to bathe. 
Lind has recommended sea-water in scabies and obstinate forms of 
ulceration. M. Delaporte has treated a great number of individuals 
affected with scabies by means of sea- water baths, and M. Zompitoute" 
has combined their action with that of the sulphuret of potassa, a 
method that deserves recommendation, especially in the cases of sailors 
and of soldiers quartered in seaports during the heats of summer. 

I have myself seen very obstinate diseases of the skin, and particu- 
larly chronic eczemas of the verge of the anus, which had resisted 
arsenical preparations, get permanently well after one or two seasons 
of sea-bathing. Should the disease return, the sea-bathing must be 
resumed the following summer, until the cure seems established. 
This practice is said to be very generally followed in the hospital at 
Newcastle ; and we may soon expect to be in possession of valuable 
reports on this interesting point of therapeutics, which has not yet 
been sufficiently attended to, from the physicians to the establish- 
ments for sea-bathing which have been formed in France at Dieppe, 
Boulogne, Havre, and Rochelle. It is of some importance also to 
point out those cases in which sea-bathing is contra-indicated, as 
well as those in which it proves advantageous. I have thought that 
it was prejudicial in spare and irritable temperaments. In very 
extensive skin affections, and in squamous inflammations, it is generally 
well to advise a few tepid baths, before entering on those of cold 
water. It is seldom that sea-bathing, as a remedial means, is em- 
ployed alone ; it is generally combined with some internal treatment, 
which, of course, always enters for something in any result obtained. 

I Description des appareils a fumigations etablis sur les dessins de M. Darcet, 4 
l'hopital Saint-Louis, en 1814, etc., in-4. Paris, 1818. 

s Clarke (Arthur). An essay on diseases of the skin, coniaining practical obser- 
vations on sulphureous fumigations, etc., in-12. London, 1824. av - 111 " 11 uusc ' 

9 Wallace (W.). Observations on sulphureous fumigations, etc., in-8. Dublin 

10 Decarro (J.). Observations sur les fumigations sulfureuses. Vienne l«i<J 

II Eph. nat. cur. Dec.iii. Ann. vu et viii obs. 68.-Frank.de curand. homin I ,hi„ 
p. 155.— Ranoe. Act. reg. soc. med. havn., vol. i., p. 331. "■*■*»» UD. iw» 

■ 2 Gotz. Bulletin des scien. med. de Ferussac, t. iv., p. 288. 
" Annales de Montpel., Dec, 1812. 



PRELIMINARY CONSIDERATIONS. 



35 



131. At Paris, artificial alkaline baths, which approximate, in a cer- 
tain degree, in their composition to those of sea-water, are prescribed 
under similar circumstances. These are prepared in the hospitals 
by dissolving from four to six ounces of the subcarbonate of soda, in 
an ordinary tepid bath. Common culinary salt sprinkled on the sur- 
face of cutaneous eruptions, has been recommended by Schelling. 1 
The salt-water contained within oysters, is a vulgar remedy for ulcers 
of the leg ; and I know a patient who succeeded in getting rid of a 
very disagreeable eczema podicis, by employing this water as a lotion. 

[The brine of salt-meat is another popular remedy, in England, 
against various forms of skin disease.] 

132. Baths of saline, natural mineral-waters, have also been occa- 
sionally employed in affections of the skin, the species of which, 
however, have not been particularly described. 

133. Soap lotions, formerly much recommended in skin diseases, 
are still generally used as a means of cleanliness, and have lately 
been advised by M. Lugol, in cases of scabies. 

134. Local baths — (manuluvia — pediluvia — hip-bath) — have been 
prescribed, not only as topical applications, but with a view to promote 
the absorption of various medicinal substances. Foot-baths contain- 
ing corrosive sublimate or nitro-muriatic acid, have been tried in 
several eruptive diseases, and in syphilitic affections, but with very 
variously-reported effects. 

135. Saliva, which is spoken of by Galen and Celsus, 2 is still a 
popular application to the scales of pityriasis, and to lichen of the 
face. Nurses often employ their spittle to allay the violent itching 
which children surfer who are attacked with strophulus. 

136. The urine, especially that first passed in the morning — urina 
sanguinis— was an ancient remedy, and is still used by the vulgar, when 
they are attacked with itch, pediculi, and chronic eczema of the hairy 
scalp. 

137. General and partial vapour baths* may be of service in restoring 
to the exterior certain inflammations of the skin that have receded, in 
the removal of squamae and of scabs, in exciting the circulation in 
those regions of the skin to which they are particularly applied, and 
in stimulating inflammatory affections of an indolent nature. They 
are further usually employed under a great variety of circumstances 
which I shall be careful to expose in their proper places. P. Frank 
even tells us that the vapour which exhales from the body of an animal 
just killed, has proved a remedy in certain cases of cutaneous disease. 4 

138. Several chronic forms of inflammation of the skin have been 
successfully treated by iodine and its compounds. 5 This medicine has 
been particularly recommended in cutaneous affections occurring in 
scrofulous constitutions. I have seen good effects from the combina- 
tion of iodine with mercury, sulphur, and opium in scrofulous lupus, 
and in tubercular and ulcerated syphilitic affections. These com- 
pound remedies, as their action is very energetic, require to be care- 
fully watched. Like all the preparations of iodine, they have a very 
marked effect on the constitution. 

Externally, an ointment or pomatum of iodine and of the proto- 
ioduret of mercury, as also solutions of iodine of various degrees of 
strength, general or local iodated baths, iodated cataplasms, caustic 
iodine (a solution of an ounce of iodine and an ounce of ioduret of 
potassium in two ounces of water), &c, have all been employed by 
M. Lugol and others, in the treatment of scrofulous lupus {scrophules 
esthiomenes) and of some other cutaneous affections. I have myself 
particularly tried the action of the iodurets of mercury and of sulphur. 

1 Marcus unci Schelling. Jahrbucher der Medicin als Wissenschaft, ii B. 1 St. p. 42. 

2 Galenus. De simpl. medic, facultatibus, lx. — Celsus. Lib. v., cap. 1, De papula. — 
Schurig. Sialogia, p. 132. 

3 Atumoneilli. Memoire sur les eaux minerales de Naples et les bains de vapeurs. 
Paris, 1804. — Assalini (Paolo). Ricerche mediche su i bagni a vapore e di calorico, 
e sulle fumigazioni di sostanze ammoniacali e balsamiche, di zolfo, di mercuric etc. 
Naples, 1820. — Rapou. Traite de la me'thode fumigatoire, 2 vol., in-8. Paris, 1823. 
Philouze. Essai sur les bains de vapeurs employes a Saint-Louis, in-4. 1826. 

* Frank (P.). De curand. homin. morb., lib. iv., p. 63. 

s Gimelle. Obs. sur l'emploi de l'iode dans le goitre, les scrophules et les dartres 
(Revue medic, 1821, t. vi., p. 81, and Journ. univ. des scienc. med., t. xxv., p. 5). — 
Kelley. Emploi de l'iode dans le goitre, les scrophules et les dartres (Journ. compl. t. 
c. xvii., p. 307). — Belliol, Essai sur les avantages de l'iode dans le traitement de la 
dartre furfuracee, etc. Paris, 1825, in-4.— Lugol. Mem. sur l'emploi de l'iode, in-8. 
Paris, 1829. Troisieme Memoire sur l'iode, in-8. Paris, 1831. (Scrophules cutanees 
ulcereuses et esthiomenes, pp. 46-61.) Masson (Th.). Sur l'emploi de l'opium joint a 
l'iode dans la scrophulecutanee ulc£reuse (Journ. de med., t. iv., p. 117). 



Internally, the iodated mineral water, prepared according to the 
formula of M. Lugol, appears to me the best of all the forms devised 
for the exhibition of iodine. The medicine may also be prescribed 
in the solid state in gradually increasing doses of half a grain, three- 
quarters of a grain, one grain, one grain and a quarter daily. I shall 
have occasion to revert to the effects of this active remedy under tin- 
heads lupus and syphilitic affections. 

139. Styptics and astringents to the skin have been strangely abused 
by quackery. Lorry cites a serious instance of their ill effects. He 
is, nevertheless, of opinion that the cure of old and obstinate cuta- 
neous affections having been once obtained, it is proper to endeavour 
to give tone to the affected parts of the skin by the use of various 
styptics, such as washes of the acetate of lead, acidulated baths, so- 
lutions of alilm, &c. ; and it is undeniable that this practice, much 
extolled by Bell, is often advantageous. The ill effects of the salts and 
oxides of lead have been greatly exaggerated. 7 These preparations 
are often useful in allaying certain inflammations of the skin, accom- 
panied by morbid secretions. Preparations of zinc s are used under 
similar circumstances, and with the same views. 

140. The sulphate of alumina 9 in solution as a wash, in the pro- 
portion of an ounce, or an ounce and a half of the salt to a pint ot 
water, lessens the morbid secretions of the skin in eczema fluens. 
lichen agrius, &c, and greatly relieves the itching that accompanies 
these diseases. This means, recommended by Turner, is not duly 
appreciated by Lorry. Borax 10 has also been employed externally, 
united with hog's-lard and alum, in the treatment of pityriasis and 
several other chronic inflammations of the skin. 

The sub-acetate of copper, or verdigris, besides a multitude of 
other preparations of this metal, 11 have long been familiarly used as 
external applications in cutaneous affections, especially in those of a 
syphilitic nature. 

141. Lotions and fomentations of simple cold water may be advan- 
tageously employed in a number of cases to diminish uneasy sensations 
of heat and itching. 

Compression 12 recommended by Bell, and particularly by Baynton in 
the treatment of ulcers, by Bretonneau in phlegmonous erysipelas of 
the legs, and by Velpeau in cases of severe burns, has been tried in 
eczema, scirrhous tubercles, nam, and Arabian elephantiasis. The 
situation and disposition of parts may sometimes render compression 
difficult or painful, and as it does not attack the conditions that lead 
to the formation of cutaneous diseases, it is generally to be regarded 
as a remedy of secondary importance. 13 

142. Charcoal 14 has been tried internally and externally as a remedy 
in scabies, which may be cured more certainly and easily by other 
means. Thomann obtained the cure of tinea in three cases, in the 
space of from three to five days, by the use of charcoal in powder, 
and soapy lotions. M. Brache did not succeed by the same means 
in less than a month. According to Hunold, charcoal made into a 
paste with rum is a popular remedy in various skin complaints in 
the city of New York. The trials I have myself made with charcoal, 
either alone or combined with sulphur, have satisfied me that it is of 
no use in favus, and that the other affections of the hairy scalp yield 

6 Vidi hominem suppressos per saturnini effectum herpetes longis atque atrocibus 
malis ventriculi atque hepatis redimere. (De morb. cutan., p. 342.) 

i Alexandri Tralliani, lib. i., c. 13. — Pauli^Eginetas, lib. iv., c. 2, p. 20. — Aitkin 
(John). Observations on the external use of lead. London, 1771, 8vo. Goulard. Traiie 
sur les effets des preparations de plomb, etc. Montpellier, 1766. — Delabrosse. Journ. 
de med., t. xxv., p. 576. — Frank. De cur. homin. morb., lib. iv., p. 67 (non esse tain 
perniciosum). 

s Journ. gener.de med., t. xxvi.,p.465. — Hanke. Emploi duchlorurede zinc (Arch, 
gen. de med., t. xx., p. 277). — Bell. On ulcers. 

o Lindt. Diss, de alumin. virtut. med. Gcett., 1784.— Alexandri Trail., lib. i., c. 13 
seq. — Paul. iEgin., 1. iv., c. 20. (Terra cimolia succo solani subacta.) 

10 — Reinhart. Utilite du borax contra les dartres furfuracees. (Revue medic, t. 
xvi., p. 462. — Arch. gen. de med., t. xiv., p. 458.) 

11 Desault. Journ. de Chirurgie, t. iii. — Stark. Inst, clinic, p. 30. 

12 Bretonneau. Avantages de la compression dans les inflammations de la peau,in-4. 
Paris, 1815.— Guerin. Journ. analyt., t. i., p. 93. Nouv. Bibliotheque, med., aout 1816. 

13 This remark certainly will not, and is not probably meant to apply to the treatmeni 
of ulcers of the legs, in which graduated compression is one of the most valuable 
curative means we possess. — R. W. 

«* Duval. Obs. et Reflexions sur le traitement de la gale idiopathique par la poudre 
de charbon. Bulletin des Sciences, t. viii., p. 228. — Thomann. Ann. inst. clinici de 
Virceb., 1799. Extract in Journ. gene"r. de med., t. xix., p. 223. — Grioris (F. B.). Con- 
siderations sur l'utilite de la poudre de charbon de bois dans le traitement de lateigne 
de la gale et de quelques autres affections cutanees, ia-4. Paris, an xii. 






DISEASES OF THE SKIN. 



application of charcoal in pow- 
tln- ulcers ipus, fcc., powerfully stimulates 

- th( quantity of discharge. 

rcoal told M. Poissant, a practitioner at Brest, 

ped Bcabies and tetter (la gale ei les dartres). 

I inflammatory affections of the skin 

.1 l> v the carburet of sulphur. 

143. e, 1 in powder, has been used outwardly 

■rut in the treatment of old ulcers; combined with various 

'<>ry ; and along with one or two parts of lard, 

pplication to different eruptions of the skin and scalp, with 

• (feet, ii is said, when these diseases had advanced to a state 

of ulceration, than when they were simply scaly or miliary. The 

workmen employed in the mine of manganese 2 at Macon" are said not 

i" he subject to itch ; and the people in the neighhourhood, attacked 

with this di k a remedy hylahouring at the works for a time. 3 

I he oxide in pills, and even by way of gargle in the same, and also 

in syphilitic affections, has been recommended by Dr. Kappof Bareuth. 

The muriate of manganese has heen prescribed, in various cutaneous 

aflections, in the dose of from one to twenty grains daily ; but I have 

made trial of the medicine myself. 

1 ! 1. Several inflammatory diseases of the skin, primarily of achro- 

nic nature, or become so, often remain long stationary ; circumstances 

in which local stimulants are had resource to with advantage. The 

practice is followed by a temporary exasperation of the symptoms, 

after which complete recovery sometimes follows. In the use of 

means we are to beware of exceeding certain limits ; for by 

pushing them too far the disease may be aggravated, and made to 

hie a more serious character than it had originally. 

1 15. time, united with an equal quantity of soap, is used to destroy 

small tumours, warts, excrescences, and naevi. Hufeland, 4 in cases 

of tinea, recommends a mixture of equal parts of olive oil and of 

lime. Lime appears to be the basis of a quack depilatory powder 

employed in France with success in favus. Combined with sulphur 

and some fatty body, lime also forms a pomatum of the same character, 

often employed in various forms of skin disease, particularly in scabies. 

I; must not be forgotten that when used externally, either by itself or 

mixed with oil, lime sometimes stimulates too much, or otherwise 

causes the too rapid disappearance of cutaneous eruptions. Internally 

the bydrochlorate of lime (muriate of lime) has been recommended 

hi cases of scrofula, lupus and elephantiasis. 

1 16. The liquor ammonia; properly weakened has been recom- 
mended to cheek the spreading of the inflammation in burns. Lotions 
of this preparation, and various salves into which ammonia enters 
have been long used in different cutaneous affections, with what ad- 
\ antage is doubtful. 

111. . lei ■■/ lotions, and liniments with various proportions of dif- 
concentrated acids have been recommended in the treatment 
of such chronic inflammations of the skin as impetigo, rosacea, pru- 
rigo, t\C. 

. leefic acid diluted with water, of old recommended in lepra and 
lichen, 5 lias been recently brought again into notice in these diseases 
1 \ Mr. Wilkinson. 

Sulphuric arid 6 has been used externally as a cautery or as a stimu- 
lus to certain chronic inflammations of the skin. .Wrie aria? combined 
with lard forms an ointment that has been greatly vaunted by Alyon. 
In a state of purity it is employed to cauterize various eruptions, or to 
destroy the surface of foul and ill-conditioned ulcers ; diluted with 
wa'i i it forms an excellent wash to many sores of the same description. 
The hydrochloric (muriatic) acid diluted with water favours the recovery 

i Bulletin des sciences meil.de Ferussac, t. xi., p. 315. 

leet Morellot. Memoiresur I'oxyde de Manganese dans les maladies cutanees 

\ctc*. de la societe de medecine de Lyon, t. ii., pp. 62-65.) — Bylvy. Quelques vues 

sur I'emploi de L'oxjde de Manganese dans le traiiemeDt des maladies cutanees. — 

Morellot. Sur le meme sujet (Annates de la sociele de medecine de Montpellier, t. 

ni., part i., p. 2fi2). — Villard fils (Actes de la societe de same de Lyon, t. ii., p. 112). 

3 Journal de Lerour, t. xvi.. p. 128. 

\ bibliolheque medicate. 1828, t. 3, p. 453. 

• s Opera omnia, in-8. 2 vol. ed. van der Linden. Ludg.Batav., t. i., 606. 
l)e humidoruui osa. 

e. and Physical Journal, 1802, p. 11 et suiv. — Agricola. Com- 
ment, in Puppium, de vuriolo, p. 547. 

sur les propriety tnedicales de l'oxyene, in-8o., 1791. 



of frost-bitten parts ; made into an ointment with lard, or united with 
sume fixed oil, it has been prescribed in tinea, various scaly eruptions, 
and scabies. The medicinal hydrocyanic, arid in the proportion of 

one part to two of spirit and twenty of water, has been found by Dr. 
A.T.Thomson to allay the pain and irritation of impetigo. 8 Dr. 
Schneider, of Dusseldorf, has derived peat benefit from the use of a 
drachm and a half of hydrocyanic acid, added to six ounces of spirit 
and as much rose-water, in many scaly aflections attended with severe 
itching, and especially in those eruptions upon the genital organs that 
often prove so troublesome. These prescriptions I have myself tried, 
and by and by shall have occasion to refer to the results. 

I 18. Deimann and Van der Bosch have celebrated chlorine applied 
externally in some skin diseases, 9 and Dr. Kapp has reported new 
instances of its successful use in cases where there appeared an excess 
of plastic power. Duncan has recommended in tinea and some ulcer- 
ated states of the skin, the application of an oil through which a current 
of chlorine has been passed. Chlorine has also been tried in scabies, 
and the Pharmacopee unwerselle gives a recip6 for a pommade anti- 
psorique or itch ointment composed of a drachm of chlorine and an 
ounce of hog's lard. 

149. The chlorate of soda was used by Alibert in lupus (dartres 
rongeantes) and by Roche in a case of tinea favosa (porrigo lupinosa, 
Willan) which had resisted other remedies. 10 We have also reports 
of three cases of eczema of the hairy scalp (tinea mucosa) treated by 
the same means, in the work of Chevallier, 11 who has given the for- 
mula of a pommade composed of chlorate of lime and turpeth mineral, 
which was found beneficial in a case of obstinate tetter (dartre rebelle.) 
According to M. Derheims 12 scabies may be cured in from six to ten 
days by a dilute solution of the chlorate of potassa, soda, or lime, or 
better by the same compounds prepared directly and containing an 
excess of chlorine. Prurigo of the female labia and various irritable 
stages of the vagina yield readily to lotions with the chlorate of soda. u 
I have further to add, that I have myself experimental proof of the 
usefulness of the chlorates in the treatment of a great number of 
chronic diseases of the skin. 

150. Experience has taught us that the nitrate of silver 14 may often 
be employed advantageously as a superficial cautery to the skin, when 
affected with obstinate chronic inflammation ; but it is also known 
that this active substance, prematurely employed, may be followed by 
an aggravation of the symptoms it was intended to counteract, and 
that when indiscreetly applied, it has sometimes caused great altera- 
tion in ihe texture of the integuments, and given rise to indelible 
cicatrices. 

151. M. A. Severinus 15 had recourse, in several cases of lupus, to 
the actual cautery, which had been previously employed by Albucasis 
in the same formidable malady. Saucerotte details the case of a little 
girl attacked by an ulcer consequent upon a burn, which he remedied 
by exposure to the powerful rays of the sun. 

152. It is very long since proposals were made to change chronic 
into acute inflammations of the skin, and thus by modifying their 
nature and accelerating their progress, more speedily to bring about 
their cure. It was with this view that Hippocrates 16 added cantharides 
to the ointment called karikon, which was used to dress certain ulcers. 
Celsus 17 also treated severe papulae by an ointment of cantharides. 

• 8 Thom ,™ n (A- T 0- On the employmentof the prossic acid as a local application in 
impetigo (The London Medic, and Phys. Journ., Feb., 1822). Bull, de soc. medic, 
demul., 1822, p. 165.— Bulletin des sciences medicales de Ferussac, t. ix. p. 268.— 
Revue medicale, t. xvi., 460.— Arch. gen. de medec, t. xvi p 289 

» Diemann.Doering's Journal fur die neueste hollandische Litteratur, 1 B. 1 St. p. 
Mt^buTi!' P ' 415 - An extract from *e medical annals of 

"> Bulletin des sciences medic, de Ferussac, fevr. 1824 p 153 

''Chevallier. L'Art de preparer les chlorures, in-8. Paris, 1*829 n 201 
w Gazette de sante du IS Decernbre, 1827. ' P " 

"Notice sur I'emploi du chlorure de soude en medecine. (Extr. du Bull des sc 
med. de Ferussac, t. vni., p. 91. k***u. uu duii. ctes sc. 

" Home (Everard). Practical Observat. on the treatment of ulcer* p.,. a™ t™ 

don, 1793.-Guillemineau (L. G.). De I'emploi du n S d W^'f ". f' T 

traitement ex.erne de quelques maladies, in-4o. Paris 826 -Icoli iZl^n *" 

v. x. p. 672. Jobert (de Lamballe). Emploi des caus inues da„," £ ,£, f " 

maladies de la peau (Journ. hebd. 2e serie, t. vi., p 9 Veloeau P m V • < ? CDt dM 

tiques dans le Ir. des mal. de la peau. (Nouv. rev. med., t. fv r "«f ? P ' deS CaUS " 

is M. A. Severinus, de efficac. medic. Francf., 1646, in-fol p 255 

'« Hippocrates, lib. de ulceribus., p. 515, ed. Focs.-(Econo'mia Hinnocr A„ 

" Celsus. De papulis, lib. v. "'Ppocr., Art. ** (l x n . 



PRELIMINARY CONSIDERATIONS. 



37 



Galen 1 advises us to excite suppuration in points of the skin affected 
by obstinate disease (lupus, mentagra), by means of a mixture of 
cantharides and hellebore, incorporated with grease and a variety of 
other articles. Paulus iEgineta, and particularly Aetius, have advised 
the same practice, which was revived by Pare 2 when, upon the recom- 
mendation of Hollerius, he ordered a blister to be applied to the face 
of a woman affected with rosacea. Several other pathologists have 
had recourse to applications of cantharides in lepra, lupus, and pso- 
riasis. Lorry was witness to the same disturbing means successfully 
resorted to by a quack. I have myself had frequent and successful 
recourse to it ; but I have always preferred ordering repeated small 
blisters, to the application of a single large one, where there was 
a considerable extent of diseased integument to be treated. It is 
proper to remember, that the patient of Pare suffered a violent fit of 
delirium. 

M. Blin thinks that the meloe proscarabeus made into an ointment 
with grease, is more useful than any other remedy in the treatment 
of common cutaneous diseases (dartres); and he has proposed to try 
this salve in tinea. 3 Selle, before this, however, had recommended 
the same means, which causes the diseased parts to which it is applied, 
to suppurate as a preliminary to their cure. 4 

Poultices of house-leek (sempervivum), and of the greater celan- 
dine (chelidonium majus), the juice of the euphorbiaceae and of other 
acrid plants, the leaves of the clematis vitalba, the root of the impe- 
latoria, ostruthium, &c, are also occasionally used to stimulate cer- 
tain chronic inflammations of the skin. 

153. The essential oil of turpentine 5 has been tried in some cases 
of tinea, and of old ulcers, and the animal oil of Dippel 6 has been 
found efficacious, applied externally, either pure or mixed with com- 
mon oil, in some cases of phagedenic tinea, and of scrofulous sores. 
Poncelet had already recommended it, particularly in the latter malady. 
The remedy ought always to be used mixed with water, or combined 
with some greasy substance ; for when applied pure to inflamed sur- 
faces, it is apt to cause violent headaches. The oil of cajeput, and 
the petrolium, either alone, or mixed with other substances, have been 
given internally, in properly regulated doses, and with success, in 
some obstinate cases of skin disease. 

154. Blisters are now and then made use of to divert an erup- 
tion of the face or some quarter where it is very troublesome, to 
another region where it is less apparent or annoying. I have thus 
succeeded several times, in transferring to the arm or thigh, eczemas 
that had broken out on the ears, and on the genital organs. In less 
successful instances, the blisters have only caused new eruptions, 
without displacing the old ones. It is always proper to establish the 
drain, before venturing to employ drying or discutient remedies. 

155. Blisters 7 are further useful in restoring any eruption, the dis- 
appearance of which has shortly preceded attacks of internal disease. 
It is occasionally indispensable to apply the blister to the very place 
which the eruption had occupied. 

A servant girl was admitted into the Hotel-Dieu, complaining of a 
sore throat of several months' standing. There was no apparent in- 
flammation of the parts about the fauces, but they appeared drier than 
usual ; on learning that the pain in the throat had followed the disap- 
pearance of an eruption (dartre) from the fore part of the neck, the 
physician, M. Bourdier, ordered a blister to be applied to this region; 
on the morrow, the patient found herself much better, and the dryness 
of the throat was gone. Having quitted the hospital immediately, 
she neglected to keep the blister open, and was compelled to return 
within a fortnight, on account of a renewed attack of her indisposi- 
tion. Another blister applied to the same spot, was followed by the 
same happy effects as in the first instance. M. Bourdier now thought 
of replacing the blister on the neck by one on the arm, but no sooner 
had the former healed up than the throat again became parched. 

1 Galen. De coroposit. med. secund. loc, lib. v., cap. 8. 

* Pare (Ambr.). CEuvres completes ; in-fol., lib. xxi. Des venins, p. 790. 

5 Memoires de la Societe Linneenne du Calvados, t. i., p. 94. 

* Neue Beitraege zur Natur und Arzneygelahrtheit. Berlin, 1781, in-8., trad, en 
Francais par Coray. Montpellier, 1796, 2 vol. in-8. 

■ Biblioth. med., t. lx., p. 128. Gazette de sante, No. 21, Septembre, 1818. 

6 Bulletin des scienc. m£dic. Aout., 1818. 

7 Bnchner. Diss, de vesicatoriorum ad exanthemata a nobilioribus partibus evo- 
canda efficacitate. Halee, 1758. — De Meza. Diatrib. med. tres. Hafnise, 1775. 

10 



Blisters were in succession applied to the shoulders, and to the nape of 
the neck, but in vain ; so that at length it became necessary to apply 
a third to the immediate seat of the eruption. 8 

No case more conclusive than this as to the point proper to be 
selected for the application of blisters in skin diseases, can well be 
imagined. 

156. Blisters, so generally prescribed as drains in chronic inflam- 
mations of the skin, are almost always hurtful when the disease ex- 
tends over a considerable district of integument. For children, and 
occasionally for adults, we prefer the wood of the daphne merzereum, 
which causes an oozing of ichor, analogous to that of eczema, to the 
use of the cantharides. I have sometimes imitated the practice of 
Jaeger 9 in eczema of the hairy scalp, with advantage. — ThiS practice 
consists in applying blisters to the arms, and keeping them long open. 

Electricity is occasionally used as a stimulant in skin complaints in 
the same manner as blisters. 

157. After the sudden disappearance of a spontaneous inflammatory 
affection of the skin, when any internal disease is set up, the happiest 
effects are sometimes derived from the use of caustic issues. 10 I have 
seen subjects sprung of parents who laboured under eruptive diseases 
of the skin, and who had, without any evident cause, fallen into an 
indifferent state of health, recover their strength materially after the 
application of one of these drains. 

158. Besides the direct action which it is proper to keep up in the 
part of the integuments immediately affected in diseases of the skin, 
it is further very generally necessary to effect some modification in 
the constitution of those labouring under them. It is to this slow, 
deep, and searching action, that a multitude of medicines owe their 
reputation and efficacy. So that the opinion held of old by Oribazius, 
that the complete cure of skin diseases was not to be accomplished 
without internal or general treatment, is now very commonly admitted. 

159. I have derived the greatest benefit from venesection in nume- 
rous chronic inflammations of the skin. Several practitioners restrict 
the measure of abstracting blood, in affections of the skin, to cases 
occurring in the strong and lusty, or in subjects of a sanguine or bilious 
constitution. 11 For myself I declare that I have repeatedly had recourse 
to blood-letting, with the greatest advantage, even when it seemed to 
be contra-indicated by the general state of the patient, particularly in 
elderly persons suffering from sleeplessness caused by prurigos, lichens 
and eczemas, that had resisted all other treatment. Avicenna long 
ago recommended the same practice. 

In chronic states of inflammation of the skin, the blood is commonly 
buffy, even in the aged. This condition of the circulating fluid ought 
to be taken into account, as its appearance might incline us to recur 
to blood-letting oftener than is really necessary ; and we must be very- 
guarded not to change this state of the blood too rapidly by the 
repeated use of the lancet; the constitution of the patient would 
inevitably suffer : and further, as I have frequently had occasion to 
observe, the blood, becoming more and more serous, might, never- 
theless, preserve its disposition to coagulate with the buffy coat, and 
thus lead to serious mistakes. In general, the bleedings ought not 
to be repeated but at somewhat distant intervals, once a month for 
instance, and at the periods of menstruation in females labouring 
under skin complaints, which have been preceded by amenorrhea or 
dysmenorrhcea. 

160. When recourse is had to blood-letting, the patient ought to 
be put upon a strict regimen. He ought to have some wild vegetable 
decoction for his usual drink, and to make habitual use of baths and 
gentle aperients. Mercurialis 12 managed herpes and lichen during 
their whole course, by means of diet, general bleeding, leeches, and 
baths. Some pathologists, however, regard regimen as the mere 
preparatory treatment to a regular course of purgatives. Others, 

8 Bouchard. Essai sur l'emploi des derivatifs externes, in-4. Paris, 1816, p. 55. 

9 Jaeger (J. Ch.). Funfzig praktische chirurgische Cautelen fur angehende Wun- 
daertze. Francfurt am Mein, in-8. 1788-1792. 

10 Pujol. Maladies chroniques de lapeau,t. ii.,p.201. — Lorry. De morbis cutaneis., 
p. 325.— Kreysig. Hufeland's Journ. der praktiscben Heilkunde, xvii B. p. 126.— 
Waton. Journ. de med., torn. Ixxxiii., p. 342. 

ii Venae sectio, quae, in bibliosis atque actuosis consiitutionibus numquam omit- 
tenda, nocere tamen potest in languidulis atque inertibus. (Lorry. De morbis cutan., 
p. 323.) 

12 " Etiam si non adsint indicia mittendi sanguinis." (Mercurialis. De morb. cutan. 
De Lichenibus, p. 78, in-4. Leyd., 1623.) 






DISEASES OF THE SKIN. 



s imbining the action of pur| 

; blood-letting, with the occasional use of the tepid 
mployment being regulated solely 

is and of the skin. This last method 
1 hold applicable in a greater numbei than any of the former. 

I some have proposed the addition of 

rnal remedies known by the name of styptics and repellents, 

i (I o( nut-galls, alum, acetate of lead, &c; and we are occa- 
sional obliged to bai se to such measures. Halle 1 has pro- 
• hod analogous in all respects, with the exception of the 
bleedings, and which consists essentially -in the combined action of 
and the warm hath. 
ice of treating chronic inflammations of the skin by the 
- alone bas been generally but improperly entitled 
'/ in France. Besides the fact that there is no men- 
tion made ot these diseases in this author's book, 2 the practice is very 
old, and a physician of the name of Joubert 3 wrote particularly upon 
ubject. It requires to be carefully pursued even when the 
\ e apparatus appears to be healthy. 
Incautiously employed, purgatives sometimes induce a state of 
I irritability in the intestinal canal, followed by reaction of 
the >kin ;* or they excite chronic inflammations of the stomach and 
which are difficult to treat, and apt to bring on incurable 
alterations in the tissues of these parts. It was the fear of these 
consequences, or metastases, as they were termed, that led Van Hel- 
mont to reject the use of cathartics entirely in the treatment of diseases 
of the skin. The same apprehension has of late very much circum- 
scribed their exhibition in France, [in England, however, there is 
no such reserve ; and] I must allow it to be an unquestionable fact 
that the artificial gastro-inteslinal inflammations excited by purgative 
medicines subside from the moment the action of these remedies is 
suspended, if the irritation be not kept up and rendered permanent 
by some individual peculiarity or idiosyncrasy. 

L61. Mild aperients or laxatives are frequently employed in the 
treatment of diseases of the skin. Weak infusions of rhubarb sweet- 
ened with manna for children, the different saline purgatives, the 
sulphates of soda, of potash and of magnesia, the tartrate of potash 
and soda, the sulphate of potash with sulphur, in the dose of one or 
two drachms in a large quantity of water, or some mild mucilaginous 
fluid, as also any of the common saline mineral waters, have all 
essentially the same effects, and fulfil the same general indication. 

Sulphur and calomel are also employed as aperient medicines, and, 
like other purgatives, when prescribed along with a suitable regimen 
and the use of the tepid bath, are often of service. 

162. The ancients regarded active purgatives as very effectual 
medicines in diseases of the skin: Galen, in the case of a woman 
labouring under an affection of this description, which was stated to 
have resisted remedies of every kind, when he learned that purgatives 
had not been tried, prescribed the strongest cholagogues, and in a 
few days the patient recovered. 5 The rashness of empiricism some- 
times gains a triumph over the reserve of the better informed physi- 
cian : the powder of, lilland" has accomplished cures without number. 
Such results ought to inspire us with greater confidence in this method 
of treatment, from which I have myself derived the greatest advan- 
Whilst prescribing active purgative medicines, we must beware 
of harassing the constitution of the patient too much, and above all 
of inducing disorders more serious than the one we are combating. 7 
Oribazius 8 and Aretseus 9 have recommended the hellebore in Greek 

1 Hallo. Mem. de la soc. roy. de mfedec, in-4, torn, viii., p. 314. 

J Hamilton. Observations on the utility and administration of purgative medicines, 
8vo. Edinb., 1805. 

» Joubert. Cutest, med. 5, 6. — De affectibus pilorum et cutis, etc., 12mo. Genevae, 
15VJ. 

hmer. Diss, de purgantibus chronica cutis exanthemata nonnunquam exacer- 
bantibus. 1! 

* Galeni Method, med., lib. xiv., cap. 17. 

« A French quack medicine, the nature of which I have not been able to discover. 
From the text we may judge it to be some active purgative. — R. W. 

I T6m demCim providendum ventriculoet intestinis, ne aliquod inflammatorise irri- 
5 >ignum in pessimam degeneret phlogosin. (Lorry. De morb. cut., p. 335.) 
ctacea art. medic. Paris, 1556, in-8., lib. vii., et lib. viii., cap. iii. 
et vi. 

» Aretcci. Opera, ed. Boerh., in-fol., p. 136. 



elephantiasis, and several other diseases of the skin. Galen 10 is said 
to have cured the leprosy by .1 copious bleeding, the warm bath ;\nd 
hellebore. Paulus Egineta 11 employed the same medicine externally. 
Celsus advises the black hellebore, and, in modern times, Schmieden 
used the extract of hellebore successfully in two cases of Greek 
leprosy; Fabricius Hildanus, by the same means, cured a young girl 
labouring under a very sc\ ere affection of the skin ; Willan prescribed 
the tincture of hellebore in the treatment of squamous inflammations; 
Smith has seen good effects from the ointment of hellebore externally, 
and the tincture internally; according to Swediaur, fomentations 
with the decoction and tincture of hellebore, are useful in psoriasis, 
prurigo and tinea; Bigelow, in inveterate cases of skin disease, 
recommends a trial to be made of the ointment of the hclleborus 
viridis. I am sorry to add that these results, so favourable in appear- 
ance, are really of little value. In the first place, there is great 
obscurity as to the species of hellebore made use of by the ancients," 
and a serious error was committed when substances so dissimilar as 
the veratrum album and helleborus niger were included under the 
same common denomination. In the hospital of La Charite, I have 
prescribed the powder of the helleborus niger in doses of from 60 
to 80 grains, and the tincture of the same plant in quantities of three 
drachms, without producing the slightest disorder in the digestive 
functions, or any trace ensuing of modification in the appearances and 
symptoms of many different affections of the skin. The veratrum 
album must be made the subject of farther experiments. 

163. The gratiola officinalis 13 has often been used as a purgative 
in the dose of half a drachm or a drachm in infusion, or of 20 or 30 
grains in powder, in the treatment of skin diseases. This plant 
has even been said to be efficacious in venereal ulcers of the nose 
and throat ; and M. Delavigne has seen it used with success in 
scabies and several other cutaneous affections. Stoll and De llaen 
were in the habit of combining gratiola with the sublimate in venereal 
affections generally. 

164. The alkalies, 1 * particularly the liquor potassa?, in doses of 20 
or 30 drops, and lime-water, 15 were prescribed by Willan in several, 
especially squamous, forms of cutaneous disease. 

The subcarbonate of soda and the subcarbonate of potash, in doses 
varying from a few grains to half a drachm or a drachm in a pint of 
vegetable infusion, or combined with sulphur, have been tried in 
several cutaneous affections. Ammonia' 6 and its subcarbonate have 
been employed more especially in diseases presumed to be of a 
syphilitic nature. The subcarbonate is prescribed in doses of 10 or 
15 grains, twice a day. 

165. The acids are more generally and unquestionably useful than 
the alkalies. Each of them has properties peculiar to itself; in proof 
of which I can quote the specific action exerted by the sulphuric acid" 
on ulcerated eczema and lichen agrius, and that by the nitric acid 
on impetigo and pityriasis. The diluted sulphuric acid of our phar- 
macopoeias may be prescribed in doses of from 10 to 20 or 30 drops, 
two or three times a day, in any convenient vehicle, such as barley- 
water properly sweetened. Much larger doses than these may, how- 
ever, be prescribed without impropriety. I have myself given as 
much as a drachm, and Mursinna has gone the length of even hall 
an ounce daily. The patients ought to swallow these large doses, 
properly diluted, by little at a time, and even to drink some pure 
water afterwards, until the stomach becomes accustomed to the 
medicine. 

10 Galeni. Art. curat, ad Glaucom, lib. ii. 

11 Pauli iEgineiae Opera, lib. iii., chap. ii. 

n 4ir,r le H' a nni e n ma Tf S SUr i^fnT des a^s (Journ. gen. de medecine, t. Iii, 
p. Sfe SUr hellebores des aDcie °s (Journ. gen. de med., t. xlir. 

ErL D ge! a i V k e in-4. ** ^ ***** ^^ ^^ Usu in """bis cutanea 
'« Blane. Transactions of a Soc. for the improv. of medical anH /-Kir,,^ „„i i^-- , 

ledge, vol. ii.— Mitchell. Medical Repository, vol iv n ii ai , 9 chlrur S lcal know - 
'5 Detharding (G. C.). Diss, de aquse calcis vivae intern'o nan =oi„.„ 

morbis exanthemancis chronicis. Rostoch., 1746Jn-4 U,an In SpeCie in 

16 Ancien Journal de Medecine, t. xli., p. 387.— t. xliii p 248 —P it, 

nouveau contre les maladies venenennes, tire du resne animal on FW , cmede 

tus des alcalis volatils, in-8. Paris, 1774! animal, ou Essai sur les ver- 

n Home(F.). Clinical experiments, histories and dissections. London lvfti o 
Darwin. Zoonomia, in.-Fos broke. On the use of the dilute Mut^Ja'~ 
neous diseases. (The London Medical and Surgical Journal June 1822 ) ln ° m ' 



PRELIMINARY CONSIDERATIONS. 



39 



The utility of the hydrochloric (muriatic) acid, diluted with water 
and administered in grit gruel, decoction of elm-bark, or of dulcamara, 
has been acknowledged by good and credible practitioners. This 
acid is usually prescribed in the dose of a drachm or a drachm and 
a half to the pint of fluid, with an ounce of sugar. 

Nitric acid, 1 more energetic than sulphuric acid, has been chiefly 
employed in syphilitic cases. Alyon prescribed the pure acid to the 
extent of a drachm in two pounds of water, half a glassful to be taken 
at a time, every two hours, and sucked through a tube to protect the 
teeth. The strength of this acid varying in the shops from 20° to 
42° of the acidometer of Baume, it is always necessary to indicate 
the degree of concentration in the prescription. The various sherbets 
prepared with acetic acid, or with the citric or tartaric acids, are 
agreeable diluents, rather than very active therapeutic agents. 

166. The preparations of antimony? first tried in the cutaneous 
diseases of animals, and afterwards applied by Basil Valentine to the 
treatment of the same affections among men, have been the subjects 
of numberless experiments. They are most generally combined with 
other medicines of a more or less active nature ; and I shall take 
care to mention the most reputed of these compounds when I treat of 
the diseases in which they have been more especially recommended. 

167. The sulphuret of antimony, made use of in chronic diseases 
of the skin by Baldinger and Vogler, and in scabies by Hermann and 
Tissot, forms the basis of a multitude of quack remedies against skin 
complaints. Cullen prescribed this substance in the dose of from 
half a drachm to a drachm, during several successive weeks, without 
perceiving any effects from its use. In one or two cases only, in 
which it was given in a very large dose, did it excite nausea and 
vomiting. I have myself ordered it in doses of one, two, and three 
drachms during the course of twenty-four hours, without any benefit, 
but also without causing derangement of the digestive organs. It is, 
therefore, subject of astonishment to observe the care that is taken to 
adjust and reproduce formula? in which the sulphuret of antimony is 
administered in the dose of four, six, or eight grains. As to the remote 
effects which the sulphuret of antimony exerts on chronic diseases of 
the skin, they have appeared to me much less conspicuous than such 
as followed from the rest enjoined and the regular lives led by the 
patients in our hospitals ; circumstances that mingle with and com- 
plicate all our experiments, and that are too often overlooked or 
neglected by therapeutic inquirers. 

The same remarks are applicable to several other preparations, such 
as the antimonial ethiops of Huxham, — a mixture of antimony, mer- 
cury, and flowers of sulphur, which has been especially recommended 
in the treatment of scrofulous complaints. So are they likewise to 
the ointment of sulphuret of antimony, the effects of which used to 
be boasted of in several skin diseases, but which never seemed to 
me to have any other action than that of impure lard. The sulphuret 
of antimony, as I have said, is often combined with other remedies of 
greater or less efficiency. Hufeland prescribed it along with sul- 
phureous baths and decoction of dulcamara in doses of a scruple three 
times a day gradually increased to half an ounce ; and this was done 
successfully, for at the end of six weeks the patient found herself 
free from the skin disease under which she had previously laboured. 

The decoction of a certain quantity of the sulphuret of antimony is 
a much more active medicine than a like amount of the substance in 
powder. M. Guibourt boiled an ounce of the sulphuret of antimony 
in sixteen ounces of water till half the fluid was consumed. The 
filtered liquor, having the hydrosulphate of potash and hydrochloric 
acid added to it, let fall one grain and 8-10ths. of dry sulphuret of 
arsenic, which correspond with a grain and 44-100ths. of arsenious 
acid. This transformation of an insoluble sulphuret of arsenic, which 
exists mixed with the sulphuret of antimony, into a soluble and sin- 
gularly active medicine explains how the decoction of the sulphuret 
of antimony becomes more energetic than the sulphuret itself. I have 
seen patients take, during several days, half an ounce of the sulphuret 

1 Alyon. Essai sur les proprietes medicates de l'oxygene, 8o. Paris, 1797. 

2 Basil Valentine. Triumphwagen des Antimonii, 8o. Leipsick, 1604. — Brisbane 
(J.). Select cases in the practice of medicine. London, 1772, 8vo., p. 45. — Bell. On 
Ulcers, 8vo. Edin., 1778. — Chambon de Montaux. Observ. clinicae. Paris, 1789.— De- 
sault. Journal de Chirurgie,t. iii. — Gutgesell. Hufeland's Journ.der pract. Heilkunde, 
xi. b. — Huleland. Die Skrofelkrankheit. Tr. ea Fr. par Bousquet, in-8. Paris, 1821, 
p. 171. 



of antimony without feeling any effects from the medicine, but they 
were rather severely purged by a decoction of only two drachms ol • 
the same substance. And it may well be imagined that three-fourths 
of a grain of arsenious acid could not be taken with impunity at a dose, 
and this is the quantity of this active poison which the amount of 
impure sulphuret of antimony specified yields to boiling water. 

168. The beneficial effects of those magistral formulae entitled tisan 
of Feltz and decoction of Jirnoult, sometimes employed in the French 
hospitals in diseases of the skin, particularly in those of a syphilitic 
nature, appear to me owing to the formation of a certain quantity ot 
arsenious acid. These tisans, however, are never identical, for the 
purity or mpurity of the sulphuret of antimony employed, as well as 
the mode of preparation, makes it impossible they should ever twice 
contain the same kind or amount of ingredients. Other accidental 
circumstances may also seem at times to give the sulphuret of anti- 
mony properties which it does not possess in fact ; the ingestion for 
example of a mineral acid after a dose of the sulphuret will almost 
always excite vomiting. 

The sulphuret of antimony and mercury (antimonial ethiops) possess 
almost the same properties as the crude antimony. 

The protoxide of antimony in the dose of the tenth of a grain 
triturated with sugar and James's powder, has been recommended 
in diseases attributed to the recession of inflammations of the skin. 

169. The antimonial wine of Huxham used to be in great vogue 
in England in cutaneous affections. 3 M. Fages 4 informs us that he 
treated some of these diseases successfully by the tartar emetic in 
doses gradually increased. A patient of M. Fages, affected with 
skin complaints, took, during the first day he was under treatment, half 
a grain of the tartrate of antimony and ten grains of dulcamara ; the 
dose was gradually increased, and at the end of a hundred and seventy- 
two days, the patient was taking every day, at two different times, 
thirty-two drachms of the extract of bittersweet and thirty-two grains 
of the emetic tartar. Another patient similarly affected took towards 
the fortieth day twelve drachms of the extract of dulcamara and fen 
grains of the tartrate of antimony. A third patient by degrees obtained 
the point when he was consuming eighty-five grains of the extract of 
rhus radicans and sixteen grains of tartrate of antimony every day. 

Several patients whom I have put on this plan, beginning with a 
grain of the tartrate, were either attacked with diarrhoea or vomiting ; 
others had a number of liquid stools daily ; a few only were found 
who could bear the medicine ; but I never got the length of the 
immense doses of M. Fages. These cases, at all events, prove that 
habit is an unequivocal cause of the endurance of remedies. In the 
same manner, and in the same kind of cases as those in which M. 
Fages prescribed his medicines, some practitioners have tried the 
effects of an electuary composed of five grains of the extract of 
poisonous sumac and a grain of tartar emetic. 

170. Embrocations and lotions of the tartrate of antimony have 
also been employed to bring several chronic inflammatory affections 
of the skin into a more active state, and to accelerate their termination. 
Sir W. Blizard applied a solution of the antimonium tartarisatum in 
tinea/ and Dr. Temina 6 prescribed with good effects the same medi- 
cine in small doses to the wet-nurses of infants at the breast who were 
affected with a similar disease. M. Recamier 7 treated successfully a 
case of gutta rosea with an ointment of the tartrate of antimony. 

171. The chloride of antimony is used as a caustic in anthracion 
or malignant pustule ; and Kermes mineral (the hydrosulphate of 
antimony) enters into the composition of several salves contrived for 
diseases of the skin. 

172. When chronic inflammations of the skin are set up in weak 
or scrofulous constitutions, or otherwise, when such diseases are 
preceded by dysmenorrhoea, amenorrhcea or chlorosis, the principal 
indication is to modify the constitution, and then the preparations of 
iron are the medicines of most avail : I shall quote many cases in 

3 Huxham. Observations on antimony, p. 60.— J. Brisbane, 1. c. p. 45. — Adair. 
Medical commentaries, vol. ix., p. 35. 

* Fages. M6moire sur I'efficacite du tartrate antiraonie de potasse combine" aux 
extraits de douce-mere et de rhus radicans, dans le traitement des dartres. (Recueil 
period, de la soc. de med., t. vi.) 

* Blizard. Lond. Med. Journ., vol. viii., 1787. 

6 Annali univ. medicina. Luglio, 1829.— Revue Mcdicale, 1829, t. iii., p. 493. 
i Biblioth. medic, t. lvii., p. 340. 






DISEASES OF THE SKIN. 



i tided small quantities 

■ationa of iron to children 

phulus. Chalybeate medicines have 

il in eases of purpura hemorrl 

Van have been lauded in the same 

Carmichael lias praised the carbonate of iron even 

ctions; 1 have tried it several times in cancer of the 

skin, always unsuccessfully as the disease itself was concerned, but 

nails with advantage to the general constitution of the patient. 

\'A. Qrapkitt or plumbago, 3 looked upon some years ago as a 

rarburet of iron, now regarded as a kind of carbon or coal containing 

ae admixture of iron, has been used in the treatment 

of chronic affections of the skin, from a remark made at Venice, that 

ikinen employed in the manufactory of pencils were speedily 

cured of any cutaneous diseases they might have been labouring 

under when they begun this business. M. Marc informs us that he 

llbstance in obstinate herpetic affections. Hufeland 

i tails the ease of a lady forty-one years of age labouring under 

a which resisted every other means, but yielded to the internal 

.iel «\ti mal use of plumbago. In his report from 1817 to 1818 he 

speaks of the good effects of this remedy. It is administered internally 

in doses varying from twelve grains to a drachm daily in any form, — 

powder, electuary or pill ; occasionally it is combined with sulphur, 

and with some mercurial, as the sublimate. The stomach bears the 

medicine readily, and it is said greatly to increase the secretion of 

urine after its use has been continued some days ; two or three ounces 

are said to be enough to cure the most obstinate cases. Externally 

i' is best applied mixed with some unctuous body. Contradictory 

accounts of the value of the plumbago as a medicine have been 

published in the Medical Journal of Saltzburg. 4 My own mind is 

not yet made up on the matter; I have not had experience enough to 

•■nable me in judge. 

174. The preparations of mercury are universally employed in affec- 
of the skin, both internally and externally. 

Geber, Meuse and llhases are held the first who prescribed mercu- 
iiul ointments in cutaneous affections and ulcers, against pediculi, &c. 
Employed by Theodoric and Guy de Chauliac in scabies, herpetic 
eruptions, different species of tinea, plica, frambd'sia, and elephantia- 
sis, and subsequently applied by Jacobus Berengarius Carpus and 
I'allopius to the treatment of venereal affections, various preparations 
of mercury were afterwards administered internally by Vigo, and have 
not since ceased to be extensively employed in the practice of medi- 
cine. 

175. Mercury in the metallic state, intimately combined with grease, 
soap, or some vegetable conserve, in the dose of four, six, or eight 
grains, is a powerful remedy, the action of which, in syphilitic cases, 
and in some other affections of the skin, is most remarkable and most 
beneficial. Mercury administered in this form is a much better medi- 
> me in general than when rubbed into the system in the shape of an 
ointment. United with several other substances, mercury has been 
forced into an immense variety of forms, each possessed of a different 
degree of activity. It is now found united with sulphur, and now 
with sulphur and antimony, — the latter, a form that has been recom- 
mended by Hufeland, in chronic eruptions of the skin during child- 
hood. Lastly, the black powder called Etfdop's mineral, which is 
produced by combining a quantity of mercury with twice its weight 
of sulphur, has been tried with some success in several forms of 
cutai .ise. 

]'*'<. Since the experiments of Lalouette were published, 5 cinnabar 

rations have been had recourse to with evident advantage in in- 

ate Byphilitic and other obstinate affections of the integuments, 

bj directing the vapour through a funnel to the affected parts, or ap- 

tchreibang too Pyrmont. Leips., 17 ; 4, 1785, 2 Bde.,in-8o., 
•; li., p. 106, 183. — l!ramli<. Erfahrungen ueberdie Wirkung der Eisenmittel in alle- 

ins besondere. Hannover, 1603, 8vo. 
ii the effects of carbonate and other preparations of 
Dublin, ls09. 
Weil DerGraphil neuenideckies Heilrniltel gegen die Flechten, in-9. 

809.— Hufeland. Troisieme rapport de l'institui polvclinique de Berlin, 
rn Archlv., 1810, mar/., 387.) 
l.p. 337. 
1 Ancien Journ. de Med., torn, xiv., p. 19. 



plying it by means of a close box to the Surface of the body generally. 
Ih. quantity of cinnabar used at each fumigation is from halt to I 
whole drachm, and the process is repeated every two or three days. 
Carelessly administered, cinnabar fumigations are callable ol causing 
accidents o( a serious nature. 

Mixed with camphor and some unctuous substance, cinnabar forms 
an ointment that has been recommended in several herpetic eruptions, 
and against pediculi. It has been prescribed externally by way of 
friction, 8 and internally in small doses in the treatment of impetigo. 

177. The proto-chloride and dciito-chloridc of mercury (calomel and 
corrosive sublimate) enter into the composition of almost all the anti- 
herpetic ointments which we find preserved in pharmacopoeias and for- 
mularies. In the cases communicated to Rivcrius, we find two of syphi- 
lis cured by the use of calomel. Willan and Bateman made extensive 
use of these preparations in the treatment of cutaneous diseases, and 
certainly many cases have been successfully combatted by their means. 7 
I believe myself to have been one of the first who observed that the 
white precipitate (calomel obtained by precipitation) mixed with lard 
in the proportion of a drachm to an ounce of grease, applied in fric- 
tions to the affected parts in the quantity of one, two, or three drachms 
daily, exerts a specific power over two forms of squamous inflamma- 
tion, namely, lepra and psoriasis. I never saw these frictions followed 
by salivation, which is so frequent a consequence of the internal exhi- 
bition, even in very small doses, of calomel prepared in the ordinary 
way. In this respect, therefore, there is an actual difference between 
an ointment of precipitated calomel and the common blue or mercu- 
rial ointment, the action of which on the salivary glands is constantly 
the same. I have seen patients labouring under old and inveterate 
psoriasis use half a pound of precipitated calomel by way of friction, 
without their mouths becoming in the slightest degree affected, and 
obtain a perfect cure. Calomel, taken internally, in the dose of five, 
six, eight, ten, twelve, sixteen, or twenty grains, is commonly fol- 
lowed by several dejections ; but besides this action, it exercises 
another and not less remarkable influence on the constitution. As an 
alterative, in greatly diminished doses it often excites salivation, some- 
times after a very small quantity only of the medicine has been taken. 
I shall give several cases which prove that calomel applied to the pitui- 
tary membrane of the nose, has the power of curing syphilis. In com- 
bination with the sulphuret of antimony (Plummer's pill), with the 
golden sulphuret, or sub-hydrosulphate of the same metal, calomel 
enters into the composition of a multitude of formulae, that have pos- 
sessed and still retain a certain reputation. In fine, calomel internally, 
and corrosive sublimate externally have been recommended together 
in many forms of disease of the skin. 

178. The deuto-chloride of mercury 3 is the basis of a great many 
simple and compound medicines. Brisbane showed how eminently 
useful this active substance might become in the treatment of diseases 
of the skin, when other mercurial preparations had failed to do good. 
Lorry and many other practitioners have confirmed these fortunate 
results by their success. I am in the habit of using the sublimate 
with advantage in the treatment of chronic and obstinate eczemas, in 
smaller doses, too, than are usual in syphilitic cases. During its use, 
patients ought particularly to avoid exposure to cold and moisture. 
I have sometimes combined the action of purgatives with that of the 
sublimate. 

Sublimate baths, (from two drachms to one ounce in two hundred 
pounds of water,) conceived by Baume, have been particularly ap- 
plied to the treatment of syphilitic affections ; and this mode of ad- 
ministering mercury has been extolled by M. Caffe and M. Wedekind, 
who have proposed a particular formula for the purpose (half an ounce 

2e 6 sTrTifp. ST™" 1 ^ '* SyPh '' iS **' '" friCti ° ns cin ™brees. (Rev. med., 
' Vacquie;. Journ. complem. du Diction, des scienc. medic t vy.i n «><;* 
* Cotton (S.). An herpeti, licet non venereo snbl ma^m'rnrr ;,P » 
in-4., 17721-Hoffmann.B.ss. de mercuno in' affeSis rm a „S a' ParlS "!• 

CWittwer Ph. L.). Collect. Diss. Argent. i^Brfsbane OW? a Ar S er "° ra " 
Society of Physicians, v. i., n. 149.-Caffe. A van a~es des S»! a " d "T^ b3 ? 
traiternent des maladies cutanea et venerfennes -5 Par " Ts\Tt ft? J 
Heildelberg. klinische Annalen., 1829, p. 557 (Extract in ArrV, L \ 6 — Wedek,n,; - 
p. 275).-Bullet,n des scienc. medic, di ■ Ferussa^ ■ t xx n 2 S' *T d , raed - '' **! 
eiter. du sublim* dans les maladies de la peau (Bullet Mcs \c J^Ta^ Em V ]cn 
xvni., p. f.3).-Miguel. Inconveniens du subliro* dans les mTl a l'i,c ^ er ! ]ssac ' l 
(Arch. gen. de med., t. jvi., p. 290). maiacnes de la peau 



PRELIMINARY CONSIDERATIONS. 



41 



of sublimate and the same quantity of muriate of ammonia to each 
bath). I have many times prescribed these baths, and have never 
seen salivation follow their use ; but their good effects have also often 
appeared to me to be very questionable. I have never ventured to 
order them in a case of serpiginous ulcerated syphilis, fearing that 
the sublimate might be absorbed in too large a quantity. The length 
of time during which the baths are taken, the state of the skin, and 
especially the degree of aptitude for absorption possessed by the 
integuments, necessarily influence the advantages and inconveniences 
of mercurial baths. 

179. The sublimate has been employed as a lotion in scabies; Gow- 
land's lotion has still some reputation in England in rosacea. — At the 
Hospital St. Louis, a solution of a drachm of sublimate in a pound of 
water coloured with alkanet root is used as a common wash to cuta- 
neous affections, especially when they are suspected to be connected 
with a venereal taint. Serious consequences are said to have followed 
the application of compresses imbibed with an empirical wash, analo- 
gous to the preceding in its composition. Concentrated solutions of 
corrosive sublimate are sometimes used to destroy condylomata. I 
have already mentioned mercurial pediluvia in the treatment of syphili- 
tic affections. 

180. M. Werneck has tried the br ornate of mercury 1 in cases of 
obstinate skin complaint. I have not myself any experience of the 
effects of this compound. 

181. The iodates or iodurets [iodides] of mercury are energetic 
preparations, the effects of which have appeared to me eminently 
beneficial under many circumstances, particularly in chronic tuber- 
cular and papular inflammations of the skin. They are especially 
available in the treatment of syphilitic affections complicated with 
scrofula. The deuto-ioduret is even a more active preparation than 
the corrosive sublimate itself. Externally applied, it has sometimes 
been found sufficient to leave the deuto-ioduret in contact with the 
skin for a while, to induce a most intense erysipelatous inflammation. 
— When it is given internally, it is proper to begin with the sixteenth 
part of a grain, and to raise the dose gradually to an eighth ; very 
rarely will it be prudent to exceed a quarter of a grain. 

The proto-ioduret of mercury which is less energetic in its action 
than the deuto-ioduret, is used internally, under the same circum- 
stances, in doses of half a grain, which may be gradually increased to 
one or two grains. Externally, I sometimes make use of an ointment 
of the proto-ioduret of mercury, to aid the resolution of the tubercles 
of lupus, of rosacea, of sycosis, &c. 

182. The cyanuret [bicyanide] of mercury, 2 extolled by Chaussier 
and by Horn, has recently been recommended by Dr. Thomson, 
mixed with lard, in rosacea, eczema, and several other chronic 
inflammations of the skin. This substance has such powerful effects 
on the animal economy, that the first doses ought not to exceed the 
sixteenth part of a grain in amount, when it is prescribed internally. 

183. The red oxide of mercury enters into the composition of a 
multitude of ointments, which are often employed with advantage in 
chronic inflammatory affections of the skin. 

184. The proto-nitrate of mercury, mixed with lard, has also been 
employed, by way of inunction, in the treatment of many diseases of 
the skin. Dissolved in water, it has been applied successfully in 
porrigo, and the diseases attended with pediculi. 

185. The phagedenic inflammation of lupus excedens, and of ser- 
piginous syphilitic affections, is often stopped by one or more applica- 
tions of the nitrate of mercury with the acid in excess. 3 A drachm of 
the proto-nitrate of mercury is dissolved in an ounce of nitric acid ; a 
pencil dipped in this solution is the best means of applying it to the 
diseased surface. In case a greater effect is desired, a compress of 
lint, steeped in the solution, may be maintained in contact with the 
sore for any length of time. Many cases of lepra and inveterate 
psoriasis have been cured by this treatment. 

186. The sub- deuto- sulphate of mercury (turpeth mineral) which 
has been mentioned as a preservative against small-pox, has been 

1 Bullet, des Sc. medic, de Feruss., t. xxiv., p. 20. 

2 Horn. Researches in practical medicine, in German, p. 550; 8vo., 1813 — Bul- 
letin des sc. med. de Ferussac, t. v., p. 262. — Parent. Sur les effets du cyanure de 
mercure dans le traitement des affect, syphilitiq. (Revue medicale, 1S32, t.iii,p.833). 

3 Godart. De l'emploi du nitrate acide de mercure, in-4. Paris, 1626. 

11 



successfully employed internally in the treatment of many obstinate 
skin complaints in'doses of one-fourth of a grain repeated two or three 
times a day. The dose may be gradually increased to two or three 
grains. By mixing this preparation with lard in the proportion of one 
to eight, an ointment is formed that may be often advantageously 
employed in stimulating certain chronic affections of the skin, particu- 
larly psoriasis of an old and inveterate character. 

187. The preparations of gold* have been found available in the 
treatment not only of syphilis but of favus, and of some other chronic 
inflammations of the hairy scalp. They appear particularly well 
adapted for inducing modifications in the constitution of scrofulous 
subjects attacked with skin disease. M. Chrestien has detailed the 
mode of exhibiting these preparations, which I shall notice by and by 
when I speak of syphilis, eczema and pityriasis. 

188. The preparations of arsenic 5 appear to have been used for the 
first time in Europe, in the treatment of diseases of the skin, by Adair, 
and Girdlestone, of Yarmouth. The latter tried the arsenical solution 
of Fowler, in a case of lepra in which he had existed during fourteen 
years, and the patient recovered under the influence of small but 
repeated doses of the medicine. He informs us that he subsequently 
obtained hundreds of cures of lepra, prurigo, psoriasis and tinea. 
The second case of lepra in which he tried arsenic, exhibited phe- 
nomena that particularly attracted his attention. After three doses, 
each of eight drops of the solution, the whole body of the patient be- 
came as red as a lobster, and the face appeared as if it were attacked 
by an incipient erysipelatous inflammation. The use of the medi- 
cine was immediately suspended till the redness of the skin subsided, 
and it was then only resumed in doses of half the former amount, 
under which the leprous affection gradually disappeared. In a third 
case, the cure of the leprosy was preceded by an eruption of large 
bulla? on the hips. The curative effects of the arsenical solution 
indeed were often observed to be preceded by an increase of the 
eruption, by a crop of blebs, or by chaps in the skin of the feet and 
toes, and of the hands and fingers. A patient who had laboured for 
two years under lepra nigricans which appeared in large patches on the 
cheeks, and had resisted various plans of treatment, was put upon 
four drops of the arsenical solution twice a day : the first dose pro- 
duced a great degree of redness of the skin, tension of the belly, and 
a slight fainting fit. The patient found relief from a grain of calomel, 
and the lepra was subsequently got rid of by two drops of the solution 
taken twice a day during six weeks. Having suffered a slight relapse, 
the patient resumed the medicine in doses of four drops, which caused 
the same disagreeable effects as at first ; but he ultimately recovered 
without any inconvenience under the continued use of the solution in 
doses of two drops at a time. The largest dose of Fowler's arsenical 
solution Girdlestone ever thought advisable to prescribe, was twelve 
drops three times a day. Six drops, however, he afterwards found 
to be a sufficient dose for all good purposes. Although he sometimes 
succeeded within a few days in lessening the severity of the symptoms 
of the skin disease, he found by experience that he could not consider 
the cure as accomplished, under any dose to which the medicine could 
be carried with propriety, unless its use were continued during six or 
seven weeks at least. One patient took the arsenical solution in the 
dose of twenty drops three times a day for more than three months 
before the lepra under which he suffered disappeared. This patient 
had many nervous symptoms, fainting fits, attacks of diarrhoea, &c. ; 
accidents which, in spite of the greatest care, continued during several 
we'eks. Weakness, pains of the abdomen, nasal hemorrhage and 
cough, as also hepatic and dropsical symptoms, all accompany or 
follow the ill-regulated exhibition of this powerful medicine. Too 
strong doses cause the urine to acquire a jaundiced appearance. 
When the bowels are constipated, the arsenical solution suffices oc- 
casionally to render the motions regular, and when diarrhoea comes 
on, a quarter of a grain of opium two or three times a day corrects 
this effect of the medicine. It is always proper to begin the use of 
arsenical medicines in very small doses, never to be tempted to carry 
the ordinary solution beyond five or six drops three times a day, and 

< Niel. Recherches et obs. sur les preparations d'or,in-8. Paris, 1821. 

5 Adair. Medical commentaries of Edinb., v. ix., 1, p. 35. — Girdlestone. Lond. 
Med. Phys. Journ., February, 1806. — Harles (Ch.). De arseniciusu in medicina, in-8. 
Norimb., 1611. 






DISEASES OF THE SKIN. 



olj m it iv unattended byevi] i 
S. In children the doses must be smaller— one, two, or three 
i day. 

..al solution IS B remedy thai has been greatly abused in 
nquami I the ^kin ; Mr. Duffin, however, bas employed 

i1 in },, along with a decoction of dulcamara, of mezereon 

ii -ilia with advantage. He supposes thai small doses 
taken al short mtervals are mere useful and more certain in their 
than larger doses al longer intervals. It is rarely necessary 
in this way to prescribe more than ten drops of the arsenical solution 
mes a day, m\ are generally found sufficient, and before long — 
ten or fifteen days at most-— the effects of the medicine are apparent 
lj on the disease, but on the constitution of the patient. The 
:npi"in the medicine produces is a sensible acceleration of the 
pulse, which, under its continuance, may be found to have risen from 
twenty to thirty pulsations per minute above its ordinary rate. The 
pulse further acquires fulness and hardness ; the patient soon begins 
to complain of tingling sensations in different parts of the body, itching 
and pain of the eyes, &c; the eyelids, especially the lower, become 
puffed, and the eye is surrounded by a slight dark and livid circle. 
rhese Minpioras sometimes precede the acceleration of the pulse. If 
the remedy be still persisted in, the patient complains of weakness of 
stomach, pains of the bowels, and sometimes of shooting pains in the 
< lust ; the tongue becomes white, the countenance alters, and the 
expression acquires a sorrowful cast; anxiety about the pracordia, 
and other distressing symptoms supervene at last and compel the use 
of the poison to be suspended — these symptoms, indeed, show that it 
has been continued too long ; it should always be abandoned when 
the acceleration of the pulse and swelling of the eyelids are observed. 
The physicians of America bave also tried the arsenic in several 
forms of cutaneous disease. Dr. Rush prescribed the arsenious acid 
in the shape of pills in various severe affections of this nature. The 
>:<ise he ordered was the 15th, the 10th, and the 8th of a grain twice 
a day, mixed with soap, causing the patients at the same time to make 
use of an infusion of the eupatorium perfoliatum. M. Valentin, who 
makes us acquainted with this fact, bas seen several patients follow 
the plan of treatment indicated above, during more lhan two months 
without am good effects on their disease, but also without any apparent 
alteration of their health. Willan and Baleman also extolled the 
effects of Fowler's arsenical solution in obstinate cases of lepra, of 
lichen, of prurigo and of porrigo. They assure us it may be admin- 
1 with perfect safety if cautiously managed ; but they do not 
appear to have studied its special effects on the constitution with the 
suae care as Fowler and tiirdleslone. 

In the reflections on the use of arsenic, read before the Lyceum of 

Philadelphia, in 1812, by Dr. I. Redman Coxe, the author, after hav- 

imbatted the repugnance that is generally fell to the use of this 

medicine, relates the ease of a ladj who had laboured under leprosy 

during fourteen \ cars without deriving any benefit from every kind of 

the most active treatment, but who recovered under the use of the 

arsenical solution continued for two years and a half, and taken at last 

in doses of fifty drops three times a day. There was this peculiarity 

hi the case, that jus; as the disease was beginning to yield, the patient 

. ould not take more than five drops of the solution three times daily 

without ha\ ing tumefaction of the face, nausea, loss of appetite, sense 

( f weight in the eyes and head, — symptoms that proclaimed the 

sity of suspending the large doses for a season, (a) Dr. Otto, of 

Philadelphia, published about the same time an account of three cases 

stinate eruption which had resisted the use of sulphur, of anti- 

. the corrosive sublimate, and mercury in other shapes, pushed 

till the mouth was affected, but which \ielded to the arsenic. Two 

afterwards there was not the slightest appearance of the disease, 

no trace of ill consequence from the vise of the medicine. Dr. 

. of Manchester, has also employed Fowler's solution in 

but he dissuades from the too long continuance 

fancied he had observed the arsenic to accumu- 

also, a paper on the same subject by Dr. D. Theodore 
Cox< '(..///i. Med. $ Surg.Joum., vol. viii. 

dical Reports, 8vo. London, lt>07. 



late in the system and to produce bad effects, such as living pains, 
flatulence, paralytic affections of the limbs, Ac. If. Foder# used 
Fowler's solution with Buccess in some obstinate oases of skin disease. 

A gentlewoman, thirty years of age, exposed, from the particular 
circumstances in which she was placed, to many privations and hard- 
ships, was, among other complaints, affected with an obstinate scaly 
eruption (dartre ecailkuse) of the hands, which obliged her to work 
in "loves. This patient had in vain tried remedies of all kinds. 
The first effect of the arsenic, which was at length prescribed, was 
to regulate the menstrual function that had Ion- been disturbed, to 
render the breathing free, and the complexion clearer; but as yet 
the disease was untouched, although a considerable quantity of the 
medicine had already been taken. M. Fodeiv, however, desired its 
use to be persisted in, and at the end of a month be was desired to 
visit his patient whom he now found labouring under bronchial al- 
fection, with bloody expectoration ; at the same time the disease of 
the skin had disappeared, and the hands weir perfectly whole. The 
present more pressing malady was treated by soothing remedies, and 
the arsenic was discontinued for a month. After this period the 
skin complaint reappeared, but the patient having again resumed the 
arsenic, the hands were anew restored to their natural condition, with 
the exception of a slight degree of remaining roughness of the skin. 

189. M. Jourdan has collected, under the head Arsenic, in his 
pharmacopee universelle, almost every preparation of this metal that 
has ever been employed in medicine ; but I have contented myself 
by giving those only among my formula? which have been more par- 
ticularly recommended in diseases of the skin. I have been particu- 
larly attentive to indicate the occasions proper for the employment of 
these energetic remedies, to specify their respective doses, and to 
show their physiological and therapeutic agency, their advantages, 
and their occasional ill effects. Certain chronic and obstinate forms 
of eczema of the scrotum, margin of the anus and labia, are, of all the 
vesicular inflammations, those in which arsenical medicines are most 
frequently and most successfully employed. This class of remedies 
ought never to be had recourse to in exanthematous inflammations ; 
they are also rarely useful,'and sometimes dangerous, in chronic bullous 
inflammations. Among the papular inflammations, the circumscribed, 
the confluent, and chronic lichens occasionally require their use. 

They have been often abused in prurigo, in pityriasis, psoriasis, and 
lepra, which they, nevertheless, sometimes attack with success. 
When these diseases are inveterate, the prolonged and continued 
action of arsenical medicines is apt to alter the mucous membrane of 
the digestive organs, and to implicate the constitution without modify- 
ing the diseased conditions of the skin for which they were especially 
prescribed. 

190. I shall have occasion to analyze the observations of Mr. 
Robinson, and those of Mr. (I.) Wilson, on the use of arsenical pre- 
parations in the treatment of the Greek elephantiasis. Experience 
has taught me, that not only are the deep alterations of the skin 
which characterize this disease externally not removed by these 
medicines, but that they sometimes even cause disorders and grave 
complications when their use is persevered in for several months 
continuously, or alternated with other active remedies. In one case 
of Greek elephantiasis, M. Delpech administered Fowler's solution 
without any benefit: during two months ; the only effects it had were 
to cause a diminution of appetite, slight purging and some emaciation. 

191. Independently of the changes which arsenical preparations 
may produce in the digestive organs, and of the tremors and paralytic 
affections of the limbs, observed by different authors, the following 
case, as well as two others I possess of the same kind, tends to show 
that, administered unseasonably, they may induce true paralysis of 
the genital organs. I had under my charge, in La Charit6, a letter- 
press compositer, twenty-three years of age, labouring under lepra 
and chronic enteritis Although of weakly constitution? this man had 
hitherto enjoyed perfectly good health, lie had been attacked about 
five years before by lepra vulgaris on the knees and elbows but bv 
degrees the disease extended to all the other parts of the body ' During 
the first two years, the disease was treated by simple baths, by baths 

2 Journ. compl. des sc. medic, t. 1, p. 117. 

3 These will be found at the end of the volume. 



PRELIMINARY CONSIDERATIONS. 



43 



of sulphur and other preparations of this mineral. During the third 
year the patient tried various remedies, and was at last put upon the 
use of Fowler's solution, which he took in doses gradually increased 
from five to twenty drops, for three months. Shortly after having 
undergone this treatment, he began to complain of pains in the sto- 
mach, his digestion was disturbed, he lost his strength, he was taken 
with a profuse diarrhoea, and his genital organs were completely 
paralyzed. This state of affairs had already lasted eighteen months, 
and the patient told me that the diarrhoea was excited afresh by the 
slightest freedom in diet. 

Preparations of arsenic imprudently applied to the exterior may 
also occasion serious consequences. A young woman having made 
use of an arsenical ointment to her hair for the purpose of destroying 
the pediculi with which she was infested, was attacked five or six 
days afterwards with a tumefaction of the whole head ; the ears were 
double their natural size, and covered with incrustations; the sub- 
maxillary and cervical glands, even the parotids, swelled rapidly ; 
the eyes were sparkling and prominent, the face puffed and almost 
erysipelatous; the pulse was hard, the tongue dry, the skin hot and 
parched, and the other symptoms of violent fever were present. The 
patient, in addition, suffered from vertigo, a sense of approaching 
syncope, cardialgia, vomiting at intervals, scalding in making water, 
obstinate constipation of the bowels and tremors of the limbs, with 
inability to rise into the erect posture. At last delirium was added 
to the list of other ills. A copious bleeding was immediately prac- 
tised, which was ordered to be repeated in the night if the symptoms 
seemed to require it. Diluents of chicken broth, emollient clysters, 
pediluviae, &c, were prescribed, and the head was rubbed with an 
ointment containing a fourth of its weight of chalk in fine powder. 
Next day there was some improvement, but also considerable dis- 
position to somnolence. A few leeches were applied to the thighs. 
The succeeding night was restless; the tumefaction of the head 
seemed to have increased, and towards morning the whole body, and 
particularly the feet and hands, were observed to be covered with 
a pretty copious eruption of small pimples with white heads, like 
millet seeds. The patient was very weak, and could not sit up without 
uneasy feelings about the pracordia. Laxative medicines were now 
exhibited, and within forty-eight hours the eruption dried up, and 
fell off afterwards in scales ; the bowels became open, and all the 
symptoms abated. During her convalescence the patient lost her 
hair. 1 

192. To recapitulate : — arsenical preparations are most energetic 
medicines, of incontestable use in various severe forms of cutaneous 
disease. They act especially on the digestive organs, on the integu- 
ments, and on the nervous system, as the observations published 
on their operation and curative effects demonstrate. These prepara- 
tions ought to be prescribed internally at first in very small doses — 
the 16th of a grain of the white oxide of arsenic, for instance, once or 
twice a day, for an adult, — a dose that may be gradually increased to 
an 8th, a 6th, or a 4th of a grain, but very rarely further, although a 
whole grain has been given ; in this quantity, however, the remedy 
may act like a poison. Before venturing on the use of arsenic, it is 
proper to be certain that the digestive organs are perfectly healthy and 
not disposed to become permanently deranged under the influence of 
a stimulating plan of treatment, especially if this is proposed to be 
continued for some time. Prudence occasionally requires us to ad- 
minister these medicines ourselves, and not to entrust our patients 
with more than very small quantities of them at a time. Their effects 
on the digestive organs and nervous system ought to be sedulously 
watched every day ; should the doses we have adopted or attended to, 
cause any unpleasant symptoms, they must be lessened or suspended 
for an interval, and when they bring on pains in the epigastrium, 
constriction of the throat, anxiety about the praecordia, spasms, sick- 
ness, diarrhoea, &c, their use must be given up entirely: this is better 
than attempting to subdue these symptoms by narcotics. In treating 
chronic diseases of the skin by arsenical medicines, the fact must 
always be borne in mind, that the sensible effects of these remedies, 
slow and silent at the beginning, may suddenly acquire greater intens- 
ity and prove the cause of lesions more or less severe in their nature. 

1 Recueil periodique de la sociele de med. de Paris, t. vi., p. 22. 



If it be allowable cautiously to try every known means in the treatment 
of rebellious diseases, it would be culpable temerity to persist for too 
long a time in the use of remedies possessed of such energetic actions 
on the economy, that they are apt themselves to become the cause 
of serious disorders. 

193. The obstinate characters Avhich the chronic diseases of the 
skin occasionally present, have led to some bold experiments on the 
internal use of cantharides. Employed in the time of Pliny, and not 
always with the best effects, 2 in lepra and the lichens, recommended 
by Avicenna and Mead, 3 in the treatment of Greek elephantiasis, and 
more recently 4 in various other cutaneous diseases, cantharides is a 
medicine which, in the shape of tincture, is now very frequently 
employed in lepra, psoriasis, and several other chronic affections of 
the skin. I shall be particular through the course of this work, 
especially when treating of lepra and psoriasis, in insisting on the 
precautions which are requisite not to turn, at the very outset, an active 
remedial agent into a deadly poison. I may, however, just observe 
here, that if it be well proved that the tincture of cantharides has 
often caused the disappearance, in a few weeks or months, of certain 
skin complaints, which had resisted every other form of treatment, it 
is not less certain that patients have occasionally taken even as many 
as 150 doses, of 10, 15, 20, and 30 drops of the medicine, and that 
others have used it uninterruptedly during several months, without 
deriving from it any benefit whatever. It is impossible to overlook 
the circumstance, also, that whatever the skill and care of the practi- 
tioner in the exhibition of this medicine, the genital and urinary organs 
will, in a greater or less degree, always become affected. I have 
seen some patients worn out by painful erections, and others labouring 
under unequivocal symptoms of inflammation of the bladder in con- 
sequence of its use. Females in general bear this medicine much 
worse than men. 

To complete this review of the many therapeutical experiments to 
which the diseases of the skin have given occasion, I have still to 
speak of a great number of vegetable substances whose curative effects 
in these complaints have been admitted on grounds of different degrees 
of worth and stability. 

194. Various species of asclepias 5 (Asc. Gigantea, Asc. Vincetoxi- 
cum, Linn.) have been recommended in the treatment of lepra, of 
frambcesia, of elephantiasis, and other obstinate cutaneous affections. 

195. Knakstedt has published, in the memoirs of the academy of St. 
Petersburg, a notice in which he shows that the root of the elecam- 
pane (Inula Helenium, Linn. 6 ) administered internally, and applied ex- 
ternally, is extremely efficacious in eruptions and other diseases of the 
skin. In many districts this root, reduced to powder, and incorporated 
with grease, is a popular remedy in scabies. 

196. Sudorific properties, of some avail in cutaneous affections, 
have been ascribed to monkshood or aconite (Aconit. Napellus, Linn. 7 ). 
Tommassini has, however, prescribed the extract of aconite in doses 
varying from 10 to 90 or lOO grains daily without success in a case 
of syphilitic eruption (dartre syphilitique). On the other hand, we have 
accounts of the aconite, even in small doses, producing serious acci- 
dents, lypothymia, vertigo, general tremor, &c. I have tried the drug 
myself, not only in diseases of the skin, but also under other circum- 
stances ; and I find that the medicinal extract of monkshood varies 
extremely in its action, according as it is procured from the aconite 
of the hills or from that cultivated in gardens, according likewise to 
the care with which it has been prepared and preserved. I find further 

2 "Cossinum,equitem romanum, amicitiaNeronis principis notum.cum islichene 
corruptus esset, vocatus ex iEgypto medicus ob hanc valetudinem ejus a Ca?sare, cum 
cantharidum potum praparare voluisset, interemit. Verum illitas prodesse non 
dubium est, cum succo taminee uveb et sero ovis vel capra — efficacissimce omnes ad 
lepras lichenasque." (C. Plinii Secundi. Hist, mundi, lib. xxvii. Lugd., 1587, 
p. 719.) 

3 Mead's Works, 3 vols. Medica sacra, chap. ii. 

4 Home. Clinical Researches, p. 471. — Smith. In Medical Commentaries, vol. i., 
n. 6. — Cullen. Materia Medica, vol. ii. — Brisbane. In Med. Obs. and Inquiries by a 
society of physicians. London, v. viii., p. 5. 

* Bulletin de la Societe philomathique, t. i., p. 184, 2e part.— Plaifair. Sur le 
Madar et ses proprietes. — Arch, gener. de medec, t. xvii., p. 574. 

s Kuhn. Phys. Medic. Journal, 1800, p. 139. — Ambrose Pare recommends an oint- 
ment of elecampane and mercury. (CEuvres, liv. vi. c. 14.) 

7 Pallas. Voyages dans differentes provinces de l'empire de Russie ; t. v., p. 389. — 
Tomassini (Gazette de sante, 21 mars, 1810.) — Journ. gen.de med., t. vi. p. 186. — 
Rayer. Art. Aconit. (Diction, de m£dec. et de chirurg. prat., in 8o. Paris, 1829). 



11 



DISEASES 01 THE SKIN 



therapeutical efl 

tcnbed. 
combine the aconite with the deuto- 
syphilis. 

ume pratensis* in 

e skin in dosesofone or two grains daily. M. 

i i in curing obstinate eruptions (dartres) by the 

a day during some months, of one grain and a half 

f anemone mixed with eighl times its weight of sugar. 

I ted ] ished with a decoction of hyoscyamus and 

ipplying the anemone nemorosa, Linn., 
Other observations have been published 
■ our of the anemone pulsaHUa. 

ion of the root of the bur-dock (Arctium Lappa, L.) 2 
in the proportion of one or two ounces to the pint of water, has been 

■i' in inflammation of the skin that had gone j 
into the squamous or rurfuraceous state. The use of this decoction 
requires to be continued for several months, as it only acts with e\- 
ms to have been a frequent practice formerly 
to appl\ the leaves of bur-dock bruised to the head in chronic affections 
of the hairy scalp. 

Hemlock Conium inaculatum, Linn.:) 3 has been recommended 
not only in various less formidable shapes of skin disease, but also in 
the treatment of scrofulous [and even of cancerous] sores; Joannes 
in the Kith century, was the first who employed this plant in 
herpetic affections, (dans les dartres,) and this is one of the forms of 
skin disease, in which Stoerck has recently found it most beneficial. 
Hufeland prescribes it both internally and externally in affections of 
the hairy scalp; .Murray only ventured on its outward use. — Syphilitic 
itions have been subdued by the officinal hemlock. 

200. In a number of diseases the principal indication is often to 
ome modification of the general constitution; this indication, 

indeed, at times absorbs all the others. We have consequently been 
recommended to treat those complaints to which people of a scrofu- 
lous, lax, and lymphatic habit are subject, by the juices of the 
cochlearia officinalis or scurvy grass, of the cochlearia armorica or 
radish, of the water-cress (sysimbrium nasturtium), by watery 
infusions and beer of the hop (humulus lupulus), of the buck-bean 
(menyanthes trifoliata), of the stone crop (sedum acre) house-leek, 
(sempervivum tectorum), &c. On the same principle decoctions of 
Peruvian bark, of the Virginian snake-root, &c, were employed to 
stoeeten the blood, and remedy the cachectic state of constitution ob- 
servable along with the appearance of impetigo scabida in elderly peo- 
ple, and of rupia and ecthyma luridum, at all ages. 

201. J. Bauhinus employed the colchicum externally to destroy pe- 
diculi of tin' head and pubes. Dr. Elliotson' 1 cured a man sixty years 
of age of prurigo, in three weeks by the use of half a drachm of v'inum 
colchici three nines a day. I have obtained some success myself from 
the use of the tincture of colchicum, in several cases of lichen com- 
plicated with 1, out or rheumatism. 

202. A greal number of eases collected by Carrere, Razou, Ber- 
trand-3 Crichton, and other physicians, leave no doubt as to the 
value of the Dulcamara or bitter-sweet (Solatium Dulcamara, L.) 5 in 
the treatment of eczema, and squamous inflammations of the skin. If 
Messieurs I >esbois and Alibert tailed in deriving the same good effects 
from this medicine, their want of success must be attributed to their 
having used it in too small doses, or to their having made but short 
trial of its efficacy ; for if the dulcamara produces no good in some 

. it is certain that in others its beneficial influence is speedily 

' Murray. Apparat medicam.. t. iii., p. 93. — Bonnet. Ancien journ. de med., t. 
B3S, HS3.— Chomel. Planles usuelles, t. ii., p. 376. 
'.aux. Observat. clinic. Paris, 1789. 
* Pare (Amb.). CLuvrcs, lib. xvi., c. 2. — De Preval. Journ. de med., t. xxxviii.. p. 
139. — F telle de Gardanne, p. 113. — Landeatte. Journ. de medec, t. xxvi., 

P- 335- i urn. de med., torn, lxxxiii., p. 342.— Despine. Journ. gen. de 

medec t. xtxviii.. 

■tie, v. ix.. p. 31.— Arch. sjJne'r. de med., t. xvi., p. 270. 

s Li' de dulcamar.'i, in-lo. Upsal, 1771 (Amcenit. acad. v. viii., No. 

e (J.-B.-F.). Traite des proprie'tes, usages et effets de la douce-amere 

jrnscandens.dan* le iraitement deplusieurs maladies et surtoutdes maladies 

dartreu - — Hertrand de La^resie. Essai sur le Iraitement dec 

sor l'efficaciie de Pextrait de douce-amere, in- 12. Paris, 

r. Enoploi de la douce-amere dans les maladies de la peau (Arch. 

gener. de mwdecine, t. xxv., p. 267). 



apparent. Neither must it be forgotten that whilst simple psoriasis ot 
the elbows and lent withstands the freest exhibition of this 

substance, chronic inflammations of the same kind, extending to la 
surfaces of the integuments, are frequently seen welding readily t< 
is much smaller in amount. In even case thedoseofthe remedy 
should be gradually increased. I have used as much as lour ounces 
of the root in decoction in the course of four and twenty hours, and 
from two scruples to two drachms of the extract in the same interval 
of time. 

Baths of decoction of dulcamara have been recommended in the 
same kind of affections as those in which the decoction and extract 
have been given internally, and especially in those syphilitic eruptions 
which have withstood the influence of mercury. I have never studied 
the action of these baths. 

203. Galen, Oribazius, JEtius, Avicenna, and Mesue, among the 
ancients, and among the moderns, Gilbert, Pinel, Sprengel, and others, 
agree in considering the herb fumitory (fumaria oflic. Linn.)' 3 as useful 
in scaly tetters, and even in elephantiasis. The expressed juice usually 
exhibited, during two or three months in the spring, in doses of from 
two to six ounces, may be subsequently increased to twelve. Menu- 
ret prescribed the extract of fumaria combined with hemlock and 
calomel. I have myself sometimes employed this plant medicinally, 
but always in union with other remedies of different degrees of energy, 
a circumstance that prevents me from giving an opinion upon its 
peculiar properties. 

204. M. Loiseleur de Longchamp prescribed with success the 
leaves of the Daphne gnidium, 7 the use of which had already been 
recommended by Russel, Wright, and Swediaur, in diseases of the 
skin. Cullen tells us that he had seen numerous ulcers of the skin 
persisting after a mercurial course, get well under the use of the 
decoction of this substance continued during two or three weeks. 
Sinclair has made some experiments on the Daphne mezereow, which 
Rouch exhibited combined with gum benzoin. On the other hand 
Wedel and Hoffman have lifted their voices against the daphne 
gnidium, reproaching it with having caused burning heat of the 
stomach, cardialgia, shooting pains of the bowels, hypercatharsis, &c. 
I have seen, and have myself prescribed the decoction of the bark of 
this plant to many patients ; and whilst I allow that several experi- 
enced such symptoms as those I have just mentioned, I have still ti 
add that in no case were they so violent as to make me regret having 
given the medicine a trial. 

205. Tar-water* is a very ancient internal remedy in chronic dis- 
eases of the skin. In the Pharmacopoeias of Edinburgh, Dublin and 
the United States of America, formulae for different unguents and 
liniments as external applications, into which tar enters as an ingre- 
dient, may still be found. I commonly mix one part of tar and four 
of hog's lard to make an ointment, which I often find to prove effectual 
in papular inflammations, and especially in prurigo. Pitch has been 
exhibited internally in a dose of from half a drachm to half an ounce 
every day, in chronic ecthyma, and several inflammations of a squamous 
nature. 

206. Those vegetables characterized as sudorifics* such as sassa- 
fras, sarsaparilla, guaiacum, &c, are powerful remedies in syphilid! 
and several other cutaneous affections. In our practice these sub- 
stances are commonly exhibited in too small doses ; I have pushed 
them advantageously to the length of 6, 8 or 10 ounces daily in 
decoction during one or two months. 

207. The infusion of the Acorn, 10 and of the Galium aparine ; th< 
juice of the CEnanthe crocata, the extract of the bark and husk of the 
Juglans regia," the decoction of the bark of the Ulmus campestris, 
and especially of the Llmus pyramidalis, 1 * of the Rumex patien 
Rumex acutus," and stems of the Viola tricolor; 14 infusions of the 

de 6 m°ed e C ( . B t'om?-i. ^ * ^^ T^'" ^ Y ^ *+ ^9.-Menuret. Jon. 
7 Manuel des plantes usuelles, part 2, p. 46. 

« Bateman. A pract. synops. of cutaneous diseases, in-8, 1829 n fi-> 
9 Akakia. Ergo cutaneis affectibus hydratica ? Paris 1679 wi,V„i , , 

nalderprakL Arzn., ii. b., p. . 188-Home. Clinical researches 9 ~ Hu,dan<L JoUr " 



Kerron. Journ. compl. des sciences medicales, t. xltii. p 3^7 

Hunezovky. Anc. journ. de medec, t. lxxvii., p. 2'JG 
« Banau (J. B.). Hist. nat. de la peau., in-8. Paris, 1*802 
13 Aertcei. Curatus. diuturn. ii., c. 13. 

u Haase. Diss, de viola tricolori, p. 105.— Oberneffer fHufpian^ 1 
Heilkunde, ix. b). ucrneuer (."uteland Journ. der prakt. 



PRELIMINARY CONSIDERATIONS. 



45 



Ledum palustre, 1 and of the Rhododendron chrysanthum; the extract 
of the leaves of the Rhus toxicodendron radicans 2 in the dose of 
fifteen to twenty grains three or four times a day, carried, within the 
space of six weeks, to the extent of from half to a whole ounce in 
the four and twenty hours ; the decoction of different species of Sca- 
biosse, as of the scab, succisa, scab, arvensis, and their juice in doses 
of two, three or four ounces, and various other vegetable extracts, 
infusions and decoctions, have been recommended in skin diseases, 
of various characters and appearances. — Although I have collected 
a certain amount of practical information on the action of these sub- 
stances, I have still many doubts unresolved as to the peculiar effects 
and degrees of efficacy, in a therapeutical point of view, of many of 
them: it will be seen, however, that I have made the study of their 
properties a particular subject of attention, and that I have constantly 
endeavoured to discover the circumstances which render their exhibi- 
tion more rational, and their usefulness less a matter of uncertainty 
than it is. 

208. I shall conclude this therapeutical review by a few critical 
observations. 

The numerous and diversified experiments which the obstinacy and 
frequent relapses of cutaneous diseases have provoked, are unques- 
tionably not without their importance ; but it is an abundant mine 
from which careful study and observation alone teach us to extract 
the treasure. Moreover, if it be a fact that many remedies, such as 
purgatives, antimonial preparations, sulphureous and arsenical medi- 
cines, &c, are at the present time successfully employed in almost all 
the chronic diseases of the skin, whatever their form, and whatever 
the order to which they belong; it is not less evident that more 
accurate experiments, made under more determinate conditions, that 
is to say, with reference to well-ascertained species, must be more 
useful, and more easy of application : such has been, and such neces- 
sarily required to be, the end and aim of my own experiments. 

From these therapeutical essays, too, there results the sad truth, 
that obstinate diseases have been opposed by remedies of the most 
opposite descriptions in their physical and chemical properties; and 
that, even at the present time, it is often difficult to decide upon the 
choice of a remedy, or to reason on the propriety of its exhibition. 

It is also easy to perceive why physicians who have been struck 
with the salutary nature of certain inflammatory affections of the skin, 
and who have observed the evils that sometimes follow their cure 
or disappearance, or who have felt discouraged with their frequent 
relapses, have been led to pursue a purely expectant or palliative plan 
of treatment, or to substitute for these diseases some sort of drain, or 
issue, or artificial inflammation ; a practice which, on the continent, 
is still frequently followed in the cases of children and elderly persons. 
Other practitioners have evidently viewed inflammations of the skin 
as external phenomena, connected with internal conditions more 
serious and important in their nature, and they have acted on the 
notion that it was imposssible to accomplish their complete cure 
otherwise than by effecting some great modification of the constitution 
by regimen and appropriate remedies. To those of a sanguineous 
temperament and plethoric habit, they have recommended bleeding, 
the warm bath, milk diet, &c; to the scrofulous, tonic bitters, pre- 
parations of iodine, &c; to those disposed by descent to herpetic or 
scaly eruptions, sulphureous, antimonial, arsenical preparations, &c. 
Other practitioners, without losing sight of the important and even 
necessary distinction between constitution and disease, have never- 
theless given themselves up to the search after specific remedies adapted 
to each particular kind of skin disease, and to each of its periods; 
they have insisted on the propriety of the system of expectation, or 
moderate antiphlogistic plan, in eruptive fevers ; on the virtues of 
mercurial preparations in the syphilitica?; on those of sulphureous 
medicines in scabies and chloasma ; on the demonstrated usefulness 
of natural and artificial sulphureous waters in a great number of cuta- 
neous affections ; on the advantages of depilation infavus of the hairy 
scalp ; on the good effects of the sherbets of the nitric and sulphuric 
acids in lichen and prurigo ; of the iodurets in scrofulous lupus ; of 
chalybeate medicines in cutaneous inflammations complicated with 

1 Linnaeus. De ledro palustri. Upsal, 1775. 

2 Dul'resnoy. Dcs proprietes de la plante appelee rhus radicans. Paris, 1788. 

12 



amenorrhcea, dysmenorrhea, &c. ; acknowledging, however, that in 
some obstinate cases recourse must be had alternately to bleeding, 
purgation, vapour baths, alkaline baths, arsenical preparations, &c, 
before a permanent cure can be obtained. Others, again, having 
found by experience the advantages derived from acting on the 
immediate seat of the disease by means of simple or variously medi- 
cated baths and fomentations, lotions, cataplasms, unguents, fumiga- 
tions, stimulants, cauteries, &c, have insisted on the great value 
of external remedies, which, indeed, are generally efficacious when the 
alterations of the skin to which they are applied are merely local, or 
when their action, like that of the preparations of sulphur, of arsenic, 
of mercury, of iodine, &c, exhibited internally, is extended to the 
constitution at large, or when they are combined with the internal 
exhibition of such medicines as exert this powerful influence. 

Lastly, it is undeniable that theoretical views have often given 
particular turns to therapeutical investigations, which have been of 
service to science. Thus the known uses of purgatives and emetics 
would not have been discovered at so early a period, without the 
bilious origin attributed by the old writers to diseases of the skin ; 
the inconveniences attending the exhibition of these and other medi- 
cines, such as the preparations of antimony, of arsenic, of cantharide*, 
&c, would not have been inquired into so diligently, and exposed 
with so much zeal, but for the severe attention with which the 
partisans of the physiological school in these latter days have studied 
the diseases of the stomach and apparatus of digestion, — without the 
systematic tendency in this sect to exaggerate the sensibility and the 
influence of the gastro-intestinal sympathies, 3 previously ill conceived, 
or entirely overlooked by practitioners, whose minds were too exclu- 
sively occupied with the state of the integuments. 

To recapitulate : — it is necessary, would we bring the treatment 
of an affection of the skin to a successful issue, to recall to mind its 
natural progress; to calculate the probable amount of its beneficial 
or noxious influence on the constitution, its relations with the general 
state of health or with preceding diseases, and its affinity to other 
maladies, whose ulterior appearance is more or less to be apprehended ; 
it is further needful to estimate beforehand the extent of the influence 
which will be exerted by a change of the diet and general mode of 
life, not only on the disease, but on the constitution ; the effects of 
age and of climacteric changes must also be taken into account ; lastly, 
from among the therapeutic agents at our disposal, that one must be 
selected which appears at once best adapted to the individual con- 
stitution, and to the nature, severity, extent and date of the disease. 
As now stated, this problem is more complex than it appears at first 
sight: the true therapeia of cutaneous diseases must be sought for in 
the history of their species, and better still in the observation and 
comparative study of a great mass of particular cases. 



OUTLINES OF THE PATHOLOGY AND REMEDIAL TREAT- 
MENT OF DISEASES OF THE SKIN. 

BY THE AMERICAN EDITOR. 

He who will carefully peruse the " Introduction" and " Preliminary 
Observations" to the present work, can hardly fail to acquire an ex- 
tended view of the general pathology and therapeutics of cutaneous 
diseases ; but as these, by their very fulness, may not, perhaps, be as 
readily comprehended and distinctly remembered as could be desired, 
it has seemed to the editor that he might render an acceptable service 
to the practical investigator into these matters by a condensed sum- 
mary of the subject, in which it is not, however, his intention to 
restrict himself entirely to the Treatise of M. Rayer. 

Without entering into details of the minute anatomy of the skin, it 
is enough for us to be aware of the fact, that this portion of the tegu- 
mentary system consists of two main layers, viz., the epidermis or scarf 
skin and the dermis or true skin. Each of these again is subdivided 
into other layers ; the superficial layer of the epidermis is the cuticle, 
and the deeper layer, the retc mucosum or rete Malpighii of older writers ; 

3 I own that I have myself shared and abetted in extending this mistake. Vide Art. 
Estomae, Diet, de Sc. Med., in 18 vols. 



\ i 



STRl CTURE AM) Fl NOTIONS OF THE S 



uned the papillary; the lower one, ot 
The epidermic is properly a secretion 
. which il serves to protect. At first fluid, il becomes 
I md in proportion as it is separated, layer after layer. li- 
mn. t laver, the and cellular, and in contact with 
tpillan layer of the dermis, from which Latter it receives its 
form. and Roussel de \ auzeme, to whose labours we are 
indebted for our present knowledge of cutaneous structure, 
ompared the rete mucotum, in its conversion into epidermis, to 
\ melted wax, one half of which is liquefied by heat, while the 
other is condensed by the external cold. The cuticle, or external epi- 
dermic layer, is laminated in its texture, and ns the superficial laminae 
intinually removed by attrition, new ones are as continually 
reproduced upon its internal surface. The degree of thickness of the 
is dependent on, and bears an accurate proportion to the degree 
nf development of the papilla of the dermis. The epidermis is accu- 
rate!) modeled on the papillary laver of the dermis, and each papilla 
S appropriate sheath in the newly-formed epidermis or rete muco- 
The colour of the skin, varying in different races, and even 
people of the same race, is owing to the presence of pigment in the 
cells of the epidermis. The pigment cells are most abundant in the 
furrows of the dermis, and in the hollows between the papilla'. 

in designating the epidermis as a secretion from the dermis, the 
e of organization, except of the lowest grade, would seem to be 
implied, for its connection with the functions of absorption and exha- 
lation are more physical than vital. The assertion of Breschet and 
Roussel de Vauzeme, that the epidermis becomes organized like false 
membranes, gives to the former too high a place in the scale of vitality, 
which it possesses more in the manner of vegetable than of animal 
organization. We cannot allow much importance to the assertion 
nf Schultze, that he injected with oil of turpentine a very delicate 
net-work of vessels, which separated with the epidermis from the true 
skin, since these vessels may have belonged to the sub-epidermic 
layer, and have been mechanically torn away. (Mailer's Physiology, 
Bell's edition, p. 426.) 

The dermis or cutaneous tissue proper consists of an interlacement 
of fibres, in which secreting organs of different kinds an 1 imbedded. 
It is composed of elastic and contractile fibrous tissue, which is, also, 
at the same lime areolar, and of nerves, blood-vessels and lymphatics. 
It is white, and never partakes of the colouring matter of the epider- 
mis. Under it are seen the vessels and nerves which penetrate it, 
and openings for glandular bodies, and, on its external surface, the 
dermis assumes a membranous appearance, and is perforated for the 
passage of the secreting and absorbing apparatus. 

The papilla 1 consist, or rather the papillary layer, consists of conical 
minute prominences, arranged in the palm of the hand and sole of the 
fool in a regular order, in their being collected into little square masses, 
each containing from ten to twenty papillae, which are disposed in 
parallel rows. 

The special secretions of which the skin is the seat are, in addition 
to its chief one, the epidermis, the hair, the sebaceous matter, and 
the perspiration. Hairs are described to be horny appendages of the 
skin, or processes of the epidermis, penetrating the dermis.- They ' 
are produced by the involution and subsequent evolution of the epi- 
dermis; the involution constituting the follicle in wdiich the hair is 
enclosed, and the evolution the shaft of the hair. The producing organ 
of the hair consists of a pulp analogous to a papilla of the dermis, and 
is the organ whence the hair is produced, — in a manner identical with 
that of the formation of the epidermis by the papillary layer of the 
dermis. The colour of the hair, like that of the epidermis, is due to ! 
the presence of pigmentary granules contained within the cells. The 
ills glands are minute branched follicles, imbedded in the sub- 
u the dermis, and often by orifices distributed over its surface. 
They terminate for the most part in the follicles of the hairs. In the 
scalp there are two of these glands to each hair follicle. Seba- 
glands are met with in all parts of the body, but are most 
abundant in the skin of the face, and in those situations which are 
naturally exposed to friction. 

The mdi have been already mentioned (Note to p. 

25). They are formed by small tubes of peculiar construction, which 
are spread over the whole surface of the body, and pour out their 



secretions by minute pores in the epidermis. Both the sudoriferous 
and the sebaceous glands are lined b\ an inversion of the epidermis. 

The nails are horny appendages of" the skin, identical in formation 
with the epidermis and hair, but peculiar in their mode of growth. A 
nail is implanted by means of a root in the fold of the dermis, which 
acts the pari of a follicle to the nail. Ai the bottom of the groove of 
the follicle are situated B number of filiform papillae, which produce 
the margin of the root, and, by the successive production ot cells, push 
the nail onwards in its growth. The papillary structure of the dermis, 
which produces the nail, is continuous around the circumference of the 
attached part of thai organ with the dermis of the surrounding skin, 
and the horny structure of the nail is, consequently, continuous with 
that of the epidermis. For farther details on the minute anatomy of 
the skin, see Erasmus Wilson's Practical and Tfteoreiical Treatise on 
the Diagnosis, Pathology, and Treatment of Diseases of the Skin, &c; 
also, Nouvelles Recherches sur la Structure de la Peon, by M. (J. Bre- 
schet and M. Roussel de Vauzeme; and Comparative Anatomy of the 
Skin of Man, the Domestic Animals, cVc. ( I ergleichende Untersuch- 
ungen, &c) By Professor ( iurlt, in Mutter's Archiv. A good notice 
of these two last-mentioned works will be found in the second volume 
of the British and Foreign Medical Review. 

If we inquire into the general anatomy of the skin, we discover that 
this tegument is continuous with the system of mucous membranes, to 
which it bears a close resemblance, and with which, as some allege, 
it is actually identical. One important difference, however, presents 
itself, in the proximate organic principle which constitutes the basis 
of structure : that of the dermis being almost entirely gelatin, whereas, 
the basis or proper texture of the mucous membrane is albuminous. 
In the superadded structures, as of epithelium of the mucous mem- 
branes, corresponding with the epidermis of the skin, and in the dis- 
tribution of blood-vessels, lymphatics, nerves, and glandular bodies 
or follicles, and in the double series of functions, viz., 1, absorption 
and exhalation, placing them under the domain of organic life ; and 
2, sensibility and impressibility to temperature and to the physical pro- 
perties of matter, connecting them with animal life, there is a close 
resemblance. The sympathies between the two orders of teguments 
are active and numerous, both in health and in disease, and they are 
influential as well in the pathology as in the therapeutics of diseases 
of the skin. 

From the skin carbonic acid and nitrogen are exhaled, as they 
are from the mucous membrane of the lungs ; and from both is dis- 
charged a vapour, which, when condensed on the former membrane, 
with salts, &c, constitutes sweat, and, on the latter, water, with some 
animal matter. The secretion from the sebaceous follicles of the skin, 
is paralleled by that from the mucous follicles of the respiratory and 
digestive membranes. 

By the process of absorption, gaseous and fluid matters and notably 
oxygen gas and water, find entrance through the skin into the general 
system ; as this gas and watery vapour do through the mucous mem- 
brane, of the lungs. So, also, nearly all the articles of the materia 
medica may be introduced through the skin into the circulation, 
and produce their distinctive effects on the several organs, in the 
same manner, though with less certainty of operation, as when they 
are applied to the digestive mucous surface. 

Analogous depurative functions are performed by the skin and kid- 
neys ; and the one sometimes compensates, by its increased activity, 
for the torpor or suspended action of the other. From both organs 
are largely secreted water and saline matters, and, in less degree, 
lactic acid. When the urine is secreted in excessive quantity, as in 
diabetes, the skin is dry. In hot seasons, and in warm climates, the 
urinary secretion is less abundant, the cutaneous secretion more so: 
in winter, the reverse is the case ; and, in diseases, the same alterna- 
tion of action is observed. 

The reciprocal influence exerted on each other by the skin and 
digestive mucous membranes, constitutes a most important part of 
the study of the pathology of cutaneous diseases. Eruptions of va- 
rious kinds are not unfrequently a result of crude and irritating 
ingesta ; and those of an acute and febrile character are almost always 
preceded by derangement of the prima. via>, and particularly of the 
mucous membrane of the throat and stomach. So, on the other hand 
extensive inflammation of the skin, by arresting its secretion is fol' 



CRAIGIE'S CLASSIFICATION OF CUTANEOUS DISEASES. 



47 



lowed by inflammation of the mucous membranes. Extensive burns 
have given rise to inflammation of the respiratory and digestive 
mucous membranes, but in a more particular manner to that of the 
duodenum. In exanthematous diseases, in which a morbid matter is 
secreted by the skin, the danger of the supervention of internal in- 
flammation becomes more imminent, not merely in proportion to the 
suppression of the process by which the morbid matter is eliminated 
from the blood, but also in proportion to the violence of the inflam- 
mation by which the function of the skin is arrested. (Miiller's Phy- 
siology, edit, citat., p. 459.) 

Between the effects, on the skin, of physiological and pathological 
excitement of parts with which it sympathizes, there is this differ- 
ence, that while the former is followed by a diminished action of the 
skin, the latter is most generally succeeded by corresponding, if not 
identical excitement, or increased and morbid action of this tegument. 
The therapeutical inference is, that, while we may hope to abate and 
remove some diseases of the skin, consisting in morbid afflux and con- 
gestion, by purging and diuretics, there will be a risk of aggravating 
them by irritants, which, regarded sometimes as pretended specifics, 
would light up phlogosis of the digestive mucous membranes. 

In its physiological conditions, as of heat and coldness, dryness 
and moisture, fulness or shrinking, we know that the skin is greatly 
modified by the nervous system, according as the latter is excited, 
depressed, or otherwise disturbed. That the prolonged operation or 
frequent alternation of some of these states will contribute to the 
production, or, where they are present, to the exasperation of some 
cutaneous diseases, we can readily imagine, cl priori, even if direct 
facts were wanting. 

In the etiology of cutaneous diseases, we study the causes which 
act directly on the skin itself, or indirectly, by some organ with which 
it sympathizes, or through the blood and nervous system, and in this 
way on the constitution generally. Of the first of these causes, various 
external irritants, beginning with seasons and climate, and coming 
down to artificial heal and uncleanly habits, stand out most conspicu- 
ously. Lichen tropicus, or prickly heat, is a familiar example of the 
effect of high temperature in causing cutaneous disease, as is ery- 
thema intertrigo of that of cutaneous friction, and pityriasis or scurf 
by the repeated friction of the razor on the chin, and sometimes of 
a rough comb or hard brush on the hairy scalp. In illustration of 
the occurrence of secondary or sympathetic irritation transmitted from 
another organ, causing eruption and morbid alterations of the skin, 
it will be sufficient to mention urticaria ab ingesiis, or nettle rash 
from certain kinds of food, particularly shell fish, and rosacea from 
gastro-enteritis. To the same purport, we may cite strophulus or 
red gum, as resulting often from the irritation of teething. The most 
distressing and remarkable example of cutaneous disease caused by 
a depravation of the blood and constitution generally, is in the syphi- 
lides, or syphilitic eruptions. As is stated by the author in the text: 
— "In the epidemic syphilis of the 15th and 16th centuries, venereal 
eruptions occurred so commonly a short time after infection, that the 
disease was regarded as a contagious affection of the skin.' 1 '' From a 
similar cause, or general constitutional deterioration, come cutaneous 
scrofulous tubercles. 

The question of the hereditariness of certain cutaneous diseases, or 
at least of strongly inherited predispositions to acquire them, presents 
itself naturally to the mind of the practitioner. He will find that acne, 
sycosis and porrigo having occurred in the parents, are very apt to 
show themselves in the children at an age, and during a period nearly 
identical with those in which the former had been affected (Plumbe, Ji 
Practical Treatise on Diseases of the Skin fyc, p. 29, Am. Edit.) 
Ichthyosis, or fish skin disease, has not only been transmitted from parent 
to child for several generations, but is at times congenital. Pella- 
gra has been often observed to appear in those whose parents had 
suffered from the disease. 

Very little reflection must soon convince us, that a knowledge of 
the causes and connections of many cutaneous diseases, will not a little 
influence us in our therapeutical views. Thus, for example, when 
the eruption depends on the irritation of teething, we can have 
but little hopes of its entire removal, until the process of dentition is 
completed ; nor shall we feel inclined to harass the little patient by 
various remedies, but wait patiently for the period of irritation to pass, 



and with it the sustaining cause of the disease. When, again, we 
encounter a cutaneous eruption sustained by gastric or by gastrointes- 
tinal irritation, we direct our remedies to this latter morbid condition 
as to the source of the malady. So, in eruptions depending on con- 
stitutional cause we cannot hope for, and ought not to promise, their 
entire removal until time is allowed for the operation of appropriate 
remedies, to alter the state of the blood and constitution. This is 
eminently the case in syphilitic and scrofulous eruptions, and in pella- 
gra, and it may be added in a majority of cutaneous diseases. The 
eruption is properly but a symptom, or at any rate not more than a 
part of the entire disease. 

Classification of Cutaneous Diseases. On this point, the author 
has detailed the views of his predecessors by which they were guided 
in their arrangement. Willan, it was stated, followed Plenck in 
founding his on the external characters of the diseases of the skin when 
at theiracme or height. Plumbe gave his arrangement as " founded on 
the constitutional causes of the disease, and due consideration of the 
organic structure and physiology of the part of the skin on which it 
is seated." It is doubtful if more than an approach to an anatomical 
basis can be made in the present imperfect state of our knowledge of 
the several parts of the cutaneous tegument affected in the different 
eruptions. Reference has been already made, in notes, both by the 
author and translator of the present work, to Dr. Craigie's distribu- 
tion of diseases of the skin upon anatomical grounds. It merits more, 
notice than in these passing allusions merely ; and as the work con- 
taining it (Elements of General and Pathological Anatomy) is in the 
hands of few readers in this country, the American editor believes that 
he will enhance the value of these " outlines" by introducing it in this 
place, accompanied by part of the author's commentaries on the several 
preliminary definitions. Dr. Craigie points out the fact, that Bichat, after 
the example of Cullen, attempted to distinguish cutaneous diseases ac- 
cording to their seat in the cutaneous tissue. This method, he adds, is 
obviously the most rational, and has received the approbation of such 
observers as Meckel and Beclard. The different seats of cutaneous 
inflammation are briefly stated by Dr. Craigie, as a kind of introduc- 
tion to his arrangement : 

" Cutaneous inflammation, though it eventually affect the sub- 
stance, which, however, is not frequently, may be conveniently distin- 
guished in the following manner. First, it may be seated in the 
exterior or cuticular surface of the corion ; secondly, it may affect the 
papillae or minute elevations of the corion ; thirdly, it may affect the 
substance of the corion ; fourthly, it may occur at the inner or attached 
surface of this membrane. If these circumstances be adopted as the 
basis of general division, subordinate characters may be derived 
from the mode in which the inflammatory process advances, and from 
the effects which it produces, in the following order: — 
Diffuse oh spreading! inflammation. — I. Cutaneous inflammations seated in the 
outer or cuticular surface of the corion, {cutis vera, derma,) and generally spread- 
ing along it. 

Measles, Rubeola. 

Rash fever, scarlet fever, Scarlatina. 

Nettle-rash, Urticaria. 

Rose-rash, Roseola. 

Common rash, Erythema. 

Effusive inflammation. — II. Cutaneous inflammation seated in the outer surface of 
the corion, producing a fluid which elevates and detaches the cuticle. 

Rose, St. Anthony's fire, Erysipelas. 

Bleb fever, bullose fever, Pemphigus, febris bullosa. 

Simple blebs, Pompholyx. 

Punctuate papular inflammation. — III. Cutaneous inflammations commencing in 
circumscribed or definite points of the corion, producing minute eminences. 

Gum, gown, red gum, tooth gum, Strophulus. 

Sun-rash, prickly heat, Lichen. 

Itchy rash, Prurigo. 

Punctuate desq.uamatino inflammation. — IV. Cutaneous inflammations of the 
outer surface of the corion, more or less circumscribed, affeoxing its secreting 
power, and producing exfoliation of the cuticle. 

Scaly leprosy, Lepra. 

Scaly tetter, Psoriasis. 

Dandrifr, Pityriasis. 

Fish-skin disease, Ichthyosis. 

Punctuate vesiculaii inflammation. — V. Cutaneous inflammations originally af- 
fecting the outer surface of the corion, circumscribed, definite, or punctuate, pro- 
ducing effusion of fluid, first pellucid, afterwards slightly opaque, with elevation ot 
cuticle, with or without further affection of the corial tissue. 

Miliary rash, Miliaria. 

Shingles, vesicular ringworm, or fret, Herpes. 

Heat spots, or red-fret, Eczema. 



46 



rKA! [FICATION OF CUTANEOUS DISEASES. 



I.imp : ,n - 

I inia. 

Van 

\ I Cutaneous mflamma- 
i : the corion, afterwards us substance, 
s distinct 

Variola. 
Pestts. 
,ni pustule, Persian fire, Anthracion. 

Beabies. 
>r running tetter. Imp* 

i.rm, Porri 

Pox, Ecthyma. 

i immation. — VII. Cutaneous inflammations 
iling in the substance ol -omclimes at the bulbs of the hair, and 

terminating in partial or imperfect suppuration, with formation of scaies, crusts, 
: the corial U:-sue. 
Boil, Phyma, furunculus. 

mclc, Anthrax Carbuncalus. 

Whelk, Acne. 

P or chin whelk, Sycosis. 

Lupus, noli me tangere. 
While scail, Vitiligo. 

Taws, Framboesia, rubula. 

Sibbenia. 

I MF. pilLEGMONO-TriiJIK ITLAR IHFLAMMATION, CIIROSIC. VIII. CutaneOUS in- 

( hronic, attended with general affection of the fibro-mucous tissue. 

Arctoic leprosy, radesyge, Lepra Norwegica. 

Lombard evil, pellagra, Pellagra. 

Soherlievo, Falcadina, Lepra Piedemontana. 

Astunan iich or scab, Mai di Rosa, Lepra Asturiensis. 

('run evil, Krimmische krankheit, Lepra Taurica. 

Arabian leprosy, Elephantiasis. 

Soli tubercle. Molluscum. 

Wan, Verruca. 

" a. Cutaneous inflammations scaled in the outer or cuticular surface 
if the corion, and generally spreading along it. — Inflammation of (he 
enter surface of the corion maybe diffuse and continuous, as in scarlet 
f< \< r, diffuse and interrupted, as in common rash (crytliema), nettle- 
rash and rose-rash, or diffuse and of determinate figure, as in measles. 
The redness with which superficial cutaneous inflammation is attended 
varies. Though il disappears on pressure, it returns immediately. 
In scarlet fever, though its tint is indicated by the name, it often has 
a shade of brown ; in erythema, or simple rash, it is rarely so vivid 
as in oilier forms of cutaneous inflammation; in rose it has a tinge 
of yellow. In measles it assumes the shape of crescentic or lunular 
patches. In simple rash it terminates gradually in the sound skin ; 
hut in one variety of this rash {erythema marginatum), and in rose 
it is marked by a distinctly circumscribed edge, or is said to be 
marginate. The swelling of superficial cutaneous inflammation is 
rather a general distension than obvious elevation. When it is obvious 
to the eye, or felt by the finger, and is at the same time confined to 
definite red patches, these are named wheals. A familiar instance 
of this occurs in the effect produced by the bite of several insects, 
the blow of a whip, or the stinging of nettles. Spontaneously it is 
■nil in the disease named nettle-rash. In rose, elevation, extensive 
and continuous, conterminous with the redness, and like it bounded 
h\ a distinctly circumscribed edge, is uniformly observed. 

" Superficial cutaneous inflammation bei»g seated in the extensive 
vascular net-work, [rete vasculorum, reseau vasculare), of the corion, 
always destroys to a greater or less extent its scarf-skin, which comes 
■away in small portions or scales, sometimes in larger pieces, while 
a new but thinner and more transparent scarf-skin is formed. The 
process by which these changes are effected is termed desquamation, 
and is observed in measles, scarlet fever, nettle-rash, rose-rash, com- 
mon rash, and rose when it does not proceed to the formation of 
blebs. As the process thus defined forms a good mode of distin- 
guishing its varieties when seated in the outer or cuticular corial 
surface, I adopt it on the present occasion. 

'• According to the definition above given, it comprehends the fol- 
lowing diseases: — Measles, rash fever, scarlet fever, nettle-rash, rose- 
rash, common rash. 

" k. Cut' .situate chiefly in the outer surf ace of 

ucing sero-albuminous fluid, which elevates the scarf- 
s, (Bullae, Phlyctaense), commencing in 
certain jnirts of the corion, but spreading continuously. 

-face of the corion may be inflamed in such a manner 
as not to terminate in desquamation or resolution, but to pour forth a 



\cllowish fluid, which detaches the cuticle and eh rates it in 
the form of a bleb or blister. This is verj well seen in the instance 

of scalding by boiling fluids, on the application of the blistering fly 
[Meloe vesxeatorius), 01 < fen in some cases oi' friction ol parts natu- 
rally tender. In each of these cases, in a shoil time large watery 
elevations or bladders appear. The same process lakes place spon- 
taneonsh in rose, in common blebs and in the bullose or bleb fever. 
The form of these blebs is not determinate; nor even are they always 
uniform in appearance. The action by which they are produced, 
though more violent in degree, is not different in kind from ordinary 
cutaneous inflammation, "it is attended, nevertheless, with more 
swelling of the corion, more exquisite burning heat, and more searing 
or scalding pain, than the other forms of superficial cutaneous inflam- 
mation. The fluid secreted by this process is sero-albuminous. When 
the raised cuticle is divided, a yellowish transparent watery fluid 
escapes ; and when the cuticle is detached so as to expose the inflamed 
spot, the inflamed skin is found covered by a quantity of soft, cellular, 
gelatinous matter, of a yellow-white colour, somewhat tough and 
similar to coagulable lymph. This substance is traversed by firm 
linear partitions, not uniform in number or direction, but forming 
interstices from which serous fluid, the same as that which escaped 
first, is discharged. The coagulable matter, which is albuminous, 
at the same time contracts, and forming a covering to the corion, 
while the latter begins to secrete a new cuticle, is at length thrown 
off in the form of opaque patches. These facts show that the new 
secretion, though discharged fluid, afterwards separates into a serous 
and an albuminous portion, and is an imperfect or modified coagula- 
ble lymph; that both are the product of the inflammatory process; 
and that the latter is analogous to that producing albuminous exuda- 
tion from serous membranes. This analogy has not escaped Bichat, 
who remarks, that vesications do not occur in the latter, solely 
because they want epidermis. To this head belongs the inflamma- 
tion of cutaneous whitloe. 

" c. Cutaneous inflammation commencing in circumscribed or definite 
points of the outer surface of the corion, and producing minute eminences 
or pimples (papulae), which disappear gradually or terminate in scarf, 
or minute exfoliations of the cuticle. 

" When cutaneous inflammation appears in the form of innumerable 
minute points, which, without spreading or coalescing, remain in 
general distinct, it differs in nature from that which has been already 
considered as the spreading or diffuse inflammation. The simplest 
form under which this is observed to occur is that which consists of 
the minute pointed elevations named pimples (papulce), which may 
be described as small conical eminences, surrounded by a red circle, 
and sometimes attended with superficial redness of the neighbouring 
skin, but without definite figure. They are slow in progress, do not 
proceed to suppuration, and after remaining an uncertain time, sub- 
side gradually, occasioning a branny or scurfy exfoliation of the 
scarf-skin with which they are covered. 

"These seem to have been the circumstances which induced Dr. 
Willan to consider pimples as arising from inflammation of the papilla 
or conical eminences of the corion. I cannot say that personal ob- 
servation has enabled me to determine whether this is at all times 
truly the case or not ; and I therefore will not positively deny the 
accuracy of the opinion. On this point, however, I remark,— that I 
have seen and daily see instances of strophulus, in which the papular 
eruption can neither in form nor distribution be traced to the cuta- 
neous papillae ; that the eruption of lichen in adults appears in situations 
in which the papilla? are few, as regularly and abundantly as in those 
in which they are numerous ; and that we meet with local examples 
of papular eruption in which it is difficult to suppose the disease to 
be an affection of the papilla? of one region of the skin only For 
these reasons it may be justly doubted whether in all instances papular 
eruptions consist in inflammation of the papilhe 

« Of the anatomical characters of pimples, little is accurately known. 
They are not diseases necessarily fatal ; and when death takes place 
during heir presence, their distinctive characters are either much 
changed or entirely gone before the anatomist can inspect them In 
some instances of strophulus in infants cut off by other diseases I 
have seen the corion rough and slightly raised in irregular spots which 
were the seat of closely-set pimples during life P ' 



CRAIGIE'S CLASSIFICATION OF CUTANEOUS DISEASES. 



49 



" d. Cutaneous inflammation of the outer surface of the, corion, more 
or less circumscribed, affecting its secreting power , and thus producing 
first , exfoliation of the scarf-skin, afterwards vitiated scarf-skin. 

" Though the scarf-skin (cuticula, epidermis), and nails are. inca- 
pable of injection, and are therefore believed to be inorganic, the 
former is remarked to be more sensible when thin and semitrans- 
parent, than when thick and opaque, which it may be in certain 
regions. It is also observed, that when it is removed by a blister, 
or the effect of a scald, the surface of the corion, when it ceases to 
discharge the sero-albuminous fluid already noticed, becomes covered 
by a thin pellicle of transparent membrane, so delicate that it affords 
very little defence to the subjacent skin. This same transparent 
pellicle is observed in the skinning or cicatrization, as it is named, 
of cutaneous wounds. If, under these circumstances, the formation 
of this pellicle be observed, it will be found that it is deposited from 
the outer or cuticular surface of the corion, like a secreted substance 
in a viscid or semifluid state, and afterwards becoming hard, dry and 
semitransparent. 

" When the outer surface of the corion becomes inflamed or other- 
wise disordered, its secretion is no longer performed with the same 
perfection or regularity. The effect of this is seen in the vitiated 
state of the scarf-skin, which is no longer the uniform, continuous, 
firm, semitransparent membrane observed in health, but becomes 
broken, thickened, opaque and divided into numerous scales. Of 
the various modes in which this secretion may be deranged, and of 
the varieties in cuticular disease to which it may give rise, too little 
is known to speak with precision of their individual forms. But it 
may be considered as certain, that every morbid state of the outer 
surface of the corion gives rise to certain unnatural conditions of the 
cuticle, and that every anormal state of the cuticle depends originally 
on a morbid state of the cuticular or secreting surface of the corion. 
In genera], this morbid state consists in some degree of inflammation, 
or at least it is attended with some degree of this process, though in 
the chronic form. In some instances, this chronic inflammation is 
obviously the immediate cause of the derangement of secretion ; but 
in other instances, the disordered secretion continues after the inflam- 
mation subsides. The former is observed in the Greek leprosy 
{lepra), and the scaly tetter (psoriasis), in both of which the forma- 
tion of the morbid opaque scales is preceded and attended by a red 
inflamed state of the corion taking place in minute spots. It is less 
obvious in dandiiff (pityriasis), in which the surface of the corion, 
though dry, harsh and rough, is not particularly red or vascular, and 
which, therefore, appears to exemplify the latter statement. The 
fish-skin eruption (ichthyosis), is in general so chronic that it is diffi- 
cult to say whether it is or is not attended with any degree of the 
inflammatory process ; but when its commencement can be traced, it 
is generally possible to recognize marks of inflammation of the outer 
surface of the corion. 

"e. Cutaneous inflammation originally affecting the outer surface of 
the corion, circumscribed, definite or punctuate, producing effusion of 
fluid, first pellucid, afterwards slightly opaque, with elevation of cuticle, 
ivith or without further affection of the corial tissue. 

"Inflammation may be developed in many minute points of the 
corion simultaneously, and, continuing limited to these points without 
spreading, may terminate in each in the formation of a pellucid fluid, 
afterwards becoming more or less opaque. These may either be 
confined to the outer surface of the corion, without affecting its sub- 
stance, or, beginning originally at the surface, may thence affect its 
substance. 

" The individual points appear first like a common rash, with 
general redness of the skin, sometimes like pimples or minute ele- 
vations, with a good deal of redness surrounding them. After some 
hours, a white pearly point appears at their summits, while the sur- 
rounding redness diminishes in breadth, so as to form a mere circle 
or hoop (areola), which, if minutely examined, is found to consist 
of a zone of vessels, circumscribing the inflammatory process, and 
forming in their centre the fluid which gives the elevation the white 
appearance. After 12, 20 or 30 hours more, according to circum- 
stances, the white pearly appearance extends, assumes a tint of 
yellow, and is depressed on the summit, indicating the advancement 
of the process of circumscribed inflammation. In the course of two 
13 



or three days, there is detached a thin crust or scab, which consists 
of the cuticle of the part with the dried fluid adhering to it. Minute 
elevations of this description haA^e been termed vesicles (vesicuhr), 
and the contained fluid lymph by Dr. Willan. The fluid thus dis- 
tinguished is not the same as the coagulable lymph of J. Hunter. It 
is nevertheless sero-albuminous, and appears to be quite similar to 
that which is secreted in the first stage of suppuration. The process 
by which it is secreted is confined to the vascular surface of the 
corion, and is not attended by ulceration of that surface in millet-rash, 
shingles (herpes), and the red-fret or mercurial eruption (eczema). In 
chicken-pox it is sometimes attended by ulceration of the corial sur- 
face, sometimes not. 

" In the other two forms of vesicular inflammation, though the 
process commences at the surface of the corion, it finally affects the 
substance of that membrane. 

"In the limpet-shell vesicle (rupia), inflammation of the punctuate 
or circumscribed character commences in one or more points of the 
outer surface of the corion, and causes the secretion of a thin clear 
fluid, which first elevates the cuticle into a broad flat vesicle, and 
soon becoming opaque, oozes through the broken cuticle, and is 
hardened into thin, superficial, but in general, laminated scabs. 
These vesicles are surrounded by a red, hard and painful margin or 
base, indicating slow inflammation of the corial tissue. 

" The progress of this form of cutaneous inflammation, demonstrates 
clearly and satisfactorily the gradual transition of the morbid action 
from the surface to the substance of the corion. The inflammation, 
confined at first to a small spot by the usual zone or areola, causes 
merely sero-albuminous secretion, and consequent elevation of the 
cuticle. If at this time the cuticle be removed accidentally or inten- 
tionally, the subjacent surface of the corion is intensely red, soft or 
velvety and pulpy, elevated and extremely tender, while the sur- 
rounding ring or hoop of skin is hard, and equally elevated and 
red. From the softened inner portion the secretion of sero-albuminous 
fluid, generally of a reddish tint, continues ; and the surface itself 
begins to become rough, and to loose its velvet aspect. This indi- 
cates incipient ulceration, which proceeds to affect the substance of 
the corion, until it is either much or wholly destroyed, generally in 
the form of an inverted cone ; while the place of the destroyed skin 
is supplied by the sero-albuminous secretion, which hardens as it is 
formed, and seems thus to sink deeper and deeper into the skin. In 
the meanwhile the surrounding portion of the skin is much indurated 
and inflamed, and seems to form a hard ring in the skin; and the 
whole process is attended with extreme pain, searing heat, and con- 
stitutional distress. These phenomena are most distinctly seen in 
the rupia prominens and escharotica, and in a variety of the eruption, 
which I have witnessed in the persons of those who have been affected 
with the constitutional symptoms of syphilis, and who have for this 
been subjected to repeated courses of mercury (rupia cacheclica). 

" Cow-pox (vaccinia), whether in the teat of the cow, or the skin 
of the human subject, consists in local inflammation of the outer 
surface of the corion, which, by causing the secretion of a thin semi- 
transparent fluid, elevates the cuticle into a vesicle. At the same 
time, the surrounding skin is red, sore and hard (areola); and the 
inflammatory process denoted by these signs causes suppuration of 
the corion, with some destruction of its substance, or what is termed 
ulceration. 

"If the thin fluid secreted by the vaccine vesicle either in the teat 
of the cow, or in the skin of the human subject, be taken before it has 
become opaque or puriform, and applied to the surface of the human 
corion exposed by scratching, slight incision, or suitable abrasion of 
the cuticle, it is followed by local inflammation of the same characters 
as those of the original sore or vesicle, from which the morbid fluid 
is taken. The vaccine inflammation is naturally divided into two 
stages." 

" During the progress of the local inflammation, some disorder of 
the constitution fakes place generally about the seventh or eighth 
day, in the form of loss of appetite or sickness, slight thirst and heat, 
and dryness of the skin. The pulse is almost never affected. The 
vaccine vesicle may also produce sundry cutaneous inflammations, 
very transitory, and of a secondary nature. Of these the vaccine 
rose-rash (roseola vaccina) is the most important and frequent. 






CRAIGIE'S ( LASSIFICATION OF CUTANEOUS i 



ae fluid, when applied to 
eruptive disease like 

at first 

.Hid perli;, bers. jB 

shows that its action 

which it is applied; thai these, 

;eal of genuine vaccine inflammation ; 

ami u. other morbid changes in the skin 

i said to succeed, the communication of cow- 

buman body, are not the result of its genuine or proper 

i ami truly a local morbid process." 

a cutaneous inflammation sometimes affecting 
I have already merely spoken. Like instances 
inflammation, though it commences at the surface of 
with sero-alhuminous secretion, it very often proceeds to 
suppuration, and illy alfects the corial tissue. This is seen 

in the lenticular and more distinctly in the conoidal chicken-pox, in 
luppurated points are marked by depressions. The cuta- 
Ctuate inllammation of chicken-pox maybe considered as 
the link which connects the vesicular and the pustular eruptions. 
" The facts now adduced show that it is impossible to draw a 
Ct line between the vesicle ami the pustule, as was attempted by 
Willan and liateman. Looking only at the pathological process by 
which they are developed and advance to maturity, it is more natural 
tsider them as differing in degree only, and as gliding by im- 
ilile shades into each other, than as always capable of being 
itely distinguished. What is a vesicle, when first observed, may 
assume the appearance of a pustule on the following day ; and the thin 
sero-albuminous fluid, by which they have been supposed to be dis- 
tinguished, may be converted into purulent matter before the termina- 
i the disease. As the terms, nevertheless, are useful as precise 
distinctions in nomenclature and description, and as they occasionally 
may be traced to a pathological difference, I retain them in the present 
rvationsi 
11 f. Cutaneous inflammation originally affecting the outer surface 
of t/ie corion, afterwards its substance, and producing purulent matter 
or less perfect. 
"Inflammation* of the minute circumscribed kind, though com- 
mencing originally on the surface, may speedily affect the substance 
of the corion, and in its progress may produce more or less loss of 
substance, with formation of purulent matter. The objects thus 
formed are named pustules, and are to be viewed as instances of 
genuine phlegmonous or rather purulent inflammation of the skin. 
Practical authors enumerate four forms under which this species of 
cutaneous inllammation may take place: — 1st, the psydracium ; 2d, 
har; 3d, the foams; and 4th, the phlyzacium. To this number 
I feel it necessary to add the phlyctidium. 

" The psydracitm may be viewed as the connecting link between 
the vesicle and pustule. It is small, often irregularly circumscribed, 
producing but slight elevation of the cuticle, and terminating in a 
laminated scab. It is attended with little or no redness of the 
surrounding skin (areola), does not affect the corion deeply, and 
rarely almost never leaves a hollow scar. Several of them often 
appear together, and becoming confluent after discharging the scanty 
puriform matter which they furnish, pour out a thin watery fluid, 
which on drying forms an irregular incrustation. 

•■ The aehor differs not much from the psydracium. It appears in 
: in of a minute pointed elevation, of a yellow-colour, and suc- 
I by a thin brown or yellowish scab. It contains straw-coloured 
matter of the appearance and consistence of strained honey ; it is sur- 
rounded with little inflammatory redness, and seems to affect the 
corion as little as the psydracium. In ordinary circumstances it leaves 
no s 

" 1 "i may be esteemed the next degree of inflammation of 

It is Larger and flatter than the last-mentioned pustule, 

not pointed, and contains a more viscid matter than the achor. It is 

surrounded by a slight-red, irregular, marginal ring, indicating a more 

le affection of the corial tissue. It is succeeded by a yel- 

-emitransparent, and sometimes cellular scab, like honeycomb. 

■ A : ran of pustule referable neither to these, nor to that which is 

to follow, I must here mention, — the phlyctidium or genuine small-pox 



pustule. It consists in a circular or annular spot of inflammation ot 
the corion, encircled l>\ a red rin , which is ' '" 

st of the rial surface, bi ; ' al ' ;lll( ' e ) evate "» 

Within this suppuration takes place. Though the phlyctidium is 
observed spontaneously in the distinct small-pox, it is also produ 
artificially by friction of tartar-emetic ointment. 

" The phlyzacium is the most perfect example of the most violent 
degree of this form of cutaneous inflammation. It is described as i 
larfe pustule, raised on a hard circular base, of a lively red colour, 
antt succeeded by a thick, hard, dark-coloured scab. It is generally 
slow in progress, and, commencing at once on the surface and in tin- 
substance of the corion, is attended with considerable surrounding 
inflammation ; and the suppurative process which follows is always 
accompanied with more or less destruction of the corial tissue. It 
often leaves a hollow scar. The surrounding redness, hardness and 
elevation; the slow progress and sometimes tedious suppuration; 
and lastly, the loss of corial substance, are the circumstances which 
indicate the peculiar scat of this form of cutaneous inllammation. 

" Into the pathological characters of the individual pustular inllam- 
mation the limits of this treatise do not permit me to enter. On one 
or two of them, however, I shall offer a few remarks which may tend 
to illustrate the general nature of cutaneous pustular inflammation. I 
begin with small-pox as one of the most interesting." 

" The most doubtful point of this account (a) [by Cottugni], of the 
variolous inflammation, is that which relates to the disease being 
entirely confined to the mucous body of Malpighi. The existence 
of this membrane is very doubtful, and if it cannot be demonstrated, 
the opinion of small-pox being confined to it is obviously inconclusive. 
If the term outer surface of the corion be substituted for mucous body, 
the whole description may be regarded as not far from the truth. The 
depressed pit or navel of which Cottugni speaks, corresponds with 
the central slough of John Hunter, to which I shall advert in its proper 
place. At present, the process of variolous inflammation, if divested 
of hypothetical language and opinions, may be stated in the following 
terms : — 

"The small-pox eruption consists of circumscribed points of in- 
flammation developed simultaneously in many spots of the corion. 
These inflamed spots (phlyctidia), always commence at the cuticular 
or outer surface, and in general penetrate to a depth which is greater 
or less in different circumstances. After no long time, each phlycti- 
dium is surrounded with a hard, red circle, somewhat raised, which 
may be conceived to indicate the process of cutaneous inflammation. 
Hunter would say, and perhaps did say, that this inflammation is of 
the adhesive kind, and arises from lymph effused into that part of 
the corion which is red, hard and swelled. I believe it cannot be 
in every instance shown that this hard swelling depends on effusion 
of lymph ; and it may be doubted whether it arises from such effu- 
sion in the case of small-pox. First, hardness and swelling take 
place at a period of the eruption so early, that it appears unreasonable 
to ascribe them to effused lymph. Secondly, hardness and swelling 
accompany every example of circumscribed or definite inflammation. 
Thirdly, it is not easy to understand in what particular part the lymph 
could be effused, for the corion does not contain cells or cavities like 
the filamentous tissue, but the outer surface consists of a smooth 
dense membrane, abounding in minute blood-vessels. Fourthly, it 
is as easy and more natural to think that if effusion took place, it 
would do so into these minute vessels. In point of fact, the capil- 
laries of the corion of the pustular redness and hardness are numerous 
and distended ; and we believe that the truest conclusion is, that the 
redness, hardness and swelling of each pock, consist in the unusual 
distension of the corial capillaries with blood. 

"Pustular inflammation of the skin naturally terminates in suppu- 
ration, which may be either with or without destruction of the corial 
tissue. In the variolous phlyctidia, when distinct, destruction of the 
skin is rare, but may occur. There is reason to infer that it takes 
place in consequence of a true process of ulceration " 

" From these facts and observations, [after Hunter, Adams and 

(o) It is not deemed necessary to repeat here the description bv 
this author, as given by Dr. Craigie. *■ y 



CRAIGIE'S CLASSIFICATION OF CUTANEOUS DISEASES. 



51 



Cruikshank,] as well as those which it has occurred to myself to 
make, the following conclusions may be drawn: — 

" The phlyctidium or pustule of small-pox consists of a cutaneous 
inflammation, which may produce, 

" 1st. Secretion of puriform fluid without permanent injury or 
destruction of the corion. In lenticular chicken-pox, and distinct 
small-pox, there is no doubt that though suppuration takes place 
from the cuticular surface of the corion, it is not necessarily connected 
with destruction or ulceration of that membrane. 

"2d. Suppurative ulceration of the corion. In conoidal chicken- 
pox, in some instances of distinct small-pox, and in many instances 
of small-pox partially or wholly confluent, each pock goes on to 
ulceration of the corion. It does not appear that the pock slough 
described by Hunter is present in every case. It is admitted by 
Adams to be wanting in the vesicular small-pox, which appears after 
cow-pox, and in some other occasions. 

" 3d. Death of numerous spots of the corion constituting sloughs. 
In some cases of distinct small-pox this has been observed ; but it is 
most frequent in the confluent eruption. It then appears in the form 
of a white circular patch lying at the bottom of each pock. 

" 4th. Along with sloughs at individual points, an extensive spread- 
ing redness of the skin rapidly terminating in sloughs of irregular 
shape and limits not unfrequently occurs in certain bad forms of 
variolous eruption." 

" Of the diseases termed malignant jmstule, by the French and 
other foreign authors, (Anthracion; Nar al-Parsi; Persian fire), we. 
can scarcely speak from experience in this country, in which, so far 
as I am aware, the disease is unknown. From the description given 
by Enaux and Chaussier, Vicq-d'Azyr, Pinel, Ozanam and others, 
it appears to consist in inflammation of the outer surface of the corion, 
speedily depriving that membrane of its vitality. It may commence 
in one or two modes; first, as a hard, red, burning, not elevated 
point, speedily causing bluish or reddish-blue fluid secretion, elevat- 
ing the cuticle into a purple or pale blue blister (phlyctcena) ; second, 
' as a hard knotty substance slightly elevated into a doughy swelling, 
and causing detachment of the cuticle by similar effusion. In both 
cases the affected corion undergoes mortification partial or general, 
and is then detached as a foreign body. In some respects this 
resembles the ordinary carbuncle of this country. But it differs par- 
ticularly in this, that the malignant pustule {anthracion), is ascribed 
by the best authorities to contagion, and very often is traced to 
epizootic contagion, or pestilence occurring among the lower animals. 

"The great pock (ecthyma) consists in an eruption of red, hard, 
sore pustules (phlyzacia), distinct, seldom numerous, without primary 
fever, and not contagious. In the three species of ordinary (E. vul- 
gare), infantile (E. infantum), and dingy pock (E. luridum), the 
pustules are round or oval hard masses fixed in the substance of the 
skin, which is red, hard and swelled, and terminating first in elevation 
and desquamation of the cuticle, and then in imperfect softening, dis- 
charging a serous and generally blood-coloured fluid, which concretes 
into a foul dark-brown or reddish scab, which at length drops off", 
leaving the subjacent skin reddish, and marked by a depressed scar, 
indicating the affection of the corial substance. 

11 g. Cutaneous inflammations originating in the substance of the 
corion, sometimes at the bulbs of the hair, terminating in partial or 
imperfect suppuration, with formations of scales, crusts, and occasion- 
ally sloughs, and more or less destruction of the corial tissue. 

" The pathological reader may perceive that the last disease which 
came under consideration forms a preparatory step to those of the 
present order. The hard phlyzacious pustules, by which it is dis- 
tinguished, denote a more complete affection of the corial substance 
than is known to take place in any previous cutaneous inflammation ; 
while the slow, crude and imperfect solution which they undergo, 
and the discharge of blood-coloured rather than purulent fluid, indi- 
cates a variety of the inflammatory process different from those already 
examined, and approaching to those now to follow. The transition, 
therefore, if not insensible, is at least natural, to a tribe of diseases 
of which the general character is inflammation of the corion, which, 
modified in various ways, gives rise to the varieties of disease referred 
to this kind. The principal modifying circumstances maybe referred 
either to duration, to circumscription, or to difference in kind. 



" 1. The influence of duration is observed in the comparative 
difference of progress of the common boil, which is rapid, and that 
of the whelk {acne), canker {lupus), and yaws (frambcesia), which 
are slow and tedious. 2. The influence of circumscription or diffu- 
sions is evinced in those inflammations which are confined to a spot, 
and those which spread to some extent. In the whelk and boil the 
inflammatory process is restricted to a point ; in carbuncle, on the 
other hand, it affects a great extent of the corion through its entire 
thickness. 3. Whether the inflammation of the corial substance be 
different in one disease from what it is in another, there are few 
means of ascertaining. Though various facts seem to indicate some- 
thing of this nature, too little is known to justify positive conclusions. 

" The boil or bile (Die Beule ; Furunculus ; le Clou ; il Ciccione) ; 
may be adduced as an instance of acute inflammation of the corion 
confined to a certain spot. Pearson admits that its seat is the skin ; 
but, by afterwards saying that it may occur in any part which abounds 
in cellular membrane, leaves the alternative either that skin contains 
this substance abundantly, or that boils may occur in many other 
tissues. Boyer, by placing its seat in the cellular tissue, confounds 
it with phlegmon. The opinion of Bichat differs from either, but 
partakes of both. This anatomist represents the corion to be pene- 
trated by a great quantity of cellular tissue, which fills its areola, and 
is the exclusive and proper seat of the boil. The truth of this opinion 
depends on the idea attached to the term cellular tissue. If by this 
be meant the loose fatty matter with its intersecting threads, on which 
the inner surface of the corion rests, the opinion is erroneous ; for 
this is the proper subcutaneous cellular tissue. To this doubtless 
the inflammatory action of boil may descend ; but the phenomena and 
termination of the disease show that it consists at first of circum- 
scribed inflammation of the corial substance, soon but slightly affect- 
ing the subjacent cellular tissue. The circumstances which indicate 
the corion as the seat of furuncular inflammation, are, — the defined 
knotty tumour with which the complaint begins, the minute pustule 
to which it gives rise, and the imperfect and tardy suppuration with 
formation of sloughs, and the perforated appearance of the skin. 

" Of the same nature are the inflammatory tumours termed epinyc- 
tis and terminthus mentioned by all authors almost from Celsus to 
Wiseman. 

" Though in this place I notice carbuncle as an example of spread- 
ing inflammation of the substance of the corion, yet the question of its 
precise seat is not free from ambiguity. Hunter believed it to begin 
in the skin, and going deeper to affect principally the cellular mem- 
brane, of which it caused mortification ; and with this Pearson agrees. 
Boyer places it in the teguments and subcutaneous cellular tissue ; 
while Monteggia, who repeats the fact that it destroys a considerable 
portion of the teguments and cellular substance down to the muscles, 
seems to regard it as a peculiar action affecting seAeral tissues simul- 
taneously and successively." 

"Upon the whole, it may be concluded that the corion is the 
primary seat of disease in carbuncle, and that the affection of the 
cellular membrane, with which it is uniformly accompanied, is the 
effect of spreading inflammation of the corial tissue. 

"The whelk (acne; ionthos ; varus, vari, Celsus) consists of 
minute portions of corion, round, oval, ttr spheroidal, hard, circum- 
scribed and elevated. Of the four sorts enumerated by Bateman, 
three only, the simple (A. simplex), the inveterate (A. indurata) and 
the crimson (A. rosacea), can be considered as examples of inflam- 
mation of the substance of the corion. The black whelk (Acne punc- 
tata), doubtless arises from disease and obstruction of the mucous 
follicles, or sebaceous glands. Both the simple and indurated whelk 
may produce ulcerative destruction of the true skin, and leave a 
smooth depressed scar ; and I have seen them, by extending to the 
roots of the hairs, render the skin entirely depilous. 

"The crimson whelk (A. rosacea, gutta rosea; dartre pustuleuse 
couperose of Alibert), is an affection rather complicated; and I doubt 
whether it is justly classed with those now mentioned. It is doubt- 
less an affection of the corial substance ; but it commences with red- 
ness and slight diffuse swelling of the skin of the nose and cheeks, 
not unlike that of erythema marginatum. This is followed by the 
appearance of two or three small seedy particles, very hard, but red 
and tending to suppurate, which they at length do partially at their 






CRAIGIE'S * LASS] - S DISE 



;,!, red Mid firm. As the rod 

ah particles 

,n(l undergo ii course ; 

rorm hroad tubercular blotches of ;i crimson or 

ikin is not, bow- 
all limes permanently red. I have seen this 
light coloured, that in 
■ '1 ; but in the latter part of the 
wine, ami j warm, they assumed an intense 

crimson. In the advam , when numerous 

les appear, and the surface is gen igh and red, ihe 

--kin swells diffusely ami i y, and is traversed by tor- 

purpli \ i nis, the nose is enlarged, the nostrils become dis- 
tended, their surface notched into lobular d i red hard bodies 
of the cheeks become large and coherent, and the whole countenance 
i into a crimson tumid mass, in which the original features 
are prodigiously deformed. These whelks do not often undergo 
suppuration, but are constantly casting the cuticle in the form of 
peelin crusts. When suppuration occurs it is liable 
to terminate in had and intractable sores. 

"The chin and scalp whelk (sycosis, mentagra, dartre pustuleuse 
. i onsists in chronic pustular inflammation of the substance 
of the corion at the bulbs or conduits of the hairs. (Celsi, lib. vi. 3.) 
" Inder the head of canker (lupus, noli me tangere, wolf of Wise- 
man and others, dartre rongeante, Pine! and Alibert), may be noticed 
a disease consisting in hard elevated tubercles set in the corion, from 
which they appear to grow. The name of noli me tangere is applied 
by Wiseman to a 'small round acuminated tubercle,' without much 
pain, unless when 'touched, rubbed, or otherwise exasperated by 
topics.' Though most frequenton the face, it may occur on other parts. 
One of ihese, of a bluish colour, and looking like a vein, appears 
from the description to have been of the nature of erectile tissue. 

"One example of bluish spherical tubercle . I have seen in the 
person of a woman of about 65 years of age, otherwise healthy. It 
was situate on the side of the nose near the middle of the nasal bone. 
It appeared first in the form of a small red prominence less than a 
pea, bul gradually shot up from the skin, so as, in the course of twenty 
months or two years from its commencement, to project at least one- 
third of an inch from the surrounding skin. It was then round or 
spherical, smooth, and even shining, and of a blue or light purple 
colour, which, on close examination, was derived from numerous 
minute vessels. It was connected to the skin by a neck, the base 
being narrower than the summit, but did not adhere to the bone. 
What was the ultimate fate of this person I did not learn ; but no 
doubt can be entertained that if life were continued a sufficient time, 
the tubercle would terminate in destructive fungating ulceration. 

" I have seen also many cases of ragged ulceration of the coun- 
tenance, and one or two in the incipient state before it spread to any 
i stent. One mode in which this disease appears to commence is by 
the formation of a patch of hard, red skin, slightly but diffusely 
swelled, and which is the seat of a hot, gnawing, smarting sensation. 
Though smooth on the surface, it is found by examination to be 
irregular, or very soon becomes so by the formation of small, hard, 
round bodies (pustulo-tubercular), which after some time begin to be 
acuminated, and cast the cuticle in thin peelings. Occasionally they 
give rise to thin watery vesicles of no determinate shape, which 
either burst their cuticle and discharge their fluid, or appear to cause 
an Insensible dewy oozing all over the surface. The most usual seat 
of this form of cutaneous inflammation is the side of the nose, one of 
I n, or a small portion of the cheek. After subsisting in this 
form for some time, it may disappear spontaneously, the skin becom- 
ing of its natural colour, soft and without pain. More frequently, 
'ue cuticle continues to be cast off in peelings, vesicles 
and pustules continue to be formed, and one or other more red and 
painful than the rest is at length covered by a scab, which, dropping 
-■•s a small sore with a smooth ungranulating surface, and a 
., thin, bloody-coloured, puriform discharge, which generally 
i rust or scab. This either spreads without showing 
any disposition to heal, or coalesces more or less completely with 
sores which are generated in the same mode, and undergo the 
same process. After proceeding in this manner for weeks or months, 



a tendency to heal is manifested in some parts while others continue 
to spread. The parts which be.d are irregularly seamed and scarred. 

This form of disease appeal espond with what Wiseman 

.iics under the mime of herpes e.rcdcns. 

"Another form of pustulo-tubercular disease I have seen take 
place on the skin of the face, generally on the forehead, m the form 
OUnd hardish bodies, with flat summits, to the number of eight, 
ten or twelve, disposed in a circular arrangement. The surfaci 
the skin was red, glossy and occasionally easting cuticular scales and 
shreds. These bodies were stated to be' the scat of an uneasy sensa- 
tion of heat rather than of pain. They had not advanced to ulceration. 
Upon removal by the knife, they became pale, white, and shrunk 
considerably. Internally they consisted oi' gray-coloured substance, 
interspersed with a tew blood-vessels, not hard, so much as doughy, 
tough and fibro-cartilaginous. They did not, nevertheless, pre 
the characters of carcinoma, but seemed to consist in an inflammatory 
induration of the corial tissue. 

" On the anatomical characters of the white scall (vitiligo), I possess 
no accurate information. I have often suspected that the appearances 
referred to this disease are in truth the effects of others more known. 

"Yaws (frambcesia) consist in chronic inflammation of the corion 
taking place in circumscribed spots, attended partly with death of a 
portion of the corial substance, partly with growth of granular fungi, 
— the result of a peculiar morbid poison." 

" Not only are yaws an inflammatory disease of the skin, but they 
are not, strictly speaking, an example of tubercular disease of that 
membrane, as in the arrangement of Willan is erroneously repre- 
sented. The phenomena show that they consist in an inflammatory 
process of the corion commencing in minute points, and gradually 
spreading in extent and penetrating in depth, till it generates a pecu- 
liar morbid product, which, after undergoing certain changes, is at 
length spontaneously removed, and allows the sore to heal. Thomson 
justly remarks, that the disease is at first papular, then pustular, and 
afterwards consists of yaw, though the latter is not constant, as the 
ulcer may heal without this substance ; when it must be accounted 
pustular. At no period does it appear to be tubercular; for the 
yawey growth, to which alone this term can be applied, is rather an 
effect of the pustular or chronic corial inflammation modified by the 
proper yaweyvaction. It may, in short, be inferred, that when the 
yawey action is sufficient without being excessive, it generates the 
proper fungous growths, under which the corion is either not mate- 
rially injured or is regenerated ; if the action be too violent, this 
growth is either destroyed or prevented from appearing; and in either 
case the corion is irreparably injured. 

" Sivvens, though a disease affecting not only the skin, but the 
fibro-mucous membrane, is entitled to notice in this place, as causing 
cutaneous inflammation not. dissimilar to that of yaws. Like most 
inflammations depending on the action of a morbid poison, when 
it affects the constitution, it induces inflammation of the corion in the 
shape of pustules terminating in bad ulceration and sloughs,— of 
furuncular tubercles and ulcers,— and of pustular sores affording the 
raspberry granulating fungus. 1 

"/;. Cutaneous inflammations, chronic, affecting at once the surface 
and the substance of the corion, and attended with general affection of 
the fibro-mucous tissues. 

" Of the disorders which I refer to this head, several are so similar, 
that they are probably to be viewed as varieties of the same morbid 
action. Of this kind are the Radesyge, Spedalsked, Liktraa or 
northern leprosy, the Pellagra or Lombard evil, the Scherlievo of 
the same place in Italy, the Mai di Rosa of Asturia, and a cutaneous 
disorder prevalent in Crim Tartary. In whatever points these dis- 
orders differ, all of them agree in being preceded by distinct febrile 
commotion, in consisting of inflammation affecting the corion in 
dehnite points, and in causing at the same time more or less inflam- 
mation, punctuate or diffuse, of the mucous and fibro-mucous mem- 
branes of the nasal cavities, the throat, the Eustachian tube and 
tympanal cavity. ' 

i Gilchrist in Essays and Observations, Phys. and Lit., vol. iii art x\ VA 1771 
Diss.Inau?. deSyphilnide Insontium,&c. Auct. A. Freer FH !■»•»« A .' 1 

pery.&c. By James Hill, Sorgeon. Ed., 1772. Observation! Ton M^Vkm C ^ s . esin 8 ? r ' 
By Joseph Adams, M. 1). London, 1807, chap. it. 2d ed *"' Polsons .* c - 



CRAIGIE'S CLASSIFICATION OF CUTANEOUS DISEASES. 



53 



" In these diseases, the affection of the corion is neither pustular 
nor tubercular, but consists in inflammation of its substance occurring 
in many minute points, and causing first an appearance like papulae, 
or sometimes only an extensive diffuse redness and roughness of the 
skin ; then desquamation of the cuticle ; then pustule-tubercular or 
minute hard eminences seldom suppurating completely, but some- 
times causing, partly by sloughing, partly by ulceration of the corion, 
deep foul sores, destroying the corial texture and the bulbs of the 
hair. This is particularly the case in the Radesyge, the form of dis- 
order prevalent in Iceland, the Scandinavian peninsula, the Feroe 
Islands, and the peninsula of Jutland. In those prevalent in Italy, 
Austria and Criin Tartary, ulceration of the corion appears to be less 
frequent. 

" The limits of this treatise do not permit me to enter at large into 
the history of these diseases, which, perhaps, are not to be viewed as 
merely cutaneous affections; and I shall simply refer to the best 
sources for further information. 1 

" To this head also may be referred some of the cutaneous erup- 
tions which occur either among the secondary symptoms of syphilis, 
or in the persons of those who, for this disease, have been subjected 
to one or more courses of mercurial medicines. Though these erup- 
tions may appear sometimes in the form of papulce, sometimes as a 
variety of rupia, and sometimes as ecthyma, they are also not unfre- 
quenlly of the chronic pustulo-tubercular nature, originally taking 
place in the corion, and causing more or less ulceration of that mem- 
brane. Their connection with inflammation of the mucous and fibro- 
mucous membranes is well known. 

" Upon elephantiasis so much accurate information has been of 
late years collected by Dr. Adams, Mr. Lawrence and Dr. Lee, that 
little difficulty can be experienced in settling its character as a morbid 
state of the skin. The case described so well by the last of these 
observers, I had repeated opportunities of seeing ; and the appearance 
of the skin could leave no doubt of the disease affecting the substance 
of the corion. The exact nature of this affection is perhaps less easily 
determined. By calling it a tubercular eruption, after the manner 
of Dr. Bateman, little exact information is communicated. Bichat 
states, that he has seen the corion manifestly disorganized in elephan- 
tiasis, 2 but says nothing of the anatomical characters of this disor- 
ganization. Pinel, Beclard and Meckel are equally silent on this 
subject. In short, though we have good descriptions of the external 
visible appearances of Arabian leprosy, an accurate description of its 
anatomical characters is still a desideratum. 

"The chronic soft tubercle (molluscum diuturnum), is a rare dis- 
ease ; and I have seen only one example of it in the person of a 
man of 40, in whom these bodies were disseminated over the cuta- 
neous surface of the face and scalp, the trunk, the upper extremities, 
the nates and thighs. Of two of the larger tumours which were 
removed from the palpebrce, the greater part was composed of firm, 
tough, whitish-gray matter, of the consistence of condensed cellular 
texture, penetrated through its whole extent by numerous minute 
blood-vessels, but exhibiting in no other respect traces of organiza- 
tion. This substance, when macerated in water, was resolved into 
gelatinous, flocculent filaments, easily lacerable, and presenting no 
definite structure. Imbedded in this, and removable most easily by 
maceration, were several small bodies not larger than a pin head, 
like fat in appearance, of a regularly spheroidal shape, of a lemon- 
yellow colour, and specifically lighter than water. The matter of 
these bodies was unctuous. It communicated an oily stain to paper; 
it liquefied and became transparent at a temperature not exceeding 
97° Fahrenheit, so that when attached to the body, it must have been 

1 For Radesyge, Dissert. Inaug. de morbo cutaneo luem veneream consecutivum 
simulante, auciore C. F. Ahlander, Upsalise, 1806. Diss. Inaug., sistens Obs. in ex- 
anthema arct. vulgo Radesyge, auctore Isaaco Vought. Grypheae, 1811. Geogra- 
phische Nosologic von Fried. Sehnurrer, M.D., p. 440. Morbus quern Radesyge vocant, 
&c. Commentatio Auctore F red. Hoist, M. D. Christianize, 1817. Ueher die Aussat- 
zartige Krankhcit Holsteins, &c. Von Ludwig Aug. Struve, M. D. 1820. — For Pel- 
lagra, S. Const. Tilii crat. de Pellagra; Patholosia. Viteberg, 1791. De Pellagra Obs. 
quas collegit Caiet. Strambio, 17S4-89, Medio). Franc. Frapolli Medio). Animad- 
vers. in Morburn vulgo Pellagra, Med. 1771. N. X. .lansen de Pellagra, Lug. 1787. 
Frank Delect , torn. ix. p. 325. Holland in Medico-Chirurgical Transactions, vol. vii. 
— For Mai do I!u-a, Tliiery Observations de Physique et Medecine, torn. ii. chap. vi. 
— For Scherlievo, Annali Universal! de Medecina. — For Crim Tartary disease, the 
travels of Falk, Gueldenstadt, and Pallas. 

2 Anat. Generate, torn. iv. p. 688. 

14 



fluid ; it was insoluble in alcohol, ether and water, but formed in 
the volatile oil of turpentine a colourless solution. When this was 
exposed to the temperature of the spirit-lamp, the greatest part of 
the volatile oil was evaporated, leaving a transparent, colourless, 1ml 
viscid and semifluid substance, communicating to paper a slain be- 
coming less deep, but not wholly removable by exposure to a high 
temperature. These results favour the idea that the matter of these 
bodies is oleaginous: but I was unable to observe any action of 
aqua potassce or aqua ammonite, after repeated trials, both at the 
ordinary temperature of the atmosphere and when liquefied by a 
gentle heat. By the sulphuric acid it is hardened and blackened ; 
by the nitric acid its yellow colour is rendered more intense. 3 

"Whether the presence of these yellow adipocirous bodies is uni- 
form in the molluscum I have had no subsequent means of ascertaining. 
If they are, it may be reasonably conjectured that their formation 
depends on some morbid or vitiated state of the sebaceous follicles. 

" Wart and corn are believed to depend on morbid accumulation 
of cuticle. The former, however, is vascular at its basis ; and it may 
therefore be inferred that its production depends on morbid action 
of the surface of the corion at the particular point at which it appears. 

"2. Dermatcemia Dermatorrhag-ia. — Hemorrhage of the skin ap- 
pears under two forms ; either that of a bloody or blood-coloured 
fluid oozing from certain regions, or of blood effused in the form of 
purple specks, spots, patches, or livid stripes on the surface of the 
corion below the scarf-skin. The former discharge is rare, and takes 
place chiefly as a supplementary evacuation to some natural one acci- 
dentally suppressed, as the menstrual discharge in females. The latter 
is of a different nature, and is both the effect and proof of a morbid 
state of the system. 

" Restricted in this manner, hemorrhage from the corion may take 
place in two modes ; either when the corion only is affected, or when 
it is affected in common with many other membranes. The first case 
constitutes the simple purple disease (purpura simplex) of authors; 
of the second we have examples in the hemorrhagic purples [purpura 
hemorrhagica) or land-scurvy, and in the genuine sea-scurvy (scor- 
butus.) 

" The anatomical characters of the disease consist in bright red or 
crimson spots, becoming in a day or two purple or livid, afterwards 
brown, and when about to disappear, assuming a yellow tint. They 
are occasionally attended with long livid stripes (vibices) or patches 
(ecchymomata), and in some instances, the cuticle is raised into vesi- 
cles or large purple blebs (phlyctcence), containing bloody or purple 
serous fluid. These spots consist of blood or bloody fluid, effused 
on the outer surface of the corion, which is soft or pulpy, velvety, 
and reddish, from injection of its vessels. 

" 3. Angiectasis. — Anastomotic aneurism is frequent in the corion, 
and has been observed by J. Bell, Freer, Travers and Wardrop. 
Though congenital, it must not be confounded with the ncevus mufcr- 
nus or birth-spot (Penvie), which appears to consist in a peculiar 
original malformation of the corion. A similar congenital defect is 
the white-spot (leucosis, leuccethiopia), which consists in the absence 
of the polished vascular surface of the corion. Occasionally it takes 
place during life, and in minute spots is observed to follow diseases 
in which the cuticular surface of the corion has been destroyed by 
ulceration. 

" 4. Mcliceris, Cutaneous Wen. The only encysted tumour which 
takes place in the skin consists in the immoderate enlargement of one 
or more of its mucous follicles, in consequence of obstruction of the 
excretory duct. When from any cause this takes place, the sebaceous 
matter, which in the healthy state is propelled to the surface and 
removed, accumulates in the interior of the follicle, which is thus 
inordinately distended, till, by removing the obstruction, the orifice is 
opened and the inspissated matter eliminated. It almost invariably 
again accumulates unless care be taken to keep the excretory duct 
pervious, — an object which is most easily and certainly attained by 
frequent ablution. This mode of explaining the origin of the cuta- 
neous folliculated tumour was understood by Morgagni, 4 Haller, 

3 A good painting of the subject of this case was made by my late friend StafT-Sur- 
geon Schetky, and by him deposited in the pathological collection of Chatham Hos- 
pital. 

* Adversaria Anatomica. 






Wll Ml RAL SYSTEM OF CUTANEOUS DISEA5 



... by S 

skin is not uncommon. Though il 

. n is delicate and thinly co 

jrelids, prolabium and nose, 
i r; and next to these, perhaps, arc to 

and the penis of the male, the 

i> liable to he affected by this morhid structure. 

often the seat of that peculiar carcinomatous 

irringinthi if chimney sweepers. In all these 

is much the same. In the situation of the corion 

Q a tough linn substance of fibro-cartilaginous structure, the 

bands being generally arranged in a waving direction. In 

tincl example of the disease which I examined personally 

ireinomatous degeneration of the whole skin of 

fibrous hands were disposed transversely to the long 

direction of the part, and appeared to consist of a fibro-cartilaginous 

long band folded repeatedly on itself. 

" The reparation of the corion when destroyed has been maintained 
• J many authors. Notwithstanding their assertions, however, this 
membrane is never, after its substance has been injured, restored to 
ginal stale. The breach is filled up by firm cellular tissue, the 
upper surface of which never acquires the organization of the outer 
surface of the corion. It is nevertheless capable of furnishing cuticle 
by which this new corion is covered. These facts may be verified 
in the cicatrization of burns and other injuries in which the corion 
bas been destroyed. 4 

" The nails, like the cuticle, may be diseased in consequence of a 
morbid slate of the corial surface and vessels by which they are 
nourished. In one or two instances of strumous children I have seen 
them fissured into several longitudinal portions, much thickened and 
indurated like horn, and incurvated. In others of the fingers of the 
same individuals, they were small and imperfectly developed ; and 
in some their place was supplied by a small portion of thick horny 
cuticle. Similar changes arc sometimes induced by disease or by 
injury. 

"Of the fairs the most extraordinary morbid state is the Polish 
plait ( plica Polonica); so named from being endemial in Poland, 
Lithuania, Hungary and Transylvania, from the source of the Vistula 
to the Carpathian mountains. It occurs also in Prussia, Russia, 
Switzerland, and in some parts of the Low Countries. It is impossible 
to doubt that this anormal condition of the hairs depends on disease 
taking place in their bulbs or nutritious sacs. This is proved by 
te of the skin from which the diseased hair grows, and by the 
unctuous, viscid and blood-coloured fluid which the hairs in this state 
contain. We nevertheless possess no very precise information on the 
nature of this diseased state of the capillary bulbs ; and in the absence 
\act facts I abstain from offering conjectures. 

" The piliparous sacs lose their energy under certain morbid states 
ot the system ; for instance, fever, pulmonary consumption, and the 
constitutional symptoms of lues. The hairs then drop out ; and if at 
•Ins time the bulbs be examined, the sacs are found to contain, 
according to Bichat, at least in persons who have passed through 
lever, the rudiment of new hairs. The shedding of the hairs, which 
takes place in the decline of life, and the period of which varies 
remarkably in different individuals, Bichat represents as depending 
on a total death of the piliparous sacs. 

"Accidental and anormal development of hairs is not uncommon. 
In the skin this appears in the shape of hairy moles and similar con- 
genital marks. 5 Their occurrence in the stomach, intestines and 
bladder, as noticed by a variety of authors, is also to be regarded as 

"Sedes meliceridis," says Plenck, "in glandula subentanea esse videtur. Quic- 
qu.d ergo porum excretonum glandule subcutane* obdurat, contentum sneenm 

•r Sp,SS rf m T ?i e,US a ^ rpt, £ nem im P edit ' nieliceridem producere valet." Systema 
rumorum, cl. vtt. p. 153. Viennse, 1767. 

4 Intituzione Chirurgiche, vol. ii! 

* Surgical Essa 

I ahn Commentatio de Regeneration e, &c, 1787, p. 23, &c. Andres J 
d. Murrav, Commentatio de Redinte«ratione I7a- „ \n » tv ,■ , 

Hailer. Elementa Phys. 



anormal. Lastly, the accidental development of hairs is observe,] 
in encysted tumours, especially those of the ovaries, in which masses 
or balls of hair mixed with I idipocirous matter, arc 

not unfrequently found." On tl in which these hairs are 

formed nothing satisfactory is known 

The last system of classification is thai adopted by Mr. Erasmus 

Wilson, in his work already referred to. He calls il the Natural Sys- 

Sting upon Anatomy and Physiology. "The dermis and its 

dependencies, its glands, and its follicles, are the undoubted seat of 

all the changes which characterize Cutaneous Pathology." 

The following is Mr. Wilson's classification arranged in a tabular 
form. 



•I. DISEASES RMIS. 



( Congestive 



( Specific 
I 



I 

I Non-specific 



f Asthen 

(.Sthenic 



f R'.il i 

' atina. 
-; Variola. 
I Varicella. 

[Van 

( Erysipelas. 
J Urticaria. 

c.la. 
Iieraa. 

V Pemphigus. 

( Rupia. 

( Herpes, 
Eczema. 
(.Sudamiaa. 



*w»*« {]'; 

_ . . f Strophulus. 

Depositee . J L.ichi n. 

(_ Prurigo. 

i Lepra. 

< Psoriasis. 

(.Pityriasis. 



Squamous 

From Parasitic An.malcules 



Hypertrophy of the Papilla; 



Scabies. 

(Ichthyosis. 

Tylosis. 
■J Ciavus. 

1 .in acse. 

I t'lunim. 



Disorders of the Vascular Tissue < Vascular Narvi. 

( Purpura. 

Disordered Sensibility 5 Hyperesthesia. 

( Pruritus. 

/Augmentation of pigment 
Diminution of pigment . . 



<, Nigritiee. 

( Pigmentary Na i 



Disordered Chromato- 
genous Function . 



Alteration of pigment 



Chemical Coloration 



f Alh inismus. 
X Vitiligo. 

fF.phelis. 

I Lentigo. 
Chloasma. 
Melai 

>, Oxyde of Silver 



II. DISEASES OF THE SUDORIPAROUS GLANDS. 

Augmentation of Secretion Sudatoria. 

.mi of Secretion 
Alteration of Secretion Abnormal Odour, Colour, &e. 

III. DISEASES OF THE SEBACEOUS GLANDS. 

Augmentation of Secretion Stearrhcea. 

Diminution of Secretion 

Alteration of Secretion Ichthyosis Sebacca. 

fComedones. 
/Duct Open 



Retention of Secretion . . / 

VDuct Closed . 
Inflammation of Glands and adjacent Textures 



J Sebaceous Accumulations. 
1 Small Sebaceous Tumours, 
( {Molluscum Contagiosum.) 

f Sebaceous Miliary Tubercles. 
J Calcareous Miliary 1 

; Serous Cysts. 

led Tumours. 
( Acne. 
( Sycosis. 



IV. DISEASES OF THE HAIRS AND HAIR-FOLLK 

Augmented Formation Pilous Nsevi. 

Diminished Formation J Alopecia. 

.... ,~ , ( Cah < „ 

Alteratton of Colour 

Disease of the Hair-Pulps Plica Poloni, 

Disease of the Follicles 5 Inflarnmatio Folliculorum. 

I Favns. 
Abnormal Direction 5 Trichiasis. 

( Felting.'' 

It will be seen, from the preceding systems, that the views of der- 
matologists tend to an arrangement of diseases of the skin based 
upon an anatomical and physiological basis, which, although' as vet 
confessedly imperfect, is preferable to any arrangement deduced from 
the more external features or physiognomy of the cutaneous emotion 
and other disfiguration, as adopted by Plenck, Willan and Bateman, 

« Bichat, torn. iv. p. 828. 

' Meckel. Journ. Compl., t. iv. and Brkhe'.eau, Journ. Compl., t. x v 



CONNECTION BETWEEN DISEASES OF THE SKIN AND OF MUCOUS MEMBRANES. 



55 



and, with more qualification, by M. Rayer himself. Plumbe, while 
he admits the value of the anatomy and physiology of the skin as a 
guide, lays stress on the etiology of the diseases of this tegument, in con- 
nection, especially, with constitutional conditions of the system, which 
originate or modify them. Even if we should fail to establish a suc- 
cessful classification from these premises, it is all important that we 
should continually bear them in mind, in proceeding to the treatment of 
cutaneous diseases; for in this way alone shall we be saved from the 
empiricism which, up to the present day, is still prevalent when this 
subject is brought up. Plumbe's criticism, as conveyed in the follow- 
ing words, is too well founded: — "A classification of the external 
and ever-changing forms of the accumulated secretion of disease on 
the surface — one day a pimple, the next a vesicle, on the third a scab 
or crust, the fourth a falling scale, the fifth a red spot! This might 
have served the purpose at the time, for want of a better; but to 
pronounce it a better classification than one founded, whether with 
solid foundation or not, by its originators, on etiology, or the causes, 
external and internal, of the cutaneous disease, would be manifestly 
absurd." And again: — "Purpura or scurvy stands foremost among 
these. Its different states, in different and not unfrequently in the 
same person, may, at uncertain periods, be found putting on the 
mask of pimple, vesicle, pustule, scab, or scale; blue flat discolora- 
tions ; large vesicles, half filled with bloody serum, and others, smaller 
in dimensions, of a yellow, transparent colour. Again, it may show 
itself in the form of what is commonly called thrush, either in the infant 
or adult. It may appear in the form of erythema nodorum, which is a 
scorbutic inflammation of the integuments, ending in a partial effusion 
of serum and blood into the cellular structure. Erythema andrupia are 
the pustular forms of it, ending in scabs." [P. 44, op. cit. Am. Ed.] 
But, whatever differences may exist between the modified artificial 
arrangement of M. Rayer, and the alleged natural one of Mr. "Wilson, 
or between them and the mixed one of Mr. Plumbe, there is among 
these writers a general agreement respecting the organic condi- 
tion of the skin, in most of the forms of eruption which we commonly 
speak of as constituting its diseases. Inflammation is the primary 
and chief pathological change, that on which the phenomena that more 
immediately strike the eye depend. According to the division of the 
cutaneous system affected, and in degree to the duration of the affec- 
tion, will be the physiognomy of skin diseases. M. Rayer, in his 
table, (p. 21,) includes the larger number of diseases of the skin, 
under the head of "inflammatory affections distributed according to 
t lie number and form of their elementary lesions;" and of these, the 
larger number, or nine classes, have only a single elementary form. 
"Peculiar states of the skin, not referable to inflammation, are com- 
paratively few." He enumerates some, again, as "morbid states 
of the secreting function," and, under another head, introduces "neu- 
roses of the skin." His fifth chapter is "faulty structure or unusual 
states of one or other of the elements of the skin;" and the sixth is 
"degenerations." In a second division, he places "alterations of the 
dependencies of the skin," such as diseases of the sebaceous and 
piliferous follicles. 

Recurring to the original proposition, we find a vast majority of 
cutaneous diseases, viz., exanthemata, bulla, vesicular, pustules, furun- 
cidi, gangrenes, papulee, squamae and tubercula, recognized as depend- 
ing on inflammation of a single elementary form, and syphilis, ambus- 
tio and pernio, having several elementary forms inflamed. 

Mr. Wilson, also, while he refers the larger number of cutaneous 
diseases to the dermis, regards the organic changes constituting them 
as depending on inflammation, in its several varieties of congestive, 
effusive, suppurative, depurative, squamous, or from parasitic animal- 
cules. 

Mr. Plumbe, although he does not lay down thus broadly inflam- 
mation as the sole pathological basis of diseases of the skin, is hardly 
less explicit, when introducing their several divisions to his readers ; 
as when he speaks of some of these diseases being marked by chronic 
inflammation of the vessels secreting the cuticle, others characterized 
by active inflammation, with or without constitutional debility or 
derangement of any kind. 

The general division of diseases of the skin into those of an acute 
and febrile, and those of a chronic and apyretic character, is gene- 
rally admitted ; but we much fear that too broad a contrast is supposed 



to exist between the two, to the oblivion, if not actual denial, of the 
chronic class being also inflammatory, and of their having, like 
the acute, their periods of incubation, attack and decline. Few of 
the diseases of the skin, if carefully watched from their early in- 
ception, would be found wanting in these stages; and the chiet 
difference between the two divisions will, on careful analysis, be 
found to consist in this, that the acute and febrile, after having run a 
definite course, terminate either in health or death — putting aside, for 
the moment, complications which do not essentially belong to them ; 
while the slow, or chronic, go through a similar course, but with a termi- 
nation only temporary and incomplete ; so that, after a period, the cuta- 
neous irritation and congestion, or other organic changes are renewed, 
either in the same or at another region, and go through a series of 
stages like the first. It is this partial suspension and renewal, more 
or less complete, according to the hygienic system pursued by the 
patient, that give reputation, for a season, to a particular remedy or 
plan of treatment, and tantalizes the sufferer with the prospect of a 
cure, which, in a short time, is shown to be fallacious. Until we get 
the measure of these alternations of relief and exasperation, and of the 
constitutional state and changes accompanying them, we cannot pro- 
mise ourselves to make any great advances in the rational therapeu- 
tics of cutaneous diseases. 

In the acute febrile diseases of the skin, and particularly in the 
exanthemata, or eruptive fevers proper, the mucous membranes suffer 
often as much as the dermoid texture. Their being primarily affected, 
has been already adverted to. In the case of the skin, however, the 
inflammation is generally diffuse, and extends over the entire surface ; 
whereas the mucous membranes are but partially affected, or, at any 
rate, suffer most in particular regions, as the fauces in scarlatina and 
small-pox, the air-passages in measles, &c, at any rate, at the begin- 
ning or first stage of the disease ; while, towards its decline, the 
lower bowels may become the seat of secondary irritation, or phlo- 
gosis, manifested by diarrhoea, or the kidneys be the organs thus 
secondarily affected, giving rise to albuminaria and anasarca. He 
who does not continually carry in his mind this connection in function 
as well as in disease, between the two great divisions of the general 
tegumentary system, will have very limited views of the pathology 
of febrile cutaneous diseases, and be not a little embarrassed ia 
arriving at a rational treatment. 

In a more advanced part of the present volume, the reader will 
find a "parallel between the diseases of the skin and those of the 
mucous membranes," which might have been introduced with advan- 
tage, by the author, at a much earlier period. "If we except," says 
M. Rayer, par 1282, "the white wheals of urticaria and the patches 
of roseola, we find in the mucous membranes almost the whole of 
the varieties in form and appearance, presented by the exanthema- 
tous inflammations of the skin." "As to the brown, gray, or slate- 
like discolorations presented by the mucous membranes, in conse- 
quence of their inflammation, we observe very similar tints following 
chronic inflammatory affections of the skin." M. Rayer then proceeds 
to describe the various forms of eruption on mucous membranes, 
such as exanthemata, bullae, vesiculae, &c, similar to those seen 
on the skin. Mr. Wilson very properly places rubeola, scarlatina, 
variola, varicella, vaccinia, under the head of inflammation of the 
dermis and mucous membranes, with constitutional symptoms of a 
specific kind. It is now eighteen years since the editor, in his 
" Syllabus of a Course of Lectures on the Institutes of Medicine and 
Medical Jurisprudence," printed for the use of his class, (at the 
Philadelphia Medical Institute) enumerated variola, varicella, ru- 
beola, scarlatina, erysipelas, urticaria, and herpes, as a class desig- 
nated as "Diseases affecting the cutaneous and mucous systems 
simultaneously, or cutaneo-mucous diseases." To this conclusion 
he was the more determinately led by the results of extensive clini- 
cal experience in epidemic small-pox, measles and scarlatina. 

It is not meant that the treatment of the exanthemata should be 
described here, in anticipation of the time when it will come up in 
regular order. One remark, however, of practical importance may 
be made, viz., that independently of the varieties in their intensity and 
progress, depending on differences in individual constitution, we meet 
with great modifications during different epidemic seasons, requiring 
corresponding changes in treatment; so that scarlatina, for instance, 






TREATMENT OF CUTANEOUS DISEASES. 



pie and benign, in another displays 
ich, at one time, will be benefi 

mother will not allow of evacua- 
i nature, ■ dtmands early recourse to 

In ;' ■ t of the chroni ns of the skin, we are yet 

. but, on the contrary, learned empi* 
'l'he chief indications to be fulfilled are, 
ment, and often inflammation, and .1 

ry function. The morbid action, undue 
cretion, being arrested, there is seldom much 
ilty in procuring a ready absorption of the new and abnormal 
. or between its lamina. In carrying 
out the above in a little aided by recurrence 

to the principles already laid down, respecting the general sameness 
ioid ami mucous membranes, (see also Mandl, Man. <!\ biat. 
~ .) and of the sympathy, .is well as antagonism of action be- 
1 portions of the teguraentary system, and also as 
:i of this principle, the dependence of the cutaneous 
or Iota! malady on the constitution. In fact, the principles and 
practice that govern the treatment of a chronic inflammation of a 
, ought to direct us in that of a cutaneous disease. The der- 
moid system, sa^ s .Mandl (op. cit. p. 5 17), may be regarded as an ex- 
1 creting solid matters, yiz., the epidermis and the epithe- 

lium. Hence, while we abate the afflux by purgatives and diuretics, 
■ othe irritation by baths of various kinds, and at such a tem- 
perature as the experience of the patient and the powers of reac- 
tion may justify. After perseverance, for a period, in this course, we 
direct some one, or a succession, it may be, of those medicinal sub- 
stances which arc believed to display alterative properties. These 
are ref'ernble to two great classes : the abaters of action, or contra-sti- 
mulants proper, and those which tend to remove, by absorption, and 
renovate the tissues. Among the former, the antimonial preparations, 
tented by tartar emetic, are entitled to a precedence, and next 
among the mercurials, calomel and blue mass. The latter display 
very decided powers of reducing morbid excitement of the raom- 
B; and on this account, as well as by their beneficial action 
on the mucous membranes and digestive apparatus generally, they 
are entitled to rank high, in the list of curative agents, in pro- 
I chronic affections of the skin depending on inflammation. 
Mercurials may well be alternated with tartar-emetic, by their being 
in small doses, and aided by large use of diluents, so that 
c the stomach nor bowels shall be harassed or disturbed nor 
ptyalism be induced. The warm or vapour-bath, regularly employed, 
useful adjuvant to the medicines just mentioned. 
Without foregoing the use of antimonials and mercurials, even 
where they have not answered expectation, recourse might be had to 
salines; either those of a purgative or a diuretic nature, and particu- 
larly the latter. Various mineral waters answer a good purpose in 
this way, alter having, it is presumable, entered largely into the cir- 
culation ami penetrated into the dermoid tissue. Still contributing 
to the end proposed, of abating cutaneous excitement and modifying 
morbid secretion of the skin, wdl be the administration of colchi'cum 
and digitalis. The first of these can be usefully combined with 
salines or alkalies, or magnesia, according to the stale of the prima? 
ind the propriety of acting on the bowels or of modifying the 
renal secretion. 

•ties, — hyoscyamus, belladonna, stramonium, dulcamara, and 
centum — are also coincident with the measures just proposed; and 
may be combined with mercurials or the tartar emetic, or "riven 
»1 only allay irritation of the skin, but abate, by their 
vous system, the process of morbid nutrition and de- 
desirable to give any of them in a dose beyond that 
wl,lch P 1 " 01 ' as evidence of the purity of the 

artu * le - M ned by their regular use for a length of time 

administration of large doses, whose operation raav be too 
manifestly narcotic. The alternate or even combined use of this 

is often decidedly efficacious in 
1 which there prevails'either irritation 
« '•" : > or ol the digestive mucous surfaces, or of the renal 

apparatus. 



The external medication in harmony with the internal, as just re- 
amended, will consist in the employment ol' the warm, or tepid, or 
simple vapour bath, warm fomentations or emollient cataplasms, and 
infusions of some narcotics, or ointments of the latter. Preparations 
of lead, and more particularly of the subacetate adequately diluted, 
will, in some cases in which the disease is of circumscribed extent, 
exert a sedative effect. Recourse to articles of this nature ought, 
however, always to follow the general or constitutional treatment, and 
to be used with great circumspection, if at all, in those forms of disease 
which assume an ulcerous character, and have been long discharging. 
and which we may encounter in children during dentition, or in aged 
persons. 

When, on the other hand, either from the duration of the disease, 
and the subsidence of irritation and excitement, and the absence of 
disorder of the digestive mucous surfaces, or the want of success from 
the soothing treatment, more stimulating remedies are demanded, 
we shall have recourse to sulphur, iodine, arsenic, cantharides, and 
the different mineral and vegetable tonics and astringents. 

Sulphur has long enjoyed a great reputation for the cure of some of 
the most common, and at the same time occasionally inveterate dis- 
eases, such as scabies, or itch and lepra. But, if had recourse to 
early, when there is yet much irritation and vascular excitement, or 
if it fail to purge, this medicine will not only disappoint us of the de- 
sired effect, but prove positively injurious. Hence, it is most effica- 
cious when combined with salines in either natural or factitious 
mineral waters, or, as in the popular formula, with cream of tartar, and 
occasionally with magnesia. Used in this manner, the sulphur prac- 
tice is a transition from the reducing or sedative to the stimulating 
plan of cure ; and may be well entitled to a trial before medicines of 
more power, either for good or evil, are resorted to. In lymphatic 
temperaments, and in broken-down constitutions, suffering from scro- 
fulous eruptions, sulphur may be given at the same time with some 
preparation of iron, or, if the indications be more direct, with a vegetable 
bitter. In venereal eruptions it will be administered in conjunction 
with mercury. 

Iodinic preparations are contra-indicated in those cases in which 
there is either much vascular or nervous excitement, or in which gas- 
troenteric irritation prevails. The least stimulating form is the 
iodide of potassium ; the most so, the alcoholic tincture of the iodine 
itself. Between these two are the compound solution and compound 
tincture of iodine. Largely diluted in a solution of some purgative 
salt, the iodide of potassium maybe administered after the subsidence 
of the first stage, that of gastro-intestinal and febrile irritation, of 
various cutaneuos diseases, and more especially the papular and 
tubercular forms. In this state of combination, or even alone largely 
diluted, the iodide can be continued for a length of time, until every 
tissue is permeated, and in a degree, its organic nutrition modified. 
It often comes in opportunely to relieve the depression of the 
system and feeling of wretchedness induced by the uncalled for, or 
excessive use of mercury, and realizes that which was expected from 
the latter. 

No benefit can be promised from the tincture of iodine that is not 
procurable with less inconvenience and drawback from the iodide of 
potassium, or if a more stimulating preparation than this latter be de- 
sired, we have the solution of the ioduretted iodide of potassium, or the 
compound solution of iodide of potassium. The use of this medicine 
will be alternated with that of compound saline waters and sometimes 
in conjunction with them, and some one or other of the narcotics, 
where the irritation of the skin, even in the chronic sta°-e of the dis- 
ease, is still considerable. Its use is compatible with abundant nutri- 
ment, should this be deemed advisable, and especially so in ansemic 
subjects, and also in those of a lymphatic temperament. 

Arsenical preparations used in the appropriate period of a cutane- 
ous disease, that is, when the stage of inflammatory and irritative 
excitement has subsided and when there is no complication of castro- 
enteritis, have often a singularly {mod effect Tl,,.„ ^-^ 
, , 1 < 1 , 41 ° J P ,,. l,n(l - *ncy are particu- 

larly adapted to the squamous or scaly affectxonsof the skin Thedose 
should be small, and, if symptoms of irritation are induced b v the 
medicine, conuira or some other narcotic should be associated with 
it. The safest formula for the administration ol is the I t 

of the arsenite of potassa, or Fowler's solution, as it is more generally 1 



THERAPEUTICS OF CUTANEOUS DISEASES. 



57 



called. Of late, the solution of the iodide of arsenic and mercury, or 
Donovan's solution has been given with great success in obstinate cases 
of long standing, particularly those of syphilitic eruption and of lupus. 

Arsenic requires more care in its administration in sanguineo-ner- 
vous habits, and in these the customary cautions respecting its use 
should be promptly enforced. When the patient feels any febrile 
movement, heat, thirst and a feeling of weight and heat at the epigas- 
trium, or complains of heaviness and pricking sensation about the 
eyelids followed by puffiness of these parts, the use of the medicine 
should be suspended, and in its place mild aperients prescribed. The 
resumption of the arsenical preparation must be in a smaller dose than 
that in which it was first administered. 

Cantharides is a remedy of great power in certain chronic skin dis- 
eases, as eczema, lepra and psoriasis ; but its exhibition requires 
caution, and it should not be continued after any symptoms of urinary 
irritation are manifested. 

There are two stages of chronic cutaneous diseases in which the 
state of the constitution requires careful notice, and the use of active 
general remedies, but of opposite characters. Of the first, or that of 
excitement, I have already spoken, as well as of the depleting and 
sedative remedies required for its removal. In the second, or that 
of debility and imperfect nutrition, owing to chronic derangement of 
the digestive organs, a tonic course is indicated. This may be either 
the primary one, or adjuvant to the special treatment ; as when we 
administer iron, in addition to, or in combination with, sulphur or 
iodine ; quinine with mercury. In all cases of complication of consti- 
tutional disorder with chronic cutaneous affections, it will be wiser 
to make the removal of the former the chief object, and to direct the 
remedies for the latter in this subordination. The iodide of iron, in 
the form of solution, as directed to be prepared in the Pharmacopoeia 
of the United States, is adapted to a large number of cutaneous 
diseases of a chronic character, occurring in cachectic habits or in 
constitutions that have long suffered from disorder of the digestive 
apparatus. Auxiliary to its tonico-alterative effects, are the vegetable 
bitters and certain depurative syrups, such as the compound syrup of 
sarsaparilla, syrup of pipsissewa, &c. 

In anemic constitutions, and particularly in female subjects, suffering 
from chronic cutaneous diseases, the prolonged use of a chalybeate, 
combined or in alternation with a laxative, will be productive of much 
good ; as will the sulphate of quinia in those who have been afflicted 
with periodical fever in its various forms. 

In the external or local treatment, of a stimulating kind, great im- 
portance has always been attached to baths, in which various sub- 
stances of an active nature have been held in solution. In aid of in- 
ternal remedies these will often do much good. Trusted to alone, 
they will more generally fail us. This class includes the simple and 
the medicated warm and hot baths. The most conspicuous of the 
latter are those largely impregnated with sulphur, iodine, corrosive sub- 
limate (bichloride of mercury) the alkalies and mineral acids ; the two 
former are combined either with water or with vapour. 

Preparatory to the systematic and prolonged employment of stimu- 
lating baths, it will be proper to subject the patient for some time to 
the use of the simple warm water or vapour bath ; both as a means of 
removing any remaining excitement of the cutaneous system, and as 
an aid to diagnosis, by revealing more completely the physiognomy of 
the disease. The real state of the dermis may be masked by the 
white branny scales covering its diseased regions, as in the squamae, 
or by dry scabs, as mfavus and impetigo. These removed, we often 
find active dermoid inflammation, requiring a soothing and sedative 
treatment in place of stimulating applications, that seemed to be indi- 
cated by superficial signs of an indolent state of the parts. Plumbe (p. 
41) points out the difficulty of diagnosis in many cases of scalled head 
of pauper females, in which he had to deal with masses of scabs, and 
scales interwoven and matted with the hair of these parts, requiring 
for their removal ointment, the use of soap and warm water, before 
an opportunity was offered of examining the diseased cutis. In all 
chronic affections of the skin, a sponge dipped in warm water should 
be rubbed over a part, at least, of the diseased surface, and the slightly 
adherent cuticle removed, so as to allow of the real state of the der- 
moid tissue being seen. 

Of the stimulating baths, those of the sulphurous kind have been the 
15 



most extensively used, and productive of the greatest good in a large 
number of diseases of the skin. Their beneficial operation depends 
mainly on their temperature and duration, as already indicated by M. 
Rayer,parag. 127. Little can be expected from a sulphur bath, unless 
it be at least 90° F.; but in chronic disease and in apyretic states of 
the system, it may be brought nearly to blood heat. When the patient 
is required to spend a long time in the bath, and from one to three 
or four hours is not an uncommon period, the temperature should be 
such as just to convey a grateful sensation of warmth, and no more. 
By this protracted immersion time is allowed both for the passage of the 
simple fluid and its medicated constituent, through the epidermis to 
the dermis, and for the textural and vital modifications of this latter 
requisite for the removal of the disease. It needs little reasoning 
to show, that the period in which the external treatment by bathing 
is carried on, is that in which alteratives of various kinds may be 
resorted to ; and, if they do not exert a principal effect in procuring a 
favourable result by their action on the capillaries, saline and sul- 
phurous mineral waters, natural or factitious, blue mass, or iodide of 
potassium, according as there is any constitutional excitement or 
syphilitic or scrofulous taint, will be found to meet the indications at 
this time. 

Experience has not yet enabled us to define the cases in which the 
water-sulphurous bath should be preferred in the dry vapour or sul- 
phurous fumigation. In a general way, the latter may be said to be 
best adapted to old forms of cutaneous disease, in habits in which 
there are a languid circulation and general debility. It is true that 
patients often complain of exhaustion after these fumigations ; but the 
debility is here obviously of the indirect kind, following increased 
activity of the circulatory and respiratory functions. 

The alkaline sulphurets, as those of potassa and soda, or rather of potas- 
sium and of sodium, are employed in the composition of artificial baths 
— in various proportions and combined with other matters. One of the 
formula, recommended by M. Rayer, consists in dissolving 3iv of sul- 
phuret of potassium in thirty gallons of water. It must be prepared 
in a wooden bathing vessel. Dupuytren's gelatino-sulphurous bath is 
prepared by adding one pound of Flanders glue (previously dissolved 
in water) to the sulphuretted bath just described. This is an imitation 
of the Bareges waters, so celebrated in France for the cure of obstinate 
diseases of the skin ; although recent analysis (by M. Longchamp) 
shows that sulphuret of sodium is the predominant compound into 
which sulphur enters in these waters. Their temperature, in the dif- 
ferent springs, is from 85° F. to 114° F. Of 111 military men 
affected with various forms of psoriasis and impetigo, vaguely called 
herpetic disorders, who visited Bareges in 1829, 66 were cured. 
The cures of the more simple kinds, 51 in number, were 31. 
The proper imitation of the Bareges water for bathing is as follows : 
crystallized sulphuret of sodium, carbonate of soda (crystallized), 
chloride of sodium of each 64 grammes ; pure water 320 grammes. 
These salts are to be dissolved in the water, and the solution is to be 
promptly poured into a bottle closely corked. This quantity will 
serve for a common bath of about twenty gallons. 

Baths of water impregnated with iodine, or the iodide of potassium, 
in different degrees of strength, have been spoken of by M. Rayer 
and the formulae, after M. Lugol, for their preparation will be found 
in the " formulary" at the end of this volume. Iodine maybe readily 
vapourized in water of a moderate heat, and in this way applied to the 
cutaneous surface for the required period. 

Washes made of a solution of corrosive sublimate, are more used 
than a general bath of this salt. The solution of the bichloride of 
mercury of the London Pharmacopoeia is made of ten grains of the 
mercurial salt and the same quantity of hydrochlorate of ammonia^ 
dissolved in a pint of water. Diluted with an equal quantity of 
water, this solution is used as a wash for herpetic and scabious erup- 
tions. In smaller proportion, or half a grain to a pint of water, Baume 
recommended the solution in the form of a pediluviun, to produce 
salivation. He directed the feet to be immersed in it for a period of two 
hours. Such a practice will be found for the most part inert, as this 
salt of mercury, externally applied, is little liable to salivate unless the 
cuticle be removed or abraded. 

Alkaline baths have been occasionally used with advantage in 
some chronic cutaneous diseases ; but whether as simple exciters 



B6 



THERAPEUTICS OF CUTANEOUS DISEASES— EXANTHEMATA. 



n it chemically, we arc not apprised .see parag. 

ided benefits may be expected from baths, to which 

i mineral acids, and particularly the nitric, and nitfO- 

lic or Bitro-hydroebloric acid, baa been added, in the proportion 

of the latter to 30 gallons water, in a wooden 
tab. Where we are prerented from directing the internal adminis- 

D of the mineral acids, of which M. Kaycr thinks so highly, 
(parag. lo'' 1 ,' recoorae should be bad to their employment externally 
undei '-onditions as those that govern them in the former 

Dging M the class of stimulating baths, are those of sea-water, 
brought up to the degree of blood heat, or a little below, as at 96° F. 
In torpid habits the temperature of the bath may extend beyond 
LOO F. 

If the situation and circumstances of the patient do not allow of 
recourse to medicated baths, a good substitute will be found in apply- 
ing the active articles, such as sulphur and iodine, and even the 
mineral acids, in the form of ointment. Iodine, in this way, has 
been found to be one of the best remedies, especially when conjoined 
with its administration externally, in prurigo senilis. To give full effi- 
cacy, however, to this form of medication, a simple water or vapour 
bath should lie employed daily, or on alternate days, so as to place the 
skin in the most favourable state for absorption, and to remove par- 
tially detached epidermis and adherent morbid secretions. If the 
e embrace an extended cutaneous surface, it will be better 
to rub in carefully the ointment prescribed for the occasion, on a 
limited region at one time, and then apply it in like manner to 
another, than to attempt to anoint the entire surface, and most pro- 
bably fail thereby in doing justice to any one portion. 

To the class of external stimulating applications belong, in an 
eminent degree, those of a caustic or escnarotic character, such as 
chlorine, nitrate of silver in substance, corrosive sublimate in strong 
solution, tincture of iodine, iodide of mercury, chloride of antimony, 
sub-acetate of copper, &c, and of a somewhat milder nature solu- 
tions of the chlorides of soda and lime, and, with a different view, 
again, cantharides. I shall not pretend to specify the distinctive 
merits of these substances, if at any time such an attempt could 
be successful, but content myself with mentioning that in the 
milder forms of herpetic eruptions, I have found washes of the chlo- 
ride of soda or of lime answer a good purpose ; and, in the more 
obstinate diseases, I give the preference to the nitrate of silver. In 
a bad case of favus (tinea favosa) of several years' duration, in which 
the greater part of the hairy scalp was implicated, I succeeded in 
entirely removing the disease, by having the head kept shaved and 
applying a strong ointment of nitrate of silver ; administering, how- 
ever, at the same time, laxatives and iodide of potassium in small 
doses. 

Of all the modes of treatment of chronic diseases of the skin, 
there is none comparable, for successful and permanent results, to 
the hygienic ; nor can we place any reliance on the most approved 
therapeutical remedies, unless the rules of hygiene be implicitly fol- 
lowed. All careful observers of the affections of the skin, must be 
sensible of this truth, which it is difficult, however, to impress fully 
on the minds of the patients themselves. Impatient to be relieved 
of a troublesome disease, they fly from doctor to doctor, tryino- 
every remedy in quick succession, sometimes at the peril of their 
. but refusing, often, to abide by the dietetic conditions on 
which alone their cure mainly depends. M. Rayer has pointed out 
(parag. 113-117) the good effects procurable from an appropriate 
diet, and, in some cases, from fasting, and the mischief ensuing on 
ermrs in regimen. I was early impressed with the facts mentioned 
Mibert, (Precis. Thtorique et Pratique sur les Maladies de la 
Peau,) of a milk and vegetable diet bringing about the cure of some 
of the most protracted diseases of the skin, which had been rebel- 
lious to all other modes of treatment. 

Hut it is not enough for patients to take proper food ; they must 

»lso enjoy the advantages of adequate exercise and breathe a pure 

air, at the same time, also, that justice is done to the skin itself, by 

ance of the extremes of temperature, and by recourse, at short 

intervals, to the use of the bath. Alibert states his having had fre- 



quenl occasion to observe that, at the hospital of St. Louis, herpetic 
eruptions, of various kinds, were kept up by defective nutriment and 
an impure air. In view of the whole subject, the habitual frame of 
mind must not be overlooked, nor pains omitted to give it a healthy 
tone. 

Coming, also, under the head of hygiene, is change of climate, 
which in some cases develops, while in others it cures certain cuta- 
neous affections. 

The question, to what extent the physician is justified in curing 
chronic affections of the skin, in reference to any danger of more 
serious internal disease occurring afterwards, does not admit of a 
decided answer. All the circumstances of the case must be taken 
into consideration ; the time when the eruption first appeared, whether 
it followed immediately on some visceral disease ; its duration ; the 
general health of the patient at the time ; his inherent or acquired 
tendencies to particular diseases. In those predisposed to phthisis 
pulmonalis, or to cerebral disease, epilepsy or mania, for example, 
we should attempt, with great diffidence, any means of suddenly 
removing the cutaneous eruption ; or r if this is done, it ought not to 
be by external remedies, but rather, mainly, by internal treatment and 
the use of counter-irritants, or the substitution, for awhile, of a drain 
by a small blister, or tartar emetic, &c. In children, and in aged 
persons, the greatest reserve must be exercised in the use of any 
repellents to the skin, by which either chronic eruptions may be 
driven away, or chronic sores dried up. 

J. B. 



SECTION I. 

INFLAMMATIONS HAVING A SINGLE ELEMENTARY FORM. 

I. EXANTHEMATA. 

Vocabulary, Art. Exanthema. Exanthemalous. 

209. I have designated by the title of exanthemata several inflam- 
matory diseases of the skin which are characterized externally, at their 
acme or highest degree of development, by the morbid accumulation 
of blood in a point, a district, or the entire surface of the integuments. 
These inflammations terminate in resolution, in delitescence or reces- 
sion, and in desquamation. 

This group comprises erythema, erysipelas, rubeola, scarlatina, 
roseola, urticaria, and several inflammations artificially produced. 

210. The common and generic anatomical character of these inflam- 
mations is the red tint in the parts of the skin affected ; the red colour 
disappears on pressure, and returns immediately on its removal. The 
injection of the skin, which is slight in roseola and rubeola, and often 
very passing in urticaria, is more intense and permament in erythema 
and erysipelas. Its principal seat is in the vascular network of the 
skin ; but in erysipelas, urticaria, and even in rubeola and scarlatina, 
it will sometimes extend to the subcutaneous cellular tissue. 

The degrees of heat and tumefaction attending the exanthemata are 
very various. The same thing may be said of the pain, which is 
sometimes not complained of in roseola, but is often tensive and 
continuous in erysipelas. 

When these diseases terminate in resolution the epidermis is de- 
tached in scales, as in scarlatina and erysipelas, and in almost imper- 
ceptible furfurae in rubeola and roseola. The greater the injection of 
the skin has been, the more considerable is the subsequent desquama- 
tion ; and the thicker the epidermis is, as on the hands, the elbows, 
and soles of the feet, the more apparent is the process. After the 
detachment of the epidermis, the skin is smooth and shining and often 
redder than in the natural state. After one desquamation'^ the ex- 
anthemata, particularly in scarlatina, a second is often observed to 



EXANTHEMATA. 



59 



occur. It would appear in this case that some remains of inflamma- 
tion keep up the epidermic secretion in excess ; in fact, it is only after 
the skin has lost the morbid redness it had acquired, that the new 
epidermis puts on the appearance of that which covers the healthy 
integuments. During convalescence from and at the crisis of several 
acute diseases, the epidermis is detached from the skin without its 
having been sensibly inflamed. 

211. When death happens on the invasion or during the height of 
an exanthematous inflammation, if the body be examined a few hours 
afterwards, scarcely can a few injected capillaries be detected on the 
surface of the parts that were inflamed. The swelling of the cellular 
tissue also, is always much less than during life. If the body be 
inspected several days after death, the epidermis may be detached 
more readily than from skin unaffected by disease. The epidermis 
in a general way is found to come from off the sacral region and the 
trochanters more easily than from any other part, for no other cause 
apparently than the previous irritation the skin has undergone from 
the recumbent posture of the patients during their lives. 

212. The cutaneous exanthemata coincide with inflammations of 
the same nature of the gastro-pulmonary mucous membrane. Many 
of them, indeed, only possess interest in a practical point of view, by 
reason of these important relations. Among the precursory pheno- 
mena which often usher in an attack of exanthematous inflammation, 
there are some, such as shivering fits followed by moist warmth of 
skin and frequency of pulse, which are rather expressive of disturbance 
of the functions generally than of a local affection ; others, again, such 
as redness of the edges and point of the tongue, a greater or less 
degree of thirst, distaste for animal food, difficulty of deglutition, 
cough and bronchial rattle, &c, are evidently indicative of an asso- 
ciation of some degree of inflammation of the internal mucous mem- 
branes with that of the skin. 1 There is sometimes a pretty exact 
relation between the intensity of the inflammation of the skin and that 
of these membranes ; more frequently, on the contrary, the external 
evolution of the exanthemata is interrupted by the occurrence in any 
degree of intensity of such gastro-intestinal, pulmonary, or cerebral 
affections. It may sometimes happen, too, that other lesions are 
associated with these already complicated circumstances, which are 
rendered additionally dangerous according to the importance of the 
organs implicated and the nature of the cause that produces the 
additional derangement in the functions. 

213. Exanthematous inflammations are generally acute and con- 
tinued in their progress, and do not often last more than from two to 
three weeks. Several of them, however, do occur with the intermit- 
tent type. These are, indeed, the only class of inflammations of the 
skin which seem capable of coming on in paroxysms and of present- 
ing true intermissions. When not consequent on a distinct febrile 
attack, these intermittent phlegmasia} of the skin most commonly ap- 
pear during the exacerbations of some affection of the digestive organs, 
a condition the influence of which is particularly remarkable in the 
production of urticaria and intermitting erysipelas. 

214. In the exanthemata, the limits of the dermis and vascular rete 
are much more easily demonstrated than on the healthy skin ; a simple 
incision through the substance of the skin is enough to exhibit these 
two layers; it is then, in truth, as M. Gendrin well observes, if at any 
time, that we must be induced to conclude that the vascular reticula- 
tion and the dermis form two distinct and superposed membranes. 
When the inflammation has run high, the vascular rete is of a red, 
and even of a brownish colour, as in erythema nodosum, rubeola, nigra, 
and gangrenous erysipelas ; a certain quantity of blood then appears 
to be extravasated into the tissue of the skin. Lastly, there sometimes 
exists an infiltration of serum into the cells of the dermis, a circum- 
stance that frequently happens in erysipelas and scarlatina. 

215. The exanthemata at their acme cannot be confounded with 
any other order of the inflammatory affections of the integuments. 
When we have to distinguish between the species that compose this 
group, and to detect them at the bedside of the patient, we must not 
forget that three other affections implicating the skin may also present 
themselves under the form of exanthemata, namely, exanthematous 
burn, frost-bite, and syphilis. Among negroes, the red tint of the 

'Talma. Diss, sur les maladies eruptives, in-4. Paris, 1819, No. 25. 



exanthemata is of course obscure, and their diagnosis, therefore, more 
difficult than among whites. 

The red colour produced by effusions of blood into the subcuta- 
neous cellular tissue or into the substance of the skin itself, differs 
from that of the exanthemata in this, that it cannot be made to disap- 
pear by pressure. This circumstance, as well as other considerations 
derivable from the nature of the diseases, should have kept Willan 
from placing petechial affections and purpura hemorrhagica among 
the exanthemata. In papular and squamous inflammations, after the 
detachment or removal of the epidermis, and in vesicular bullous and 
pustular inflammation after the fall of the scabs, red blotches are per- 
ceived upon the surface of the body which are easily distinguished 
from the primary efflorescence of the exanthemata, by their form and 
their standing, by the history of the changes the skin had undergone 
before the appearance of these spots, or better still, by leaving them 
to themselves for a few days, and giving them an opportunity to put 
on their essential characters, (a) 

(a) The progressive changes on the skin, in the exanthemata, are 
well described by M. E. Wilson, (op. tit.,) as follows. 

" The immediate seat of the inflammatory congestion of the exanthe- 
mata is the vascular rete of the dermis, and the difference of tint ob- 
servable in these diseases at their height and during their decline, is 
sufficiently explained by reference to the structure and normal pheno- 
mena of the skin. When the degree of excitation of the cutaneous 
nerves is small, and the arterial determination but little exalted above 
the ordinary standard, the vascular rete of the dermis is only partially 
congested, and the redness produced by this congestion is slight; such 
is the redness, with slight modifications depending on degrees of 
intensity of nervous excitement, which is seen in erysipelas, roseola, 
and erythema. When, however, the nervous activity is aroused to 
its highest pitch of energy, as in scarlatina, the congestion is most 
intense, and the bright scarlet of the arterial blood coursing through 
its vessels is little obscured by the thin veil of epidermis which binds 
it in its sphere. The congestion in rubeola, scarlatina, and variola, 
is not confined to the parallel strata of the vascular rete of the dermis, 
as in the second group of exanthemata, but many of the papillae of the 
dermis are also distended with blood, and give rise to that puncti- 
form appearance of the redness which is characteristic of these erup- 
tions. 

"The crescentic form of the congested patches seen in rubeola, 
depends upon some unexplained peculiarity in the distribution of the 
cutaneous nerves, and corresponds with that natural appearance of 
the skin which is so frequently seen in healthy children, and which 
is denominated mottled. Again, I have observed, that in injecting 
the limb of an infant with size and vermilion, I can imitate all the 
forms of redness seen in the exanthematous diseases, by ceasing to 
inject from time to time, or by filling the capillaries to their utmost. 

" The decline of congestion of the dermis is accompanied by certain 
alterations in the tint of redness which betokens its presence. Thus 
the red patches are observed to lose their vivid brightness, to become 
duller in their hue, and to pass through various shades of purple, 
until they become bluish and livid. These changes depend upon 
the degree of excitement of the cutaneous nerves at the several 
periods indicated by alteration in the colour of the exanthem. When 
the nervous energy is at its highest point, the capillaries contract 
actively upon their contents, and maintain a rapid current of arterial 
blood through their channels. But as the nervous excitement be- 
comes gradually allayed, the capillaries lose their power to contract, 
and become distended by the full stream that moves more and more 
tardily onwards in its course, giving time to the arterial current to 
combine with the carbon of the tissues through which it flows, and 
become converted into venous blood. 

" The above phenomena will explain, also, the differences of colour 
which the exanthem may assume at an earlier period than its decline, 
and even from the commencement of its appearance, as, for instance, 
in scarlatina maligna, or more strikingly, in rubeola nigra. The first 
step or motive influence by which this change is effected, is depres- 
sion of nervous power ; this depression, depriving the capillaries of 
their tonicity, or, in other words, of their means of resisting the pres- 
sure of the arterial current, they yield, they become dilated, and from 



60 



EXANTHEMATA. 



-j I » . complicate ether inflammatory 

skin, and in particular tlio.se of a papular, vesicular 

ami bullous land pelas, left to itself, is often accompa- 

milarto those ol pemphigus; sieved in this way il 

•in the intermediate link between the ezanthematous and 

bullous forms of inflammation. 

initiation of the other affections thai may lie associated 

mats is one of the most interesting points in diagnosis: 

and it is always of importance to establish distinctions between these 

complicated instances and the more simple cases before laying down 

rules ot treatment. 



ERYTHEMA. 
t). An. Erythema, Efflorescence, Red-gum, Intertrigo, Macula' volaticx. 

217. Erythema is an uninfectious exanthema occurring without 

characterized by one or more red blotches, varying from a few 

lines to many inches in diameter, confined to one or scattered over 

s.-v. ial regions of the body, the duration of which, in the acute state, 

vanes from one to two weeks. 

J IS. Acute erythema presents seven principal varieties: 1st. Ery- 
thema interttig*. In new-horn babes and persons who are somewhat 
corpulent, the repeated rubbing of two contiguous surfaces sometimes 
rise to this variety, which may occur under the mamma;, in the 
axilla 1 , the groins, the upper part of the thighs, the navel, between 
tin' buttocks, and, generally, wherever the skin lies in folds, or is 
wrinkled. Intertrigo may also be occasioned by the contact of the 

capillaries, which they were, they are converted into a venous plexus, 
through which the blood moves feebly and slowly, gathering carbon 
in its tardy course. 

" Congestion of the capillary rete of the dermis necessarily gives 
rise to tumefaction, the extent of swelling being, to a certain degree, 
the measure of the increased quantity of blood distributed through the 
part. Hence it is obvious that all exanthematous patches must be 
raised above the level of the surrounding skin, even although the 
degree of tumefaction be really very slight. 

" Another cause of tumefaction in an inflamed and congested tissue, 
also follows as a natural consequence from the over-distension of its 
Vessels. I have already endeavoured to show that the nervous exci- 
tation of the part must have diminished before over-distension of the 
capillary vessels can take place, but so soon as that change has ensued, 
another phenomenon is immediately developed. This is transudation 
of the watery part of the blood by imbibition into the surrounding 
textures, thereby physically relieving the congested vessels of their 
overload of fluid.. The iluid which is thus transuded through the 
coals of the vessels is serum, containing in solution more or less of 
fibrin. The seat of this imbibition is for the most part the subcu- 
taneous areolar tissue, where it gives rise to oedema. I may instance 
scarlatina in some cases, erysipelas cedematosum, and erythema laeve, 
as particular illustrations of this kind of tumefaction, although it will 
be found, upon close observation, to be much more extensively pre- 
sent among the exanthemata. This important phenomenon is not 
confined to the dermoid tissues ; it occurs also in the mucous mem- 
brane, and sometimes with fatal consequences, as, for instance, in the 
laryngitis of scarlatina and rubeola, where it is apt to induce oedema 
of the glottis. 

'• Besides the oedema resulting from serous infiltration into the sub- 

dermoid tissues, it may happen that the transudation occurs also in 

the tissue of the dermis itself, in which case the skin presents a red, 

ted, and brawn-like appearance, as in some forms of erysipelas. 

I gain, not confined to the subdermoid and dermoid tissues, the 

9 fluid may, after the repletion of those textures, be effused upon 

irface of the dermis, and raise the epidermis in the form of vesi- 

id bulla-, as we frequently see to be the case in common erysi- 

This character associates erysipelas with the third natural 

s of the skin— namely, with inflammation of the der- 

ombined with serous effusion upon its surface, including the 

orders Bullae and Yesicuke of YYillan." 



matter of fluor albus, and of gonorrhiea, by the dribbling -'I the urine, 
or escape of the faeces, by the th>w of the tens, of the mucus ol the 
nose, fee. In the intertrigo podieit of new-born infants, or in that 
which sometimes occurs about the groins and upper parts ol the thighs 

in women who neglect proper attention to cleanliness, a seio-pm uleiit 
fluid of a faint and disagreeable smell, accompanied b\ severe itch* 
ing, often exudes for several days at a time from the inflamed surface 
of the skm. If this affection 'continues unchecked, and the causes 
that first produced it be allowed to continue, the skm becomes hard, 
and presents chaps of different depths, indicated by red lines travers- 
ing the moist and grayish-white coloured surface of the affected parts. 
When intertrigo appears between the toes, on the vulva, the prepuce, 
the margin of the anus,&c, these parts are always affected sooner or 
later with chaps and excoriations. 

Dr. Ehrenberg 1 has given an account of a remarkable variety of 
intertrigo which attacked all hands on board of a vessel in the Red 
Sea. The skin of the scrotum was much inflamed, very painful, anil 
at the same time greatly relaxed ; a purulent secretion exuded from 
its whole surface ; the disease disappeared as soon as the crew dis- 
embarked ; but returned often and suddenly on the men again rejoining 
the ship. The Arabs suffered less than the Turks. 

In infants at the breast ill-tended, and dressed with linen impreg- 
nated with urine and faeces, spots of erythema are often observed oa 
the buttocks, the upper parts of the thighs, and on the scrotum, which 
are of a bright red colour, without any elevation of the surfaces at- 
tacked. The skin thus inflamed is hotter than in other parts of the 
body ; the subcutaneous cellular tissue is not swelled, but the pulse 
is sometimes frequent. Children also while teething, have often spots 
of a bright red colour on the cheeks, which are hot but unaccompa- 
nied with tumefaction of the subjacent cellular tissue. There is at 
the same time heat of the mouth, pain and swelling of the gums, 
dribbling of the saliva, and the disposition to be constantly chewing, 
These red spots, at first merely accidental and temporary, sometimes 
end by becoming fixed ; and then the heat and redness having sub- 
sided, the skin of the cheeks is left rough and chapped. 

Prolonged walking or riding, constant pressure, by lying or other- 
wise on the same place (eryth. paratrimma), the prick of a needle, or 
the sting of an insect (eryth. a punctura), the morbid distension of the 
skin from oedema or anasarca (eryth. Iceve, Willan), the neighbour- 
hood of a pustular or vesicular inflammation, or of an ulcer or a 
wound, all frequently cause this superficial inflammation of the skin, 
which differs from intertrigo in nothing but being unaccompanied by 
any morbid secretion. . 

2d. Erythema papulatum (Willan). This shows itself most fre- 
quently in females and young people, commonly on the back of the 
hands, on the neck, the face, the breast, the arms and forearms. The 
small red spots that characterize it are irregularly rounded and seldom 
exceed the size of a small lentil, or a large split-pea ; they are slightly 
prominent, and as it were papular ; of a bright red at the commence- 
ment, they soon assume a violet hue, particularly about their centres; 
they disappear almost entirely under the pressure of the finger. This 
eruption is commonly enough preceded by some degree of fever and 
sense of lassitude and weakness, by anorexia, and pains in the limbs. 
It sometimes shows itself in individuals labouring under acute rheu- 
matism {rheumatic eruptive fever). The spots may be numerous, and 
by their junction form irregular groups of variable, sometimes of con- 
siderable, extent ; within a day or two they sink to the level of the 
skin that surrounds them, and the redness itself disappears after 
continuing one or two weeks most generally without any perceptible 
desquamation. 

3d. Erythema tuberculatum differs from the preceding variety in 
the occurrence between the papular-looking patches, of numbers of 
small, slightly prominent tumours, which sink down within a week, 
whilst the patches disappear more slowly, becoming livid and only 
vanishing after a week more. The erythema tuberculatum is pre- 
ceded by fever, and accompanied, during its course, by general un- 
easiness and sleepless nights. 

4th. In females, children, and young persons of weekly constitution 
and lymphatic temperament, another variety of erythema is rather 

1 Bulletin des Sciences medicales de Ferussac, t. xiii. p. 232. 



ERYTHEMA. 



61 



frequently observed — the erythema nodosum of Willan. General un- 
easiness, depression, and slight fever precede by a few days, or 
accompany the evolution of this eruption, which commonly appears 
on the arms and fore parts of the legs, under the form of red oval spots, 
slightly elevated in the centre, and varying in extent from a few lines 
to an inch and a half in their greatest diameter. By passing the hand 
along these spots, they are felt to form true elevations on the skin. 
These small red and painful tumours, the greater diameters of which 
are parallel to the trunk when they occur on the legs, seem hasten- 
ing to suppuration; but their size soon diminishes; a bluish colour 
takes the place of their primary red tint, and they are resolved in the 
space of ten or twelve days, leaving behind them bluish or yellowish 
stains, as if the skin had been bruised. I have seen this species of 
erythema come on during the course of a rheumatic attack, having 
been preceded by very severe pain. 

5th. The erythema marginatum is characterized by circular patches 
of a livid red, from half an inch to an inch in diameter, the circum- 
ference of which is distinctly separated from the healthy skin, raised, 
prominent, and slightly papular ; their shining surface appears vesi- 
cular, but there is no actual effusion of serum beneath the cuticle. 
These spots, which may be preceded or accompanied by febrile symp- 
toms, appear on all parts of the body, on the limbs, the face, the hairy 
scalp, and even on the conjunctiva. 

6th. The patches of erythema sometimes form complete circles, the 
centres of which are healthy (eryth. circinnatum). The circular form 
of this variety seems to assimilate it to the herpes circinnatus, but it 
differs essentially from this disease in the absence of vesicles as well 
as in its progress and duration. It is still farther removed from the 
rings which are observed in the train of lichen circumscripta, and of 
lepra, the cure of which diseases has commenced and gone on from 
the centres towards the circumference of the patches. 

7th. Erythema fugax is the title given to that variety in which the 
redness is greatly diffused, always superficial, without appreciable 
swelling of the skin or subcutaneous cellular membrane, and which 
occurs unequally spread over the different regions of the body. This 
red colour of the integuments often differs little from the natural hue ; 
but the skin is dry, and the heat of surface always higher than the 
proper temperature of the body. Both the arms of an adult labouring 
under dothinenteritis or furunculous inflammation of the bowels were 
observed on the day of his reception into La Charite to be of nearly 
as vivid a red as is observed in scarlatina ; I caused him to be blooded ; 
and in thirty-six hours the redness had disappeared. This eruption 
may occur in an intermittent form, or appear and disappear under the 
influence of febrile exacerbations or paroxysms. When it happens 
towards the end of serious disorders, all traces of it vanish after death, 
and sometimes also on the approach of dissolution. This form of 
erythema is usually followed by desquamation of the cuticle, and 
occasionally, when it has continued long, by the loss of the hair ; 
phenomena which do not occur till a week or a fortnight after the 
disappearance of the redness of the integuments. 

219. Chronic erythemata. The workmen who use putrid urine in 
cleansing and whitening woolen cloths, bricklayers and masons who 
handle quicklime, miners and smelters employed in extracting lead 
and copper from their ores, blacksmiths and others exposed habitually 
to intense heats, are often attacked with chronic exanthemata of the 
hands. The skin first red, then dry and scaly, becomes hard, chaps, 
and is never bent without increasing the cracks, which usually cross 
the palm transversely betwixt the thumb and forefinger. The skin 
is rarely cleft through its whole thickness ; the edges of the crevices 
are hard, and their bottoms often bleed, especially in the winter season. 

Chronic erythema and chaps of the feet are only seen in those per- 
sons who walk about with these parts uncovered, or who go without 
stockings and neglect proper cleanliness. When the feet are chapped, 
the cracks run across the heels, along the lines of the sole, or between 
the toes. 

The lips also have their erythemata, and are often chapped, espe- 
cially, in the opposite extremes of intense cold or excessive heat, or 
during the continuance of a very dry and parching state of the air. 

In women nursing, especially for the first time, the repeated appli- 
cation of the child and its eager suction, often excite erythematous 
inflammation of the nipple, which sometimes runs so high as to force 
16 



the mother to give up suckling, each visit of the infant causing intole- 
rable pain, followed by sleeplessness and fever. The chaps that fol- 
low have been seen surrounding the base of the nipple, and penetrat- 
ing so deep as to cause this part to be detached altogether, an event 
which is usually succeeded by ulceration to a greater or less extent of 
the mamma. 

Pregnant women, too, during the last months of gestation, when 
the integuments of the abdomen are suffering the greatest distension, 
now and then suffer from redness and chapping of the skin of the 
belly. The same thing happens in the same place and also in the 
legs of those who are suffering under dropsy. 

The chaps of the verge of the anus may be the effect of erythema 
and other chronic inflammations of the rectum, or of some excessive 
distension of this opening caused by the excretion of hard and bulky 
faeces. Chaps in this situation are often complicated with a spasmodic 
stricture of the anus. 

Chaps of the prepuce are sometimes caused by the erection of the 
penis, which distends and splits the part when the opening is narrow. 

Chapping of the vulva is almost always consecutive to lichen agrius, 
or to eczema rubrum developed in the genital parts ; or otherwise it 
succeeds to difficult labours, without being sensibly preceded by ery- 
thema. 

220. Chronic erythema, arising independently of external causes, 
is often a very obstinate apyretic affection ; such is that which is vul- 
garly designated under the name of fiery spots, (taches defeu), which 
very often co-exists with rosacea, and succeeds it even more frequently. 
This variety of erythema is habitually subject to return, and is charac- 
terized by a red colour of the skin, which becomes pale under the 
finger, and by slight vascular arborizations or net-works that spread 
upon the cheeks, over the cheek-bones, and on the alae of the nose. 
It is attended with pruritis, and a feeling of heat and tension, espe- 
cially when there happens to be any accidental determination of blood 
to the head or face. Lastly, at the period of the epidemic disease 
which prevailed at Paris in 1829, I had occasion to observe an im- 
mense number of chronic erythematous inflammations of the palms of 
the hands and soles of the feet ; but they were accompanied by so 
remarkable an epidermic secretion that their description must be in- 
cluded under that of pityriasis rubra, or rather of the epidermic disease 
of which they constituted one of the principal features. (See in the 
Vocabulary, under the word Acrodynia.) 

221. Diagnosis. — A previous eruption of vesicles, a more abundant 
and more serous secretion, and a greater obstinacy of inflammation, 
distinguish eczema of the ear, of the genital organs, of the verge of 
the anus, of the umbilicus, &c, from intertrigo of the same parts. As to 
the hlenorrhagice and intertrigos of the navel, especially, account must 
be taken not only of the appearance of the inflammation, but farther 
of its cause, to keep us from mistaking these for other affections. 

It may be difficult to distinguish the papular and passing forms of 
erythema, from some varieties of roseola, although this last disease in 
its progress bears a greater analogy to the class of eruptive fevers. 
Urticaria differs from papular erythema by the greater breadth of its 
spots, by the peculiar itchiness that accompanies it, by its irregular 
progress, which is often fleeting and intermittent, and by the absence 
of the violet or livid hue which is observed in erythema. In lichen 
urticatus the papulee are less in size, rounder and firmer ; their colour 
is not nearly so deep as that of the patches of papular erythema; as 
in urticaria there is always a great degree of itching present, a symp- 
tom which in strophulus is so troublesome as entirely to deprive chil- 
dren of sleep. I have, in fine, seen the papular erythema appearing 
on the forehead, on the face, and on the breast, after two or three days 
of feverish symptoms, in such a manner as greatly to stimulate the 
elevations and spots that precede the development of the pustules of 
small-pox. 

At first sight the violet spots of the papular erythema might he 
mistaken for syphilitic patches in their first stage ; but the progress 
of the latter, were they accompanied by no other symptom of a vene- 
.real taint, would suffice to distinguish them, if even they failed to 
present the shining appearance and coppery or grayish colour that so 
peculiarly distinguish them. When these two eruptions occur to- 
gether in the same patient, the determination of the patches belonging 
to each requires some discrimination and not a little care. 






EXANTHEMATA. 



man complication of chronic erythema of the face 

rank for having united two dis- 

istind ander the same description, In fact, the 

thematous affection, whilst rosacea is decidedly 

i at importance to distinguish, 1>\ means of 

■ il examination into the state of the different organs, the idio- 

frthema of the buttocks, verge of the anus, scrotum, and 
led l'v fdthiness, from that which often coincides in 
.-born infants with acute or chronic inllammatory affections of 
the mucous membranes of the caecum and colon, and which has very 
ntly the saint' appearance. A like redness about the buttocks 
and genital organs of the infant has also been mistaken, by superficial 
mptoms of B syphilitic affection; at the present time 
such mistakes are, happily, very rare. This variety of erythema, the 
only one that can be confounded with erysipelas, differs from it by 
the absence of tumefaction in the subcutaneous cellular membrane. 
As to the other varieties of erythema, erysipelas is precisely the form 
of skin disease with which they are least likely to be confounded. 
Tin 1 chaps consequent on eczema, lichen, and syphilitic affections of 
the yulva, margin of the anus, ears and nipples, and the cracks pro- 
duced li\ pityriasis or psoriasis of the palms of the hands and soles 
ol the feet, differ from those observed in the chronic erythemata, by 
being preceded or accompanied by other elementary and characteristic 
conditions. 

Erythema nodosum cannot be confounded with any other variety 
of exanthema : it differs entirely from roseola by the deep tumefac- 
tion that characterizes it. It sometimes accompanies attacks of 
rheumatism. Erythema annulatwm differs from annular herpes by 
not being surmounted by vesicles. To the erythema lave, some 
artificial cxanthematic inflammations might with propriety be con- 
nected. 

222. Prognosis. — Acute erythemata, whatever their extent, are not 
in themselves serious complaints, and their duration does not, gene- 
rally, exceed two or three weeks. Chronic erythemata, produced 
and kept up by external causes, get well rapidly under proper treat- 
ment ; hut the cure of very old erythemata, that have come on with- 
out any evident physical or chemical cause, is as difficult as it is 
uncertain. 

223. Treatment. — When the varieties of acute erythema are apy- 
retic, and without complication, they get well of themselves in the 
space of a week or two. When they are painful or accompanied 
1>\ lever, they must he treated by means of emollients, by baths and 
fomentations of the decoction of althea or of bran, gently warmed 
or almost cold ; by general bleeding, if the disease extends to the 
conjunctiva, and if the patient is of a robust constitution or subject 
to epistaxis. The diet oughf to be cooling; and diluents, such as 
lemonade, whey, barley-water, &.C, ought to be freely used. 

The pain and morbid secretion in the intertrigo of children are 
often diminished by attention to cleanliness, by changing the napkins 
frequently, and by powdering the inflamed and chapped skin well, 
alter having bathed and cleansed the parts by means of a muci- 
laginous fomentation. 

In adults, when intertrigo am appears to be the effect of riding, or 
that of the tops of the thigh follows much walking, the skin must be 
rubbed with tallow softened by heat. When the erythema is pro- 
duced by pressure or the weight of the body, (eryth. paratrimma 
ges,) the part must be covered with some soft or soothing 
r, and the weight of the body and the pressure thrown as 
much as possible upon other regions. This species of erythema is 
accompanied by cutaneous or subcutaneous ecchymosis, a two- 
alteration that is frequently followed by gangrene in patients 
ed with dothinenteritis, and in elderly persons. To prevent 
this unfortunate termination, the decoction of bark, solutions of 
alum, and infusions of oak bark are sometimes had recourse to with 

The erythema that is produced by the distension of the skin in 

■•» Md an ! ' be treated by cold mucilaginous lotions, 

horizontal position of the limbs, the support of a bandage, 

and but rarely by the local abstraction of blood, which, however, is 

some- ; in addition to these, the treatment proper 

in dropsical complaints must be enforced. 



The lesions that precede oraccompan) the development of acute 
erythematous inflammations, present peculiar indications. Genera] 
blood-letting is always required at the beginning of a rheumatic erup- 
uve fever; local bleedings from the abdomen or margin <>! the anus, 
are often useful in cases of gastro-enteritis, or of cseco-colitis in 
infants at the breast, attacked at the same tune with cry thematic affec- 
tions of the buttocks and thighs. 

224. Chronic erythemata o\ the hands and feet, caused by exter- 
nal circumstances, are to be met by warm fomentations and bathing, 
by soothing cataplasms, and sometimes by vapour baths. Liniments, 
consisting of oil or lard, to which the oxide of zinc, in the propor- 
tion of an eighth [or a little camphor], is sometimes added, are usual 
remedies for chapped hands and feet. The affected parts are to he 
smeared, and a glove or leather sock to be worn night and day, in 
order to restore to the integuments the softness and pliancy they 
have lost. 

Chaps of the nipples are to be treated with mucilaginous fomenta- 
tions, as decoction of marsh-mallows, poppy-heads, &c, with the 
addition of a certain quantity of acetate of lead or sulphate of zinc— 
The nipple is to be kept anointed with any mild unguent, with 
which, when the pain is very severe, a small quantity of opium may 
be mixed. [The nitrate of silver in solution, or mixed with sperma- 
ceti ointment, often proves the best of all remedies in this trouble- 
some and, at times, serious complaint.] The nipple must be gently 
washed with tepid water, before the infant is applied, when nursing 
is not given up entirely. All remedies, however, commonly prove 
unavailing, unless the mother consents to deprive the child of its 
milk for some days at least, as, without this measure, the repeated 
application of the mouth causes so much irritation that the chaps are 
continually renewed. The mamma? are best depleted by the appli- 
cation of a proper cupping-glass furnished with a syringe, or by 
steaming the breasts over hot water. Should we succeed in healing 
up the excoriations in this way, suckling may be tried again, pro- 
vided the secretion of milk has not disappeared. 

Chapping of the nipples may sometimes be prevented by habitu- 
ating the parts to a certain measure of irritation, by gentle suction, 
previous to delivery, and keeping them covered with a shield of 
elastic gum, [bee's-wax or silver. The yellow bee's-wax shield to 
prevent the pressure of the clothes, the application of the nitrate of 
silver ointment (gr. iv to gr. viii, to =ss of unguent, cetac. or lard) 
and the use of the shield and prepared cow's teat, will, in a considera- 
ble number of cases, do away with the necessity of even suspending 
suckling for a day, much more of giving it up altogether]. («) 

Excoriations of the prepuce require the operation for phymosis, 
when they are owing to the distension and traction of the part during 
the erection of the penis. 

Excoriations of the anus require the use of soothing suppositories, 
hip baths, and bland injections; when the affection is complicated 
with spasmodic stricture of the rectum, it commonly yields to gela- 
tinous fomentations or stuping, but is cured more certainly and 
speedily by the double incision proposed by Boyer. 

Excoriations of the legs, complicated with oedema and petechia?, 
are best treated by the horizontal position of the limbs, by the pres- 
sure of a light bandage, and when the skin is very much inflamed, 
even by the abstraction of blood locally. 

Chaps and excoriations of the toes require the feet to be frequently 
washed, and a piece of soft lint to be interposed twice a day, between 
the several digits. 

The superficial excoriations to which new-born children are sub- 



(a) Small benefit will be derived from topical remedies in this 
troublesome and often exceedingly painful affection, unless the so 
frequently associated febrile irritation and derangement of the diges- 
tive function be removed. This is done by purgatives alternating 
with magnesia and the alkalies. Of the first, calomel, followed by 
castor-oil, Epsom salts, or rhubarb and magnesia, with compound 
powder of jalap, answers a good purpose. 

When stimulating washes are indicate,], I ] i;ive derived most 
benefit, in some cases, from the solution of sub-borate of soda in 
water and alcohol, and in others, from the fluid chloride- of soda of 
the shops, diluted with equal parts of water. 



ERYTHEMA. 



63 



joct, get rapidly well by attention to cleanliness alone, by the use of 
baths and fomentations, and the free application of powder to the 
inflamed parts. [If they are obstinate, some weak metallic wash 
(as zinei sulph. gr. xii to aq. font, vel rosa) giv) heals them imme- 
diately.] 

As to those chronic erythemata that are independent of outward 
causes, and fiery spots of the face (taches de feu), they often resist 
every curative means attempted. They have occasionally been 
successfully treated by the use of baths and steaming, alternated with 
the local administration of sulphureous vapours; in some cases, too, 
the cure has appeared to be aided by the use of purgatives. 

Historical Notices and Cases of Erythema. 

225. Erythema has been differently and often imperfectly described 
in books of pathology. One of its varieties (redness about the margin 
of the anus), has been signalized as a disease peculiar to childhood ; 
another chronic erythema has been entitled dartre erythemo'ide, thus 
mixing it up with vesicular and scaly diseases; and a third, erythema 
diffusum, has been confounded with erysipelas. — Cullen erred when 
he asserted that erythema was always without concomitant or second- 
ary fever. By regarding it as the lowest degree of erysipelas, Callisen 
shows that he was unacquainted with its principal varieties, though 
they are well described by Willan. Pellagra, which belongs to the 
order of squamous affections ; and acrodynia, which, in many respects, 
bears a strong analogy to pellagra; burns and frost-bites, which may 
appear under the bullous and gangrenous forms ; the hydrargyria, 
whose form is vesicular, have all of late, but improperly, been in- 
cluded among the erythemata. Cases of the principal varieties of 
this exanthematous eruption, may be found in various special and 
periodical publications. 1 

Case I. Symptomatic Erythema of the buttocks and thighs: cceco 
colitis. The daughter of M. ****, six months old, at the beginning 
of Nov., 1824, presented all the symptoms of acute cco-cseolitis or 
inflammation of the mucous membrane of the caecum and colon: she 
had frequent liquid, glairy, sour, and at times sanguinolent motions ; 
pain was evidently excited by pressure along the course of the colon, 
which was not the case in the districts occupied by the other viscera 
of the abdomen ; the great intestines were distended with flatus which 
was often expelled; there were fever and loss of appetite: the tongue 
was nearly natural. At the same time a number of red spots from 
half an inch to two inches in diameter, of an oval or irregular shape, 
strongly defined, but not prominent, appeared on the upper parts of 
the thighs, around the trochanters, and in the inguinal and ischiatic 
regions. The subcutaneous cellular substance did not participate in 
Ihe inflammation of the skin. — The symptoms all yielded within 
twelve days to the application of leeches to the anus, to the use of 
the warm bath and of emollient cataplasms, to injections of small 
quantities of decoction of marsh-mallows and of poppy-heads into the 
rectum, and to the antiphlogistic regimen generally. A month after- 
wards there was a fresh attack of intestinal inflammation, and a new 
eruption of these erythematic spots. The same plan of treatment was 
followed, and with the same success. The inflammatory affection of 
the great intestine has since recurred at intervals remote in various 
degrees from each other, and has always been accompanied by symp- 
tomatic spots of erythema on the hips and thighs; but the plan of 
treatment indicated, has always proved adequate to put an end to the 
disorder; and since the month of March, 1825, the child has thriven, 
and has always enjoyed good health. 

Case II. Erythema marginatum ; patches scattered over the face and 
surface, of the body: Bronchitis. — I. Bailliot, 26 years of age, of a 
sanguine temperament and strongly built, entered La Charite on the 
13th of Feb., 1827. This patient had been eight days previously 

1 Schenck. Obs.med*. rarior. in-fol. lG44,p. 295 (Eryih.of the mammas).— Willan. 
Reports of the public Dispensary. — Edinburgh Med. and Surg. Journ., Jan. IN 11 (three 
cases of eryth. tuberculosum). — Journ. des hopitaux, in-fol., annee 2, p. 10 (Eryth. 
of the lips). — Journ. hebdomad, I. iv. p. 72 (Eryth. ciicinnaties). — Bulletin des 
sciences med.de Ferussac, t. xiii. p. 232 (intertrigo scrotalis). — Lond. Med. Gnz.. t. 
xi. p. 37-415 (Irritative eryth.). — Lond. .Med. Gaz., t. i. p. 587 (Sure navel 
W. Hunter). — Lond. Med. Gaz., t. v. p. 655 (Eruptive rheumatic fever. Cock). — Ali- 
bert. Precis sur les maladies de la peau, t. i. p. 273 (Dartre erythemuide). 



attacked with the eruption for which he now sought assistance. It 
was characterized by spots of a red colour, which disappeared on 
pressure, of an irregular shape, of various sizes, slightly prominent, 
and not itchy. A certain number of these spots were seen on the 
forehead and nose ; the right eyelid was red and slighty cedematous, 
the left was only injected in a very small district. Similar patches 
were observed on the dorsal aspects of the forearms, where they were 
larger than on the face, and also behind the ears. Their surface 
looked as if sown over with small white elevations ; but on raising 
the epidermis with the point of a pin, it was seen that there was no 
fluid effused beneath it. Some of the patches appeared to be sur- 
mounted by accidental vesicles. The patches were often confluent, 
others were distinct, and from three-quarters of an inch to an inch in 
diameter. The chin was covered with solid red lumps, with little 
tubercles flattened on their summits, in the intervals between which 
the skin had its natural appearance. Similar elevations, but of less 
size, occurred in different parts of the cheeks and neck ; the cuticle 
that covered these was shining. One of the lumps of the chin was 
covered with a yellow crust, produced by the drying of a vesicle. 
The lips, of unequal redness, seemed marbled; on each conjunctiva, 
there was a patch of a very vivid red, towards the inner angles of the 
eyes, which were weeping. On the fore parts of the legs spots were 
also visible of a less intense degree of redness than those of the face. 

This erythema first showed itself upon the neck after two days of a 
violent cough and sense of lassitude. On the third day the patient 
took to his bed, since which time he has had shivering fits every 
evening; these continue all night. He complains of headache; the 
tongue is moist, without any redness of the edges, and is covered by 
a yellowish fur; he suffers from eructations and constipation, having 
had but one motion within the last eight days ; the pulse is full, a 
little more frequent than in the healthy state ; mucous rattle at the 
posterior part of the left lung — (Venesectio ad sxii, mucilaginous 
lemonade for drink, and low diet prescribed ) . Feb. 15th. — The blood 
was found strongly buffed ; the patient was sweating profusely : the 
spots of the eruption were prominent and less red on the face ; the 
cuticle appeared wrinkled on the surface of those behind the ears ; 
some of the spots on the other parts were also of a less vivid red or 
livid hue. A few adventitious vesicles were observed full of serum. 
Feb. 16th. — The spots on the legs have faded ; several of those on 
the face are white and shining, and on the lips they are paler and 
more collapsed. He complains less of headache, he sleeps better, 
the fever is diminished, and the expectoration is easy. Lemonade 
was continued as drink, emollient injections were prescribed, and 
better diet, broth or soup several times a day was allowed. 17th. — 
The patches of the forearms are becoming white towards their centres, 
and form a sort of ring ; those of the right forearm have become con- 
fluent ; those of the left are a little more extended ; others, as those 
behind the ears, and on the right upper eyelid, have disappeared, or 
such as still remain form little islets surrounded by the white or rose- 
coloured skin ; a slight desquamation is taking place about the root 
of the nose, and behind the left ear. The spots on the legs are shrunk. 
He sleeps well ; the respiration and expectoration are easy, and the 
appetite has returned. 18. — The redness of the spots declines more 
and more; their prominence diminishes gradually, especially in the 
centre ; the cedema of the eyelids is no longer visible ; in a word, 
from this time forwards, the erythematous patches everywhere disap- 
peared, and were succeeded by a slight desquamation, so that the 
patient left the hospital perfectly well on the 28th, after a fortnight's 
confinement. 

Case III. Several varieties of erythema in the same individual. — M. 
Dalivot, 21 years of age, entered the hopital Saint Antoine, on the 
4th of May, 1830. This young man, strong and well formed by na- 
ture, had never hitherto suffered from any disease of the skin. Within 
the last week, however, some red patches had appeared on the face, 
attended with itching which prevented him from sleeping. The 
digestive functions having been out of order, leeches had been ap- 
plied to the epigastrium. On the 5th of May, the face, the upper and 
fore parts of the chest, and the legs presented an eruption of spots of 
a livid red colour, raised above the level of the skin, irregularly cir- 
cumscribed, and not disappearing completely under the pressure of 
the finger. Some of these were as large as a sixpence, and rounded 



M 



EXANTHEMATA. 



| the hand, appeared slightly com 
on thei ferencewas shining and transparent 

: under the epidermis; but when this was 
wed but a little blood; on the legs the spots 

. as it w.re knotted, and of a violeni 

tint, I if both hands, and the dorsal aspect of both fore- 

papular, and of the size of small lentils. On the 
e hair, small elevations were felt The patches 
rather violent itching. The patient complained of 
eyes m re somewhat bloodshot, the pulse was full and 
hard, : white. The right side of the chi St was less resonant 

than t! V. mention was made of pain in the epigastric region. 

- bled to = \ii, and put upon lemonade as a diluent. The 8th 
patches are shrunk, their surface shows slight furfura?, 
and their circumference no longer appears shining; the redness now 
disappears on pressure, and instead of hard risings along the legs, a 
number of brownish and yellowish marks alone remain. The patient 
left the hospital some days afterwards quite well. 

i l\. Papular anil tubercular Erythema; Bronchitis; Rheuma- 

i ■/ uii'irc rheumatic Fever. — Marie Michaud, 22 years of age, a 
::i i^irl , of a soft and lymphatic constitution, has been unwell, 
during the last four months she has lived in Paris. Some days after 
coming into the hospital she observed red patches on different parts of 
her person ; they are now distinct on both elbows and on the arms, 
and are of various sizes, from that of a sixpence to that of the palm 
of the hand. These patches are prominent, painful, and disappear 
under pressure, to reappear from their circumference towards their 
centre as soon as it is removed ; their colour, generally red, is in some 
of a livid cast. The elbow joint appears swollen; motion there is 
difficult, and it is very painful to the touch. The appetite is gone, 
the breath disagreeable, the pulse frequent ; sweating, no cough, the 
menses flowing. On the 1st of March, 1830, both elbows and both 
knees are swelled and painful; the former is half bent and cannot be 
straightened. The patient also suffers pain in the w T rist, and a little 
in the lingers, which, however, she cannot move without the greatest 
suffering. The red patches observed last evening are in the same 
stale ; others of a smaller size — from that of a lentil to that of a six- 
pennv-piere — have appeared on the thighs. They are projecting, 
smooth, and painful to the touch. The pulse is frequent and full ; 
anorexia. (Two bleedings of oxii., each were practiced within the 
twenty-four hours. Mucilaginous drink.) 6th. — The wrists only are 
now painful ; the red patches of the elbows have gone ; several livid 
and bluish patches are disseminated over the limbs : cough ; hissing 
and mucous rattle. The rheumatic pains continue ; on the elbows 
and wrists the patches have a marbled appearance; the tongue is yel- 
low, foul, ami thickly coated ; there has been vomiting; no passage 
of the bowels ; pains in the belly; insomnia (thirty leeches to (he epi- 
gastrium, tiro emollient injections, low diet). 8th. — Bluish marks re- 
place the red patches; the left knee is painful, the wrists and elbows 
but slightly so (thirty leeches to the knee, a bath). 9th and 10th. — 
The patient still suffers in the knees and wrists, which are a little swol- 
len ; pains of the epigastrium and abdomen ; tongue still coated and 
yellow (broth allowed, and the bath repeated). 11th. — The right knee 
is leas painful; the appetite has returned (same diet). 17th. — The 
patient sutlers less. [The baths are continued ; better food.) 22d. — 
Convalescent. The patient discharged well on the 3d of April. 

C IBS V. Papular, confluent and hemorrhagic Erythema. — Bridoux, 
a shoemaker, 23 years of age, entered La Charite on the 1st of June, 
L831. From a very early age he had been accustomed to be purged 
every spring; a measure which he had neglected this season. For 
1 months he had been working very hard, rising at four o'clock 
in the morning, and going to bed at midnight ; he had also been living 
than usual. His temperament might be characterized as lym- 
phatic. 

On the 31st of May, he had been in a violent passion ; towards the 
the same day, he felt his face puffed and hot, and a sense 
bing in different parts of his body. Soon after, red patches ap- 
1 on the arms, the breast, die back, the belly, and lower limbs; 
: catches rose above the level of the skin ; of small extent at first, 
:>read rapidly and became confluent in many districts. There 
leither pain oi' the throat nor of the eyes : the night was disturbed. 



June Is:.— The patient exposed himself to a current of cold air. At 
night the lice was somewhat puffed, and of a general pale-reddish 
colour; all the rest of the surface of the body, especially the 
rior region ^( the trunk, presented patches of greater or smaller mast 
oitude, generally irregular in shape, evidently prominent to the eye, 
as well as sensibly so to the touch. The redness disappears on pressure 
and reappears again immediately. The patches are completely indo- 
lent. Since the morning he has had slight cough ami soreness of 
throat; the tongue is moist and rather clean, the respiration is natural, 
pulse !)(!, (tisan with mucilage and honey, syrup of diacoilium half m 
ounce). June 2d. — The night tranquil, sleep only interrupted by the 
cou<di. The patches on the whole of the posterior region of the 
trunk are shriveled, and their former vivid red colour is replaced by 
a pale violet tint. On various points corresponding to the primary 
patches, and on the spaces that separated them, spots, evidently he- 
morrhagic, and similar to those of purpura, have appeared ; these 
neither disappear nor diminish in intensity by pressure. On the belly 
and limbs, the red colour and prominence of the patches observed 
the preceding evening remain. Pulse 108 and rather hard — [bleeding 
to Sxii, mucilaginous lemonade, low diet.) By seven o'clock in (he 
evening of the same day, the patches of the trunk are shrunk; a vio- 
let hue has succeeded the bright red that characterized them in the 
morning. On the legs and thighs, the patches still preserve their 
prominence and their red colour, though in a less degree. The heat 
of surface has increased ; it is particularly great on the back, where 
a portion of the skin that has hitherto remained white has acquired 
a livid hue, which disappears under the pressure of the finger. On 
other regions, large patches of a violet colour are observed, which do 
not vanish under pressure. The blood drawn is not buffy ; no cough ; 
pulse from 86 to 100 ; the patient can close his hands, which he could 
not do last evening on account of the swelling and stiffness of the 
fingers. June 3d. — Ecchymoses are seen stretching in lines or in irre- 
gular patches upon the shoulders and loins. The general livid colour 
of the integuments of the back disappears on pressure. On this 
ground, isolated maculae appear scattered here and there, having the 
colour of ecchymoses. The sanguineous suffusion is especially con- 
spicuous on the back : the macula?, very closely set and large, are 
most numerous on the thighs, the loins, the flanks and belly ; the arms 
are freer. These stains disappear completely under the pressure of 
the finger. June 4. — A pale yellow colour begins to be visible amidst 
the general livid hue of the back. Several of the confluent stains, 
too, present an appearance of commencing absorption towards their 
centre, the yellow tint of which parts is in strong contrast with the 
purple of their circumference. The countenance is natural ; the appe- 
tite has returned. June 5 and 6. — The livid colour continues to yield 
to the yellow, and by the 7th the skin, except on the thighs, had re- 
gained its natural appearance ; better food was now allowed, and on 
the 9th the patient left the hospital cured. 

Case VI. (Edema of the legs; petechia; chaps. — Fr. Martin, 63 
years of age, and labouring under these symptoms, was received into 
La Pitie on the 5th of August, 1826. In the course of the year 1822, 
after undergoing great fatigue, he had been affected in a similar way, 
and been cured by simple lotions with cold water. He had, however, 
for 15 months afterwards, suffered with chapped hands. Employed 
for the last 14 days in a species of work that fatigued him greatly, 
his legs became cedematous, so as to pit under the finger; red patches, 
which disappeared on pressure, at the same time appeared on the in- 
sides of the legs; besides these patches, which now form groups in 
different places, a great number of petechia?, disposed in clusters or 
running in longitudinal or circular lines, are visible, principally on 
the fore parts of the legs ; the cuticle seems raised over some of these 
petechia? ; in some places the blood has even traversed the skin, and 
the tops of the petechia? are then covered with a small drop of dried 
blood. The skin of the legs is farther divided by numbers of irregular 
and mostly transverse chaps or cracks, half a line in breadth and seve- 
ral lines in length ; some of these are deep, and a yellow transparent 
viscid fluid is poured out between their edges, which forms linear 
concretions along the legs ; the feet are cedematous, but not otherwise 
affected. 

Whilst under treatment, 60 leeches were applied to the legs which 
were covered in the intervals with emollient poultices. The oedema 



ERYSIPELAS. 



65 



petechia, and chaps amended gradually, and the patient quitted the 
hospital on the 15th of August, 1826. 

Cask \U. Chronic Erythema of the nose and of the malar regions 
preceded by habitual Epistaxis, and by Erysipelas of the face— Baptiste, 
30 years of age, had suffered repeated attacks of erysipelas and boils, 
and had had itch, besides two gonorrhoeas, which lasted six months 
each, between 1800 and 1818. He has also been subject, from his 
infancy till two years and a half ago, to bleeding from the nose, so 
incessant that he never in all that time sent an handkerchief to be 
washed that, was not stained with blood. He then became affected 
with deafness, which lasted two months and got well without any 
treatment. It was now for the first time that he perceived some red 
spots upon the nose and cheeks, which have since slowly increased 
in size. On the 20th of May, 1828, I noted three of these vulgarly 
styled fiery spots (taches defeu) on different parts of the face, two on 
the cheeks, the third on the base of the nose. These spots, of a 
■deep-red colour and well defined, are not hot, except when the blood 
mounts to the head ; he does not complain of their itching at present, 
and when he has, he has only passed his hand over without scratch- 
ing them. By compressing the skin of the nose between the fingers, 
a few serous points are forced out apparently from the follicles. The 
skin has never been greasy, neither has there been any transudation 
of red fluid, as in eczema rubrum, nor any appearance of pustules, as 
in rosacea, nor of papulae, as in lichen. Before consulting me, the 
patient had made use of several ointments of the composition of 
which he is ignorant. ( Ordered to be bled, whey for drink, lotions with 
almond emulsion, milk diet.) After the bleeding, which was copious, 
the red colour of the skin disappeared for a while, but soon returned. 
I ordered six leeches to be applied thrice within the nostrils, after 
the application of which, the patient complained of greater heat in 
the cheeks. For the last two months he has had a blister on the arm, 
which does not appear to have had any influence on the progress of 
the exanthematous affection. Purgatives and sulphureous lotions had 
the effect of causing a notable diminution in the eruption ; to such an 
extent, indeed, that the patient, despairing of a radical cure, gave up 
paying farther particular attention to his complaint. 

Case VIII. Chronic erythema of the hand and forearm. 1 — M. F****, 
nearly 46 years of age, of a very hasty temper, and habitually given 
to disputation, after several days of unremitting exertion, perceived a 
sudden eruption of rather large patches, of a bright-red colour, which, 
however, uniting together, soon assumed a livid appearance, upon 
the back of the left hand and forearm of the same side. As he was 
subject to an eruption of this kind, which showed itself on different 
places, he betook himself to the use of diluents, baths, fomentations, 
strict regimen, &c, and abandoned his labours, — a very rational plan 
of treatment, which he was accustomed to pursue with success in 
former instances. But after the lapse of three weeks, the disease, 
which used to disappear at the end of 12 or 14 days, had attained a 
great degree of severity, and I was consulted. The eruption now 
extended from near the elbow to the first phalanges of the fingers; it 
was slightly elevated, and almost of the colour of wine-lees, accom- 
panied with much itching, which the patient had great difficulty to 
prevent himself from trying to appease by scratching ; the surface was 
rough, soft, and presented several islets of healthy skin. I ordered 
the application of a number of leeches around the disease, and to the 
points in the midst of it that were unaffected, a practice that was fol- 
lowed by very little relief. I directed two vapour baths, to be followed 
by the local administration of the hydro-sulphurated vapour. The 
appearance of the eruption was by this means quickly changed, and 
by persevering in the treatment of ten days, the disease was subsided 
entirely. 



ERYSIPELAS. 

Vocab. Erysipelas, Ignis sacer, Rosa volatica, Rose, St. Anthony's Fire. 

226. Erysipelas is a spreading non-contagious, exanthematic in- 
flammation, characterized by a red colour of the skin, with swelling 



17 



1 Rapou. Traite de la methode fumigatoire, t. ii. p. 27. 



of the subcutaneous cellular tissue, commonly ending in resolution 
and desquamation, sometimes in suppuration, seldom in gangrene. 

227. Causes. — Erysipelas may be developed under the influence of 
appreciable causes, such as filthiness, rude and repeated frictions, ex- 
posure to violent heat, the contact of poisonous plants, of certain 
insects, or of the juices or fluids excreted from their bodies ; the 
application of topical irritants, pricking with instruments impregnated 
with animal fluids in a state of corruption, and external injuries 
generally, — a contused wound, a surgical operation, the vaccine and 
variolous inoculation, &c. Among other well-authenticated causes 
of the disease, we must also include certain influences engendered by 
the nervous system under paroxysms of passion, profound grief, &c. 
As to bad and corrupted food, high seasoning, the abuse of spirituous 
liquors, and indulgence in the pleasures of the table, these may cer- 
tainly give cause for the development of erysipelas, but there is 
nothing to prove that they occasion this more frequently than any 
other disease. The etiology, however, of a vast number of cases of 
erysipelas, is involved in the greatest obscurity. It is known that 
the appearance of the disease coincides with a buffy state of the blood, 
analogous to that observed in acute rheumatism ; and it is not less 
certain that diffused and flitting erysipelas, coming on in patients worn 
out by some chronic inflammation, is the precursor of approaching 
dissolution ; the observer confirms these facts every day without being 
able to ascertain their causes. Other circumstances, again, do not 
admit of so rigorous a construction. " There are seasons," Mr. Cal- 
med writes to me in 1828, " when erysipelas spreads universally 
among the insane, and causes a suspension of the revulsive measures 
which form, as it were, the bases of our treatment in cases of mental 
alienation. The application of a seton, or a moxa, or a blister, is 
then followed by erysipelatous inflammation ; a superficial wound of 
the skin has the same consequences; the slightest stroke, the opening 
of a vein, the application of a leech, all are followed by erysipelas. 
The present year (1828) has been particularly remarkable in this 
respect ; during the last six months, the infirmaries have been filled 
with the insane labouring under erysipelas. The disease begins on 
any part of the body, sometimes on a healthy part of the skin, but 
most frequently in the vicinity of an issue. After four or five days of 
treatment, it extends to the surrounding parts, and in the space of 20, 
30, 40, or 50 days, it has spread over the whole, or nearly the whole, 
of the surface of the body. Treatment by compression did no good ; 
the bites of leeches became new centres for the disease ; many patients 
were reduced to extremity and several died. In preceding years, I 
have seen a similar epidemic constitution prevailing in the asylum at 
Charenton, but never to the same extent as at present." Facts of 
the same description have been observed at the Bicetre, Salpetriere, 
Saint Louis, La Charite, [and in almost all other great hospitals,] at 
certain times, and during certain periods, when the disease of ery- 
sipelas occurs so frequently as to assume the character of an epidemic. 

It has been said that erysipelas was capable of being transmitted 
from one individual to another by contagion. This opinion, lately 
revived by Weatherhead and by Dr. Wells, and which a case observed 
by Costallat seems to countenance, has arisen, perhaps, from two or 
more individuals exposed to the same influences, having been suc- 
cessively or simultaneously attacked by the disease. Erysipelas is 
more frequent during the spring-time and autumn than at any other 
season. It sometimes recurs in the same individuals at determinate 
intervals, variously remote from each other ; some have one or two 
attacks every year, just as others suffer from eczema and lichen. In 
amenorrhoea, erysipelas sometimes appears periodically at the times 
when the menses ought to flow ; men are less subject to such attacks 
and relapses than women. The disease, arising from external causes, 
attacks, in preference, persons of a fine and delicate skin. 

228. Symptoms. — When erysipelas is the effect of causes that have 
not acted directly on the skin, certain morbid phenomena common to 
a great number of acute diseases, are almost constantly observed be- 
fore the attack ; such as headache, pain in the epigastric region, 
nausea, bitter taste of the mouth, constipation, slight shivering fits, 
hardness and increased frequency of the pulse, &c. — the erysipelatous 

fever of Hoffman. 

1. Towards the second or third day of this febrile state, simple ery- 
sipelas is proclaimed by the following symptoms (initium) : slight and 






EXANTHEMATA. 



bed tumefaction in some part of the integuments, 
of the skin, with a tinge of jrel- 
of bhie, disappearing on pressure, reappearing 
is removed, sharp and pricking pains in the 
anied by smarting, and a sensation of dry and 
Darning 1 I ptoms and the febrile condition increase in 

the third or fourth day [augmentum), and continue for about 
■ riod with the sama degree of intensity (status). The in- 
comes covered with vesicles analogous to 
i or miliaria (erysipelas miliaris). Sometimes, also, 
bulla- or bhbs appear on different parts of the inflamed surface (ery- 
! blebs, isolated or confluent and similar 

i<p the blisters produced by a scald, break on the very day of their 
1 most commonly towards the fifth or sixth day of the 
; the fluid they contain dries and forms hard yellowish crusts 
which subsequently become brown or black, and are a line, or even 
several lines, in thickness. 

The most favourable termination of erysipelas is in resolution ; an 
i vent which is indicated by the svmptoms, after having continued for 
or four days in all their intensity, beginning to subside (decre- 
mriitiun) ; and the certainty of the issue is known by the gradual 
disappearance of the redness, the pain, the heat and the tumefaction. 
The cuticle then falls off in scales, the crusts are detached, and there 
is soon nothing remaining but a slight pastiness, which is not long of 
going also. The process of desquamation is more or less apparent 
according to the nature of the parts attacked with erysipelas, and its 
intensity. Mr. Wilson was accustomed to exhibit every season for 
several successive years, a patient to his pupils who was subject to 
annual attacks of erysipelas, at the end of which, the cuticle of the 
hands was entirely detached in the form of a glove, and that of the 
feet, like B hag. A case of the same kind is recorded in the sixth 
volume of the Philosophical Transactions. 1 

Of all the forms of inflammation to which the integuments are sub- 
ject erysipelas is that which has the greatest disposition to vanish 
suddenly, an event that is often followed by its appearance in some 
other part of the body (erysipelas erratica, vcl ambulans), or the de- 
velopment of inflammation in some more important organ (erysipelas 
mttastatica). Thus it has been seen extending successively from the 
hairy scalp, the forehead and the face, to the neck, and then to the 
shoulders, whilst the lace and scalp were freed from it; or otherwise, 
appearing momentarily on the face, and, vanishing thence, replaced 
by a mortal affection of the brain or its membranes. 

Fever, heat of surface, sleeplessness, and gastric disturbance com- 
monly attend in the train of erysipelas ; more intense as the inflamma- 
tion advances, the symptoms decline in the same proportion as the 
inflammation subsides towards the seventh or eighth day of the disease. 
The termination at this period is sometimes announced by a sediment 
in the urine, by the bowels becoming open, or by the occurrence of 
some slight hemorrhage. 

2. Phlegmonous erysipelas, as its name implies, partakes of the nature 
of phlegmon and of erysipelas at the same time ; the skin and the 
subcutaneous cellular substance may be alone affected, or the inflam- 
mation may reach the sub-aponeurotic cellular tissue, cause the most 
alarming symptoms, and bring the life of the patient into jeopardy, if 
he be not promptly and effectually aided. The various shades of this 
species of erysipelas may be arranged under three different degrees 
according to the intensity of the morbid phenomena. 1st degree. — 
At the outset, anxiety, followed by smarting and redness in the part 
about to be affected with inflammation ; anon a sense of burning in 
the inflamed part, a bright red colour of the skin, diminishing insensi- 
bly round the circumference of the seat of disease, and disappearing 
for an instant on pressure being made with the finger, after which the 
point compressed regains more slowly than in simple erysipelas both 
its morbid colour and its former level. The portion of integuments 
affected, raised by the swelling of the subcutaneous cellular tissue, 
forms a lar^e tumour, hard, and penetrating deeply ; the pain becomes 
r. the heat burning, the lymphatic glands inflamed, and a con- 
siderable degree of fever is present. If, towards the fifth or sixth day, 
the skin is observed to become less red, less tense, to be covered 

i Chevalier. Lect. on the General Struct, of the Hum. Body, p. 122. 



with branny scales, and the subcutaneous cellular tissue to resume 
its original volume, the phlegmonous erysipelas will end in resolu- 
tion, or in effusion, the fluid of which will be absorbed after a few 
days. If, on the contrary, the pam becomes pulsative, symptoms of 
suppuration will not be long of showing themselves. The abscesses 
that follow, opened naturally or by an incision, are found filled with 
laudable pus and soon heal up. 2d degree. — The phlegmonous 
en sipelas is of larger extent ; the degree of' redness, of heal, of suffer- 
ing, and of fever all greater in amount. Between lb*' sixth and the 
ninth day, if the inflammation is left to itself, purulent deposits are 
formed here and there under the skin, and even in the spaces between 
the muscles: when these are opened, sphacelated shreds of cellular 
membrane are discharged along with a quantity of pus ; sinuses and 
fistulous passages are formed and pour out an ichorous and fetid mat- 
ter. Occasionally, the skin, detached from the parts beneath and very 
thin, becomes grayish in colour, and folds in upon the edges of the 
ulcerous cavities. The mucous membrane of the stomach and intes- 
tines inflames, and the patient often sinks exhausted by fever, diarrhoea, 
and the copious discharge that takes place from the subcutaneous 
cellular membrane. 3d degree. — The symptoms in this last degree 
are even more violent from the outset. Within the space of two ot 
three days, the erysipelas attains its greatest intensity; the skin, 
smooth, tense, and' shining, is of a bright red colour, and scarcely 
preserves for an instant the impression of the finger. The distress of 
the patient increases: his pulse is hard and frequent; he suffers great 
pain; tossing about in his bed, he gets no sleep, becomes delirious, 
and is parched with thirst; all these symptoms are even aggravated 
towards evening. About the fifth or sixth day, the inflamed skin 
loses its sensibility, puts on a livid hue, becomes softened and covered 
with phlyctena? filled with reddish or blackish serum. Ecchymoses 
and eschars form (gangrenous erysipelas), at the same time that several 
abscesses are produced. Under the most favourable circumstances, 
these sphacelated parts are thrown off* and the sores slowly heal ; but 
in the great majority of instances, the patient sinks from the absorption 
of pus into the system, from serious affections of the stomach, of the 
bowels, of the brain, announced by the following symptoms: tongue 
covered with a yellow, greenish, brownish, or even black coating, 
moist at first, then dry; sordes about the teeth and gums; fetid 
breath ; vomiting of bilious stuff"; diarrhoea ; involuntary passage of 
the urine and feces, which are black and offensive ; pulse hard and 
frequent ; slow and tardy replies to questions, vertigo, rambling, low 
delirium, subsultus tendinum and death. 

3. Nothing is more common than to see oedema of the subcutaneous 
cellular tissue supervene on the last stage of simple erysipelas, or on 
the first period of phlegmonous erysipelas : it is even a constant oc- 
currence in erysipelas of the eyelids and scrotum ; but the title of 
cedematous erysipelas has been given more especially to that variety 
of the disease in which the swelling formed by the skin and subcuta- 
neous cellular tissue is developed in a slow and gradual manner, and 
offers the resistance of oedema and of emphysema, instead of the 
tension of phlegmonous erysipelas. The skin, smooth and glistening, 
pressed on by the finger, retains the pit for a long time. It is uncom- 
mon to see any accidental blebs on the skin in this variety, and when 
they do occur, they are smaller and less elevated than in simple or 
phlegmonous erysipelas. They appear between the third and the fifth 
day, reckoning from the period of formation of the swelling, and, 
bursting, are succeeded by crusts of little extent or thickness. 

The genital parts in the female, the scrotum in the male, the legs 
and swollen limbs of dropsical subjects, are the most common seats of 
(edematous erysipelas, which frequently occurs after the punctures 
made in the skin and loaded cellular membrane with a view to draw 
off water. 

Of all the modes in which this affection terminates, gangrene, it 
maybe conceived, is the most deplorable. This is indicated by vio- 
lent pain, a red colour and shining appearance of the skin, which by 
and by becomes livid or leaden in its aspect. 

229. The organization, or intimate structure of the skin and subcu- 
taneous cellular membrane, modified in different regions of the body, 
renders these more or less liable to be affected by one or another of 
these varieties of erysipelas. 

1. Erysipelas of the face is unquestionably the most frequent of all. 



ERYSIPELAS. 



It begins in the nose, the cheeks, the eyelids, or the lips, and extends 
with greater or less rapidity to the half and more commonly to the 
whole of the countenance. The lax tissue of the eyelids is swollen 
and (Edematous ; the eyes are closed and watery, the nose is enlarged, 
the nostrils are dry, the lips puffy, the ears red and shining; a copious 
secretion of saliva fills the mouth, which is opened with difficulty ; 
sometimes the inflammation even extends to the nasal fossae, the pha- 
rynx, and cavity of the tympanum ; often, whilst the epidermis is 
detached in bran-like scales in some places, the phlogosis continues 
or appears in several others, especially on the nose, on the forehead 
and hairy scalp. Of all the varieties of erysipelas, that of the face is 
most subject to recede or disappear suddenly. This disagreeable 
termination is most commonly preceded or followed by affections of 
the brain or its membranes, announced by delirium, profound or 
lethargic sleep, subsultus tendinum, &c. In some cases the disap- 
pearance of the erysipelas has seemed to me to be subsequent to the 
affection of the brain. The most usual termination of erysipelas of 
the face is in resolution ; it may be so ended on the one side, and on 
the other be terminated by the establishment of several suppurating 
points. ' Leveille has seen erysipelas of the face complicated with pseu- 
do-membranous inflammation of the larynx and trachea, the existence of 
which was not suspected till after death. Coryza, ophthalmia, ex- 
ternal otitis and bronchitis are the most common complications of this 
variety. 

2. Erysipelas of the hairy scalp has almost always the characters of 
phlegmonous erysipelas. Punctures and contusions, simple or com- 
plicated with wounds {traumatic erysipelas), and the incisions from 
operations performed on the scalp, are the most frequent causes of the 
disease. It usually first appears in the vicinity of the parts irritated, 
and sometimes on the opposite side, from the sixth to the tenth day 
after the solution of continuity in the integuments. At the beginning 
the pain of the head is dull rather than acute ; the integuments are 
affected by an cedematous infiltration, and are soft and doughy. The 
skin, of a pale red colour, as if whitened over, pits under the pressure 
of the finger, preserves the print for a long time, and only very slowly 
regains its colour and former level. The slightest touch renews or 
increases the pain, which is always accompanied by febrile symptoms ; 
the tension of the integuments of the occiput, and the swelling of the 
external ears, often make lying on the back or side almost impossible. 
If this disease be left to itself, shivering fits at irregular intervals 
supervene, and the patient falls into a state of coma. The inflamed 
skin becomes thin in parts, bursts, and gives vent to a quantity of 
pus and of shreds of cellular membrane, and of the occipito-frontal 
aponeurosis, become gangrenous. The scalp is almost never stricken 
with gangrene; being, according to the judicious remark of M. Du- 
puytren, furnished with blood-vessels which are independent of those 
that are distributed to the pericranial cellular substance. On the fol- 
lowing days new openings are formed in the most depending parts near 
the centre of the erysipelas, and additional shreds of cellular membrane 
and of aponeurosis are detached ; the discharge is abundant and of- 
fensive, the bones of the cranium are sometimes exposed, and if the 
disease be not checked in its progress, delirium, diarrhoea, and various 
other serious symptoms give warning of the approach of death. 

3. Erysipelas of the mamma in women often presents all the cha- 
racters of the phlegmonous form of the disease in the highest degree. 
The exposure of these organs to cold soon after delivery, the irritation 
arising from the sucking of the child, the first time of nursing, [and 
the excessive distension of the mammae with milk, which is too often 
allowed to occur,] are the most frequent causes of the affection. It 
almost always ends in suppuration, and is usually accompanied by 
inflammation of the axillary glands. 

4. Erysipelas of the umbilical region is principally observed among 
the new-born infants in foundling hospitals, lying-in hospitals, and 
similar institutions; it sometimes extends to the hypogastric region 
and to the genital organs. Gangrene is one of the common termina- 
tions of this affection, which, left to itself, is often fatal. Its occur- 
rence is often ascribable to violence done to the umbilical cord, to 
bad food, and to the insalubrity of many of the establishments where 
the newly-born are collected. It is frequently complicated with peri- 
toneal inflammation, and with umbilical phlebitis. 

5. Erysipelas of the groin is occasionally symptomatic of the infiltra- 



tion of fecal matters consequent on a perforation of the intestine towards 
the crural arch or inguinal canal. In this case the cellular tissue is 
crepitating and emphysematous. 

6. Erysipelas of the scrotum and of the prepuce often ends in gangrene 
in elderly persons. The cedematous swelling of the prepuce is some- 
times so great that the patient cannot void his urine ; the scrotum, 
twice or three times its natural size, usually sphacelates at the points 
where it is in contact with the bed. 

7. Erysipelas of the limbs is most usually confined to the forearm or 
to the leg. When it is set up in the neighbourhood of the articulations 
it is occasionally accompanied by inflammation of the synovial mem- 
branes. If the inflammation has extended deeply to the subcutaneous 
cellular tissue, the dimensions of the parts mny be singularly changed : 
I have seen the arm acquire nearly the size of the thigh. The limbs 
are the most frequent seat of phlegmonous erysipelas: rest and proper 
position are two conditions indispensable to the obtainment of a speedy 
cure. 

8. M. Renauldin gives a case of general erysipelas occurring in the 
person of a woman about fifty years of age. The whole skin of the 
trunk and of the limbs, slightly swollen, presented a very intense ery- 
sipelatous red blush ; the face was the part least affected ; the patient, 
who felt as if consumed by fire, was soon restored by the use of ape- 
rients, and tepid baths frequently repeated. 

230. Anatomical Observations. — The most simple erysipelas attacks 
not only the vascular rete of the skin, but extends to the entire thick- 
ness of this membrane and to the cellular tissue lying beneath it. — 
Phlegmonous erysipelas does not differ in reality from simple erysipelas, 
save by the higher degree of inflammation that attends it. Accord- 
ing to M. Ribes, in erysipelas the small veins of the integuments are 
the vessels principally affected, the ramuli of the arteries being less 
inflamed ; the lymphatics appear to be implicated in a less degree 
than either the veins or arteries. The inflammatory blush is peculiarly 
remarkable on the internal coat of those small veins, the canals of 
which are filled with pus. On the termination of erysipelas in gan- 
grene, the walls of these A r essels are black, and tear with the greatest 
ease. 

In my opinion, this condition of the arteries and veins is by no 
means constant ; I have not found the slightest trace of inflammation 
of these small vessels in several cases of erysipelas I have examined. 
Besides, these remarks of M. Ribes could only apply to the subcuta- 
neous veins ; the vessels of the rete, and of the papillae of the skin, 
are all too minute to permit of any demonstration of their inflamed 
state being made. But an alteration of the subcutaneous veins them- 
selves is not a constant condition, and they may contain pus which 
has been absorbed. This was actually the case in one patient, the 
history of whose disease I shall detail particularly by and by. The 
skin of the face was pale everywhere, except on the eyelids, which pre- 
served a slight degree of redness in the parts that had not been covered 
by phlyctenae. The subcutaneous and intermuscular cellular tissue of 
the face was infiltrated by a yellowish sero-purulent fluid ; small ab- 
scesses, containing laudable pus, existed in front of, and behind, the 
orbiculares palpebrarum muscles, among the cellular tissue of the 
orbit, and extended towards the temporal fossae ; the cellular sub- 
stance of the scalp itself was also infiltrated. The parietes of the 
veins of the face and neck, although lying bathed in pus, showed no 
trace of inflammation. Many of these minute vessels contained puru- 
lent serum similar to that effused into the inflamed cellular membrane. 
The minute arteries were healthy. I have also found pus in the lym- 
phatic vessels of a lower limb attacked with phlegmonous erysipelas, 
without any visible alteration of the parietes of the blood-vessels. In 
fine, I have met with true inflammation of the principal veins in limbs 
that were the seat of phlegmonous erysipelas or of simple phlegmon, 
and as a consequence of paronychia or of amputation. If I may be 
allowed to draw a conclusion from my own- experience, I should say, 
that phlebitis complicates inflammation of the cellular tissue more 
frequently than that of the skin. 

In phlegmonous and gangrenous erysipelas the morbid conditions 
of the skin and cellular substance are carried to a higher pitch ; the 
pus is collected within one or more abscesses, or infiltrates the cellu- 
lar membrane, which, in other places, appears loaded with sero- 
sanguinolent fluid. The skin, the subcutaneous cellular tissue, the 



08 



EXANTHEMATA. 



aponc. im and tb< themselves 

: those who sink under these diseases pre- 
• belong to pulmonary, cerebral, and | 
nal inflammations, such as small collections of pus in the lungs, 

m tli. ■ '1 thai th.' blood in erysipelas 

! \ as in health, and that nevertheless it most 
the bully coat 

I he inflammation in measles is too general and 
perficial to he confounded with erysipelas, moreover i1 isd 
or disposed in small wavy or curved lines. Scarlatina, e\ en when 
the er r the whole of the body, differs from ery- 

- in being contagious, and almost invariably preceded and 
panied by considerable soreness of throat; the strawberry red 
colour of scarlatina is, farther, very different from the deep red hue of 
erysipelas. In erythema, the inllammation often disposed in spots, is 
always more Mipcrficial and less extensive than in erysipelas, which, 
on the contrary, is spread over a large surface, often covered with 
phlyctens or resides, and always attended by the tumefaction of the 
subcutaneous cellular membrane. Numerous characters distinguish 
erysipelas from bullous diseases, particularly from pemphigus. It is, 
in conclusion, impossible to confound this exanthematous disease 
with phlegmon, furuncle, or anthrax ; a position, which the descrip- 
tions of each of these complaints, if consulted, will make abundantly 
evident. 

.. Prognosis. Simple erysipelas, without all complication, is a 
disease of little consequence, especially if the skin be inflamed over 
but a small extent of its surface. When the inflammation of the in- 
teguments has come on under the influence of causes that have acted 
primarily on the nervous system, or on the organs of digestion, or 
when (and this is the most common case) the cause is altogether un- 
known, the prognosis is less favourable. Phlegmonous and deep and 
extensive erysipelatous inflammations of the limbs are dangerous dis- 
eases ; diffuse and wandering erysipelas, developed in the course of 
chronic disease of a febrile nature, is a symptom of the worst augury; 
phlegmonous erysipelas complicated with phlebitis or with the ab- 
sorption into the circulation of purulent matter is almost always fatal. 

On the other hand, peripneumonia, rheumatism and gout, have 
occasionally been seen replaced by an erysipelatous attack occurring 
shortly after their invasion. But it is in chronic inflammations of the 
skin that the appearance of an erysipelas has sometimes proved more 
especially advantageous. 

The sudden and spontaneous disappearance of erysipelas is always 
an event of the most untoward kind ; it is very frequently caused by 
the accidental evolution or progress of another disease more or less 
dangerous in its character. 

233. Treatment. When slight erysipelas has been produced in a 
healthy individual by some evident cause, rest, the horizontal posture, 
especially if the disease have appeared in the lower limbs, lotions with 
tepid or cold water, or with any mucilaginous decoction, or gently 
anointing the part with lard, together with mild diluents internally, 
commonly sutlice to put an end to the complaint, which, indeed, gets 
well almost as certainly if left to itself. 

If the erysipelas is more intense and of greater extent, and if to the 
local inflammation there is superadded a burning and general heat of 
surface, dryness of the mouth and tongue, frequency, hardness and 
bounding of the pulse, fee., or if a plethoric state of the system at 
large exists, and seems an obstacle to the evolution and regular course 
of the disease, it is proper immediately to open a vein, and boldly to 
bathe the affected parts with cold mucilaginous lotions ; in the course 
of die same day, or on the morrow, a local bleeding practiced at a 
certain distance from the limits of the inflammation, secures the wood 
effects of the general depletion. These local bleedings ought to be 
repeated on the following days, if the blood have been very bufly, 
and if, when the disease is fully formed, the accompanying fever con- 
tinue with the same degree of 'intensity as on the first appearance of 
the eruption. Whenever the erysipelas is complicated with phlebitis, 
the practice ought to be even more energetic. 

It will be needless to recur to very active measures if the fever 

•dined either after the appearance of the eruption, or after the 

first bleeding, or in consequence of the disease, in its natural course, 

arriving at the period of decline. In the aged and cachectic, in 



gangrenous erysipelas, or after the absorption of pus is deemed to 

have occurred, bleeding does mischief and ought to be shunned. If 
simple erysipelas has been preceded by symptoms of irritation in the 
Stomach and bowels, it is well to apply leeches once or twice to the 
abdomen. Whenever the constitution of the patient has warranted 
the practice, or when the .severity of the symptoms has required it, 
blood-letting has always appeared to me the surest means of combat- 
ing erysipelatous inflammation occurring after one or several days of 
fever, and without any evident or appreciable cause — [erysipelatous 
fever). In erysipelas of the face, after the employ incut of blood-letting, 
the mustard foot-bath, blisters to the legs, and purgative glysters have 
often appeared to me useful and evenjhecessary auxiliaries, and al- 
ways to be recommended when there were threatenings of cerebral 
mischief. 

The importance of blood-letting, then, in the treatment of simple 
erysipelas, extending to a large surface, or complicated with other 
diseases of greater or less gravity, is to me a demonstrated truth ; but 
to be really serviceable, the quantify of blood withdrawn must be 
considerable, and must be taken away at the beginning of the disease, 
the symptoms of which it often moderates, witnout, however, cutting 
them short. When practised timidly, or too late in the disease, 
venesection neither prevents the ulterior progress of the inflammation 
of the skin and subjacent cellular membrane, nor the sympathetic 
mischief of greater or less amount that generally attends it. 

When the digestive apparatus is free from inflammatory symptoms, 
which is by no means uncommon, another plan of treatment may be 
adopted ; this consists in the administration of emetic doses of tartar- 
ized antimony. I have seen this mode succeed, whether the patients 
got rid or not of a considerable quantity of bile. Nevertheless, after 
a number of comparative experiments, I remain convinced that blood- 
letting is generally the most advantageous method of treatment, and 
that it is applicable in an infinitely greater number of cases than the 
tartar emetic plan. The often renewed idea that emetics in certain 
medical constitutions constantly cure erysipelas, then unsuccessfully 
attacked by other means, must by no means be received as a demon- 
strated truth. During one period (January, 1833), when this assertion 
as to the necessity of having recourse to tartrate of antimony and 
ipecacuanha was reproduced at the royal Academy of Paris, several 
patients did very well in La Charite under the influence of the 
expectant system, after one or two venesections. Emetics, however, 
it maybe conceived, are always necessary when erysipelas appears to 
be owing to the ingestion or to the presence of any acrid or poisonous 
substance in the stomach. Emetics and purgatives, so generally use- 
ful to the scrofulous, have been administered with advantage in 
erysipelas of the face, either as depletive agents or as derivatives; 
after a bleeding or two, combined with the foot-bath and purgative 
injections, they are often employed with greater success than when 
given alone, (a) 

As to the system of expectation, it may be ventured on in cases of 
simple erysipelas, or of erysipelatous fever of little intensity ; the cure 
is accomplished by the powers of nature ; at one time, without any 
other phenomena than those that belong to the resolution of the in- 
flammation, at another, after some form of crisis. In the epidemic 
constitution of 1721, during which erysipelas was very common at 
Turin, C. Richa informs us that the disease was often ended by slight 
diarrhoea, and occasionally by epistaxis. I have never observed such 
crises in my own practice ; perhaps it is that I have not been careful 
enough in looking for them, or that I have interfered with their oc- 
currence by my treatment. 

Too unlimitedly adopted, the expectant method would certainly 
lead to the detraction of blood being delayed so long as to make it 
either less serviceable or altogether inadmissible ; this is a difficulty 
which those practitioners who have assimilated erysipelas with the 
eruptive fevers, have not always succeeded in avoiding. 

Frictions with mercurial ointment, and with lard or butter though 
they seem occasionally beneficial in simple erysipelas have notwith- 
standing, no influence in preventing the phlegmonous form of the dis- 



(a) In continuation of this antiphlogistic and revulsive treatment 
colchicum, digitalis and antimony, with salines, may be advantage- 
ously had recourse to. 



ERYSIPELAS. 



case from generally running into suppuration. In cases of erysipelas 
of the face, I have often caused one side to be rubbed over with lard 
and the other with mercurial ointment ; several times, too, one of 
these unguents was applied to one side of the face, whilst the disease 
was abandoned entirely to itself on the other ; and I never perceived 
that the course of the disease was influenced by any of these proceed- 
ings. Such topical medicamentation has much less effect than those 
who have recommended it imagine. This is particularly evident in 
those cases of erysipelas that are preceded by fever of a day or two's 
-continuance, and whose periods of increase, of status, and of decrease, 
are not interrupted by external remedies, which, in fact, do no more 
than diminish the heat, the dryness, and tension of the skin. With 
the same view it has long been the custom to dust limbs attacked 
with erysipelas with flour or powdered starch, to apply cataplasms 
with Goulard's wash, lotions containing alcohol or ether, &c. 

Superficial cauterization with the nitrate of silver has been said 
■quickly to stop the progress of erysipelas. The results of some trials 
I have made of the remedy are in opposition to this statement, (a) 

Wandering erysipelas may be attempted to be fixed by the appli- 
cation of a blister to the place it occupies, or to that it has first pos- 
sessed ; internal inflammatory affections, should they occur, are to be 
met at the same time. Unfortunately, wandering and diffuse ery- 
sipelas often show themselves as ultimate phenomena, as the harbin- 
gers of inevitable death, in patients exhausted by long suffering. 
These erysipelatous affections are reflexions of a lesion deeper seated 
and more serious than a blister will reach or cure. 

Intermittent erysipelas is a very rare disease ; Ihave never seen it but 
in the face, and then it was preceded and accompanied by paroxysms 
of facial neuralgia. Whatever the type it affects, it commonly yields to 
the bark or sulphate of quinine, exhibited as in cases of periodic fever. 
If called in time to see phlegmonous erysipelas of the limbs, after 
having bled once or oftener, according to the age and constitution of 
the patient, a number of leeches, in proportion to the extent and in- 
tensity of the inflammation, are to be applied; to encourage the 
bleeding from these the patient is to be plunged into a warm bath, 
and the parts affected are to be covered with soothing or narcotic 
cataplasms almost cold ; the tepid bath should be repeated on the suc- 
ceeding days, for it is a powerful means, acid too much neglected in 
the beginning of the disorder. Unfortunately, when patients enter 
our hospitals, pus is usually already formed, and infiltrates the cellu- 
lar membrane, or is collected within abscesses in different places. 
The skin is then hot, tense, shining, and of a deep-red colour. The 
limb has a pasty or doughy feel, which Boyer signalizes, with justice, 
as one of the signs of the termination of this disease in suppuration. 
It now becomes necessary to make a certain number of incisions im- 
mediately, which, by loosening the skin and the aponeurotic sheaths, 
are productive of great relief, give place to a large flow of blood and 
of sanies, and allow an exit to the pus infiltrated into the cellular 
substance, or collected into abscesses. In this way the formation of 
large and numerous abscesses, the occurrence of gangrene of the cel- 
lular membrane, and of extensive separations of the skin, are all pre- 
vented. The incisions are still useful though the pus is not yet 
collected into centres. This assertion, made by Mr. C. Hutchinson 
and disputed by Mr. Samuel Cooper, has become, to my mind, an 
incontestable truth, since I have witnessed the success with which M. 
Beauchene, surgeon to the hopital St. Antoine, pursues the practice. 
The number of these incisions ought to be relative to the intensity of 
the inflammation, and their depth must be calculated according to 
the swelling of the limb. When gangrene has already occurred in 
one or several points, it is proper to incise freely, and thus to fight 
against the inflammation wherever sphacelus has not yet taken pos- 
session of the parts. If, then, the advantages of incisions be incon- 
testable, the practitioner must still be on his guard, and not permit 
any inconsiderate love of action to induce him to slash, and scar in- 
delibly the whole of a limb attacked with phlegmonous erysipelas, 

(a) Saturated alcoholic tincture of iodine, made of two scruples to 
an ounce of fluid, applied by means of a camel's-hair pencil over the 
whole erysipelatous surface and the surrounding sound skin, is an 
active and useful remedy. Velpeau recommends a solution of sul- 
phate of iron ; one ounce to the pint of water. 
18 



which repeated bleeding, the application of emollients, and the use 
of gentle purgatives would have cured, or at least made curable by a 
very small number of incisions, (a) . 

Several observations have been published in praise of blisters to 
the painful parts in the second stage of phlegmonous erysipelas, ine 
surface of parts affected with traumatic erysipelas has also been 
slightly cauterized with advantage. The form of the iron employed 
foAhis purpose is of little consequence ; it is only necessary that the 
instrument should be applied by a narrow surface to a great number 
of points of the integument attacked with the inflammation. — Whilst 
I acknowledge the good effects of these methods of treatment, com- 
parative trials have led me to prefer another: general and local bleed- 
ings, and purgatives. These are more effectual in preventing the 
termination of phlegmonous erysipelas in suppuration and gangrene, 
whilst incisions give vent to pus infiltrated or collected into abscesses, 
and always produce a relaxation of parts that is favourable. 

Compression, often useless and sometimes dangerous in the early 
treatment of phlegmonous erysipelas, is employed with advantage, 
towards the end of the disease, to diminish the cedematous and loaded 
state of a limb. It is the best means at our command in oedematous 
erysipelas. It has been successfully used in phlegmonous erysipelas 
complicated with phlebitis. 

The precepts relative to phlegmonous erysipelas of the limbs are 
applicable to some cases of erysipelas of the hairy scalp, that resist 
bleeding, diluents, emollient applications, emetics and cathartics. 
An incision that implicates at once the skin, the cellular membrane 
and the occipito-frontal aponeurosis, eases the painful constriction 
caused by the distension and stretching of this fibrous membrane. It 
is usual to put a piece of lint between the edges of the incision in 
order to prevent their union, which should not be allowed to take 
place till the swelling of the scalp has completely subsided. Twenty- 
four hours after the incision, the patient is commonly relieved, and 
serious symptoms, such as delirium, and others proper to affections 
of the brain, generally yield within the same space of time. 

Erysipelas, to conclude, is occasionally a salutary affection. It has 
been studied under this point of view by M. Sabatier: it is particu- 
larly in regard to some chronic diseases of the skin that erysipelas 
has brought about effects which perhaps would never have been 
determined by any other curative means. This beneficial influence 



(a) Incisions, as practised by Dr. Hutchinson and Mr. Lawrence, are 
intended, not to evacuate matter already formed, but to prevent its 
formation. They constitute a mode of blood-letting, and give relief 
to a tense and over-distended skin. Mr. Lawrence, in place of seve- 
ral free incisions through the integument, down to the muscles, of 
about an inch and a half in length, and two or three inches apart, 
and varying in number from six to eighteen, recommends one long 
incision, through the whole extent of the affected part. The incisions 
will be of comparatively little use, unless they penetrate the fascia ; 
and if the inflammation be suspected to have passed beneath the fas- 
cia, this should be divided. 

Puncturing the part affected, a practice recently introduced by 
Sir. R. Dobson, of the Greenwich Hospital, is extolled by Mr. Lis- 
ton and Dr. Bright, but is not thought well of by Mr. Travers. Mr. 
Nunnely declares that he has not seen a case in which puncturing did 
not seem to be advantageous, or where any unpleasant effects fol- 
lowed. " The comfort produced in a very short time is often per- 
fectly surprising ; the heat and burning pain become much less, the 
swelling is diminished, and the tendency to spread moderated. An- 
other important advantage is, that it does not interfere with, nor 
prevent, any other application." {A Treatise on the Nature, Causes 
and Treatment of Erysipelas. Am. edit., p. 201.) Punctures serve 
to abstract blood, and, in this respect, are a substitute for leeches. 
The best method of making them is to hold a sharp lancet tightly 
between the finger and thumb, at such a distance from the point as 
we wish it to penetrate, thus making the finger and thumb the shoul- 
ders of the lancet blade. The depth will vary from one-fifth to two- 
fifths of an inch ; the latter being that which is necessary only in the 
limbs where the swelling is considerable, when we wish to evacuate 
effused serum as well as blood. The flow of blood may be pro- 
moted by sponging the punctured surface with warm water. 






[AANTIIKMATA. 



,,!,, D ti,, ion remote, 

from the affected parti. And this salutary 

confined to mere vesicular, or papular, or 

,rd, i" the morbid production.- thai exisl 

on the but a certain thickness of tiie dermis; 

d inducing iht- resolution and suppuration 

is tubercles, of indolent glandular swellings, modifying 

markable manner squamous eruptions of ancient dale, causing 

rotation and disappearance of syphilitic tubercles, accomplish- 

prompl cicatrization of rebellious ulcers, favouring the re-union 

oi the skm with the parts beneath in the fistulous passages about 

scrofulous sores, limiting lupus in its progress, &c. I shall have 

n to recur again to this influence: in such cases the erysipelas 

may be left to itself, provided itscondition and progress be attentively 

watched. 

prophylactic treatment of erysipelas is a point worthy of con- 
sideration under certain circumstances. Its development maybe 
prevented in f< males labouring under amenorrhea, by the detraction 
of blood every month, at the periods of the menstrual flux. The 
same plan is to be pursued when the disease seems to occur in lieu 
of some habitual hemorrhage. 

Historical Notices and particular Cases of the Disease. 

234. There are numerous details of cases and several monographs 
that may be consulted with advantage on simple erysipelas, 1 on phleg- 
monous erysipelas, 2 on gangrenous erysipelas, 3 on general erysipelas, 4 
on erysipelas of the whole of one side of the body, 5 of the face, 6 and 
of the navel, with inflammation of the umbilical vein ; 7 on intermittent 
erysipelas,' on epidemic erysipelas; 9 on the contagion of erysipelas, 10 
on the diagnosis of erysipelas and erythema; 11 on erysipelas that is 
salutary or critical, 1 ' on the retrocession of erysipelas, 13 on its compli- 
cation with phlebitis, 14 and with cerebral affections. 15 Observations 
have also been published in favour of compression 16 in the treatment 
of the disease, of acupuncture, 17 of anointing with lard, 18 with oil of 
sweet almonds, with cream, and with mercurial ointment 19 whether 
the disease were simple or of the phlegmonous kind; in recommenda- 
tion of blisters 20 in cases of erratic and of phlegmonous erysipelas; of 
cauterization with the nitrate of silver 21 or of the actual cautery 22 in 

1 Mariande (15. M. B.). Essai stir Pcrysipftle simple, in-4. Paris, 1811. 

■ Pmtissier. Essai sur l'erysipele phlegmonous, in-4. Paris, 1N15. — Olivier. De 
I'erv-ipole phlegmonous in-4. Paris, 1830. — Leialenet (J. B.). Diss, sur l'erysipele 
phlegmoneux des membres, in-4. Paris, 1824. 

3 Cooper's Surg. Dictionary. Art. Gangrene. 

* Mercier. Erysipele universel apres l'accouchement. — Rennes. Arch. gen. de 
med.. t. xxiv. p. 652. 

eller. (Loder Journ. fur die Chirurg., iv. B. 1. St. p. 149.) 

« Leveille. Erysip. de la face.compl.de laryngo-tracheite. (Rev. med., t. xvi. p. 
146.)— Piorry. Gaz. med., 1833, p. 281. 

1 Dupes. Recherches sur les maladies des enfans nouveau-nes, in-4. Paris, 1819. 
— Robert Lee. Lond. Med. Gaz., t. iii. p. 533. 

■ Lane. Fr., I. vi. p. 247 (Erys. intermitt. de la face). 

» Velpeau. Lancette franc. 1831, t. v. p. 105. — W. Gibson. Relation d'un e>ysi- 
p»le epiddmique, observe a Montrose, 1822. — G. H. Weatherhead. An Essay on the 
diagn. between erysipelas, phlgemon and eryth. (Epidemic on board a vessel.) 

"> Gibson (Eilinb. Mod. and Surg. Journ). — Wells. (Trans, of a Society for the 
Improv. of Med. and Surg, knowledge, vol. ii. n. 17.) — Costallat. Propositions et 
reflex, sur quelques points de med. et de chir., in-4. Paris, 1832, p. 4. — Willan. Art. 
Erysipelas. 

" Hume Weatherhead. An Essay on the diagn. between erysipel., phlegm, and 
eryth. Lond. isu). 

" Sabatier. Propos. sur Ten-sip. et les mal. cutan. in-4. Paris. 1832. 

'» Journ. coinpl. t. xxxi. p. 193. — Bullet, des sc. med. de Ferussac, t. xix. p. 221. — 
Blandin. Delire a la suite de la repercussion de l'erysipele. (Arch. gen. de mej., t. 
xxviii. p. 2t'i3.) 

M Klandin. Jonrn. compl., t. xli.p. 68. 

1S Nvmpiomes d'encephalite, sans lesion du cerveau. (Journ. hebd., t. iv. 2e ser., 
P . 110.) 

'« \ elpeau. Mem. sur 1'emploi de la compression dans l'erysipele phlegmoneux et 
dans les brtlures. (Arch. gen. de med.. t. xi. p. 102. — t. v. p. 27.) 

•ht. ^ Acupuncture dans l'erysipele. (Gaz. med., in-4. Paris, 1833.) 

i- Martin-flokm. Lanceue franc., t. v. p. 217. 

>» Ricord. Lancette franc., 1S31, t. v. p. 109.— C. Broussais. Lane, franc., t. v. p. 
—Lane, franc., fevrier 1833. 

•• Patissier. Op. cit. 

ti Higcinbottom (J.). Guerison de l'erys. de la face par l'appl. ext. du nitrate d'ar- 
gei. U* t xri. p. 288.) — Cfaomel. Lane, franc., t. vi. p. 241. 

« Larrey. Emploi du cautere aciuel dans l'erysip. traumatique. (Rev. m£d., t. ix. 

r >"•) 



certain species of the discas,.. Several remarks on the (fleets oi 
bleeding" ought likewise to be referred to, as also on emetie 
the disadvantages of tincture of opium externslly, &< 

Under the general title of erysipelas- Mr. Lawrence has included 
the ordinary or simple disease", and th.it in which the inflammation 
extends to the subcutaneous cellular tissue, the subcutaneous glands, 
the fibrous sheaths, and the synovial membranes. Rust* considers 
erysipelas rather as an exanthematous fever than as a simple inflam- 
matory affection of the skin; and this idea would be correct, were all 
those diffuse forms of inflammation we see produced by local excita- 
tion to be thrown out of the class of erysipelas. P. C. Louis 28 has of 
late ao-ain called attention to the fact of lever frequently preceding 
the eruption ; lastly, Rust has said that erysipelas is always accompa- 
nied by a certain accumulation of animal electricity, which is percepti- 
ble to the hand applied to the inflamed skin, a circumstance which I 
have endeavoured to verify, but in vain. 

Case IX. Phlegmonous' erysipelas of the face, more decided on the 
right than on the left side; arachnitis; tardy resort to blood-letting; 
death ; —pus in the veins of the face.— J. Col, 37 years of age, was 
admitted into La Pitie, the 14th of December, 1825. Five weeks 
previously, he had fallen into a ditch, where he remained three quar- 
ters of an hour, his legs and part of his body immersed in water. In 
consequence of this accident, he had pains in the legs, followed by 
infiltration of the lower limbs and abdomen. These dropsical symp- 
toms were successfully treated by frictions with an ointment con- 
taining extract of aconite. 

On the 3d of March, 1826, he complained of a sense of constric- 
tion about the epigastric region, and vomited without any assignable 
cause. March 25th. — Appearance of erysipelas of the face, occupy- 
ing the lower part of the forehead, the eyelids and nose. The red 
colour of these parts, of no great depth except on the right upper 
eyelid, disappears on pressure ; the swelling, which is little apparent 
on the cheeks, is very distinct on the forehead and nose, and extends 
to the temporal region on the right side ; the eyelids are (edematous, 
especially those of the right eye, at the inner angle of which there 
exists a phlyctena ; the inflamed parts are affected by a sharp and 
pungent heat, more violently felt in the eyelids than anywhere else. 
The abdomen is soft and tender to pressure, the tongue is dry and 
coated ; the thirst very intense ; anorexia, flitting colicky pains, con- 
stipation ; free excretion of urine ; cough without oppression ; skin 
hot ; pulse full and very quick ; headache, disturbed sleep. 26th. — 
The forehead, the eyelids, the two cheeks, and the upper lip are red, 
swollen and shining; the parotid regions and the superior and lateral 
parts of the neck are also inflamed. The redness that extended over 
the right upper eyelid is replaced by a large bleb containing a sero- 
purulent fluid ; a small vesication of the same kind exists on the inner 
angle of the left eye. The nose and the whole of the right cheek are 
covered by yellowish incrustations, formed by the desiccation of a 
fluid that exudes from between the closed eyelids. The patient com- 
plains of darting pains through the whole extent of the parts affected. 
The febrile symptoms continue ; crepitating rattle is heard at the lower 
part of the right lung ; expectoration of mucous matter tinged with 
blood (mucilaginous lemonade). 27th. — Enormous swelling of the 
face, more especially of the right cheek, and of the parotid regions; 
livid red colour of the inflamed skin. (Forty leeches behind the ears, 
sinapisms to the feet, emollient poultices to the face, mucilaginous lemon- 
ade.) Delirium during the night; alvine evacuation (mucilaginous 
lemonade). 28th. — The swelling of the right parotid region has ex- 
tended to the lateral parts of the neck and upper part of the thorax. 
The skin of the face, in some places shining and pallid, is of a livid 
hue on the cheeks, and upper parts of the eyelids; other symptoms 
much the same ; delirium continues (same prescription). Worse and 
worse; collapse has succeeded the delirium; difficult deglutition. 
(Two sinapisms to the thighs: wine and water.) Death in the course 

« Dubourg. Arch. gen. de med., t. x. p. 584.— Louis. Arch, gen de med t xviii 

p. 330. 
24 Desault. Remarq. et Obs. sur l'erysip. (CEuvres de Desault, t. ii. p. 581.) 
2 > Guiaud. Obs. d'un empoisonnement produit dar l'applic. du laudanum a trop 

forte dose. (Bull, des sc. med. de Ferussac, janv. 1827, p. 77.) 
« Lawrence (W.). Obs. on the nature and treatment of erysipelas, 8vo 1828 
27 Rust. Sur les caract. spec, de l'ervsip. (Gaz. med., in-4*, 1833 p 10 V 
*» Louis. Gaz. med., in-4, 1831, p. 339. ''' ' ; 



RUBEOLA. 



71 



of the day. 30th. — Examination of the body. The face is pallid, 
except the eyelids, which are a little red in the parts that were not 
covered by phlyctenae. The subcutaneous and intermuscular cellular 
tissue cut into, is found infiltrated with yellowish and puriform serum, 
and small collections of true pus exist before and behind the orbicu- 
lares palpebrarum muscles. This purulent infiltration is also found 
in the cavity of the orbit, and extends towards the temporal fossae; 
on the left side, indeed, the cellular tissue of the scalp is itself full of 
matter. The tumour of the parotid region is formed by a copious 
effusion of the same purulent serum into the cellular substance sur- 
rounding the gland ; the gland itself is not affected, but the cellular 
substance that enters into its composition, is loaded. A similar infil- 
tration is observed to extend to the subcutaneous cellular tissue 
covering the pectoralis major of the right side. The parietes of the 
veins of the face and neck, although immersed among pus, present no 
traces of inflammation. Many of these small vessels contain purulent 
serum similar to that which is effused into the inflamed cellular sub- 
stance. The minute arteries appear equally free from particular 
disease. The arachnoid membrane covering the superior hemispheres 
of the brain is thickened and opaque ; the corresponding sub-arach- 
noid cellular substance is loaded with serum. The dura mater on 
several parts of the base of the skull is red, as is also the superposed 
arachnoid. The third ventricle of the brain contains a large quantity 
of serum ; the lateral ventricles are less distended. The consistency 
of the brain and cerebellum is natural. Thorax and abdomen. Par- 
tial but old adhesions of the pericardium to the heart ; heart some- 
what larger than natural ; adhesions between the lungs and pleura ; 
lungs crepitating ; redness of some of the ramifications of the bron- 
chia ; redness of the raucous membrane of the oesophagus; blackish 
and greenish hue of the great end of the stomach, and of some parts 
of the small intestines, which appear to be the result of inflammation 
and putrefaction ; the other organs of the abdomen present no parti- 
cular appearance of alteration. 



RUBEOLA. MEASLES. 



Vocab. Rubeola, Morbilli, Blactiee, Measles. 



235. Rubeola, or measles, is an exanthematous and contagious 
inflammation, preceded by chills and shivering fits, accompanied by 
watering of the eyes, sneezing, and hard dry cough, and character- 
ized externally by an eruption of small red spots of the size of flea- 
bites, prominent at the points where the cutaneous follicles surpass 
the general level, separated by irregular narrow interstices, in which 
the skin seems healthy, forming afterwards, by their conjunction, 
small crescent-shaped patches, which decline towards the seventh or 
eighth day from the date of the attack, and are commonly followed 
by a furfuraceous or bran-like desquamation. 

236. Measles presents several varieties: 1. Rubeola vulgaris; 2. 
Rub. sine catarrho, sive spuria; 3. Rub. nigra; 4. Febris morbillosa; 
5. Rub. anomala; Rub. maligna. 

237. Rubeola vulgaris, (morbilli benigni, vulgares). Common 
measles presents three stadia. 

1st Stadium. — {Stadium contagii, Rosen. — apparatus efflorescentice, 
Morton.) — Common measles begins with alternate chills and flushes, 
general uneasiness, lassitude of the limbs, and feeling of depression, 
pain and weight over the eyes and in the forehead, accompanied by 
drowsiness and a disposition to sleep. The pulse soon shows acce- 
leration, the skin becomes hot, the surface of the tongue is whitened, 
its tip and edges are of a bright scarlet colour ; thirst is complained 
of, the stomach is irritable, and there is nausea and sometimes vomit- 
ing ; the epigastrium at times is painful. On the second day of the 
attack, all these symptoms are aggravated ; the eyes grow red and weep 
incessantly, the sneezing is more frequent, the patient complains of 
itching in the nasal fossae, and there is a secretion of limpid mucus 
from the nostrils ; he is oppressed, and feels a load about the epi- 
gastric region. The throat is slightly affected ; cough, of variable 
degrees of violence, commences, and, in very young subjects, drow- 
siness, and, occasionally, slight and passing convulsive fits are added 
to these phenomena. On the third day, the severity of the symptoms 



still goes on increasing ; the eyes become more sensitive and inflamed 
than ever, the eyelids and their edges appear a little swollen ; there 
are dry and frequent cough, hoarseness, dyspnoea, a sense of constric- 
tion, sometimes of anxiety, in the chest, with drowsiness or delirium ; 
a fit of sickness or of diarrhoea in children cutting their teeth, or a 
copious sweat, of a peculiar sweetish-sour smell, precedes the appear- 
ance of the eruption, which commonly shows itself on the fourth day 
from the invasion of the symptoms of indisposition, which may cor- 
respond with the tenth, eleventh, twelfth, thirteenth or fourteenth 
day of the infection. 

2d Stadium. — (Status morbi, Morton. — Stadiicm eruptionis.) — Small 
red spots distinct from each other, almost circular, but little promi- 
nent, and very similar, in all respects, to flea-bites, appear first on 
the forehead, chin, nose, cheeks, and around the mouth, and spread 
successively, during the same day ot on the morrow, over the neck, 
the breast and the limbs. This eruption is almost always accompa- 
nied by itchiness and great heat of skin. The greater number of 
these small circular spots are, by and by, replaced by others of a 
larger size, which are sometimes disposed in clusters, (Rub. corym- 
bosa,) not exactly defined, but tending to the form of a crescent or 
semicircle (racematim coalescunt, Sydenh.). These two kinds of 
spots are blended and lost in the neighbouring skin ; under the finger 
they convey no impression of a rough, uneven, or prominent surface. 
The semicircular patches are formed by the junction of the small 
rounded spots which have already been mentioned, and the little 
points that compose them may often be counted upon the circles 
which are separated from each other by interstices or spaces where 
the skin preserves its natural colour. The colour of these spots is 
less vivid than that which the integuments present in scarlet fever. 
It is enough to stretch the skin a little, to make the redness disap- 
pear. Small rosy-coloured papular elevations are sometimes observed 
on the surface of the skin, which, when they are very numerous, give 
the eruption a peculiar appearance. On the face, the red colour of 
the patches is at its height about the fifth day; on the sixth day, the 
patches there begin to decline, at the same time that those on other 
parts of the body become deeper-coloured and more abundant. 

On the fourth day of the invasion small spots of a dull red colour 
are also sometimes to be perceived on the uvula and velum palati, 
similar to those which are seen on the skin. On the fifth day they 
become confluent. This slight inflammation causes the patient to 
complain of dryness and roughness of the throat, and increases the 
hoarseness that had come on earlier in the disease. 

When the eruption is completed, the frequency of pulse, the heat, 
the thirst, the redness of the eyes, the coryza, the soreness of the 
throat, &c, decline considerably in intensity, and sometimes even 
disappear entirely. The sense of pectoral oppression and the cough 
alone continue in some individuals; the nausea and vomiting have 
ceased from the fourth day, and the sense of heat, oppression, and 
restlessness generally vanish about the sixth. 

3d Stadium. — (Crisis ; declinatio vel desquamatio.) — On the fourth 
day of the eruption, which corresponds with the seventh or eighth of 
the invasion, the patches of measles begin to die off in the order of 
their appearance, and then assume a pale yellowish colour. These 
yellowish spots are more permanent than the redness to which they 
have succeeded ; they cannot be made to disappear by stretching the 
skin. The epidermis soon begins to be detached in a very minute 
furfuraceous scurf from those parts which the redness has left ; the 
skin, now become dry and sometimes rough, is affected with a trou- 
blesome pruritus that lasts till the tenth or twelfth day. Occasionally, 
however, the desquamation either does not occur, or is insensible ; 
this, at least, is the case on certain regions of the body, or on several 
patches of the eruption. At this period the symptoms of inflammation 
of the air-passages decline gradually ; the expectoration, which is 
always wanting in infants at the breast, affects adults slightly in this 
variety of the disease ; in less simple cases, however, the cough 
and expectoration continue for some time during the state of conva- 
lescence. 

238. Rubeola sine catarrho. — During the epidemic prevalence of 
measles, Willan observed that a certain number of patients were 
covered with an eruption, whose external appearance and course 
were the same as those of common measles, from which, neverthe- 






EXANTHEMA! \. 



inaccomMnied with fever, catarrh, i 

;,.,t an interval of several months, or even of two 

irrence of tins eruption and the de- 

s, which, however, most commonly 

r tour days after the Qon-febrile eruption. I have 

had several opportunities of verifying this feci ; and! have scon cir- 

iii which confirmed more decidedly the measly 

i, 1 have, for instance, soon all the children 

:nilv, playing and even sleeping in the same room, attacked 

. well-marked catarrhal measles, except one, who only exhibited 

the - of the 1st Btadium of the disease, and those of the 

eruption, without the bronchial affection. Arc these cases of measles 

without catarrh, considering them as effects of an epidemic cause, 

an, i of varicella observed during the epidemic 

prevalence of small-pox? It is difficult, otherwise than by their 

cause, to distinguish them from certain forms of roseola ; to distin- 

lh between them is impossible when they are sporadic. (Vide sub 

la.) 

Under the title of rubeola nigra Willan has signalized an ap- 
■ but rarely met with, inasmuch as the eruption, towards 
the seventh or eighth day, reckoning from the invasion, becomes 
completely livid, with the addition of a shade of yellow. This variety 
of the disease has principally been observed to occur in individuals 
of weakly constitution. Dr. A. T. Thomson, in the case of a child 
eighl years of age, attacked with this variety, observed that the epi- 
mifi was raised like a moist spider's web, when the wrist was 
pressed in feeling the pulse. I have seen various examples of these 
livid measles in children, labouring under tubercles of the lungs and 
chronic cseco-eolitis, and who were exhausted by diarrhoea and hectic 
fever. In these cases the greater number of the patches of measles 
do not disappear under the pressure of the finger; and when the lite 
of the children labouring under them is protracted for a few days 
beyond the ordinary duration of measles, the skin presents morbillous 
spots which differed from those of purpura simplex in their form and 
distribution, but which, like these last, exhibited shades of brown, and 
of yellowish or dirty gray, according to the degree of re-absorption 
thai had taken place in the blood efl'used into the skin. I shall give 
a case particularly adapted to make the reader acquainted with ano- 
ther variety of black or hemorrhagic measles, in which the greater 
number of the spots were of a vinous red colour, and did not disap- 
pear on pressure. This variety does not appear, like the preceding, 
to be connected with any weakening of the constitution from previous 
illness ; I have met with it in strong and well-constituted individuals. 
On this occasion I shall call attention to the fact, that in common 
measles, if the surface of the body be examined with due care and 
attention, a certain number of patches will almost always be dis- 
covered of a deeper red colour than the rest, not disappearing entirely 
on the pressure of the finger, and subsequently becoming of a yellow- 
ish colour and vanishing more slowly than the others during conva- 
lescence. 

•ill). Measles without eruption. (Febris morbillosa.) This variety, 
not less remarkable than those that precede, has been observed 
during the epidemic prevalence of measles. Sydenham mentions 
anomalous measles in 1674, and a. febris morbillosa that prevailed at 
the same time, which was characterized externally by an eruption of 
patches upon the neck and shoulders resembling those of measles, 
from which, however, they differed in being confined to the places 
mentioned, and not spreading over the whole body. Gregory goes 
further when he states that he has seen measles without any eruption 
whatever. M. Guersent has observed some individuals in families 
where measles prevailed, exhibiting all the other symptoms of the 
\eept the eruption. I have myself several times seen cases 
of measles in which the eruption was incomplete, and which might 
i referred to the morbillary fever of Sydenham, but I have 
never met with any instances like those mentioned by De Haen, 
iry and M. Guersent, although my attention has been turned to 
this point these some years past. 

Influenza and several varieties of bronchial affection sometimes 
prevail at the same time as measles. 

•J 11. Anomalous and complicated measles (rubeola anomala). In 
children who have fine and delicate skins, measles sometimes appears 



partially on the third day; i differentl) con pro, ll 

does not show itself before the fifth or sixth day ; us progress is often 

checked or altogether stopped by exposure to cold, or the unseasona- 
ble use of purgatives. A little girl attacked with measles and com- 
plaining of pruritus in the nosinls, was believed to have worms; after 
the exhibition of a purge the eruption disappeared suddenly, ami could 

not be recalled. Such a recession of the eruption is often accom- 
panied by pains of the bowels, by diarrhoea, difficulty of breathing, 
delirium, convulsions, &e.; in other circumstances the eruption appears 
on the arms after having been observed on the lace; or, otherwise, 
it is not propagated to the limbs, which do not exhibit a single patch 
over their entire extent. 

242. In new-born babes papular eruptions resembling strophulus, 
and in patients of different ages, vesicles analogous to those of miliaria, 
blebs of pemphigus, petechia', accidental pustules, pustules of the 
natural or inoculated small-pox, epislaxis, acute inflammations of tin- 
eyelids, affections of the brain, different inflammatory affections of 
various degrees of importance, such as croup, bronchitis, pneumonia, 
muco-enteritis,&c., by being associated with the eruption of measles, 
oive a vast variety of symptomatic characters to the disease, the 
peculiar form of each of which must be sought for and studied iu 
particular cases. 

When diarrhoea occurs in the course of measles, it is sometimes a 
serious symptom, especially if it be accompanied by restlessm 
frequent cough. Diarrhoea occurring during convalescence may prove, 
according to its nature, duration and effects, either dangerous or criti- 
cal and salutary. 

Convulsions frequently enough accompany the disease when it hap- 
pens during dentition, and very often terminate fatally. 

243. Measles may sometimes exert a beneficial influence on chronic 
inflammations of the skin. I had a young woman under my care at 
the hopital St. Antoine, on account of chronic eczema of the face, of 
the hairy scalp and ears, who got well under a violent attack of 
measles. On the contrary, however, M. Alibert has given two 

of children labouring under impetiginous eczema of the scalp (achor 
mvrifluus), who, having contracted the measles, were suddenly re- 
lieved of their achores, but not long after sunk and died. 

In some cases measles has appeared to cause the development of 
pulmonary tubercles; often, too, it seems to hasten their progress. 1 
When measles is contracted at the same time as small-pox, the measles is 
commonly first developed, and then causes a suspension of the pro- 
gress of the variolous eruption. Viesseux relates an instance to the 
contrary. 

244. Consecutive diseases. (Morbi secundaria; dregs.) — During con- 
valescence from measles, we frequently observe, on the back, groins 
and lower limbs, pustules similar to those of ecthyma, or an eruption 
of the same form, but of smaller size, scattered over the feet, Legs, 
thighs and scrotum. In other cases, we meet with chronic inflam- 
mation of the eyelids, of their margins, or of the conjunctiva, with 
vesicular eruptions upon the external ear, and chronic enlargements 
of the subcutaneous lymphatic glands ; lastly, with bronchial affec- 
tions, obstinate cough, analogous to hooping-cough ; inflammatory 
affections of the mucous membrane of the ccecum and colon, ot the 
lungs, pleura, &c, which are all frequently made more obstinate by their 
special cause than other inflammatory affections having the same seat 
and the same extent, but which are induced under other influences. 
Measles is a disease that is often followed by phthisis, as Fred. Hotl- 
mann long ago remarked, (a) 

245. Anatomical observations. Vogel regarded the eruption of 
measles as situated in the epidermis. More accurate investigation 
has showed that measles especially affects the reticular tissue of the 
skin and the mucous membrane of the air-passages, as these parts are 
found injected in the bodies of those who have died of this disease 
The anatomical characters of measly inflammation, the redness of the 

(a) I have seen tubercular phthisis succeed immediately to measles. 
The hectic fever seemed to be but a continuation of the rubeolous 
one, and terminated fatally in a short period — seven weeks from the 
first attack. Otitis is a common sequela of measles. 

1 Andral. Clinique Medicate Ire.,ed. iii. p. 4'J. 



RUBEOLA. 



73 



bronchial and intestinal lining membrane, and the secretions poured 
out from these, are not apparently different from those which are 
observed after other inflammatory affections not of a specific nature. 
Laennec conceives that the suffocating orthopncea, which sometimes 
carries off children after measles, is caused by true idiopathic oedema 
of the lungs. I have seen this difficulty of breathing produced by 
intense bronchitis, with a fatal pseudo-me?nbranous exudation. In 
anomalous and complicated cases of measles, lesions of various 
kinds, according to the parts affected, are discovered; it sometimes 
happens, also, that the death of the patient cannot be explained by 
any alteration of the solids detected in the examination of the dead 
body. (a) 

246. Causes. Sporadic or epidemic measles is produced by a spe- 
cific cause, the nature of which is unknown, and which, in general, 
acts no oftener than once on the same individual. The disease is 
readily transmitted among those who live in the same house ; yet, so 
necessary is a certain disposition to contract the infection, that we 
see individuals who resist the influence of a first epidemic, attacked 
during a second. Tozetti, Schack, De Haen and Meza, inform us 
that they have seen measles affecting the same individual again and 
again, whilst Rosen assures us that, during the course of a practice 
of forty years, he had not known a single instance of the kind. 
Bateman admits the possibility of such an occurrence, from the state- 
ment of Dr. Baillie. In a letter to G. L. Targioni, Genovesi 1 states 
that, during the continuance of the universally prevalent measles of 
1787, he had examined forty-six persons, children as well as adults, 
affected with measles, although they had already gone through the 
disease some years before. In the epidemic measles that reigned at 
Vire, in 1777, Duboscq had occasion to treat several children whom 
he had attended in 1773. Since the publication of the first edition 
of the present work, I have seen three very remarkable instances of 
the recurrence of measles. One occurred in the person of a little 
girl, seven years of age, who, three months after a well-defined and 
severe attack of measles, complicated with pneumonia, was again 
seized with the disease, ushered in by catarrh, dry cough, and affec- 
tion of the nose, and followed by obstinate inflammation of the eyes. 

Some individuals may have frequent communication with patients 
labouring under measles, without taking the disease. A young 
married woman having contracted measles, communicated it to her 
eldest daughter, three weeks afterwards, whilst a younger child, who 
was night and day beside her mother and sister, escaped entirely. 
Nevertheless, the number of those who appear unapt to contract 
measles, is comparatively smaller than that of individuals unvacci- 
nated, who continue to resist the contagion of small-pox. Burserius 
goes the length of saying that there is probably hardly an individual 
in existence, who is at all times unsusceptible of the infection. 
Measles attacks every age, and occurs in every climate. P. M. 
d'Anghiera says that, previously to the year 1518, when it was 
imported, the disease was unknown in the New World. 2 

The disease is usually observed in young children ; adults some- 
times suffer from it, elderly persons very rarely. Vogel and others 
assure us that infants at their birth have presented traces of measles. 
It more frequently attacks children after than before teething. Dr. 
Barron has observed that angina and cerebral affections were the 
most common complications of measles in infants at the breast. The 
disease is communicated by contact or by infection ; it may also be 
produced by the inoculation of the blood of those labouring under it, 
as the experiments of Dr. F. Home, verified by those of Speranza 
during the epidemic prevalence of measles at Milan, in 1822, have 
proved. Speranza at first inoculated six lads, in one of the work- 
houses, in whom the disease was soon developed, and ran its course 
regularly and mildly. The same experiment has been repeated by 
other practitioners, as well as by Speranza himself, under different cir- 

(a) The chief deviation from health in the state of the blood, in 
measles, as noticed by M. Andral (Hematologic Pathologique) , is in 
the increase of red globules. There is but little change in the pro- 
portion of the fibrin. 

1 Avisi sopra la salut. umana, vol. vii. litt. al Sign. dot. Lig. Targioni, pp. 267-272. 
a De Rebus Oceanicis et Orbe novo. Dec. iv. cap. ix. fol. 62. 

19 



cumstances. A very slight incision or scratch is made with the point 
of a lancet over one of the largest and most inflamed of the measly 
patches, so as to draw a little blood. A few punctures are made in 
the arm of the party to be inoculated, with a lancet poisoned with 
this blood, and the part is covered with a bandage. The effects of 
this inoculation are generally manifested a few days afterwards. Dr. 
Alex. Monro 3 and Locke 4 communicated measles by inoculating with 
the tears and saliva of persons labouring under the disease. Dewees 
informs us, on the authority of Dr. Chapman, that attempts of the 
same kind were in vain made at the dispensary of Philadelphia, in 
1801, although the blood, the tears, the nasal and bronchial mucus, 
and the exfoliated lamellae of the epidermis were successively em- 
ployed in the trials. I have not myself repeated these experiments. 

247. Measles most commonly prevails as an epidemic at the end 
of winter and beginning of spring. That observed in 1671, in Lon- 
don, by Sydenham, and that of Upsal, in 1752, described by Rosen, 
were benign; but the disease, in an anomalous and malignant form, 
prevailed at London in 1674; occurring at Plymouth in 1741, and 
mentioned by Huxham. It was often complicated with pneumonia. 
In the Foundling Hospital, in 1763 and 1768, Watson twice saw a 
putrid form of measles prevailing. Very severe forms of measles, 
complicated with miliary eruptions, were observed at Vire, in 1772 
and 1773, and are described by Poliniere and Le Pecq de la Cloture. 
The measles which prevailed at Paris in the year vi — (1797), were 
greatly complicated by abdominal affections; in the year vii — (1798), 
they were sometimes associated with scarlatina. During an epidemic 
measles, observed at the end of 1800 and beginning of 1801, by 
Consbruch, 5 several children were attacked with morbillary fever 
without eruption. They suffered under a violent fever, with all the 
catarrhal symptoms which accompany measles, and then there came 
out either an eruption that was scarcely distinguishable, and disap- 
peared rapidly, or there followed a copious sweat, or a diarrhoea, or 
an unusual excretion of urine. Every one of these evacuations had 
something peculiar about it ; they were all evidently, says the nar- 
rator, morbillary fevers, which had been preceded by influenza and 
hooping-cough. 

By contrasting the accounts of these and a great many other epi- 
demic measles that have been left us, we perceive that the majority 
of them have presented a character either of mildness or malignity, 
and that almost all, without exception, were preceded by catarrhal 
affections, by influenzas, hooping-coughs, &c. ; diseases of old pointed 
out as preludes to morbillary constitutions. These have farther, some- 
times, been observed to follow epidemic small-pox. During the 
present year, 1833, we have had occasion to remark this succession, 
referred to particularly by Storck and De Haen. I have seen many 
children who, after having had a dry barking cough (toux ferine) 
for a fortnight, have then been attacked with measles, (a) 

248. Diagnosis. — During the period of contagion or of efflorescence, 
the existence of measles may be presumed if the fever be accompa- 
nied by redness of the eyes, a copious flow of tears, and of thin 
mucus from the nostrils, with sneezing, pain and heat of throat, and 
dry and distressing cough ; if measles prevails at the time, and the 
patient have not yet had the disease ; if other members of the family 
are affected in the same way, or if any communication has been held 
with infected individuals. At the beginning of the eruption, the diag- 
nosis is not yet quite certain ; the small red spots by which the disease 
is announced bear a strong resemblance, whilst they are yet isolated, 
to those of small-pox ; but they are not long in being gathered into 
circular bunches or groups, (in racemos collects, Forestus ;) if they 
be generally a little raised, and, as it were, papular on the face and 



(a) Measles sometimes assumes an epidemic character at the same 
time as small-pox ; in its increase and decline corresponding with 
the like progress of the latter disease. This was eminently the case in 
the years 1823 and 1824, in Philadelphia, as recorded in the papers 
on " Small Pox and Varioloid," by Drs. Mitchell and Bell, in North 
Am. Med. and Surg. Journ., July and Oct., 1826. 

3 De Ven. Lymph, valvulosis, 8vo. Berol, 1757, p. 58. 

4 Gentlem. Mag., 1767, p. 163. 

s Vermischte practische Bemerkungen. (Hufeland's Journal, B. xiii. St. 3. S. 31.) 



74 



EXANTHEMATA. 



I, th< v pn mil the appearance of true stains on the breast and 

different from the ekvationt of variola, winch, ai a later 

true pustules. Measles presents characters which 

lish it completely from the other exanthemata, and particu- 
larly from scarlet ferer. In the latter disease, the redness is evenly 
and continuous, the eruption is not grouped or clustered, with 
inters] Miid skin, or its patches, at least, are much larger 

than those of measles, and have an appearance more analogous to 
what is observed on erysipelatous surfaces. When the redness and 
tumefaction of the cheeks are very great in measles, the particular 
characters of the morbillary exanthema, very evident on other parts 
of the body, may he there obscured. Lastly, in the greater number 
oi eas.s of measles, there is a hard dry cough, (toux ferine,) and 
Sometimes expectoration of a particular kind; whilst, in scarlatina, 
the tongue, the mouth, and the throat are commonly of a vivid red, 
without cough or expectoration. In scarlatina, the cuticle is thrown 
off in large (lakes, especially over the palms of the hands; whilst, in 
measles, it is detached in scales or scurf. Measles differs from sum- 
mer roseola less in the form and appearance of the eruption than in 
being so uniformly attended by weeping of the eyes, cough, altera- 
tion of the voice, &c. It is more difficult to distinguish measles, and 
especially the variety without cough, from those eruptions which 
Willan has united under the head of roseola. (See Roseola.) 

The occurrence of the eruption, in common measles, will always 
prevent the disease from being confounded with ordinary pulmonary 
catarrh, or with influenza. At the close, morbillary catarrh some- 
times gives occasion to a particular kind of expectoration, which has 
attracted the attention of M. Lerminier and of M. Andral. At first 
mucilaginous, clear and limpid, at the end of three or four days the 
expectoration becomes thick, rounded into pellets, smooth on the 
surface, of a greenish-yellow colour, remaining perfectly distinct 
from each other, and swimming in a large quantity of ropy and 
transparent mucus, similar to the matter coughed up by some phthi- 
sical patients. By and by, this form of expectoration is exchanged 
for another, which adheres to the bottom of the vessel, and seems 
composed of a grayish homogeneous mucus, mixed with air and 
saliva, and very similar to the ordinary matter expectorated during 
chronic catarrhal affections. In young people, the expectoration is 
wanting, or not at all abundant ; and many cases of measles occur in 
older subjects, without being attended with expectoration. 

In reference to those morbillary catarrlts (measles without eruption), 
which have been observed to occur during epidemic measles, and 
are owing to the specific cause of this disease, they present several 
characters, even during life, adequate to distinguish them from com- 
mon inflammatory affections of the air-passages ; the cough is sono- 
rous, and has a peculiar harsh and hoarse quality ; the expectoration 
is occasionally in pellets, {nummulaires, coined;) and the continuance 
of this catarrhal affection is analogous to that of common measles. I 
know not whether a person labouring under morbillary catarrh have 
the power of communicating common measles, accompanied with 
an eruption, or not; a circumstance which, were such a power pos- 
sessed, would constitute an important diagnostic feature in this form 
of the disease. 

In measles it is always well, by a careful examination of the organs 
Subservient to digestion and respiration, to ascertain the extent and 
intensity of the internal intlamraations which accompany the progress 
of the disease, and particularly to watch those of the gastro-pulmo- 
narv mucous membrane. 

Alu-hillary ophthalmia commonly appears before the development 
of the eruption. It is always attended by a great flow of the fluids 
of the eye, and follows the course of the principal affection. In 
weakly and scrofulous children, this adjunct does not often appear 
till towards the decline of the exanthema. As to any ophthalmic 
affection that may come on later, it must be held owing rather to im- 
prudence in diet, exposure to cold, &c, than to the special cause of 

lne.:- 

».— Epidemic measles, so generally a mild com- 
plaint in temperate seasons and climates, is often a much more de- 
structive disease in inclement seasons, and in countries that are either 
very hot or very cold. Yet the fact is certain that the same town, or 
the same province, may be visited at different times, by measles as an 



epidemic, of a very benign, or of a very destructive character.— -The 
epidemic of 1671, observed at London b) Sydenham, was benign ; 
thai of L674, on the contrary, was remarkable tor the frequency with 
which the disease was complicated with peripneumonia. 

Mild and regular measles ought to give us no solicitude, especially 
when the symptoms decline after the eruption. 

Regularity in the course of the disease, little severity in the symp- 
toms of gastric or pulmonic inflammation, and in the fever, general 
moisture of the skin after the appearance of the eruption, an equal 
distribution of the patches over the face, the trunk and the limbs, arc 
all favourable symptoms. Tissot says that considerable evacuation! 
by sweating, by the urinary organs, and bowels, in the course of the 
disease, are of good augury; I have witnessed many very speed] 
recoveries without any of these evacuations taking place, and 1 have 
generally seen diarrhoea more pernicious than salutary. 

The precursors of the eruption are generally severest in young 
children, especially during dentition. The disease is most dangerous 
in pregnant women, and in women newly delivered, in individuals 
who have long laboured under a chronic affection of some important 
viscus, and especially in those who are affected with pulmonary 
tubercles. Still the severity of the eruption is, in general, subordi- 
nate to the gravity of the internal lesions that accompany or that 
succeed it. The eruption of the measles before the third day, its 
tardy, irregular, or incomplete appearance, its sudden or rapid disap- 
pearance, a leaden hue of the patches, the evolution of petechia? with 
much dyspnoea, are serious symptoms. They often proclaim the exist- 
ence of pneumonia, which is at once detected by auscultation and 
percussion of the thorax. The livid or blackish tint of the spots does 
not make the prognosis more unfavourable in certain cases of hemor- 
rhagic measles, which in other particulars exhibit the usual symptoms 
of the common disease. 

The disappearance of the eruption from exposure to cold, may be 
followed by serious metastases, and sometimes even by death. 

The co-existence of several kinds of inflammation of the skin, and 
particularly of that of variola, renders the prognosis more doubtful if 
the general disturbance of the system is increased. Affections of the 
brain and of its membranes, croupy, laryngeal angina, and pseudo- 
membranous bronchitis may rapidly bring about a fatal termination, 
which, in the majority of cases, then happens towards the eighth or 
ninth day from the invasion, or else at a much later period, in conse- 
quence of the progress of secondary diseases. 

250. Treatment. — When the inflammation of the air-passages, that 
accompanies the eruption of measles, is of no great intensity, and the 
disease advances mildly and regularly in its course, the treatment is 
exceedingly simple. The patient must be covered so as to defend 
him from cold and sudden changes of temperature, but not so as to 
make him feel loaded and oppressed with heat ; he must be kept upon 
low diet, and directed to make free use of any mild or slightly dia- 
phoretic tepid drink ; to allay the cough and irritation about the throat, 
he may have some sweet mucilaginous mixture to take by spoonfuls, 
and inhale the vapour of warm water at intervals, which will, proba- 
bly, alleviate both the coryza and soreness of throat; the eyes must 
also be defended from too great a glare of light. Such are the means 
which it is generally proper to employ in the treatment of simple or 
common measles. During the whole course of the disease, children, 
who are apt to toss off the bed-clothes, and thus become exposed to 
the cold, ought to be sedulously watched both night and day. 

The treatment of measles without catarrh, may be all comprised 
within an unstimulating plan of diet, and the use of diluents. 

The inflammatory affections that precede, accompany, or follow 
measles, in proportion as they are severe, require a greater degree of 
care and attention on the part of the practitioner. The application of 
leeches to the epigastric region, when the intestinal canal is the seat 
of the adventitious malady, and to the fore part of the neck when 
laryngitis is threatened, with one or two bleedings from the arm, when 
the lungs are invaded, will commonly give a most favourable turn to 
the symptoms, secure the development of the eruption when it has 
not yet appeared, regulate it when it has come out imperfectly and 
bring about its restoration when it has vanished suddenly. 

Bleeding may be employed in every period of the disease should 
any complication indicate the measure as necessary ; it is most gene- 



RUBEOLA. 



75 



rally enforced previously to the breaking out of the disease. The 
appearance of the menstrual flux, or its existence, if no abatement of 
the symptoms have followed, presents no obstacle to the detraction of 
blood. In very young subjects, the application of leeches to the upper 
part of the chest is generally preferable to bleeding from a vein, and 
they ought to be repeated in numbers and frequency according to the 
urgency of the symptoms; in children under five years of age, general 
blood-letting is not indicated, except in the event of threatened and 
sudden suffocation, or of very severe pneumonia. 

The leech-bites sometimes flow so freely when the breathing is 
oppressed, that they require to be watched ; attention should at the 
same time be paid to keeping the surface of the body from all impres- 
sion of cold, of which there is always great risk whilst the cloths or 
poultices are changed, should these have been employed to encourage 
the bleeding; or otherwise, when the patient is uncovered for the 
purpose of having the flow of blood checked by the application of 
starch, or lint, or, should these fail, of the nitrate of silver in sub- 
stance. 

The oppression, anxiety, palpitations, and general restlessness, 
observed on the third, fourth, or fifth day of the disease, do not re- 
quire general or even local blood-letting for their relief, unless these 
symptoms be unquestionably due to acute laryngitis, intense pneu- 
monia, or very extensive bronchial affection. In any other case 
bleeding might be hurtful by interrupting the natural course of the 
disease, rendering the eruption less abundant, and the crisis less 
decided. When the detraction of blood is abstained from, the op- 
pression and anxiety, and difficulty of breathing, subside after the 
appearance of the eruption. I ought to add, that the general or local 
bleedings practised by Rhazes ad diliquium, and by Mead and Selle in 
greater moderation, have not so marked and beneficial an effect on 
the inflammatory affections of the air-passages depending on measles, 
as on those produced by exposure to cold, or any other cause not of 
a specific nature. 

Should the eruption happen to disappear suddenly, it is well to try 
to ascertain whether this event be owing to the accession or increase 
of any internal inflammation, or to convulsions, or, finally, be not the 
effect of exposure to cold. In the former case, the complication must 
be met directly and in the usual way ; in the latter, the patient must 
be plunged into a warm bath, or have a succession of hot cloths ap- 
plied to his chest and extremities, with a view to excite perspiration 
and restore the eruption : if the case seem very serious, sinapisms 
may even be applied over the same parts. Blisters are more particu- 
larly useful in cases of measles complicated with pleurisy or pneumo- 
nia, after one or two bleedings have been practised, (a) 

When convulsions supervene in children attacked with measles 
during teething, leeches must be applied under the ears, a blister be 
put upon the scalp or nape of the neck, and small doses of calomel 
given internally, at the same time that means are used to recall the 
eruption, should this have receded. The reappearance of the exan- 
thema in such cases ought not always to induce us to prognosticate 
favourably of the issue ; I have seen the convulsive fits continue in 
spite of this event, and children die a few hours after its occurrence. 

When there is diarrhoea, it should be treated by soothing poultices 
to the abdomen, by mucilaginous injections, and by opiates in small 
doses. The practitioner must be on his guard not to confound simple 
serous diarrhoea with those slimy and bloody evacuations that indicate 
inflammation of the mucous membrane of the caecum and colon, and 
require the application of leeches to the fundament and along the 
course of the large intestines. 

In laryngeal and tracheitic inflammation, accompanied with frequent 
distressing cough having a croupy sound, it is necessary to abstract 
blood from the fore part of the neck, and then to administer emetics 
of tartrate of antimony or of ipecacuanha; the effort of vomiting is 
almost always followed by beneficial diaphoresis; in merely purgative 
doses, these medicines prove much less useful. 

(a) In cases in which the eruption recedes, and there are accom- 
panying marks of pulmonary or bronchial phlogosis, blood-letting and 
the cooling regimen will be the most appropriate treatment. I have 
known free drinking of cold water bring out the retrocedent eruption, 
and even cause mild diaphoresis. 



Inflammation of the throat is allayed by soothing drinks and gargles, 
and by the foot-bath ; should slight epistaxis supervene, it ought not 
to be checked. 

The ophthalmia of measles, if slight, may be left to itself; if more 
severe, it should be treated by leeches and soothing fomentations ; a 
blister to the nape of the neck and purgative medicines are required 
when the affection remains during convalescence : it is, in general, a 
disease of little moment, (a) 

The expectant or moderate antiphlogistic plan of treatment is 
available in the variety of hemorrhagic measles, which, in its. symp- 
toms, assimilates itself with common measles. When, on the con- 
trary, the eruption is very pale and has a livid tinge, when the pulse 
is small, quick, and the skin is scarcely or not at all hot, and these 
phenomena appear linked with a cachectic state of constitution, weak 
wine and water, decoction of bark, camphor and ether, sometimes 
prove means of establishing a beneficial reaction ; a phenomenon 
which it must also be a main object to induce whenever the regular 
course of measles appears to have been interfered with by the abuse 
of bleeding, or the effect of any considerable accidental hemorrhage. 

Paleness and lividity of the patches, the formation of petechia?, 
prostration of strength, and other adynamic symptoms, are occasion- 
ally, and during certain epidemic morbillary constitutions, the most 
frequent characteristics of measles. Blisters applied, for short inter- 
vals, to large surfaces of the body, camphor, Virginian snake-root, 
and preparations of bark internally, are the remedies which have 
been most generally recommended in this malignant measles ; a form 
of the disease not very often seen at the present day. 

In measles, accompanied by very severe catarrhal symptoms, and 
in the disease where the bronchial affection is very great, whilst the 
eruption is but scanty, and still more, whenever suffocating dyspnoea, 
without symptoms of pneumonia, give cause to apprehend an attack 
of pseudo-membranous bronchitis, an emetic of the tartrate of anti- 
mony, or ipecacuanha, on the second or third day of the disease, will 
be found sensibly to lessen the symptoms of inflammation in the air- 
passages, and to favour the development of the eruption. The same 
means have been recommended, in a general way, to recall the erup- 
tion when it has chanced to have receded. I have had more frequent 
recourse to blood-letting, to the warm bath and blisters, when these 
serious cases have occurred in my own practice, (b) 

During convalescence, a spontaneous and passing diarrhoea has 
sometimes appeared to aid recovery from secondary inflammations of 
the conjunctiva, of the larynx and of the lungs. By leaving this 
evacuation unchecked, in every case, we should frequently run the 
risk of seeing our patient perish, under the drain and irritation of 
obstinate inflammation affecting the mucous membrane of the caecum 
and colon, — diseases much more frequent than simple serous and 
critical diarrhoea in measles. With a view to prevent or to combat 
secondary diseases, however, some experienced practitioners have 
advised us to imitate the process of nature, and to make use of the 
mildest purgatives, such as a solution of manna, of cream of tartar, 
&c, in the decline of the disease. This practice I have adopted in 
every case where the organs of digestion have escaped or been very 
slightly affected during the course of measles. 

When, in spite of this precaution, morbillary catarrhal affections 
remain stationary, or continue beyond the usual period of convales- 
cence, blisters as rubefacients, applied for a short time to the breast, 
or kept open on the arm or thigh, are always of service, (c) The diet 
of children, under measles, requires to be carefully watched. I have 
often prescribed asses' milk, in those cases of severe bronchial affec- 
tion when there seemed reason to fear that the exanthematous dis- 
ease might cause or hasten the development of tubercles in the lungs. 

(a) In children of strumous habits and whose hygienic condition 
is unfavourable, ophthalmia from measles is a protracted and obstinate 
disease. 

(b) Tartar emetic is often borne in gradually increased doses at 
short intervals in these cases, and is productive of excellent effects. 

(c) Careful diagnosis pointing out the seat of phlogistic irritation — 
in the bronchia or lungs — recourse should be had to local blood-letting, 
by leeches or cups for its removal, antecedently to the use of blisters 
or rubefacients. 



76 



EXANTHEMATA. 



i at which the contagion oi measles ceases to be subjecl 
. | . ascertained. Isolation, which is the only 

.v, should be extended td aboul the twen- 
tieth d pidemic m rere and malignant kind, 
propriety of removing children from the thea- 
epidemic. When the disease is of a favourable kind, 
u from dreading it, we have been even advised to inocu- 
naturally, in the hope of still further 
ildness, OI of protecting the constitution against the 
- of a more serious infection at a future time. 

Historical Notices "/tin' Disrate and particular Cases. 

261 . Rhaaes 1 does not speak of measles as a new disease, but was 
one "t the fust who described it accurately. He also distinguishes it 
from rariola by a particular name (hasba). The learned and labori- 
ous researches of Willan 2 do not, in my opinion, prove that this 
< was known to the Greek and Roman physicians, nor that it 
had been seen in Europe during the fifth and sixth centuries. Con- 
stantinus Africanus says it was first observed in the eleventh century, 
and described under the name of morbilli. Rhazes, Riverius and 
Sennertus have maintained the affinity of the measles and small-pox. 
Hoffmann 3 and Gruner have considered measles as a particular kind of 
cxanthematous catarrhal fever. Sydenham^ has given a good descrip- 
tion of its two principal forms — morbilli regulares, morbilli anomali. 
Some phenomena, such as the slowness of the pulse* during the period 
of desquamation, and the particular appearance of the matters expec- 
torated, 6 have given occasion to observations that are useful. Inte- 
resting remarks have been published upon congenital measles, 7 on 
the recurrence of measles, 8 on measles without eruption, (morbilli sine 
morbillis,) 9 the occurrence of which cannot be disputed. We have, 
also, much excellent matter on epidemical measles, 10 on its compli- 
cation with pneumonia, 11 with severe dyspncca, u with arachnitis, 13 with 
gastritis and enteritis, 14 with ecchymosis, 15 with variola, 10 with vacci- 
nia ; 17 on measles occupying one side of the body only, 13 and on a 
variety of the disease — rubeola varioloides — probably a complication 
with papulse or accidental vesicles; 19 lastly, on the most common 
secondary diseases, such as inflammation of the thoracic or abdo- 
minal viscera, and others fortunately of rarer occurrence, such as 

1 Rbazes. De varinlis et morbillis, in-12. Gottingcc, 1781. 

2 Willan. Miscellaneous Works, comprising an inquiry into the antiquity of 
measles, etc., in-8. Lond., 1821. 

3 Hoffmann (Fred.). De febribus, sect. i. cap. viii. (febris morbillosa). 
« Sydenham (Th.). Opera med., in-4. Geneva:, 1769, t. i. pp. 120-143. 

■ Hasper. (Hull, des sc. medic, de Ferussac, t. xi. p. 125.) 

6 Andral (G.). Recherches sur l'expectoration, in-4. Paris, 1821, p. 27. — Louis. 
Journ. hebd., t. viii. p. 439. 

7 Roften. Maladies des Enfans, chap. six. p. 255. 

Morton, Bxercit. III. cap. 3, p. 18. — De Haen. Febr. divis. — Divis. VI. 6, p. 
107. — Targioni Tozzetti (Jov.). Prima raccolt. di osservaz, p. 101, in-8. Firenze, 
175'.:. — Duboscq de la Roberdiere (Journ. de med., t. xl viii.) — Baillie. Transact, of 
a society for the improvement of medic, and chirurg. knowledge, vol. iii. p. 258. — 
Cazenave. Journ. hebdomad., t. iv. p. 301.' 

• De Haen. Tractatus de febr. divis. — § vi. De febre morbillosa: "Tempore mor- 
billorum epidemicorum, at et eo variolarum, frequentes sunt febres morbillosa; ac 
variolosa;; ita nimirnm vocals, quod febres has eodem modo, iisdemque cum symp- 
lomatibus, decurrant, ac si efflorescentiae hae subsecuturae forent, nee subsequuntur 
tamen. Curatio eadem est, quam quae fit in stadio contagiosa, variolarum ac morbil- 
lorum." — Bang (Ludov.). Selecta diarii nosocomii fredericiani pro anno 1781 (Act. 

soc. havn., vol. i. p. 206) : "Morbillis adhuc multi aegrotabant Non nulli febre mor- 

cum omnibus ejusdem symptomatibus excepto ipso exanthemate decubue- 
runt." — Consbruch. Opus, citat. — La Fievre morbilleuse de Sydenham etait une 
rougeole anomale accompagnee d'une legere eruption. 

10 Sydenham. Op.cit. — Ranoe (Andr. Br.). Act. soc. havn., vol. i. p. 206. — Lepecq 
de la Cloture. Collect, d'obs., t. i. p. 484, in-4. Rouen, 1778.— Gendron. Epidem. a 
Vendome, 1821 (Rev. m6d., t. xiii. p. 536).— Dufau. Epid. a Montmarsan (Ann. de 
la med. phvs., avril 1828). Lombard. Epid. de rougeole a Geneve, en 832 (Gaz. med. 
1833. i 

ienham. Op.cit. (epid. 1674).— Pinel. Nosogr. philosoph., t. ii. p. 61, in-8, 
1833 (epid. 1799.)— Guersent. Journ. des h6pit., in-fol., p. 521. 

I. Memorab. clinic, t. i. part ii. p. 11.— Laennec. Tr. de l'auscullat., 2 ed. 
Pans, I8S6, t. i. p. 351.— Andral. Revue medic, t. iii. p. 351. 1634. 

» Parent-Duchatelet. Traite de l'arachnitis, p. 327. 

m Bncheteau. Arch. gen. de med., t. v. p. 217. 

" Lancette franc., t. v. p. 290. 

'» De Haen. De febre morbillosa (Rat. med., t. iv. p. 87).— Rougeole suspendant 
la marche de l'incculation (Journ. gen.de m£d., t. iv. p. 460). 

|" Gregory (G.). Lond. med. gaz., vol. x. p. 440. 

•• Rust. Bulletin des sc. med. de Ferussac, t. xvi. p. 236. 

'» Sauvages. Nosol. meth., cl. iii. ord. i. gen. 4, spec. 3. 



amaurosis and anasarca connected with the particular condition or 
the kidneys, and state of urinan referred to by Dr. Bright." 

In the treatment of measles, we have also particular researches into 
the beneficial effects" and into the ill consequences 88 of blood-letting, 

remarks on the use of blisters 2 ' in the anomalous disease, on cmcto- 
cathartic medicines,** on cold lotions," on the cure of measly ophthal- 
on the inoculation of measles,' 7 on measures signalized as 
preservative from its attacks,'-' and on the mortality which it caused 
at Paris in 1830. 48 The dissertation of M. J. M. R. Lefort, 30 and 
the treatise of M. Roux, 31 are worthy of being particularly con- 
sulted. 

Case X. Hemorrhagic measles.— Laury, admitted 10th of July, 1 s 28, 
has complained for three or four days of headache, general pains ni 
the loins, irregular chills, sense of heat in the fauces, and difficulty 
of swallowing, lachrymation, symptoms of cold, redness and swelling 
of the pendulous velum of the palate and tonsils, cough with little 
expectoration, considerable heat of skin, which, in the anterior and 
posterior thoracic regions is the seat of a violet-coloured eruption 
forming small arcs of circles in no great number, and, as yet, not 
very well defined. A few scattered vesicles are, further, distin- 
guishable on the dorsal region. On the 12th the patches of eruption 
had increased in number; they evidently occurred under the form of 
parts of rings incompletely separated from each other by intervening 
portions of sound skin. These patches, of a deeper red than those 
of common measles, and rather resembling petechiae, were numerous 
and scattered over the whole surface of the body. They could not 
be made to disappear entirely under the pressure of the finger. Other 
symptoms as before; chest sonorous; a little mucous rattle; expecto- 
ration white, compact, homogeneous, and surrounded with a little 
transparent fluid ; pulse not much affected ; belly soft, and bowels 
torpid. (Diluents, cough julep; low diet.) 13th. — The patches of the 
face disappeared on pressure ; those of the trunk and other regions 
did not alter under the finger. They were not of quite so deep a hue 
on the breast as before, but on the trunk they appeared almost black, 
and, except in the circular arcuate arrangement, exactly like the 
stains of purpura hemorrhagica. The eyelids now began to desqua- 
mate. Next day, 15th, the colour of the eruption, although not quite 
so deep as it had been, was still remarkably dark. 18th. — A slight, 
and by no means troublesome cough, is now the only symptom of the 
disease that remains, except the peculiar colour of the skin in some 
districts, which, however is becoming every hour less and less livid. 
24th. — The eruption was now extremely pale, and had assumed a 
yellowish tint. The truly hemorrhagic spots were still apparent ; but 
the disease was virtually gone; to guard against accidents, however, 
the patient was not allowed to leave the hospital before the 1st ot 
August. 

Case XI. Measles ; croup ; death: loaded state of the left, inflamed 
condition of the right lung. Inflammation of the mucous membrane 
of the small intestines and colon ; idiotism ; brain apparently healthy. — 
T***, five years of age, was admitted into the hospital for children on 
the 4th of March, 1825. This child, though well-grown, -was idiotic. 
According to the story of the parents, he had for three years been 
subject to violent pains of the head, and occasionally to attacks of 
vomiting. A common cynanche tonsillaris, for which advice had 
been sought a fortnight before, had yielded to a few leeches to the 
throat and common treatment. Since leaving the hospital, however, 
the child had been affected with a troublesome cough ; he had been 
convulsed also; had vomited ; and on the 13th of March, after his 
second admission, an eruption showed itself on the face, which was 

20 Medical Reports, vol. i. 

21 Sydenham. Op. cit. (in morbillis retrocedentibus) Gendron. Gaz. med., 1633, 

p. 275. 

« Cazenave. (Journ. hebd., t. iv. p. 75.) 

S3 Rec. period, de la soc. de med. de Paris, t. iv. n. 19. 

24 Descemet. (Rec period, de la soc de med., t. vi. p. 419.) 

2; Thaer. (Rev. med., avril, 1*29, p. 127). 

26 Weller. Traite theor. et prat, des mal des yeux, trad, franc; par F. F. Riester, 
2 vol. Paris, t. ii. p. 155. 

27 Home (F.). Op. cit. — Speranza. Bull, des sc. med., t. xv. p. 60. 

*« Tounal. Gaz. med., in-8, 1632, p. 8. (Soufre preservatif de la rougeole.) 

29 Journ. complem. des sc. med., t. xli. p. 441. 

*> Lefort. Rech. sur l'oripine de la rougeole, etc., in-4. Paris, 1806. 

3 > Roux (Gaspard). Traite sur la rougeole, in-8. Paris, 1807. 



SCARLATINA. 



77 



held to be measles. 14th. — The eruption now covers the entire sur- 
face of the body ; cough dry, pulse rapid, skin hot, eyes watery, 
bowels relaxed (mucilaginous drink, cough julep.) 15th.— ( The third 
day of tlie eruption.)— Symptoms running high, bowels still relaxed ; 
eruption bright, and confluent on the face. 16th. — Matters much in 
the same state. The thorax not examined this day, the child crying 
so bitterly when touched. In the evening the voice had become 
quite croupy ; the pulse quick (eight leeches to the fore part of the larynx, 
mustard plasters to the legs.) 17th. — The leech-bites bled freely ; 
still the respiration is exceedingly oppressed ; diarrhoea continues ; 
pulse weak and filiform, great prostration, the measly eruption still 
distinct, but pale (two blisters to the legs.) The respiration gradually 
became more difficult, the patient ceased to cough, and died about 
noon. The body opened on the 19lh. — Traces of the eruption are still 
visible over the greater part of the surface of the body. The subcu- 
taneous cellular substance and inner surface of the cutis do not appear 
injected. The form and consistence of the brain and cerebellum and 
spinal cord offer no peculiarity that could serve to account -for the 
existence of the idiotic state. The upper part of the larynx was 
covered by a soft yellowish pseudo-membranous exudation ; a small 
quantity of the same substance was also found about the lower part 
of the trachea, and first divisions of the bronchi. The mucous mem- 
brane of the larynx, trachea, and bronchi, was everywhere of a uni- 
form violet-red hue. The lobes of the left lung were gorged ; the 
middle lobe of the right lung was hepatized ; the other two lobes 
were healthy. The heart was natural ; the mucous membrane of the 
stomach was covered over by a thick mucus. The pyloric orifice 
was very narrow. A few rosy arborescent spots were found on the 
mucous membrane of the small intestines, which became more and 
more numerous as the ilio-cceliac valve was approached. The mucous 
coat of the large intestines was of a deep red colour, more especially 
about the sigmoid inflexure of the colon, and in the rectum. The 
mesenteric glands were red and enlarged ; the other viscera seemed 
free from disease. 

Case XII. Measles, pseudo-membranous bronchitis, pneumonia. — 
L***, fourteen years of age, about the beginning of the month of 
February, 1825, caught a slight cold. On the 15th, all the precursory 
symptoms of measles were apparent ; weeping of the eyes, coryza, 
sneezing, cough, &c. 16th. — Great heat of skin, quickness of pulse, 
headache, anxiety about the prsecordia, frequent and dry cough. 
17th and 18th. — Same symptoms continue. 19th. — The eruption of 
measles appears over the face, the trunk and the limbs, in succession; 
crepitation, in a slight degree, in the lower third of the right lung; 
quickness and hardness of pulse, tongue red and dotted, frequent 
and noisy cough. ( Venesec. ad E viii, mucilaginous drink, cough julep.) 
20th. — Paleness of the exanthema, frequent cough, scanty mucous 
expectoration ; mucous rattle in the two lower thirds of the right 
lung ; rather sonorous rattle in the upper third of the left lung ; 
breathing short and very quick, pulse hard and very frequent. (Ve- 
nesec. ad 5xii, mucilaginous drink.) 21st. — Cough less troublesome, 
respiration less oppressed ; nevertheless, the rattle is heard over the 
same extent as yesterday ; the eruption has disappeared, leaving no 
other trace of its former presence than some slight show of desqua- 
mation on the face ; the tongue is white and less beset with red 
points. 22d. — The breathing is again more rapid ; the patient, sud- 
denly and at frequent intervals, suffers fits of great oppression ; the 
rattle less distinct, and the respiration more obscure, in those parts 
of the lungs where it had hitherto been heard ; almost complete 
absence of the respiratory murmur in the posterior and inferior parts 
of the right lung (fifteen leeches upon this place.) 23d. — Attacks of 
suffocation more frequent ; orthopncea, face slightly livid, lips blue, 
pulse 130 per minute, very small ; death at five o'clock in the after- 
noon. Examination of the body . — Encephalon healthy ; the mucous 
membrane of the pharynx, larynx, trachea and bronchi of a red 
colour, more remarkable opposite those points where the rattle had 
been heard during life ; whitish membrane-like concretions, some- 
what less consistent than the false membranes of croup, fill the rami- 
fications of the bronchi, which are distributed to the two superior 
lobes of the lungs. Gorging and first stage of hepatization of the 
lower and posterior portions of the right lung, all the remaining parts 
of which crepitate. The left lung is crepitant, and adheres at the 
20 



top to the pleura costalis. The mucous coat of the stomach was of 
a dirty white colour. There were a few red spots towards the end 
of the ilium. The other abdominal viscera were sound. 

Case XIII. Inoculated measles. 1 — A child, seven months old, hav- 
ing a copious eruption on the head and a discharge from behind the 
ears, was inoculated the 21st of March, 1758. On the seventh day 
after the operation, the child began to be unwell ; he was slightly 
feverish, had heat of skin, was restless, sneezed several times, but 
did not cough oftener than six or seven times in all, and had no 
affection of the eyes. On the 29th the eruption began to appear, and 
by the 3d of April the child was again quite well. 

On the 6th of July, 1758, another child, eighteen months old, and 
of a very delicate complexion, was inoculated. First day of the 
disease, fever and dryness of surface ; second and third, patient better ; 
fourth, cough and sneezing during the day; slight nausea ; fifth, 
some cough during the night, sneezing, great dryness of skin, ano- 
rexia; sixth, cough more troublesome, and sneezing; several patches 
of eruption appear in the morning, but they almost all recede. Seventh, 
the patches are very numerous over the ribs and on the thighs, where 
they are almost confluent. They are, however, more distinct than in 
natural measles ; the eyes scarcely water ; thirst ; sneezing at long 
intervals ; cough more frequent. Eighth, bowels relaxed. Ninth, 
purging gone ; the patches disappear ; neither cough nor sneezing. 



SCARLATINA. 



Vocab. Purpura ,■ Rossalia ,■ Morbilli conjluentes ,■ Scarlatina ,■ Scarlet Fever. 

252. Scarlatina is a contagious exanthematous disease, which, after 
one or two days' continuance of fever, is announced by an eruption 
of small red points, which are soon replaced by large irregular patches 
of a scarlet or strawberry-red colour, extending to almost the whole 
surface of the body, accompanied by sore throat, and ending in de- 
squamation to the end of the first week. 

253. This disease presents several varieties of character in its symp- 
toms, which may be referred to four principal forms: scarlatina sim- 
plex, scarlatina anginosa, scarlatina sine exanthemate, scarlatina ma- 
ligna. 

1st. Scarlatina simplex, Willan. — (Scarlatina benigna et regularis). 
First period (incubation). A sense of weakness and of general 
uneasiness, nausea, and transient chilly or shivering fits, speedily fol- 
lowed by heat of surface and a considerable degree of thirst, are the 
most usual precursory symptoms of the eruption. Headache, inclina- 
tion to vomit, or actual vomiting, bleeding at the nose, drowsiness 
and other indications of affection of the nervous system, are occasion- 
ally experienced in addition. These first symptoms, which come on 
at any hour of the day, commonly increase in severity towards even- 
ing and during the night, (a) 

2d. (Period of eruption.) — On the second day from the attack of 
the disease, which corresponds w T ith the fifth or sixth of the infection, 
the face becomes swelled ; small spots, not prominent, by no means of 
a very bright red at first, but subsequently of the most vivid hue, 
separated by intervals of the skin preserving its natural colour, appear 
in great numbers on the face, the neck, and the breast. Within twenty- 
four hours an eruption of the same kind is thrown out over the whole 
body, upon the lips also, the tongue, the palate, and the pharynx. 
On the third day the greater number of the interstices which have 
been mentioned as left between the small spots of the eruption, have 
disappeared, and are replaced by large dotted patches, irregular in 
their shapes, and ragged or serrated on their edges. The exanthema 
becomes continuous on the cheeks and limbs, surrounds the fingers, 
and acquires the scarlet colour which characterizes it. A few papular 
elevations most commonly arise at the same time on the hands, the 
chest and the extremities. The skin, which is much hotter in this 



(a) I have seen a child sicken after a breakfast eaten with its usual 
appetite, be seized with vomiting at noon, and in the afternoon mani- 
fest a distinct scarlatina eruption. 

' Home (F.). Medical facts and experiments, 8vo. London, 1758. 






EXANTHEMATA. 



than in anj other of the exanthematous diseases, is now burning, itchy, 
ider i" tin- touch. Its surface, generally smooth, is 
. like the skin oi a goose— (cutis anwrtno), — a 
..ilk remarkable about the outer and hind parts of the 
md thighs; the hands and feet, where the redness is commonly 
. swelled, stiff and painful. The efflorescence of mild 
rarelj general; on the trunk it is in large patches, 
• were around their margins, and very various in their 
outlines. The scarlet colour is more vivid and more permanent about 
the buttocks and the folds of the articulations than on any 
other pans of the body. The eruption is less vivid in the morning 
than during the night, and is always deepest towards evening, espe- 
cially 00 the third and fourth days. To make use of an expression 
of Huxham, the surface of the body appears to be strained with rasp- 
berry-juice, or dyed red. The fever commonly declines after the 
appearance of the eruption. 

Third period. — On the fifth, and at latest on the sixth day, the 
eruption of scarlet fever begins to grow pale; the redness quits the 
parts affected in the same order in which it appeared ; the puffing of 
the face becomes less, the interstices that separate the patches grow 
larger, and the colour of the latter fades. By the seventh day, the 
characters of the exanthema are already far from distinct. From the 
filth day, slight desquamation, preceded by pruritus, takes place from 
the neck, the temples, and the chest. On the eighth and ninth, large 
pieces of cuticle are detached from the skin of the hands, fingers, feet, 
and other quarters of the body. 

Before the eruption appears, and on its first breaking out, the pulse 
is full and frequent; the surface of the tongue is covered with a whitish 
fur, and its edges are red ; the pharynx presents a dotted erythematous 
appearance ; the tonsils are little swollen ; sometimes the eyes are 
injected, sparkling, and humid; the sleep is disturbed and broken by 
dreams. These symptoms present a marked remission on the second 
or third day of the eruption ; sometimes the tongue then throws off its 
coating, when its surface appears of the brightest red. 

At this period, scarlet fever, of a favourable kind, often exhibits a 
rather remarkable phenomenon (reversio). After a febrile paroxysm, 
the skin is perceived to be covered anew with red spots, less nume- 
rous and of smaller size than those of the first eruption. This renewal 
of the disease does not continue long, and is terminated by a more or 
less copious perspiration. 

The eruption of simple scarlatina sometimes takes place without 
any sensible precursory symptoms. 

2. Scarlatina angi?iosa (cynanchica, Cullen). — The preliminary 
swnptoms are more violent in this form of the disease than in the 
last. A sudden sense of stiffness in the muscles of the neck and 
lower jaw often ushers in the attack. On the second day, the fauces 
are inflamed, the voice is hoarse, swallowing is difficult and painful ; 
the lining membrane of the mouth and fauces is of the same bright 
red as the general integuments. Some days, and often on the day 
after the attack, the anterior pillars of the velum palati, the tonsils 
and fauces become covered with a thick viscid fluid, or with flocculi 
of a pultaceous, gray, yellowish-white, or caseous-looking matter, 
similar to what is observed in certain cases of cynanche tonsillaris. 
These exudations, of various colours and consistences, often form a 
kind of uniform coating over the fauces ; they differ from patches of 
coagulable lymph, by being softer ; they may also be scored with the 
point of a probe, and removed upon the end of the finger without 
pain. These pultaceous or curdy concretions are renewed from day 
to day ; they often spread over the lateral parts of the pharynx and 
extend even into the oesophagus. I am not aware that any thing of 
the same kind has been observed after death, in the larynx and 
trachea. They have been called aphthous crusts, and have been 
erroneously supposed, by Fothergill and Huxham among others, to 
be eschars and ulcers. When the tonsils happen to be unequally 
swelled and to have bled a little, these incrustations are sometimes 
tinged of a brown or black colour, and put on the semblance of foul 
ulcers, in so much the more as the breath is then apt to become 
tainted. More attentive examination, however, shows that the pul- 
taceous incrustation is very easily detached from the mucous mem- 
brane of the fauces, but never in masses or flaps, as in cynanche with 
exudation of coagulable lymph. 



The parts once cleansed byfargles and mucilaginous drinks, never 
exhibit any loss of substance or an\ trace of ulceration, circumstances 
which both occur in gangrenous sore-throat. 

On the second, third, and fourth days, the temperature of the skin 
rises to 41° and even 42° of the centigrade scale The pulse also is 
then frequent, but not very full ; the slate of the mouth changes, ih,. 
tongue is of a bright red, the papilla very distinct ; there are nausea, 
vomiting, diarrhoea or constipation, cough without expectoration, 
sneezing, coryza, guttural voice, and frequently hemorrhage from the 
nose, with some oppression of breathing. 

The eruption does not generally appear so soon as in scarlatina 
simplex ; it is often not visible before the third day, and does not 
spread so constantly over the whole surface of the body. It consists 
of isolated patches of a scarlet or raspberry colour, situated over the 
back, the flanks, the neck, the breast, and the limbs, and very regu- 
larly about the wrists. The eruption sometimes vanishes entirely on 
the very day of its appearance, and comes out again after an interval 
of longer or shorter duration. In this variety, the inflammation of 
the skin is very commonly attended with a decided tumefaction of 
the cellular tissue, especially in the face, and in the fingers, the flexion 
and extension of which are impeded. Lastly, the entire duration of 
the efflorescence is longer in this variety than in scarlatina simplex, 
and the subsequent desquamation less regularly performed ; it is, 
indeed, scarcely appreciable when the eruption has disappeared sud- 
denly, and when the exanthema has been very intense, is sometimes 
protracted beyond the third week. 

Scarlatina anginosa may be complicated with pneumonia, or an 
affection of the brain, and thus become fatal. Secondary diseases 
are also more frequent after this form of the disease than after scarla- 
tina simplex. 

3. Scarlatina maligna. — Scarlatina sometimes occurs with symp- 
toms of a still more formidable description. It commences like scar- 
latina anginosa, but in the space of two or three days is characterized 
by symptoms of extreme severity. Often, too, it is ushered in by a 
fixed pain in some part of the body, a phenomenon which De Haen 
observed to be of the very worst augury in the epidemic constitution 
of 1777-1778, described by Meza. To a violent shuddering fit 
(horror) succeeds a burning fever, unquenchable thirst, headache, 
quick and hard pulse, heat and pain of throat, vomiting and diarrhoea, 
coma or delirium, followed, three or four days after, by patches of 
eruption more raised than in scarlatina simplex, and sometimes ac- 
companied by bloody urine. 

The efflorescence in this variety is tardy in its appearance ; its co- 
lour is pale or livid ; it is sometimes mixed with petechias, its duration 
is indeterminate ; it may appear and disappear once and again. The 
pulse is small and irregular ; the teeth and tongue are covered by 
black or brown sordes ; the eyes are watery and much injected ; a fetid 
discharge is sometimes poured out from the nostrils ; the cheeks are 
of a deep-red colour; there is at the same time deafness, in adults 
delirium, in children coma and jactitation; the breath is tainted, the 
breathing noisy and laborious, owing to the thick and viscid mucus 
adhering to the parts about the fauces ; deglutition is difficult or im- 
possible ; there is constriction of the jaws, and a blackish exudation 
from the tonsils and neighbouring parts. Continual coma, extreme 
difficulty of respiration, copious diarrhoea, and the formation of nume- 
rous petechias, prognosticate speedy dissolution, which often takes 
place suddenly on the second, third, or fourth day. 

The small number of patients who survive these first formidable 
symptoms, have now to contend with the consequences of inflamma- 
tory action in the air-passages and the digestive organs, which con- 
tinues after the exanthema has gone, and with all the miseries of 
protracted illness. Gangrenous eschars often form over the trochanters 
and sacrum, which are followed by extensive ulcerated surfaces, whose 
cure, as it is difficult, prolongs still farther the period of convalescence. 
When any thing like chronic intestinal inflammation is going on at the 
same time, these sores are always serious, and sometimes fatal. 

4. Scarlatina sine exanthemate. — In the epidemic scarlet fever of 
1766, observed by Fothergill and by Huxham, it sometimes happened, 
in the cases of patients of a certain age, but very rarely in those of 
children, that after the most violent sore throat, there was no eruption, 
although the skin itched excessively, and desquamation in various 



SCARLATINA. 



79 



degrees, afterwards took place. During the epidemic of 1788, observed 
by Rumsey, in Buckinghamshire, the soreness of throat was a symp- 
tom more invariably present than the eruption. Stoll, Aascow, Bang, 
Ranoe, and, very recently, an observer, as accurate as he is well-in- 
formed, Dance, have also attested the occurrence of these scarlet fevers 
without eruption. I have not myself seen any cases of the same kind; 
but, perhaps, this is owing to the rare occurrence of the complaint 
within the walls of the hopital St. Antoine and de la Charite, where, 
adults only are admitted, as well as to the difficulty of seizing every 
feature of a disease during its epidemic prevalence, necessarily ex- 
perienced by him who is engaged with practice in a great city like 
Paris. . 

254. Whatever the form under which scarlatina shows itselt, the 
eruption may be complicated with other inflammatory affections of the 
skin. From the fourth to the fifth day of the exanthema, there is often 
observed, upon the neck, the arm-pits, and sometimes on other parts 
of the body, an eruption of sudamina,—of small semiglobular vesicles, 
containing a pearly or transparent fluid, which is quickly absorbed, 
or flows out when the cuticle is ruptured ; this is the scarlatina mihans 
of Frank. Sometimes, too, pruriginous eruptions,— such as urticaria, 
are observed at the commencement of the desquamation. Compli- 
cations of scarlatina with measles, erysipelas, and the pustular inflam- 
mations, are more uncommon. 

255. Secondary diseases.— During convalescence, from the four- 
teenth to the fifteenth day of the disease, and, occasionally, later, 
anasarca is apt to make its appearance ; and this is a phenomenon 
which deserves to be particularly studied. The affection occurs most 
frequently during the winter season, and among children, in conse- 
quence of exposure to cold. Its approach is announced by a feeling 
of languor, of depression of spirits and peevishness, by want of sleep, 
and scanty and high-coloured urine, which often resembles the wash- 
ings of meat. The face, and especially the eyelids, become swollen, 
and the cedema, spreading to the lower extremities, is not long of be- 
coming general. All authors are of one mind as to the serious nature 
of this anasarcous affection. According to Plenciz and De Haen, it 
is much more destructive than the primary disease ; and these writers, 
as well as Stoerck and Withering, look upon the dropsical affection 
as a second period in the disease, and almost as one of its distinguish- 
ing characteristics. The affection is variously ascribed, by different 
authors, to the effects of cold, to an imperfect crisis, and to an affection 
of the kidneys.' Blackall and, more recently, M. Peischer, have 
shown that the urine was often albuminous during the continuance of 
the anasarca; and there is enough in these scattered remarks, when 
united, to make us inquire whether this species of anasarca be not 
really a variety of the dropsical affection lately made known by Dr. 
Bright, which Drs. Gregory and Christison have done so much to 
illustrate by new facts, and in the investigation of which I have myself 
spent some time. 2 In fact, like the disease described by Dr. Bright, 
the anasarca of scarlatina is almost always produced by exposure to 
cold and moisture. On the invasion of both diseases, a particular 
change in the qualities of the urine is often observed ; this fluid be- 
comes brown in colour, albuminous, and loaded with cmor. Both 
are very formidable affections ; they both occasionally end in hydro- 
thorax, and in hydrocephalus, and are very different from those pass- 
ing dropsies proceeding from some obstruction to the current of the 
blood the mechanism of which M. Bouillaud has so well explained. 
I have never had an opportunity of examining the organs, and par- 
ticularly the kidneys, of an individual who has died from anasarca 
following scarlet fever, although I have very frequently had such 
opportunities in reference to the disease described by Dr. Bright 1 
observe no dissections of such cases among all those published by Dr. 
Gregory; but there is, during life, so perfect an identity in the pheno- 
mena of these two diseases, that post-mortem examination would, most 

probably, show them to be o f the same nature, (a) 

(a) Lesions of the kidneys from scarlatina are not as common as 
might be anticipated from the presence of anasarca and albuminous 
urine. 

i Ueberlacher, Abhand. vom Scharlach Fieber, S. 378. Wien. 
2 Tissot. De l'hydropisie produile par Inflection graneuleuse des veins.— 1 aris, 
1833, 4to [Also Traile des Maladies des Reins et des alterations de la Secretion 
Urinaire, &c, avec un atlas, folio, torn. ii. 1839-40.] 



As consequences of scarlatina, we also frequently observe inflam- 
matory affections of the eyes, of the ears, of the bronchi, of £e mucou 
membrane of the bowels, of the parotid glands, and of the testes in 
the adult, and swellings of the glands of the neck and groin in chil- 
dren ; but these diseases are rather adventitious than secondary. 

256. Structural changes.— When death has occurred on the second 
day from the invasion of scarlatina, I have found no more than a little 
redness in the mucous membrane of the bronchi ; all traces of the 
eruption had disappeared. When death took place on the third day, 
the mucous membrane of the fauces, of the trachea, and of the bronchi, 
presented an uniform red tinge ; the vessels of the brain appeared 
loaded, and the vascular reticulation of the pia mater was injected ; 
the mucous covering of the stomach sometimes looked red, and was 
studded with slight ecchymoses. The lesions discovered during the 
second period of the disease, are very nearly the same, with this dif- 
ference, that they are much more evident ; I have found redness, and 
sometimes a collection of pus, in the tonsils and cellular substance 
beneath the mucous membrane of the upper part of the larynx ; the 
mucous membrane of the trachea and bronchi was either red or of an 
uniform livid hue ; the minute vessels of the cerebral and spina pia 
mater were injected; their interstices occasionally presented slight 
ecchymoses, whilst the lateral ventricles were filled with serum. 
Sometimes, however, I have been unable to discover any lesion 
which could account for the symptoms of cerebral disturbance ob- 
served during life. The blood in scarlatina has been little examined. 
I do not know whether, as in measles, it possesses contagious pro- 
perties. I have sometimes met with extraordinary evolution or swell- 
ing of the glands of Peyer, and, indeed, of the generality of the intes- 
tinal mucous follicles, as also with ecchymoses into the substance, 
and effusions of blood upon the surface of the mucous membrane of 
the stomach and intestines. I have, further, observed, but more 
rarely, effusions of blood or of purulent matter into the cavity of the 
pleura, which, in the rapidity of their evolution and progress, seemed 
to partake of the nature of the disease they accompanied. The mouth, 
the nasal fossae, and the fauces, often exhibit the redness and changes 
proper to cynanche, with exudation of creamy-looking matter upon 
the surface, (a) . 

257. Causes.— Scarlatina is a contagious disease, but in a less de- 
gree than measles. Petit-Radel tried in vain to communicate it by 
inoculation, but we are told that Stoll succeeded in such an attempt; 
J. Frank tells us that it may be transmitted from the human subject 
to the lower animals,— as to dogs. Scarlatina principally affects 
children and youths ; adults are more secure from its attacks ; it very 
rarely happens that the same individual is affected twice. Out of 
two thousand cases, Willan did not know of a single instance of its 
recurrence. When the first edition of this work was published, I 
was in the same position myself, but since that time one case has 
come to my knowledge : a young man whom I had attended, several 
years before for scarlet fever, whilst recovering from pneumonia, in 
the treatment of which blood-letting had been employed to a great 
amount, contracted the disease through the ordinary channel of con- 
tagion. . 

All are not alike apt to be influenced by the contagion of scarlet 
fever ; and every variety of circumstance is not equally calculated to 
make it efficient. It attacks females more readily than males. Some 
individuals, after having been exposed with impunity several days to 
the contagion of this disease, have been seized with it at a later period 
from simply coming into contact with persons who had visited patients 
labouring under the malady. Scarlatina almost always prevails as an 
epidemic, and most frequently about the period of the equinoxes. In 
winter it rages when the atmosphere is variable, damp, cloudy and 
cold, and at other seasons after heavy rains succeeded immediately 

by great heat. 

The epidemic scarlatinas that have prevailed at different times, 
considered severally, have always a distinguishing character that 
approximates or seems to separate them from one or several others. 

(a) Armstrong says that in nine cases out of ten the air passages 
are inflamed in scarlatina, and Mr. Hamilton, in his account of the 
epidemic as it appeared in Edinburgh in 1832, bears him out in this 
assertion. 



80 



EXANTHEMATA. 



i n remarkable for 

theii i i fixed pain was one of the serious 

I ia 1777 and L778, a! Copen- 

. a malignant scarlatina was described by Sennertus, 

in 1619, and the same form of die disease was prevalent in Saxony, 

. an account of an epidemic scar- 
I a tins accompanied with buboes, and swelling of the parotid glands; 
17 18 and 17 U which occurred at the Hague, was 
with ulcerations of tlie throat and genital organs; in the 
epidemic ol I psal, 1741, described by Rosen, affections of the parotid 
glands were not held an unfavourable symptom; the epidemic ob- 
. in 1751, by Navier, at Chaldns-sur-Marae, a#d that which 
. ana, in 177t) and 1771, by De Haen and Kirchvogel, 
nted all the characters of scarlatina maligna. 
Certain epidemics, however, have had a mixed or complicated 
such was the one described by Lorry in 1777. That ob- 
served h\ Stoerck, at Vienna, in 1759, was accompanied by a miliary 
eruption , the epidemic of Cephalonia, described by Angelo Zullato, 
was remarkable for its complication with bilious and wormy affections. 
v. Scarlatina differs from measles in its precursory 
symptoms, and by the scarlet hue of the eruption, the patches of 
which are much larger, whilst their shape is much more indetermi- 
nate. Neither do they, like measles, present those slight elevations 
circularly disposed and sensible to the touch. Scarlatina is further 
distinguished by the inflammation of the fauces that almost constantly 
accompanies it. In measles, three or four days before the eruption 
appears, the patient suffers from cold in the head, from sneezing, and 
a drv and hoarse cough ; the eyes become moist and full of tears ; in 
scarlatina the eyes are hot and inflamed, and the patients complain 
particularly of pain in the throat. Measles shows itself on the fourth 
day of attack, at tirst on the upper parts of the trunk, and extends 
gradually to the rest of the surface ; the eruption of scarlet fever on 
the second day pervades the whole of the body. Measles most com- 
monly leaves bronchial, ophthalmic and enteritic affections behind it; 
anasarca more frequently follows scarlatina. According to M. Heim, 
scarlatina has a peculiar odour, which he compares to that which is 
felt in warehouses where old cheese is kept, or to that which at some 
distance is exhaled from the dens of lions and other beasts of prey. 
This odour is distinguishable from the very beginning of the disease, 
even before the appearance of the eruption. Measles has also its 
peculiar smell, which, from the invasion to about the seventh day, is 
bitter mixed with sweet ; at a later period it becomes sourish, and 
precisely similar to that exhaled from the feathers of a goose stripped 
alive or recently killed. Scarlatina differs essentially, in many of its 
characteristics, from roseola, from erysipelas (231), and from erythema 
(-2-21). The adventitious evolution of sudamina and of a few vesicles 
in scarlatina cannot render its diagnosis from sweating miliaria (miliaris 
sudatoria) difficult. In scarlatina, they are few in number, and only 
appear on certain regions ; in sweating miliaria, they are scattered over 
thi' surface of the body generally. Lastly, the existence of a scarlet 
efflorescence of the skin suffices to establish a d^tinction between 
scarlatina and the inflammatory affections of the fauces with exudation 
of a creamy or pultaceous substance, observed in certain epidemics 
of scarlatina, and designated by Johnston, Withering, Stoll, and 
others by the name of scarlatina without eruption. M. Bretonneau 
has given an excellent account of the characters that distinguish the 
scarlatina maligna anginosa from angina or cynanche maligna, which 
he entitles diphtheritis. An extreme degree of derangement of the 
circulation, similar to that which follows on the bite of a viper, may 
ed from the very commencement of scarlatina maligna; the 
rhythm of the respiration is not less affected ; the functions of the ali- 
mentary canal are perverted, and excessive vomiting accompanies 
sant diarrhoea ; at the same time the disorder of the functions of 
the nervous system goes on continually increasing, and every thing 
lis a fatal termination. The commencement of the cynanche 
maligna, or diphtheritis, is scarcely marked by the occurrence of 
■ at least, after a transient fit of fever, the pulse 
ncy and returns to about its usual state. The 
aerally, and those of voluntary motion particu- 
are so little deranged, that children who are already dangerously 
aa maligna, display their wonted appetite for food 



and continue at their play. Each of the phases of scarlatina is pre- 
sented to our observation within the terms of a limited period; no 
an be assigned to the successive of diphtheritis. Scar- 

latina, in its progress, has all the characters of a ver) acute dis« 
ma} terminate in death on any of the days from the first to the seventh 
of the single week during which it is at its height {status); diphthe- 
ritic inflammation rather affects the chronic type, if the obstruction of 
the air-passages does not put a period to its continuance by Ctusing 
the death of the patient. The inflammation of scarlet fever extends 
almost simultaneously to every part of the different mucous si 
it invades; of an eminently local nature, it is from a single point 
that diphtheritic inflammation is propagated, with various dec 
rapidity, but successively, to the surfaces over which it spreads: thus 
whilst thick concretions, altered in their appearance, have already 
covered the tonsils and fauces for several days, we find, in the event 
of the patient sinking from obstruction in the air-passages, that the 
mucous membrane of the trachea and bronchi, and nasal fos 
endued with concretions evidently of more recent dates. The in- 
flammation of scarlatina shows little disposition to invade the air- 
passages; whilst diphtheritis exhibits this tendency in a very re- 
markable degree. In scarlatina, if the patient die within the first 
week, no anatomical lesion is to be detected of importance enough to 
account for the death; diphtheritis does not prove fatal, on the con- 
trary, till the moment when the pseudo-membranous layers that line 
the air-tubes, either by their detachment or their accumulation, become 
a mechanical obstacle to the respiratory process; sometimes even 
asphyxia does not happen till many divisions of the bronchi are com- 
pletely plugged up. .No topical treatment, though it exert the most 
beneficial influence on the inflammation of the throat, abridges the 
duration or lessens the danger of scarlet fever; the first days of the 
second week bring about the desquamation of the skin, and conva- 
lescence of a more or less imperfect kind ; and the patients who have 
reached a considerably advanced period of their recovery are not yet 
beyond the reach of change, nor yet safe from the ill consequences 
of the disease ; they are still liable to be attacked with gangrenous 
ulceration of the skin, with convulsions, anasarca, cedema of the lungs, 
and numerous chronic affections, almost always accompanied by a 
remarkable change in the quantity of urine, which acquires a deep 
brownish-yellow colour, owing to an admixture of crassamentum. If, 
on the contrary, we succeed by local treatment, in modifying diphthe- 
ritic inflammation, the recovery of the patient is secured as soon as 
the local disease is at an end. The most fatal epidemics of scarlet 
fever scarcely cut off a fifth of the numbers attacked, whatever the 
mode of treatment adopted, and the mortality is generally much 
smaller ; it is well nigh demonstrated that every one affected with 
angina maligna dies if the disease be left to its own course. 

Let us add in reference to scarlatina as to measles, that the most 
important matter in a diagnostic point of view is to ascertain the mea- 
sure and intensity of the affection that accompanies the exanthema, 
and the character of mildness or malignity of the prevailing epidemic. 
The greatest attention is required in examining into cases of scarlatina 
maligna. The delirium and other formidable cerebral symptoms seem 
often due to the violence of the inflammatory affection of the skin, of 
the fauces, or of some other organ ; at times they appear to depend on 
congestion of the meningeal veins; but there are some cases where 
these phenomena, evidently independent of every kind of encephalic 
congestion, are still more serious and inexplicable. 

259. Prognosis. — Scarlatina simplex, in a well-constituted subject, 
who has not recently suffered from acute or chronic disease of any 
kind, is without danger. A mild form of the disease may, however, 
become dangerous by the retrocession of the exanthema, occasioned 
either by a stimulating plan of treatment or exposure to cold. Epis- 
taxis occurring at the moment of the eruption is reckoned a favourable 
symptom. 

The extent and severity of the inflammation of the fauces and 
mucous membrane of the stomach and intestines, which so often pre- 
cedes and accompanies the eruption, the character of the prevailing 
epidemic, and the pulmonary or cerebral affections which may super" 
vene at different periods of its evolution, make the prognosis more or 
less doubtful according as these affections themselves prove severe 
and obstinate in their character. 



SCARLATINA. 



81 



In puerperal women scarlatina is commonly a serious affection. At 
the Materniti, M. Senn observed that pregnant women when first 
received into the hospital were seldom attacked by the disease, but 
that they very readily became affected by it after delivery. 

260. Treatment.— In scarlatina simplex of a slight kind, the natural 
and regular course of the disease is favoured by the action of an 
agreeable and uniform temperature ; spare diet is to be enjoined, dilu- 
ents may be freely indulged in, and the foot bath used at night. In 
a strong and plethoric subject, if the heat of surface is very great, 
blood may be withdrawn from the arm. The patient ought not to 
yield to the inclination he feels to throw off the bed-clothes ; and the 
room in which he lies is to be ventilated with caution. Neither ought 
he to quit his chamber or be allowed to leave the hospital until the 
thirtieth day. 

261. In scarlatina anginosavel cynanchica, gargling frequently with 
milk and water or some mucilaginous decoction, the detraction of 
blood from the arm, the application of leeches to the neck or epigas- 
trium, of emollient poultices, in the form of a cravat, to the throat, 
and diluted sinapisms to the extreme parts, are generally useful mea- 
sures. When perseverance in such steps does not seem longer 
allowable lest the natural course of the disease should be interrupted, 
we must have recourse to the application of a blister to the nape of 
the neck, and of cloths or sponges wrung out of cold vinegar and 
water to the epigastrium and those parts of the body where the heat 
is felt to be excessive. 

Other methods of treatment have had numerous partisans. Currie, 
Withering, Bateman, Dr. A. T. Thomson and many other English 
physicians especially have boldly had recourse to cold ablution or 
the affusion of cold water in scarlatina. The patient is placed in an 
empty bath or washing-tub and one or two pails of cold water are poured 
over his head. He is then dried quickly, and again put to bed, 
where, should the cold continue, he should have little of some warm 
drink, or warm wine and water. In a few minutes the pulse becomes 
less Frequent, the heat of surface declines, the thirst is less intense, 
tranquil sleep succeeds to the previous state of agitation, and is com- 
monly followed by the breaking out of a sweat that proves of service. 
If the morbid symptoms recur, if the heat becomes pungent and very 
high, the affusion may be repeated with the effect of assuaging them 
again. 

The fear of repelling the disease expressed by the patients or the 
bystanders has sometimes obliged the advocates of cold affusion, to 
be content with merely sponging the face, neck, chest, and extremi- 
ties with cold water. The room should be ventilated at the time 
that the heat of the body is by this means reduced. 

" We are possessed of no physical agent," says Dr. Bateman, " not 
excepting even the use of blood-letting in acute inflammations, by 
which the functions of the animal economy are controlled with so 
much certainty, safety, and promptitude as the application of cold 
water to the skin under the augmented heat of scarlatina. I have had 
the satisfaction in numerous instances of witnessing the immediate 
improvement of the symptoms and the rapid change in the counte- 
nance of the patient produced by washing the skin." (a) 

(a) Long experience in scarlatina, and familiarity with this practice, 
induce me to coincide fully in the praises of the latter by Dr. Bateman. 
By no other remedy is the patient so speedily and pleasurably soothed 
and thrown into a refreshing sleep, as by cold or tepid affusion according 
to the heat of the skin and general excitement. The rules that ought 
to govern us in this practice, are well laid down by Dr. Thaer in ap- 
plying it to the treatment of measles. I shall quote on this occasion 
from my work on Baths and Mineral Waters. 

" The conditions for prescribing cold ablution in these cases were, 
1. That the temperature of the body of the patient should be above 
98° Fahrenheit, and that there co-existed restlessness and shortness 
of breath. 2. That the water for ablution should be colder in pro- 
portion as the body of the patient was hotter. Dr. Thaer was, in this 
respect, regulated by the table of Froelich which he always carried 
about with him, together with a small thermometer, the bulb of which 
he placed under the axilla of his patient. 3. That sponging or ablu- 
21 



Several English physicians have proposed to treat scarlatina by 
purgatives alone, affirming that they never produce the nervous symp- 
toms, and the depression of pulse sometimes observed after bleeding. 
Willan employed calomel, in doses of two or three grains, combined 
in the beginning of the disease with the same quantity of antimonial 
powder. The same combination he informs us was freely adminis- 
tered by a physician, at Ipswich, in 1772, in large doses; and of 
three hundred patients thus treated none died. 

To diminish the fever, heat and restlessness, the tartrate of antimony 
in emetic doses repeated every twenty-four or forty-eight hours has 
been recommended by some practitioners. A single exhibition of this 
or another emetic at the onset of the disease is a safe and, perhaps, a 
useful medicine ; but such a mode of employing the remedy is sup- 
ported neither by experience nor principle. 1 (a) 

Two drachms of chlorine to eight ounces of water in the course of 
twelve hours has been extolled by Mr. Bathwite as a specific remedy. 
I have not myself tried any of these various medicines. 

262. In scarlatina simplex and scarlatina anginosa complicated with 
violent inflammation of the stomach and intestines, of the larynx and 
bronchia, with cerebral or arachnitic congestions, &c, the activity of 
our antiphlogistic treatment ought to be in the ratio of the number 
and of the severity of these affections. At the onset they require 
general blood-letting, and the application of leeches to the throat, the 
epigastrium, and to whatever points the inflammation may have 
reached. Bleeding, however, either generally or locally is never to 
be carried so far as to produce the effects of a hemorrhagic condition 
of the system. Neither are we always to ascribe every case of deli- 
rium to inflammation of the brain or its membranes. Something must 
be left to the influence of time in this as in every other form of fever. 
We may next be called upon, as in the case of measles, to endeavour 
to restore the efflorescence of scarlatina by means of the warm bath 
and rubefacients, when it has disappeared in consequence of exposure 
to cold and moisture, and to give the eruption fixity, so to speak, by 
the agency of blisters when it comes and goes alternately. When 
this irregular progress of the disease is connected with paroxysms of 
internal irritation, as is most usually the case, the best way to fix the 
exanthema of the skin is to attack and subdue, if possible, these in- 



tion was never to be resorted to when the little patient was in a tran- 
quil state, or perspiring. 2 

" I shall here introduce the table of Froelich which will serve as a 
useful guide to direct the practitioner in the employment of bathing, 
and also as an apt illustration of the principles on which the remedial 
powers of the bath must rest. The greater the heat, and the higher 
the excitement, the colder is the water and the longer the period of 
immersion : a practice perfectly in accordance with the creed which 
admits the direct sedative power of cold, but contradictory and absurd, 
if we suppose with Currie and others the stimulating power of this 
agent. 



Heat of the body 


Temp, of the water 


Duration in minutes of the 


by Falir. Therm. 


by Fahr. Therm. 


Ablutions. 


Baths. 


98 


90J 


4 




99J 


85 


4 




100 


75 


4 


li to 1 


101 


65 to 70 


6 


1 to 2 


102 


60 to 70 


4 to 6 


2 to 3 


103 


60 to 70 


8 


6 to 8 


104 


60 


... 


3 to 4 


105 


55 


... 


2 to 3 


106 


40 




1 to 3 


107 


40 




1 to 3 


108 


35 




3 to 4 


1084 


35 




3 to 4 


109 


35 




3 to 4 


110 


35 


... 


3 to 4 


111 


35 




3 to 4" 



(a) An emetic at the beginning of the disease, and small doses of 
tartar emetic in its progress, where the pulse is active, is a part of a 
practice with which I have much reason to be pleased. 

• Bateman, Synopsis, p. 77. 

2 North American Medical and Surgical Journal, Vol. VIII, p. 414, 415. 



82 



EXANTHEMATA. 



• orna l . a which, unfortunately, is not always 

,n.i maligna, what therapeutic means can we hope 
lmI delirium, and the effusion of blood into 
,,i.li, the pleura, the meninges, &c. ? Bleeding 
ntl) ineffective; the pulse sinks with a rapidity that 
of dothinenteritis, the character- 
- of which are sometimes found on opening the bodies of 
I In the other hand, the writers who have been loudest 
in praise of cold washing and cold allusion, tell us that in this form of 
•in- disease the remed] is of no avail. Ipecacuanha and tartrate ot 
antimony by exciting vomiting sometimes expel the sanious phlegm 
i in the fauces, and seem occasionally to restore the dis- 
a more regular type. Fumigations with vinegar, and decoc- 
. liark and contraverva acidulated with simple oxymel or muriatic 
arid, or made pungent with the chloride of lime, or slightly stimulat- 
. the addition of a small quantity of spirits, have very generally 
amended. Transient blisters, and sinapisms to the throat 
tlso been held up as advantageous. Purgatives, too, and particu- 
larly calomel, in a dose of eight or ten grains, are said to have been 
ally beneficial than any other means. I have not tried 
them myself; indeed, scarlatina maligna is a disease rarely met with, 
i i:her in general practice or in the hospitals at Paris. («) 

nling as the scarlatina sine exanthemate presents itself with the 
characters of simple or of complicated scarlatina, or with those of 
scarlatina anginosa or maligna, ought to be the variety of treatment 
pursued in regard to each particular case. 

. During convalescence, every possible precaution must be taken 
i the occurrence of anasarca. The patient must be put on his 
LMiard against exposing himself to cold; a tepid bath or two may be 
taken, and if the colour of the skin assumes a pallid aspect, frictions 
with dry and warm flannels, either unmedicated, or medicated with 
some aromatic or slightly stimulating powder or vapour may be 
practised. 

When anasarca supervenes, either spontaneously or from some im- 
prudence on the part of the patient, it ought to be attacked by general 
blood-letting, if the state of the constitution warrant such a measure, 
by the repeated use of the warm bath, by the acetate of potash in 
quantities of half a drachm daily, or by calomel in purgative doses. 

265. Dr. Hahnemann,' having announced that during the epidemic 
prevalence of scarlet fever, those children and adults to whom bella- 
donna was administered were preserved from the disease, although 
they had had communication with those who were attacked by it, the 
profession everywhere showed great anxiety to put this statement to 
the proof. In 1820, a violent epidemic scarlet fever having broken 
out at Guterslob, none of the children to whom the extract of bella- 
donna was administered were attacked; 2 the medicine was exhibited 
for a week. Hufeland has collected the reports of thirteen different 
German physicians who have tested and confirmed this opinion in 
regard to the preservative power possessed by belladonna against the 
attack of scarlet fever. M. Martini 3 also avows his faith in this virtue. 
M. I nvlisle, practising at Metz, saw twelve children preserved by 
belladonna from scarlatina which attacked two hundred and six, sur- 
rounded by whom they lived. 4 Dr. Velson administered this medi- 
cine to two hundred and forty-seven persons, of whom only thirteen 
contracted scarlatina. His formula was two grains of the extract in 



(a) Adequate stress is not laid by the author, on the topical reme- 
dies to the throat in scarlatina maligna. In addition to washes and 
gargles of chloride of soda or of lime in solution, nitrate of silver is 
applied, by penciling the part affected with it, or by injecting 
into the back part of the mouth a strong solution of this salt— or of the 
sulphate of copper, or some mineral acid diluted with water. Large 
ins of effused or false membrane and tenacious mucus, may be 
,'nt away from the throat by means of a stick of whalebone, to 
:nl oi which a piece of linen or sponge has been carefully tied. 

• Hahnemann (Samuel.) Heilung und Verhutung ties Scharlach fiebers Nflren- 
ber;:. 1801, in-8. 

ue medicate, t.x. p. 213. 
.e medicale, I. li. p. 371. (Arch. cen. tie med., t. v. 204.) 

* Bulletins de la sociele medicale d'emulaiion, avril 1823, p. 201. 



two ounces of water, and two drachms of alcohol, a mixture ol which 
from fifteen to twenty drops daily was exhibited. From the researches 
of Dr. Wagner, on the sum of the epidemics of scarlet fever in which 
belladonna has been prescribed, compared with others in which it was 
not employed, it follows that in the former the mortality was at most 
one in .sixteen, whilst in the latter it was as high as one in three.' 
Whole villages kept themselves free from the epidemic by the use of 
the belladonna, liernt recommends two grains of the extract to be 
dissolved in an ounce of cinnamon water, and during the prevalence 
of the epidemic, two drops of this solution to be administered night 
and morning to children of a year old, and to those farther advanced, 
one or two drops more than the number of their years. It may be 
urged that the continued use of belladonna during the course of an 
epidemic of long continuance might prove not unprejudicial. The 
effects of a medicine so active as belladonna, even in small doses, 
ought to be attentively watched. All the documents on the virtues 
of belladonna as a preservative from scarlet fever have been collected 
by Hufeland. 6 Schwarze, Cock, 7 and other practitioners have denied 
this preservative influence of belladonna entirely, which seems to re- 
quire further confirmation. 

Doctor Hahnemann discovered that belladonna sometimes produced 
a more or less fleeting redness of the skin, and dryness of the throat, 
homoeopathic symptoms which, according to him, explain the peculiar 
properties of this medicine. 

A combination in equal parts of yellow sulphuret of antimony and 
calomel 3 has been recommended as another preservative against scar- 
latina. The dose for children of from two to four years of age, is 
from a third to a quarter of a grain of the mixture added to a little 
sugar or magnesia; and this is repeated three or four times a day. (a) 

In large towns, it is impossible to ascertain the numbers that may 
be attacked in the course of an epidemic scarlet fever. I have not, 
therefore, been in a position to undertake any experiments into the 
prophylactic virtues of belladonna, or of the mixture of sulphuret of 
antimony and calomel that has just been mentioned. 



Historical Notices and particular Cases of the Disease. 

266. Jos. Frank thinks that scarlatina, at least the scarlatina ma- 
ligna, was known to the Greek and Arabian physicians, but the pas- 
sages of Aretaeus, of Aetius, and of Avicenna he refers to in support 
of this opinion are very obscure. 9 Ingrassias 10 was the first wdio, in 
unequivocal terms, gave the characters of this disease ; he tells us it 
was known at Naples under the name of Rossania or of Rossalia pre- 
vious to the year 1500. Forestus 11 ranks it among the epidemic fevers, 
and describes it under the name oi purpura; Ballonius signalizes the 
epidemic that prevailed at Paris in 1581 under the name of rubeola, 
and John Coyttar, 12 a physician of Poitiers, appears to have seen it 
about 1557; since which epoch, the disease has been the subject of 
a multitude of observations and inquiries. 

Numerous remarks have been published on the characters of scar- 

(«) Dr. Sims states that the best preventive which he has met with, 
is a small dose of rhubarb ; a few grains taken every morning so as 
to procure an evacuation in the course of the day. 

5 Journ. des progres des sciences medicales, t. i. p. 242. 

6 Ueber das shutzende Kraft der Belladonna gegen Scharlach Fieber, 8vo. Berl. 
1326. 

> Medic. Gazette, 1832, p. 530. 

s Thomassen a Thuessink. Fats over de Voorbehoeding van de Rooderak. Gro- 
ping. 1808. 

9 Aretaeus. De morb. acut, lib. vii.— AStias. Telrab. ii., serm. 4.— Avicenna, 
lib. iv. fin. 3, tr. 4-6. (Scarlaiinain Hemeka id est botam rubram vocal?) 

«o Ingrassias. De tumoribus praMer naluram, 1556, cap. i. p. 19 1 : « Alteram vert 
idcirco Rossaniam nuncupant. Quoniam rnalcula? per unirersum'corpus plurime 
magnae ac parvoe, ignitae ac rubra? cum vix effatudigno tumore, instar rmilia seorsum 
disuncta erysipelata disperse sunt, ut totum corpus igmium appareat.... Si puer qui- 
dem febriens, variolas antea passus sit, non eas at morbillos expectant- quod si 
uirumque horum prrccesserit, jam Kossaliam timeiit." ' * 

ii " Hie cum in febrem malignam incidisset, diende eiiam purpura correptus esset 
non pustulas rubras easque latas wstar morbillos habebat, quamvis ah iis non nihil 
distabant. (Foresli Obs. et cur. medic, chirurg. Rothomagi, in-lol., 1553 "i ID v i ti 
p. 258.) 

12 Coyttar (J.). De febribus purpuratis epidemics qua; anno 1557 vul-ata: sunt 
Poitiers, 1578, in-4. 



SCARLATINA. 



83 



Jatina, 1 on several forms of this disease, 2 on scarlatina simplex and 
scarlatina sine exanthemate ; 3 on scarlatina anginosa;* on scarlatina 
complicated with typhoid affections, — scarlatina typhodes, 5 with ataxic 
or adynamic symptoms; 6 with nervous symptoms, 7 with arachnitis," 
with encephalitis , 9 with affection of the parotid glands, 10 with coryza 
accompanied by pseudo-membranous formations, 11 with severe diar- 
rhoea, 12 with miliary eruptions,™ with vesicular, pustular, or bullous 
eruptions, 14 with varioloid eruptions, 15 on the occurrence of scarlatina 
in puerperal women, 16 and in children during teething; on the second- 
ary diseases of scarlatina, such as anasarca," rheumatism, 13 and 
purpura; 19 on the diagnosis of scarlatina and angina maligna or diph- 
theritis; 20 on the alterations of the viscera consequent upon scarlatina ; 21 
on the recurrence of scarlatina. 22 The treatment of scarlatina has also 
been the subject of particular inquiries ; we have remarks on the good 
and on the ill effects of blood-letting, 23 on the virtues of chlorine , M on 
the influence of cold affusion or cold washing, 25 on the use of emetics, 26 
of purgatives, 21 and particularly of calomel. 23 

267. The following cases will show that varicella has no influence 
in interrupting the course of scarlatina; that purpura hemorrhagica is 
not always a serious complication, and that blood-letting is sometimes 
an ineffectual remedy in certain cases of scarlatina, accompanied with 
delirium, and complicated or not with pneumonia. 

Case XIV. Scarlatina simplex, arid vesicular varicella, running 
their course regularly. — Adele Despreux, 16 years of age, has been 
vaccinated, and has never had either variola or measles. On the 
15th of October, 1830, she complained of chilly fits, general uneasi- 
ness, lassitude, and great thirst, without cough, or any pain of the 
abdomen ; she perspired freely in the night between the 17th and 18th. ' 
In the morning she complained of sore throat, and the eruption of 
scarlatina became apparent. The face, arms, and part of the legs, 
were of a crimson red, brightest on the outsides of the limbs, and 

1 J.ihn. Jo urn. cnmpl. des sc. mt'd., t. xxxvi. p. 387 ; — t. xxxvii. p. 149. 

2 ftiebel. Bullet, des sc. med. de Ferussac, t. xii. p. 319. — Armstrong. Pract. 
Illust. of the Scarlet Fever. Lond., 8vo., 1818. 

3 " Angina cum febre, sine eruptione, minus semper periculosa, quarto vel septimo 
morbi die, larga salivatione, haemorrhagia narium,sudore,.vei etiam abcessu ad aures 
finiebantur (Aascow. Obs. pract. de scarlat. epidem., anno 1777 et 1778. — Act. soc. 
Havn. vol. ii. p. 99, § xi.) — Bang. Act. soc. Havn., vol. ii. p. 83. — Eichel. Hid., p. 
3a. — Collins. Med. communic, vol. ii. art. 22, p. 363. 

4 Withering. On the Scarlet Fever and Sore Throat. London, 1779. — G. Pistollet. 
Diss, sur la scarl. angineuse qui a regne epidemiqtiement a Langres en 1801, in-8, 
Paris. — Lanthiez. Diss, sur la scarlat. qui a regne epidemiquement a Boralle en 
1819, in-4, Paris. — Trousseau. Arch. gen. de med., t. xxi. p. 541. 

s Rut. Journ. hebd., t. vi. p. 55. 

s Weber. Journ. hebd., t. v. p. 86. — Guernset. Lane, franc, t. v. p. 221. 

' Broussais. Gaz. medic. 1831, p. 200. 

s Parent-Duchatelet. Traite de l'arachnitis, p. 34, in-8. Paris, 1821. 

9 Kreysig (F. Ludw.). Abhandlung uber das Scharlachfieber, etc., in-8. Leipzig, 
1802. 

10 Tissot. De cynanche purpuro-parotidea.— Lemercier. Epid. de scarl. compliq. 
de parotides. (Rev. med., t. v. p. 435.) 

" Journ. des hopit., in-fol., p. 313. 

12 Johnston. Mem. of the Med. Society of London, vol. iii. part 16. 

13 Lorry. Mem. soc. roy. de med., t. ii. p. 134. — Chomel. Lane, franc, t. v. p. 89. 
■* Stark. Ann. med. secund., p. 46. — J.P.Frank. De cur. homin. morb. 

15 Revolat. Lane franc, t. v. p. 411. 

10 Malfalli.— Hufeland's journal, xii. B. 3 St., p. 120.— Senn (L.). Sur la scarlatine 
puerperale, in-4. Paris, 125. 

w Sennert. De febr., t. iv. cap. 12. — Vieusseux. De l'anasarque a la suite de la 
scarlatine (Journ. gen. de med.. t. vi. p. 378-401). — Meglin. Memoire sur l'anasarque 
a la suite de la fievre scarlatine (Journ. de med. chir. Janvier 1811.) — Blackall (J.). 
Obs. on the nature and cure of Dropsies, 8vo. Lond., 1818. — Peschier. Urine albu- 
mineuse apres la scarlat. (Journ. de chim., t. vii. p. 10.) 

13 Murray. On a species of rheumatism consecutive to scarlet fever (Med. and 
Surg. Journ. of Edinb., v. xxxiii). 

19 J. Paul. (Med. and Surg. Journ. of Edinb., v. xxxvii. p. 28.) 

80 Perkins (W. B.). Essay for a Nosological and Comparative View of the Cyn- 
anche Maligna and the Scarlat. Anginosa. London, 1787. — Bretonneau. Arch. gen. 
de med., t. xiii. p. 29. 

21 Dance. (Arch. gen. de medec, t. xxiii. p. 321-401.) 

22 J. Frank. Praxeos. med. univ. praecept., vol. ii. part i. p. 256. 

23 Dance. Ut sup. (advantages). — Marbeck. Bull, des sc. mcd.de Ferussac, t.xx. 
p. 62. (Inconveniences.) 

21 Bathwite. Of the utility of oxygenat. muriatic acid in the cure of Scarlet Fever. 
(Ann. of med., for the year 1803, p. 487.) 

z ~' Carrie (James.). Medic. Reports on the effects of Water, cold and warm, as a 
remedy in Fever and other diseases, 8vo. Liverpool, 1798. 

26 Stoll. Rat. med., part ii. 171-361 ; part iii. p. 5-6. 

2 " Strach. Hufeland. Journ. der prakt. Heilkunde, xix. B. 2 St. 132 (before and 
after the eruption).— Hamilton. Op. cit. 

28 Hufeland. Journ. der prakt. Heilkunde, xii. B. 2 St. p. 86;— vii. B. 2 St. p. 77;— 
xvi.B. 1 St. p. 24. 



disappearing on pressure. The tongue is white and furred, the fauces 
painful, and of a livid-red colour; the tonsils look slightly swelled; 
evacuations from the bowels; chest sounding well, no cough; thirst, 
skin hot, pulse frequent. — {Low diet, mucilaginous acidulated drink.) 
19. — The efflorescence is more vivid on the lower extremities, and a 
fresh eruption has come out on the face and trunk, where a great 
number of small vesicles, — Varicellje, — isolated, and transparent 
on their summits are distinguishable. 20th. — The efflorescence of 
the scarlatina declines ; the throat is less red and painful ; the vesi- 
cles observed yesterday are more numerous, larger, and more in- 
flamed at their bases. The scarlatina and chicken-pox ran their 
course naturally, and the patient left the hospital cured on the 27th 
of October. 

Case XV. Scarlatina with hemorrhagic points ; vesicular varicella 
evolved on the parts not occupied by the efflorescence of the scarlatina. — 
Mandler, aged 24, admitted 18th October, 1829, had the scars of 
vaccine inoculation on the arms. Three days previously he had ob- 
served that his belly was of a red colour; he had not felt unwell, had 
had no soreness of throat or headache, and had not discontinued his 
work. 19th. — Pulse natural; slight heat of the skin, bright-scarlet 
colour of the whole anterior part of the trunk and upper half of the 
thighs; less intense efflorescence on the lateral parts of the trunk, 
where it appears as small close-set dots or points of the colour of a 
boiled fresh-water lobster; the eyes, the nose, the throat, are not at 
all affected. — (Mucilaginous drink; spare diet.) — 20th. — The efflo- 
rescence has extended to the neck, the face, the arms, and legs ; there 
are, moreover, some black or very deep-coloured spots, that do not 
disappear on pressure, scattered here and there ; the throat and velum 
palati are, also, of a dotted and somewhat deep-red colur — (same pre- 
scriptions). 22d. — This day, over the arms, the upper part of the 
chest, the thighs, &c, wherever the efflorescence of the scarlatina 
had not been visible, there is an eruption of vesicular varicella, or 
chicken-pox. From this period nothing remarkable occurred ; the 
scarlatina, petechiae, and varicella went through their usual stages, 
and the patient left the house well on the 10th of November. 

Case XVI. Scarlatina, petechiae, and epistaxis; (purpura hemor- 
rhagica) blood-letting; recovery. — N. Duquesne, aged 24, having had 
small-pox when four years old, and measles when five. — On the 17th 
of January he complained of wandering pains in his lower limbs, of 
lassitude, and, for some days, has felt a distaste and disinclination to 
food ; he is thirsty, and has violent headache, and some pain in (he 
eyes, though the skin is not hot. 19th. — Same symptoms, and, in 
addition, pain and heat of throat, and a brightish efflorescence over 
the legs, which, on the few next succeeding days, spread successively 
over the thighs, the trunk, the arms, and the neck, the face alone 
preserving its natural colour. During all this time there was no com- 
plaint of nausea, nor of pain of the epigastrium, and the urine de- 
posited a thick sediment. 

25th. — The neck, arms, and anterior and posterior parts of the 
trunk, are covered with a raspberry-red efflorescence, which is more 
intense about the natural folds of the skin, and the projecting parts, 
such as the margins of the axillae, the ham-strings, &c, as well as 
the districts habitually exposed to friction, such as the shoulder and 
buttocks, than elsewhere. The efflorescence appears stippled or in 
minute points, in parts abundantly supplied with follicles, but is no- 
where disposed in circlets, as in measles ; the scrotum is of the most 
vivid colour. Besides the eruption, a great many petechiae are visible 
on the legs, which, by being joined, two or more together, sometimes 
form spots of a larger size ; the anorexia and thirst continue ; the tongue 
is of a violet-red colour, and the papillae are very prominent. The whole 
lining-membrane of the mouth and fauces is of a scarlet colour, with- 
out any trace of pultaceous exudation ; pain and heat of the fauces, 
deglutition difficult, darting pains in the nasal fossae, and, during the 
last two days, clots of blood have been discharged from the nostrils. 
No very urgent symptom; respiration free, some dry cough, pulse 
full, conjunctiva slightly injected, eyes watery. 26. — Efflorescence 
declining, tongue bright red, and moist ; epistaxis during the night. — 
(Barley water for drink, broth.) 27th. — Renewal of the epistaxis; 
bowels opened twice; desquamation on the forepart of the neck. The 
petechiae and ecchymoses grow pale and turn yellow. 28th. — Cough, 
expectoration, hoarseness, tongue less fiery, appetite. 29th. — The 






EXANTHEMATA. 



een- 

q, and more abundantly 

h and hoarseness continue. — (Same plan.) From 

. 9th. — Desauamation goes on over the whole 

9th.— Renewed epistaoris, cough, 

agand full (Venes. ad 5xii.) — 10th 

ill symptoms of the malady now disap- 

al w.is dismissed cured on the 14th. 

XVII. S irlatina . circumscribed pneumonia; de- 

— Daynal, 16 years of age; had been vaccinated, and 

scarlatina. Five days before his admis- 

hospital on the 12th of September, 1S29, he had been seized 

h coryza, sore throat, headache, fever, and diarrhoea, for which 

u applied to the neck. The skin was of a 

. vivid-red colour, which disappeared on pressure, over the abdo- 

n and lower extremities. On the breast and upper extremities the 

stippled, and of a pale-red colour, as if it were 

eady declining on these parts; the tongue and posterior fauces 

like the skin; the tonsils so much swelled that they touched; 

p tin in the bowels, liquid dejections. In the evening, delirium and 

rotation; the tongue dry, pulse frequent and full, heat of 

e. — (Twenty leeches behind the ears, mucilaginous drink.) 

, and not so incessant ; the patient knows the bystanders ; 

I issing and crepitating rattle at the posterior and inferior parts 

of both lungs. — (Venes. ad .s x i i , cough mixture, mucilaginous drink; 

| Blood strongly buffed, delirium continues, tongue parched, 

no Stool. The leeches bled a great deal; death at 2 o'clock in the 

morning [of the 15th]. Dissection thirty-two hours after death. The 

lominaJ viscera present no remarkable appearance. The lungs, 

1 with black blood, crepitate throughout their whole extent, 

ept in one small circumscribed point in their posterior part, where 

the tissue is hard and hepatized, and from which the blood does not 

flow freely as it does from other parts when they are incised. The 

mucous membrane of the bronchi is a little redder than it ought to be. 

There was a tablespoonful of serum in the ventricles of the brain, 

the structure of which appeared healthy. The left tonsil contained a 

little pus, the heart was hard, red, and enlarged. 

Case XVIII. Scarlatina, delirium, blood-letting, death without any 
serious a //era /ion of the solids. — A. Proukis, 27 years of age, of a 
healthy constitution, has been unwell several days; her child, 8 years 
old, had but just died of the scarlet fever. On the eighth day, she 
herself felt very unwell and kept her bed. Next day, a dotted cillor- 
BSCence appeared over the body, with pain in the throat and epigas- 
trium, vomiting, purging, and delirium. — (Venesection, leeches to the 
epigastrium.) 21st of May, 1830. — Skin hot, of an uniform red 
colour, as it' it had been stained with raspberry juice, but less intense 
on the face and legs ; pulse full and frequent, throat painful and 
swollen, tongue of a crimson red ; tonsils enlarged and of a deep livid 
hue, which extends into the pharynx, and over the velum palati ; 
thirst, sickness, epigastrium painful, diarrhoea, chest free, agitation, low 
delirium. 22d. — Night restless, the patient moans, epigastrium pain- 
ful. — (12 leeches behind the ears, 20 to the epigastric region; sinapisms 
to the feet.) 23d. — The leeches bleed freely, the delirium continues ; 
no amendment; the eruption is paler. — (16 leeches behind the ears, 
lirements, sinapisms to the feet, mucilaginous drink, loio diet.) Death 
during the night. Dissection 30 hours after death. The stomach 
- B few livid marblings; its mucous membrane is natural in consist- 
ence and thickness. The glands of Peyer, towards the extremity of 
the small intestines, are well marked, prominent, show some black 
dots, and are surrounded by a little redness ; no particular redness, 
and no ulceration in the intestines; no enlargement of the lymphatic 
dominal glands; a small quantity of serum in the pleura, without 
is of intlammation, false membranes, &c. ; heart natural ; the blood 
■ lack, fluid, and contains some bubbles of air; the tonsils are 
double their usual size, and injected ; the brain and its dependences 
healthy. 



ROSEOLA. 



N Rash], Measles— fuLe Eruption— anomalous rosy Efflorescence— 
crysipclutou- 

268. In the first edition of tins work, I followed Willan in describ- 
in>j, under the name of Roseola, several eruptions, acute in their 
nature, not contagious, transitory, and characterized by red sj 
variously figured, slightly, or not at all, prominent, and usually pre- 
ceded or accompanied by febrile symptoms. 

Farther experience has since satisfied me that it was impossible to 
distinguish several species of roseola from erythema; moreover, I at 
one time instituted serious inquiries with a view to ascertain whether 
another variety, the spots of which greatly resemble those of measles 
(roseola infantilis), and which forms the principal type of this group, 
was not itself a mere modification or a variety of measles mthout 
catarrh. But my facts are not sufficiently decisive, nor is my mind 
yet sufficiently made up to allow me to destroy the group formed by 
Willan, under the title of roseola. At all events, the following may 
be taken as the characters of the various eruptions he has characterized 
by this name, the existence of which is not to be disputed, were they 
ever so variously designated, or ever so differently arranged in differ- 
ent nosological schemes. 

1. Roseola cestiva. — This variety, which is sometimes preceded 
by slight fever, appears first on the arms, the face and the neck ; within 
the space of a day or two it spreads to the rest of the body and causes 
tingling and severe itching. It appears under the form of small dis- 
tinct patches, larger, paler, and more irregular than those of measles, 
separated by numerous intervals where the skin preserves its natural 
colour. Of a lively red at first, they soon acquire the deep tinge that 
is proper to them. The pharynx exhibits the same hue, and the 
patient feels a sort of roughness and dryness when he swallows. The 
eruption still continues bright on the second day ; immediately after 
which it begins to decline, slight patches of a dull red continue to 
the fourth day, and disappear entirely on the fifth along with the con- 
stitutional disturbance. 

At times this efflorescence, limited to certain parts of the face and 
neck, and the upper part of the breast and shoulders, shows itself 
under the form of very slightly elevated patches, which cause violent 
itching, but without the sense of prickling that accompanies urticaria. 
The disease lasts at most a week. The eruption occasionally ap- 
pears and disappears again and again, without any perceptible cause, 
or in consequence of violent moral affections, or after the ingestion 
of spiced food and heating liquors. The recession of the efflorescence 
is usually attended by derangement of the functions of the stomach, 
by headache, a state of languor and of lassitude, which the recurrence 
of the eruption causes immediately to cease. 

This variety of eruption usually occurs during the summer in 
females of irritable constitution ; it is sometimes connected with the 
intestinal affections of the season ; it seems to form a kind of a middle 
state between erythema and urticaria, and requires to be treated by 
moderate abstinence, acidulated drinks, [when these do not disagree] 
and occasionally by gentle laxatives. 

2. Roseola autumnalis. 1 This variety attacks children in the au- 
tumn, and shows itself under the shape of distinct circular or oval 
spots, of a dusky red colour, which gradually increase in extent till 
they have attained the size of a shilling, or something less. They 
appear principally on the arms, and sometimes end by desquamation ; 
this eruption is not accompanied by any great amount of uneasy feel- 
ings or of pruritus. It is evidently a variety of erythema. 

3. Roseola annulata. This species is sometimes accompanied by 
febrile symptoms: its duration then is brief; in other cases, there is 
no disturbance among the functions generally, and the eruption con- 
tinues during an undetermined period. It appears on almost every 
part of the body under the form of rosy rings, the central areas of 
which are of the natural colour of the skin. These rings are not at 
first more than a line or two in diameter; they enlarge gradually and 
are sometimes at last an inch and a half in circumference. In the 

' Dr " A - T - Thomson quotes two cases from Bateman, which he refers to this 
variety, and which were attended by very serious febrile symptoms. Vide his Ed of 
Bateman's " Pract. Syn.," 8vo. London, p. 143. 



ROSEOLA. 



85 



morning the efflorescence is always less vivid. When chronic it has 
a sallow and discoloured appearance; it revives towards evening or 
during the night, and causes a sensation of heat, itchiness, and ting- 
ling in the skin. If it vanishes or fades, the stomach becomes dis- 
ordered, languor, vertigo, and pains of the limbs, are complained of, 
symptoms which are generally assuaged by the tepid bath. When 
the eruption becomes chronic it should be treated by sea-bathing and 
the use of the mineral acids. 

The description of this variety must be ultimately blended with 
that of the erythema annulatum. 

4. Roseola infantilis. — In this variety" the spots have smaller in- 
tervals of sound skin between them than we observe in Roseola 
cestiva. When the eruption is general, if the appearance of the dis- 
ease be the only element considered in laying down the diagnosis, it 
is very apt to be confounded with common measles. 1 This variety 
of roseola attacks children when teething, or it supervenes in the 
course of their intestinal and febrile affections. Sometimes it only 
exists for a single night; or it comes and goes successively during 
several days, accompanied by some disturbance of the principal func- 
tions. It may also occur in succession on different parts of the body. 

Whether this variety be a modification of rubeola, or be independ- 
ent of that disease, it ought to be considered as the type of the 
group roseola. 

5. Roseola variolosa. 2 — This exanthema sometimes occurs before 
the eruption of the natural or inoculated small-pox, preceding the 
former more rarely than the latter, in which, indeed, it is calculated 
to appear about once in fifteen cases, in the course of the second day 
of the eruptive fever, which corresponds with the ninth or tenth day 
after the inoculation. The efflorescence is first perceived on the arms, 
the breast and face, and on the following day it extends to the trunk 
and extremities. Its long, irregular, and diffused patches leave nu- 
merous intervals between them. More unfrequently this variety of 
roseola is characterized by an almost generally diffused efflorescence, 
slightly prominent in some points. It lasts about three days ; on the 
second and third, the variolous pustules may be distinguished amid 
the roseolar efflorescence by their roundness and prominence, their 
hardness, and the whiteness of their summits ; as soon as they appear 
the roseola declines. This variety of roseola has been regarded, by 
several inoculators, as announcing an eruption of distinct small-pox. 
My observations on natural small-pox, like those of Walker, 3 lead me 
to think precisely the contrary. 

The eruption of roseola variolosa is, with difficulty, repelled by- 
exposure to cold, or by cold drinks. By the earlier writers on small- 
pox it was mistaken for measles; a circumstance that led them to 
conclude that measles was sometimes turned into small-pox. 

Roseola variolosa may be very readily connected with erythema. 

6. Roseola vaccina* — This efflorescence is observed to occur in 
several children from the ninth to the tenth day after the insertion of 
the vaccine poison. It comes out as small confluent patches, and 
sometimes diffused like those of the variolous roseola, and appears 
about the period when the areola is formed around the vaccine vesicle, 
from whence it extends irregularly over the entire surface of the body; 
it is not, however, so general an occurrence as the efflorescence that 
follows the inoculation of small-pox. It is commonly accompanied by 
acceleration of the pulse and great anxiety. 

7. Roseola miliaris. — Willan tells us that this variety often accom- 
panies an eruption of miliary vesicles with febrile symptoms. — I have 
not met with it in any practice. 

8. Roseola febrilis. — In continued and typhoid fevers Bateman has 
observed an efflorescence making its appearance, resembling roseola 
scstiva, or measles. He saw this roseola occur three times at the close 
of slight fever. In two of these patients, the eruption only lasted 
two or three days; in the third it appeared on the ninth day of the 
fever, after a deep sleep and a gentle sweating fit. The spots, of a 

1 Underwood is of opinion that this error has been often committed. (On the dis- 
eases of children, vol.i. p. 87.) 

2 Dezoteux and Valentin have described the roseola variolosa under the title of 
eruption anomak rosace (Tr. hist, et prat.de l'inoculat. 8vo., p. 238). — Baron Dimsdale 
has given many cases of roseola in consequence of inoculated variola (vide Present 
method of inoculating for the small-pox, 8vo. Lond.). 

3 Inquiry into the small-pox, 8vo. Edinb. 1790, chap. 8. 

< Pearson. Observ., &c, in Lond. Philos. Magaz., Jan. 1809. 
22 



bright rose-red colour, of an oval shape, slightly prominent, and 
smooth on their surface, thrown out on the arms and the chest, were 
more particularly numerous on the inner sides of the arms. The 
eruption was attended by no pruritus, nor any other sensation. The 
febrile symptoms all subsided on the same day, and the patient no 
longer kept his bed. Next day the efflorescence had spread; the 
spots had become broad and confluent, and their colour, which was 
weakened, especially towards the centre, had acquired a purple tinge, 
whilst the margins still continued red and slightly elevated. On the 
third day, the whole of the patches had a tendency to become livid, 
and on the fourth, there was scarcely a trace of them remaining, or 
any symptom of febrile excitement to be observed. 

This variety of roseola might be described under the head of ery- 
thema, with perfect propriety. 

9. Roseola rheumatica [et arthritica]. — A roseolar form of efflor- 
escence is sometimes connected with attacks of gout and acute rheuma- 
tism. Bateman attended an individual of a gouty habit, in whom a 
roseola, accompanied by violent fever, extreme langour, complete 
anorexia, and constipation, appeared upon the lower extremities, the 
forehead and scalp for the space of a week. The efflorescence ended 
on the seventh day in desquamation, and in the middle of the night 
the articulations of the right foot were attacked by gouty inflammation. 
I have seen roseola patches occur towards the end of a rheumatic 
seizure. Case XIX. Dr. Schonlein 5 has also described this variety 
under the title of pelliosis rheumatica, and assigned it the following 
characters: pains of the articulations and extremities, of greater or 
less severity, remitting, changing their place, increasing from the in- 
fluence of cold, and becoming easier from the warmth of the bed ; 
shivering fits, followed by more or less marked febrile reaction, with 
quickening of the pulse and increased heat of skin, which is dry. 

Slight gastric symptoms with loss of appetite, clammy state and 
bitterness of mouth, and furred tongue are the precursors of the dis- 
ease. Twenty-four or forty-eight hours afterwards, and often later, a 
particular eruption makes its appearance, always commencing on the 
legs, and sometimes going no further, but most generally coming out 
on the arms and shoulders at the same time : it rarely appears on the 
trunk, and never on the face. This eruption consists of small isolated 
spots, of a round shape, of the size of a millet-seed or small lentil, 
rarely prominent, and of a deep, or violet, sometimes blackish-red 
colour. The number of these spots is very variable ; most generally 
they are neither so numerous nor so closely set as the vesicles of 
miliaria, or the spots of measles. The fever ceases, and the rheumatic 
pains either leave the patient or diminish greatly in their severity from 
the moment this eruption appears. Under the influence of appropriate 
regimen and treatment, the little spots, whose numbers may be in- 
creased by successive crops, grow pale, and the disease ends by a 
furfuraceous desquamation. If the course of this exanthemata is inter- 
rupted, whether by the influence of exposure to cold and moisture, or 
by the application of discutients, the spots disappear immediately, the 
rheumatic pains return in increased severity, the joints swell, motion 
becomes intolerable, and fever is again set up. 

This disease, observed at Wiirzburg, where rheumatic affections 
are almost endemic and frequently fatal by being complicated with 
miliaria, attacks adults and males more frequently than females. M. 
Fuchs says that it is during winter and spring, when the atmosphere 
is cold and loaded with moisture, that he has most frequently seen 
this eruption. 

The plan of treatment pursued at the hospital of Wiirzburg, con- 
sisted in the administration of tartrate of antimony when there were 
symptoms of gastric derangement ; in the exhibition of the vinum 
colchici when the rheumatic pains were severe, and the use of dia- 
phoretics, such as the acetate of ammonia and compound powder of 
ipecacuanha to favour the eruption. Tepid and soothing drinks alone 
were permitted ; the regimen was simple and antiphlogistic. 

Petzold, 6 Nicholson, and Hemming 7 have also met with arthritic 
roseola. And, to conclude, Dr. Cock 8 has particularly described an 

« Fuchs. Sur le Pelliosis rheumatica (Bullet, des sc. med. de Feruss., t, xviii. p.274.) 
« Petzold. Obs. med. chir., no. 9. — Nicholson. Lond. med. gaz., v. iii. p. 546. 

7 Hemming. Beytrage zur prakt. Arzneykunde, 2 B. 

8 Cock. Obs. on the epid. eruptive rheumatic fever of the West-Indies (Edinb. 
Med. and Surg. Journ., t. xxxiii. p. 43). 



M 



WTIIKMATA. 



etak eruptive Aeuaaettfl fever" which he saw in the Weal 

I 

10. Roseola eAo/eri iw tins variety during the epidemic 

is, ni 1832. After the period of reaction, 

in some patients, especially in women, an eruption 

( appeared on the hands and arms, and then ex- 

eek, the breast, tlie belly, and the upper and lower 

commencement it was characterized by patches 

-t part of an irregularly circular shape, of a bright red 

colour, elevated above the surface, and but slightly itchy. \ cry 

numerous on the hands, arms, and chest, they were less so on various 

Other parts; in some places tiny were crowded together, tended to 

confluence, and had an appearance very analogous to the efflorescence 

<>f slight scarlet fever; in other places the aspect of the eruption was 

r.itlier like that ot measles, and in others even more like that of 

urticaria. 

I have seen this inflammation complicated with an inflammatory 
affection of the fauces or tonsils, and its disappearance followed by 
-ravation of the general symptoms, and sometimes even by death. 
On the chest the spots occasionally became confluent, and gave rise 
to patches as broad as the hand, raised above the general level, and 
well defined. The eruption then acquired a dirty pink or rose 
colour. About the sixth or seventh day the epidermis cracked and 
was thrown off in large flakes, on almost all the places where the 
eruption had existed. 

Historical Notices and particular Cases of the Disease. 

2!Hi. I have already pointed out the principal treatises upon rose- 
ola in speaking of the varieties of this efflorescence. Orlov, 2 Seiler, 3 
Hcim, 4 and Stromeyer 5 have devoted themselves to pointing out the 
characters that distinguish it from measles and scarlatina. It is not so 
easy to establish a line of demarkation between roseola and erythema. 
No one, indeed, can confound papular erythema without fever, con- 
fined to the hands, and its prominent and distinctly circumscribed 
patches, with the more or less diffused, not prominent red spots of 
roseola, spread over almost the whole surface of the body, and ap- 
pearing after a febrile attack analogous to that of eruptive fevers 
generally. But if a certain number of particular cases of roseola and 
of erythema be compared, various points will be discovered at which 
two diseases meet and run into each other. Let but erythema 
become somewhat more general than wont, and its spots appear a 
little more prominent, or the patches of roseola, from some unusual 
violence of the accompanying inflammation, become particularly pro- 
minent, and the appearances of these two exanthemata are the same. 
So, the eruptions that accompanied cholera on their first appearance 
presented several characters that approximated them to the erythema 
papulahnn; these, however, were soon lost, for others held pathog- 
nomonic of roseola. Lastly, roseola annularis and roseola autumna- 
lis, which appear as chronic affections, ought evidently to be classed 
with erythema. 

Sydenham" thought that roseola was a variety of rubeola or measles; 
others have imagined that there subsisted between these two affections 
the same relation as we trace between variola spuria and variola vera; 
whilst a third party 7 have endeavoured to prove that roseola typified 
a particular morbid condition distinct from all the other exanthemata. 
XIX. Articular rheumatism, erythematous or roseolous ei-up- 
tion ; muco-enferids and bronchitis. Marie Hautefeuille was seized 
on the 7th of January, 1833, after a hard day's work, with shivering 
fits, which proved the prelude to a general' rheumatic attack. She 
was treated by bleeding and the tincture of colchicum. On the 26th 
and -21x\i a roseolar eruption appeared on the fore parts of the breast 




« Orlov (A- J.). ProST.de rubeol. et morbil. discrimine, 1735. in-4. 

* rr ,lfr - V' 55- , raor » 1, J",' er , et rubecl - d'torent. vera, in-4. Wmeb, 1805. 

* Heira. Journal von Hufeland, 1812 

» Su^erer. De rubeol. et morbil. discrimine, in-4. Go?tting, 1816. 

* Opera Med., sec. v. cap. 1. ° ' 

■ Hi-ffmin. Opera, t. n.-Durseri us. Inmuui.oo, vol. i. Selle, Pyretologia, p. 171. 



and abdomen, and over the lumber region, of which four or five round 
and well-defined patches did not disappear completely with pressure, 
Upon the abdomen there is ,, reddish festooned or wavy zone which 
extends obliquely from the left hvpochoiuliiuin to the vicinity of the 
spinous process of the illium ; the lower edge of this zone is sharp 
and well defined ; the superior is gradually lost in the healthy skin. 
The festoons of the lower edge are of unequal breadth. The patient 
neither complains of heat, itchiness, nor pain in the seat of the erup- 
tion, circumstances that sufficiently distinguish it from urticaria. 

On the 2Sth, the rheumatic and general febrile symptoms recur with 
new intensity; the eruption has gone from the breast, and faded on 
the abdomen. 29th. — Profuse perspiration, which gave relief; the 
eruption disappeared from the abdomen. In the night of (he _\| ,,j 
February, the patient wandered, moaned, seemed drowsy, and com- 
plained of severe pain in the wrists; constipation during the last three 
days, — (blisters to the forearms). From this time forward, the rheu- 
matic pains and fever went on declining ; and the patient, after another 
relapse of her rheumatism and an attack of diarrhcea, left the hospital 
on the 25th recovered. 

Case XX. Cholera^ roseola following reaction ; recovery. — Bougal, 
aged 43 years, had suffered from cholera for eight days, from the cold 
or collapsed state of which he had hardly recovered when he was 
admitted into La Charite. Reaction to a greater extent was excited 
by a few spoonfuls of Malaga wine, and sinapisms to the extremities; 
and within a day or two symptoms of greater vigour were manifest. 

On the 21st, an eruption appeared over the whole body, but 
cially on the belly and on the limbs. It is disposed in rather broad 
patches of an irregularly round form, and a deepish-red colour, not 
raised above the general level of the skin, and presenting all the 
characters of roseola ; in some places the efflorescence is uniform, and 
resembles a little that of scarlatina; on the breast, however, it is 
exceedingly like measles ; in other respects the patient's state is satis- 
factory, the eruption is attended by no disturbance of the general 
functions, and by the 27th, when the patient was quite convalescent, 
it had vanished without inducing desquamation. 

Many instances of this kind were observed in the wards of La 
Charite. Two of Dr. Lherminier's patients and three of Dr. Rullier's 
were affected during the period of reaction in a very similar manner. 

Case XXI. Roseola (rubeola spuria?). — Whilst dressing G. L, 
aged 4 years, on the 19th of June, 1825, the nurse observed his face 
covered with small red spots, without elevation of the skin, and very 
like measles in colour. Not only were these spots evident at the 
period of my visit the same day, but others were distinguished on the 
breast and arms. The child had no fever, had slept well through the 
preceding night, and was playing as usual ; yet the tongue was foul 
towards the base, and much dotted ; the appetite too had fallen off for 
several days, and the bowels were constipated. Pressure on no part 
of the abdomen caused pain ; the throat was not inflamed, and there 
was no cough or preternatural flow of tears. Two years previously I 
had attended this boy and his two brothers for well-marked measles, 
a circumstance which, considered along with the absence of several 
of the characteristic symptoms of measles, made me look on this slight 
eruption as nothing more than roseola, or the false measles of authors 
—(gum-water and soup for diet). The child slept quietly ; by the 21st 
the efflorescence was pale ; and two days after it was no longer visi- 
ble ; a day or two more of perseverance in the same regimen restored 
the appetite to its usual condition. 

Case XXII. Roseola (spurious or modified measles ?). — I was called 
to see a child, 10 years of age, in the beginning of August, 1825, 
about 24 hours after the appearance of an eruption of small, distinct, 
not elevated spots, broader and more irregular than those of measles, 
principally scattered over the trunk and inner sides of the arms, and 
not attended with pruritus or pain. The fauces showed an erythe- 
matous blush without any swelling of the tonsils, but accompanied 
by a slight difficulty of swallowing. The tongue was a little white 
Ltl „i i fu " ctlonal disord *r of any other ov^n-(sinapised 

Next dav fftT^' ^ SyrUP °f Z Um " S0U P> ™ lk ™ d ««*)• 
dav IflY'il e * anthema Presented nearly the same appearance ; the 

th/r-1 h ? * 6 ° Ur °- f Uie Sp ° ts had become fai " te r- The health of 
the child was in no wise impaired, and 

of the affection had left the skin. 



I, on the fourth day, all traces 



URTICARIA. 



87 



URTICARIA. 



Vocab. Aspretudo, uredo, purpura urticala, essera, febris urticuta, scarlatina urticata, 
epinyclis pruriginosa, nettle-rash. 

270. Urticaria is an exanthematous, non-contagious inflammation, 
characterized by an eruption of prominent spots or wheals, paler or 
redder than the surrounding skin, rarely of long continuance, appear- 
ing after febrile symptoms, often recurring at intervals, or becoming 
aggravated by fits, and always attended by the burning and itchy 
sensation that follows the sting of a nettle. 

Six species of urticaria have been enumerated by Willan : 1st. Urti- 
cana febrilis ; 2d. Urt. evanida; 3d. Urt. perstans ; 4th. Urt. conferta; 
5th. Urt. subcutanea ; and 6th. Urt. tuberosa. These may be all classed 
under one or another of two heads, according as their course is acute, 
or as it is chronic. 

271. Urticaria acuta. — 1st variety: Urt. febrilis. This is often 
induced by the ingestion of various articles, — such as shrimps, lob- 
sters, crabs, the roe of certain fishes, and, above all, mussels. Salted 
fish, that is, dried or smoked, and various other substances, — such as 
the white of egg, mushrooms, honey, oatmeal gruel, bitter almonds, 
and the kernels of stone-fruit generally, raspberries, strawberries, raw 
cucumbers; several medicines, — such as valerian, balsam of copaiba, 
&c, may also occasion this eruption in persons predisposed to it. It 
would, moreover, appear to be demonstrated that it is neither to any 
diseased condition of the mussels that cause urticaria, nor to any 
change they may have undergone, as mentioned by Burrows, nor to 
any poisonous substances upon which they have been believed to 
feed at times, nor to the presence of the cancer pinnotheres, a small 
species of crab they often contain, nor to the black sediment or scum, 
— the crasse marine, of which Lamouroux speaks, 1 nor yet to the sea- 
stars on which the creature appears to live, according to the interest- 
ing researches of Beunie, from the month of May to that of August, 
that their property of exciting this disease is to be attributed, but 
rather to a peculiar susceptibility, — to an individual predisposition on 
the part of those who are affected. 

An hour or two and sometimes much sooner after the ingestion of 
one or other of the articles mentioned, a weight is felt at the epigas- 
trium ; nausea, general sinking, and giddiness, are then complained 
of; the skin next becomes hot, and the eruption appears on the 
shoulders, the loins, the inner sides of the forearms, the thighs, and 
about the knees, generally characterized by red or whitish elevated 
spots, surrounded by an areola of bright crimson. The spots are 
commonly of an irregular shape, but sometimes circular, raised above 
the general level of the skin, and of very various sizes. When they 
happen to be extremely numerous or actually confluent in any quarter, 
the skin presents a general red tint, and the face and limbs are stiff 
and swelled in this case — (Urt. conferta, Willan). The eruption is 
attended with itching, and a sense of prickling of the most intolera- 
ble kind, especially during the night, or when the parts affected are 
exposed to the air. In some cases, this variety of nettle-rash is 
complicated with erythematous blotches. Besides the symptoms 
already mentioned, it is often preceded by vomiting and by purging ; 
and spasm, choking sensations, and convulsions, have occasionally 
been seen added to the list; nay, there are several cases on record 
in which this kind of poisoning even ended in death. 2 — At the end 
of 24 or 36 hours, in the generality of cases, the eruption declines in 
intensity, and soon only leaves but very faint traces of its presence on 
the skin, which are completely effaced a few days afterwards. 

The Urticaria ab ingestis is not always accompanied by white itchy 
elevations of the skin ; the eruption is sometimes no more than a 
simple efflorescence, having the colour of that of scarlatina, and be- 
longing rather to erythema than to urticaria, (a) 

(a) For the following description of the morbid phenomena caused 
by eating certain tropical fish, we are indebted to an article in the 
Cyclopaedia of Practical Medicine, written byD. Houghton, who him- 
self draws largely from Autenreith (Vbar das Gift der Fische). "In 
considering the operation of fish-poison, Autenreith divides it into 
three forms, which may be called the choleric, the eruptive or urticose 

1 Orfila. Toxicologic gener., torn. ii. p. 45. 

1 Fodere. Med. legale, t. iv. p. 85. — An account of two cases of death from eating 
mussels, by G. Man Burrows. Lond. 1815. — Van Couver's Voyage of Discovery, vol. 
ii. p. 286. 



2. Urticaria febrilis sometimes appears without any appreciable 
cause, but sometimes evidently from the effects of teething, violent 
or long-continued moral affections, griefs of a domestic nature, a 

form, and the paralytic or collapse form. The first two of these con- 
sist of those cases in which the impression of the poison is followed 
by a violent reaction of the general system, and they differ from each 
other in that the first exhibits its effects mainly in the internal organs, 
especially the stomach and bowels, while the second manifests itself 
upon the cutaneous periphery. The third form is named paralytic or 
collapse, because in it the poison acts with such intensity on the ner- 
vous system as to take away all power of reaction, so that the patient 
sinks under a gradual exhaustion of the vital powers. It is beside 
our purpose to proceed further ; but as we did not describe the pecu- 
liar characters of urticaria arising from fish-poisons in the general 
history, we subjoin here a sketch of its symptoms as constituting the 
second or eruptive form of Autenrieth : — 

" ' The phenomena commence usually a short time after the repast 
which causes them, and are ushered in by a sudden and vehement 
excitation of the vascular system, with a remarkable rushing of blood 
to the head. Whilst the carotids pulsate and the eyes grow red and 
turgid with fluid, the patient becomes affected with giddiness and the 
most violent and rending pain in the head. The eyes roll wildly in 
their orbits, and the eyelids are held spasmodically open. At the 
same time the face swells up, as do the buttocks and the limbs, and 
a scarlet redness or an urticose eruption overlays the whole body, 
accompanied with severe burning itching. In rare instances large 
vesicles or bullae rise upon the skin. The patient perhaps plunges 
his hands into cold water to mitigate the heat, but each time he does 
so he experiences a peculiar stinging or prickling in them, and also 
in the nose. With this eruption at one time is combined fever with 
hard frequent pulse, tightness of the chest, and general shivering; at 
another violent pains in the limbs or the back, or on the other hand, 
with loss of sensation, and even total immobility of the limbs. The 
inner surface of the body also takes a part in the morbid excitement, 
although in a much less degree in this the eruptive than in the cho- 
leric form of the affection. Pains in the stomach and bowels soon 
set in, which are followed by griping, purging, and vomiting. For 
the most part in the milder cases, when these evacuations take place, 
the erethism of the vessels gradually subsides, the cutaneous swelling 
sinks, the pulse loses its hardness and becomes smaller, and at length 
a favourable sweat comes, which puts an end to this short malady. 
It is frequently followed by exfoliation of the cuticle.' 

" In the cases, however, which occur after the partaking of the poi- 
sonous fish of the hot climates, the recovery is not so rapid, and the 
disease of a much deeper cast. ' For besides that the fore-mentioned 
symptoms are far severer, the heat and itching being intolerable, and 
the eruption of an erythematous form, and the giddiness increased to 
a vertiginous reeling, still further phenomena appear. Dreadful cramps 
in the limbs and in the intestines rack the patient ; a peculiar constric- 
tion with a prickling heat occurs in the pharynx, and a painful tenes- 
mus, with strangury and retention of urine, supervene. To these, in 
some instances, is added an icteroid hue of the skin, and urine, and 
even the sweat is known to stain the linen. But what is, perhaps, the 
most oppressive to the patient are the shooting pains in the swollen 
knee-joints, wrists, and the instep, and in the periosteum of the cylin- 
drical bones. When he has, under these symptoms, for a long time 
vibrated between life and death, their violence at length diminishes, 
and when this occurs the skin peels off in several places, the hairs 
fall out, and even the nails drop. Occasionally abscesses form under 
the skin, which, although coming at the close of the disease, have 
not the same critical importance as those which are so favourable a 
termination to typhus ; and they appear to be rather a purulent disso- 
lution of the cellular tissue under the skin than a regular phlegmonous 
abscess.' {Autenreith, op. cit. p. 131.) Even this laborious recovery, 
however, sometimes fails, and the patient sinks rapidly under the vio- 
lence of the symptoms, or else, having made a rally through them, 
dies exhausted by the weakness succeeding them, which is in some 
cases aggravated by successive suppuration of the skin. After death 
the stomach and pharynx have presented marks of a high state of 
inflammation." 



88 



EXANTHEMATA. 



violent paroxysm of passion, fcc. The symptoms arc then nearly the 
B«ne as those thai have just hern described, save that they are not 
usuallj accompanied hv vomiting and purging. The eruption is less 
-. ni nil, and does not last through the whole course of the disease, 
which occupies a weeh at l< asl ; it appears and disappears irregularly 
en almost all the parts of the body, and its returns are preceded by 

hi febrile symptoms. 
The patient, by rubbing any part of his body, can often excite 
of nettle-rash at will. These spots vary in the period of their 
duration from a few minutes to two or three hours. In some very 
rare easts the rash continues for two or three weeks. — (Urt. perstans, 
Willan.) The patients then sutler from depression, anorexia, febrile 
symptoms, and functional disorder of the digestive organs. — The 
eruption declines imperceptibly ; its returns are soon characterized 
by nothing more than a little itching, a symptom which is itself not 
long in disappearing. 

When nettle-rash has been very violent, and especially when the 
spots have continued long, some slight desquamation of the skin is 
occasionally observed to follow. 

•272. Urticaria chronica. — This form of the disease commonly lasts 
for several months, and I have known it to continue for several years, 
in a girl whose mother had formerly suffered in the same way. It 
occurs most commonly in females, and in those individuals whose 
skin is more than usually sensitive. A young man, a metal gilder, 
produced at will, and in my presence, the pale spots of urticaria, by 
rubbing or pinching lightly the skin of his arm or of his face. In a 
great number of cases this eruption has appeared to me to be connected 
with a deranged state of the functions of the digestive organs, and 
especially of the stomach, but I have also observed it in individu- 
als who, in other respects, enjoyed the best health. The spots ap- 
pear at irregular intervals, sometimes on one place, sometimes on 
another (Urt. evanida, WiHan). They often show themselves, espe- 
cially in one region, without being accompanied with fever, and com- 
monly disappear again within a few hours. — The patches are, for the 
most part, irregular, and bear a strong resemblance to the wheals 
produced by flagellation ; they are not surrounded by an erythematous 
areola, and are accompanied by no other symptom than pruritus of a 
very severe kind. In some cases, the pruritus is replaced by a sensa- 
tion of prickling under the skin, similar to that which is caused by 
the prick of a needle (Urt. subcutanea, Willan). The eruption, which 
is then very scanty, consists of a few red points, but little elevated 
above the level of the skin, and a small number of spots, that appear 
at very remote intervals. — This variety of urticaria is very uncommon, 
and is usually caused by violent emotions of a moral kind. 

Chronic urticaria, however, is sometimes seen with more serious 
characters (Urt. tuberosa, Willan). The disease does not then consist 
in mere slightly prominent elevations, but in true tuberosities, of vari- 
ous magnitudes, hard, deep-seated, extending to the subcutaneous 
cellular tissue, sometimes accompanied by true ecchymoses, by pain 
in moving the limbs, and a tense and very sore state of the skin. 
These tumours, which are very itchy, appear in the evening or at 
night, and disappear again entirely before morning, leaving the pa- 
tient weak, restless, and weighed down with langour and depression. 
They come out more particularly on the loins and extremities; but 
they may show themselves over the whole of the body, cause a gene- 
ral swelling of the face, of the neck, and of the limbs; be accompanied 
by dyspnoea, irregularity in the action of the heart, and other symp- 
toms, distressing in various degrees, which are commonly developed 
under the influence of a febrile paroxysm (febris intermittens urticata, 
Frank). The eruption disappears completely with the remission of 
the fever, and reappears with its accession. 

These varieties of chronic urticaria are very irregular in their pro- 
gress, and sometimes disappear for several days, to reappear, without 
any appreciable cause, at intervals of uncertain remoteness. Frequently 
it is only after the lapse of many months, and occasionally of many 
years, that they are got rid of entirely, either spontaneously or by the 
influence of some methodical plan of treatment. Turner mentions a 
case in which the disease continued for ten years, and Heberden 
speaks of one more obstinate still, in which it lasted for seventeen 
years. The exanthema, when it has been very intense, is followed 
by a bran-like desquamation. 



273. Urticaria is sometimes associated with an intermittent quoti- 
dian, or tertian fever. Jos. Frank saw it under this form, at Pavia, 
in the months of May and June, 1791, and at Wilna, during March 
and April, 1812, in so great a number of instances that this intermit- 
tent with urticaria might be held epidemical. — Urticaria is sometimes 
connected with chronic affections of one or other of the viscera. Its 
association with disorders of the digestive organs is very frequent ; it 
is less common along with diseases of the air-passages. Clarke saw 
this eruption occurring in women labouring under cancer of the uterus, 
and I have three times met with it in women of nervous constitutions 
after having miscarried. In rheumatic affections, accompanied by- 
eruptions {rheumatic eruptive fevers), I have almost as often observed 
the wheals of urticaria, as the efflorescence of erythema or roseola. 
Urticaria may co-exist with other affections of the skin, with lichen 
simplex, with erythema, with roseola, and occasionally with impetigo. 
Wichmann has observed it complicating variola, Hufeland, measles 
and icterus. I have seen an unfortunate patient, labouring at once 
under urticaria and prurigo, whose body was covered with stains of 
blood and immense scratches, tearing his person with all the eagerness 
of frenzy. 

274. Causes. — Besides the causes of urticaria already pointed out, 
there are others that require to be mentioned. Some individuals 
have a skin so susceptible and so much predisposed to this eruption 
that the gentlest rubbing and the lightest pressure are enough to bring 
it out. Urticaria appears during the summer, particularly in women, 
and individuals generally of a nervous and sanguineous temperament, 
and much more frequently in children and persons in the vigour of 
life than in the aged. Nevertheless, cold seems to have a remarka- 
ble influence on its appearance. The wheals are more particularly de- 
veloped when certain parts of the body are exposed to the air. Jos. 
Frank tells us the disease is as rare in Italy as it is common in Russia. 

Urticaria has been observed recurring periodically every month or 
at more distant intervals. 

275. Diagnosis. — The leaves of the urtica dioica, urtica urens, and 
rhus toxicodendron, the bite of the common bug, and, according to 
Reaumur, the contact of the hairs of certain caterpillars, may cause 
an eruption of wheals which, as they are very evanescent, it is im- 
portant to distinguish from chronic urticaria, generally so rebellious 
to all treatment. In these cases it is enough to inquire into the cause 
of the eruption. The white and raised wheals surrounded by areolae, 
proper to urticaria, differ not only in these respects from the spots 
and patches of erythema, but further by the particular sensation of 
pricking, scalding, and itching, which accompanies them. The acute, 
continued, and persistent course of erythema nodosum distinguishes it 
from urticaria tuberosa, which usually attacks in paroxysms. The red 
spots and patches of roseola cannot be confounded with the dull white 
wheals of urticaria, and are not attended by the pruritus that charac- 
terizes the nettle-rash. Chronic urticaria is distinguished from scar- 
latina and measles by a great variety of particulars ; nevertheless 
urticaria is not always well marked on every one of the parts it 
invades: I have seen in a case of urticaria febrilis in which the 
raised white and itchy wheals were accompanied by a vivid redness 
diffused over the scrotum and penis, bearing the greatest resemblance 
to the efflorescence of scarlet fever ; on the breast the eruption had 
very much the look of measles ; that is to say, it consisted of semi- 
annular patches, the skin continuing healthy within the rounds. In 
such cases urticaria is distinguished by its raised wheals appearing 
in some places, and by the absence of the other symptoms of measles 
and scarlet fever. 

The papulae of lichen urticatus are rounded, less extensive and 
less prominent than the spots of urticaria ; their colour is deeper, 
they are harder, and they never disappear spontaneously. There can 
seldom be any danger of mistaking the papulae or isolated tubercles 
produced by the bites of insects, such as the flea, the bug, common 
gnat, &c, which are accompanied by great itchiness, for urticaria in 
any of its forms. Lastly, there is so little analogy between the 
eruption of urticaria and the vesicles of miliaria that I am surprised 
Jos. Frank should have thought of drawing a parallel between these 
two diseases. 

275. Prognosis.— Acute urticaria of itself presents no danger; 
when it follows the ingestion of poisonous substances, these may 



URTICARIA. 



89 



cause symptoms of various degrees of severity, and even death ; but 
the eruption is of course totally unconnected with this fatal termina- 
tion. The chronic urticaria? are often most obstinate diseases. 

The disappearance of the eruption of urticaria has sometimes been 
succeeded by the development or increased activity of some internal, 
intestinal, or cerebral affection. 

On the other hand, internal inflammatory diseases have occasionally 
appeared to decline upon the appearance of this eruption. Koch 
quotes a case in which a pleuritic affection was immediately removed 
by the development of a nettle-rash. Under other circumstances it 
may be critical, or appear at the time the resolution of a serious dis- 
ease is accomplished. Such was the case in a man under my care, 
in the hopital St. Antoine, labouring under pneumonia on both sides 
of the chest who, at the moment the disease began to yield, was 
attacked with a swelling of the parotid glands, and almost immedi- 
ately afterwards by urticaria, and various clusters of the vesicles of 
herpes phlyctenodes on the ears. 

277. Treatment. — The artificial exanthema produced by the sting- 
ing of nettles, very different from the febrile nettle-rash, does not 
generally require any treatment. If the stinging have been very 
severe, however, and the eruption cause irritation, sleeplessness, and 
other nervous symptoms, these may be allayed by local applications 
— bathing the parts with cold water, either alone or with the addition 
of vinegar, or a little of the solution of the acetate of lead. 

When acute urticaria is caused by the ingestion of any substance, 
either venomous of itself, or rendered so by some peculiar idiosyn- 
crasy, if vomiting have not already taken place, it must be excited by 
the use of emetics ; some practitioners in these cases resort at once to 
the sulphate of zinc or sulphate of copper, on account of their very 
speedy effects ; others, unless the case be pressing, recommend the 
tartrate of antimony and ipecacuanha. After the stomach has been 
freely emptied, if the patient be an adult, we prescribe a drink strongly 
acidulated with nitric acid, and twenty or thirty drops of ether in two 
or three ounces of distilled water, sweetened. Next day, if the 
bowels have not been properly opened, we may exhibit an ounce or 
more of castor oil, or a sufficient dose of any other aperient ; and the 
day after that, a warm bath. 

Should acute urticaria prove independent of the ingestion of any 
poisonous substance, or be conjoined with inflammation of any of the 
mucous membranes, local bleeding from the epigastric region and 
verge of the anus, diluents, emollient glysters, the tepid bath, with 
decoction of mallow leaves, or of lettuce leaves, attention to regimen, 
and abstinence to a greater or less degree, fulfil a double indication 
in such cases, and often accomplish the cure of both complaints at 
once. When the state of the constitution opposes no particular 
obstacle to the practice, it is even necessary, in a great number of 
cases, to have recourse to bleeding; and in urticaria tuberosa the vio- 
lence of the symptoms may even require us to repeat the operation. 
The blood drawn in such cases is almost always buffy. I have found 
that nettle-rash fevers were cut short in many instances by bleeding ; 
they were uniformly very advantageously modified by the practice. 
When the disease is accompanied by inflammation of the fauces, of 
the mucous membrane of the alimentary canal, or of the bronchi, 
blood-letting may be farther required by these latter affections ; but 
the remedy must not be had recourse to again and again, in the hope 
of extinguishing the eruption, if the first abstraction of blood have 
not procured very manifest relief. I once caused a patient, labouring 
under acute confluent urticaria (urtic. conferta, Willan), to be blooded 
three times in the course of eight days, without appearing to modify 
the state of the eruption, which subsequently yielded to cold bathing. 
I have seen the spots of urticaria recalled for a brief interval by the 
use of the cold bath, but they were no longer accompanied by itchi- 
ness or heat. When the violence of the pruritus causes almost con- 
stant insomnia, recourse must be had to opiates. 

In chronic urticaria, inquiry must be made whether the eruption be 
not perhaps kept up by the habitual use of some favourite beverage, 
or some article of food, which of course it would then be imperative 
to give up. Very many patients have derived great and speedy relief, 
followed by perfect recovery, by abstaining from spirituous liquors, 
spiced dishes, &c, and putting themselves on a system of bland and 
regular diet. 
8 23 



When urticaria intermits, and seems to depend on a febrile parox- 
ysm, the eruption, along with its precursory fever, commonly yields to 
preparations of bark and other febrifuges. I have, indeed, sereral 
times used the sulphate of quinia successfully in simple paroxysms of 
nettle-rash fever, which had not the character of true intermittents, 
and during which the eruption appeared on a great number of regions, 
and with greater severity than usual. To conclude; I have seen 
several cases of chronic and obstinate urticaria which, after having 
been treated in vain by abstinence and the antiphlogistic plan,yieldeJ 
to a course of purgatives, alkaline baths, and the application of the 
vapour and hot-water douche to particular regions. Many of these 
cases of urticaria were hereditary, and the disease appeared without 
manifest cause, (a.) 

Historical JYotices and particular Cases. 

278. Celsus 1 was aware that rashes sometimes appeared on the 
skin analogous to those that followed the stinging of nettles. The 
Arabian physicians described the eruption under the name of essera," 
which has been adopted by several pathologists. The characters of 
urticaria febrilis 3 have been well exposed by Sydenham, Juncker and 
Sauvages; and the writer last named distinguished the urticaria 
evanida by the title of porcelanea. Observations and cases have been 
published on the urticaria produced by mussels,' 1 by crabs or lobsters, 5 
by pork, and by other alimentary 6 or medicinal 7 substances. Frank 
speaks of a case of urticaria complicated with sphacelus. 8 Michaelb 
has made some observations on the ill effects of its suppression, 9 and 
of its evolution as a secondary disease in variola. Some remarks have 
been published on urticaria tuberosa, 10 and its treatment, on intermit- 
tent urticaria, 11 and on the use of saline baths in the treatment of 
chronic urticaria generally. Lastly, the critical dissertation of Leech - 
ner, 12 and the memoirs of Heberden, 13 and of Kock, 14 are worthy of 
being consulted. 

Case XXIII. Indigestion in consequence of eating mussels ; urticaria. 
Madame N * * *, twenty-eight years of age, of a sound constitution 
and in the enjoyment of good health, partook abundantly of mussel; 
at breakfast on the 2d of February, 1820. A short time afterwardo 
she experienced general uneasiness, a kind of anxiety about the pre- 
cordia, and headache. Called to render my assistance, I found the 
tongue clean, the epigastrium the seat of an uneasy sense of weight, 
the abdomen natural and soft, the pulse slow and depressed, the 
respiration good, but somewhat oppressed; the whole surface of the 
body, and especially the lower limbs, were covered with numerous 
wheals or raised spots, of from half to a whole inch in diameter, of a 
paler colour than the skin, and affected with a sensation precisely 
similar to that which follows the stinging of nettles. These spot;;, 



(a) The practitioner must not yield to the impatience for immedi- 
ate relief sometimes manifested by those suffering under urticaria, and 
be led in consequence to prescribe the external application of cold 
or of saline washes. Fatal results have been brought on by these 



1 Celsus. De re modicd, lib. 1, cap. xxviii. 15. 

2 Chemniz. Diss, de essera Arabum. Hafn. 1707. 

3 Sydenham. Obs. med. § v. cap. 6. Febris erysipelatosa.r— Juncker. Consp;:'. 
med. pract. tab. 64. — Sauvages. Nosol. meth. — Scarlat. urticata. 

< Moerhing. Epist. ad Werlhof, quaj mytulorum venenum et ab eo natas papu'.i.; 
cuticulares illustrat. Brem. 1742. (Haller. collect, diss, pract., t. iii. n. 88.) 

s Gruner. Pr. De febre urticata, a cancris fluviatilibus et fragarise vesicae frucu 
Jenae, 1774. 

6 Winterbottom. Medic, facts and observations, vol. v. n. 6. 

' Frank. Interp. clinic, i. p. 41 1. (Urticaria typhodes, cum sphacelo.) 

s Frank (P.). Interpret, clinicoe, pars i. 8vo. Tubingae, 1812.— Cazenave. Nea- 
velle bibliolh. medicate, 8, 1827. 

9 Michaelis. Hufeland und Himly's Joura. der pr. Heilk. 1812. Feb. p. 54.— 1910. 
Jan. p. 29. 

if Frank (P.). Op. cit. p. 405-413.— Godard. Journ.de med. t. x. 1759. — Plane ■ in 
Journ. de med. t. xvii. 1762.— Golfin. Journ. de Sedillot, t. iv— Cleghom. Obs. on the 
epidem. diseases of Minorca. Lond. 1768. 

" Tolberg. Hufeland's Journ. der prakt. Heilkunde. xxvi. B. st. p. 12. 

12 Loechner (M. F.). De nova purpura? specie Nesselsucht dicta, an aspredoCeUi 
vel uredo Plinii et aurigo Vegetii et Apuleii 1 (Eph. nat. cur. cent. v. et vi. p. 55 i 

'3 Heberden. Of the Nettle-rash, (in Med. Trans, of the Rl. Coll. of Phvs.— vol it 
p. 133.) 

'•< Kock. Progr. de Febre urticata. Lips. 1792. 



90 



EXANTHEMATA. 



which were evidently caused by partial swellings of the true skin, 
were surrounded by inflamed areolae. (Two grains of tartrate of 
antimony to be dissolved in three glasses of water, one to be taken at 
intervals of ten minutes.) The patient vomited several undigested 
mussels, but many fewer than she had swallowed. She, however, 
felt greatly relieved. (Emollient cataplasms to the abdomen, lave- 
ments.) In the evening the wheals had disappeared, and the patient 
was better ; next day she felt perfectly well. 

Case XXIV. Urticaria, gastro-enterilic symptoms. G * * *, sixteen 
years of age, had complained for several days of headache, pain in 
the abdomen and loss of appetite. On the 25th of February, 1826, 
after eating rather less breakfast than usual, he went a short way into 
the country, but soon returned and lay down in bed. When brought 
to see him, he was complaining of an intolerable sense of heat over 
the skin, and particularly on the insides of the arms and thighs, and 
on the neck, which he compared to the stinging of nettles. These 
parts were in fact found on examination to be covered with large 
prominent spots or wheals, whiter than the skin which surrounded 
them, and precisely similar to those produced by urtication. Some- 
what later, similar prominent spots appeared on the breast ; these 
were surrounded by a highly inflamed areola. The patient had 
scratched himself severely, and to this perhaps the redness of the skin 
was owing. The face was a little puffed, the eyes sparkling and the 
head hot ; farther, the tongue was white and stippled with red points ; 
there was thirst, and pain and heat of the epigastric region ; retching 
was induced by taking a little lemonade ; the bowels had been locked 
up for two days ; the urine was scanty and high-coloured ; the breath- 
ing was unaffected (sixteen leeches to the epigastrium; demulcent drinks 
sweetened with honey; cataplasms to the abdomen after the fall of the 
leeches). Next morning the eruption had entirely disappeared ; the 
febrile symptoms and pain of the epigastrium were greatly relieved. 
Towards four o'clock in the afternoon, however, there occurred ano- 
ther paroxysm of fever, followed by a second eruption of nettle-rash, 
which in less than half an hour spread from the chin over the trunk 
and limbs (twelve leeches to the epigastrium ; drink as before; lave- 
ment). Within an hour the eruption had gone away completely, and 
the patient felt relieved. He continued bathed in sweat during the 
night. Next morning, perfect apyrexia. There was no further return 
of the nettle-rash, and the gastric symptoms subsided by a few days 
attention to diet. 

Case XXV. Acute urticaria returning at irregular intervals. Pre- 
scription of sulphate of quinia. J. Lepommier, aged 47, in the enjoy- 
ment of good health, uninterrupted till within the last six months, 
was received into the hopital St. Antoine, on the 7th September, 1829. 
On the 4th he had been thrown into a violent passion, and the same 
evening his skin became covered with wheals of nettle-rash, which 
were excessively itchy, and prevented him from sleeping. The night 
was very restless ; in the morning every part of the body was covered 
with patches of urticaria, some of which were as large as the hand, 
others much smaller ; all were surrounded by an erythematous areola. 
In several places, instead of the pale prominent wheals, broad red 
spots were observed, level with the general surface of the skin and 
irregular in their circumference. These disappeared completely under 
the pressure of the finger, whilst the redness around the wheal only 
became fainter. The pruritus continued, and came on in paroxysms; 
the pulse was full and frequent ; the face and limbs were swollen and 
covered with true nodosities. The abdominal and thoracic viscera 
were unaffected — (venes. ad Ixvi.) The blood was buffed. 9th. — 
The heat and pruritus are less troublesome ; the red areolae are more 
conspicuous than the prominent wheals ; bowels relaxed ; pulse full 
and frequent. (Mucilaginous drink ; julep ; venes. ad gviii.) 10th. — 
The blood no longer shows the buffy coat. The pruritus so trouble- 
some as to have prevented sleep ; bowels still relaxed, (medicine as 
b?fore ; cold bath.) 11th. — The patient felt comfortable in the bath ; 
on returning to bed, several new patches came out and proved ex- 
cessively itchy. Two or three times during the day fresh spots 
appeared, which vanished again within an hour or less. A fresh 
eruption has been observed to come out regularly every evening, 
which lasts several hours, and disturbs or completely prevents sleep. 
(12th. — At night ; eight grains of the sulphate of quinia at the end of 
the evening paroxysm ; lavement.) 13th. — A smaller number of spots 



showed themselves on this than on preceding days; but the patient 
is restless, and suffers from heat of skin and pruritus. 14th. — A very 
small number only of wheals had appeared, and the patient scarcely 
complained either of heat or itching. (Sulph. of quinia repeated.) The 
eruption after this appeared no more, and the patient left the hospital 
on the 23d of September cured. 



ARTIFICIAL EXANTHEMATA. 

279. Menuret 1 remarked that cloths whitened with eau de javelle* 
which had not been properly rinsed before being dried, gave rise to 
erythematous eruptions, of no great severity indeed, but yet sufficiently 
troublesome. Towards the decline of the epidemic cholera of 1832, 
I saw a considerable number of convalescents suffering from chronic 
erythematous inflammations following the application of mustard poul- 
tices. The urtica urens and urtica dioica are familiarly known to 
produce an eruption very similar in appearance to that which accom- 
panies the febris urticata. 

Odier 3 having applied the emplastrum ammoniaci cum hydrargyro 
of the London Pharmacopoeia, to a species of wen, the application 
was followed two days afterwards by an erysipelas, accompanied with 
much swelling, which spread to the whole arm. The redness and 
swelling continued for several days, when violent fever set in attended 
with an eruption over the whole body of large red spots, intermingled 
with small pimples. Two bleedings, and the antiphlogistic regimen, 
put an end to these symptoms in the course of a week. 

I once attended a man, fifty-nine years of age, labouring under a 
lumbago, who had an extensive erythematous eruption of the loins pro- 
duced by frictions with the oil of the lauro-cerasus. This affection con- 
sisted of one large red blotch, not raised in any point above the level 
of the skin, but unevenly spread over the surface, which appeared stain- 
ed and dotted in different places. This appearance was owing to the 
large red patch being formed by the agglomeration of many smaller 
ones, whose circumferences, less inflamed than their centres, melted 
away in different places into shades very little different from those of 
the healthy skin ; several points of a more vivid red than the spots 
in general, scattered over their surface, gave to these last, and con- 
sequently to the large patch resulting from their conjunction, some- 
thing of a dotted or stippled aspect. 

The red colour disappeared momentarily under the pressure of the 
finger. The patient complained of slight pruritus in this part, but 
there was no morbid increase of temperature, nor any swelling of the 
subcutaneous cellular membrane. All the principal functions of the 
body were properly performed. The efflorescence was left to itself; 
the lumbago yielded to the use of gentle purgative glysters; the red 
patches of the loins finally grew pale, and were followed about the 
seventh day by a slight desquamation of the cuticle. 

Amongst the numerous patients who are seen at the dispensary of 
La Charite, and who there take the vapour or the sulphur bath, I have 
seen many attacked with vesicular and papular eruptions, and with 
artificial exanthemata, which were always of short duration. Several 
other remedial means, such as ammoniacal or acid lotions, alkaline 
baths and sulphureous fumigations may produce artificial exanthemata, 
which are to be distinguished from each other, and from diseases de- 
pending on internal causes, by mounting to their sources. 

M. N , forty-six years of age, having at four o'clock in the 

morning taken forty-four grains of belladonna, was seized about an 
hour afterwards with supra-orbitary headache of the most violent 
description, and excessive redness of the skin, which first appeared 
about the eyes and face, and then extended to the whole of the in- 
teguments. Within a few minutes the entire surface of the body 
presented a uniform red tint exactly similar to that observed in scar- 
latina; the throat of the patient was also intensely red, and affected 
with heat, which seemed to be propagated through the whole course 
of the alimentary canal. Another remarkable symptom was this: that 
the urinary passages, and especially the neck of the bladder, became 
extremely painful. The patient, in the midst of his delirium, was 

1 Recueil period, de la soc. med. de Paris, t. xxxiii. p. 48. 

2 A solution of the chlorate of potash in water. — R. W. 

3 Mem. de la soc. roy. de med., t. iii. p. 213. 



PEMPHIGUS. 



91 



perpetually asking for the pot de chambre, and it was with difficulty 
that he succeeded each time in passing a few drops of red and bloody 
urine. All these distressing symptoms were relieved by a copious 
bleeding, demulcent drinks, soothing glysters, and the application of 
leeches. 

Several other substances taken into the stomach, occasionally cause 
exanthematous eruptions. In a case of poisoning by the Datura stra- 
monium, which occurred in a child two years old, Dr. Meigs, of Phila- 
delphia, 1 tells us that the face of the patient became of a deeper scarlet 
colour than he had ever observed it, even in scarlatina ; the skin was 
hot, the pulse very quick, the tongue and fauces dry and red ; the 
tongue was so parched that its surface appeared shining. The face, 
the neck, and the breast, were covered by a multitude of small spots 
of a brilliant red colour, many of which were star-shaped. 



BULLAE, OR BULLOUS INFLAMMATIONS. 

Vocab. Bulla. Phlyclena. 

280. Bullous inflammations of the skin are characterized when at 
their height, by small tumours, varying in size from that of a pea to 
that of a goose's egg, generally transparent, and formed by the effu- 
sion of a serous or sero-purulent fluid between the corion and cuticle. 

281. Two cutaneous inflammatory affections constantly appear 
under this form : these are pemphigus and rupia. Ampullae, or the 
vesications produced by violence, and that follow the application of 
blistering plasters, compose a group of artificial bullae very distinct 
from the preceding. Bullae are also accidentally developed in the 
course of many phlegmasiae of the skin, and particularly in burns and 
frost-bite, in erysipelas, [small-pox, varicella] and several acute spe- 
cies of eczema. 

282. Rupia was classed by Bateman among the Vesicles. 2 He says, 
" the eruption is characterized by broad and flattish vesicles." Vesi- 
cles and bullae do not differ essentially from each other except in their 
size, and I greatly prefer classing rupia with the bullous inflamma- 
tions, the disease having a much nearer affinity to pemphigus, and 
especially to pemphigus infantilis, than to scabies, miliaria and the 
other vesicular eruptions. When herpes zoster or zona, has attained 
its complete development, it very frequently appears with the cha- 
racters of a vesiculo-bullous inflammation, which seems to form the link 
of connection between bullous and vesicular diseases. Willan as- 
signed this disease its true place among the herpetes, and I committed 
an error when I removed it from that group in the first edition of this 
work. 

283. An erythematous spot of one degree of intensity or another, 
probably always precedes the formation of bullae, although this cannot 
in every case be demonstrated. The period of time required for the 
evolution of bullae is very various ; they may be formed almost in- 
stantaneously in one case, and in another advance with extreme 
slowness to their greatest height. The fluid they contain is most 
commonly serous and transparent, but occasionally it is sero-purulent 
or sanguineous ; now and then it is separated from the dermis by an 
interposed layer of coagulable lymph ; it may remain for a long time 
pent up in situations where the epidermis is thick and strong, as in 
the palms of the hands, soles of the feet, &c, or be speedily shed on 
the surface of the skin when the bullae are thrown out on such parts 
as the eyelids, the cheeks, the lips, &c. This fluid often dries up 
and forms solid scabs of various thickness, and the skin, which these 
incrustations cover, either secretes a new epidermis and heals up 
rapidly, or becomes affected with ulceration, the cure of which proves 
more or less tedious. 

284. The vesications produced by violence, by the application of 
cantharides, of liquor ammoniae or boiling water to the skin, or by 
simple over-distension of the integuments, always indicate a degree 

' North American Medical and Surgical Journal, January, 1827. Extract in Journ. 
des progres des sciences et des institutions medicates, t. iii. p. 242. 
2 Bateman, Synopsis, &c. 5th ed. p. 243. 



of local irritation greater than that which causes the erythematous 
blush ; but it would nevertheless be impossible to demonstrate that 
the skin was more violently irritated in pemphigus and rupia than in 
scarlatina and urticaria. We cannot institute comparisons between 
the intensity of inflammations of different forms unless they are pro- 
duced by the same cause. Thus the simple redness, the vesication, 
and the eschar, produced by a burn, are degrees of inflammation suc- 
cessively of greater intensity ; but when causes come to be different, 
comparisons are no longer admissible ; and we cannot say that the 
bleb of pemphigus is the index of a higher degree of positive in- 
flammation than the efflorescence of scarlet fever, or the pustule of 
small-pox. 

285. Bullous inflammations at their height cannot be confounded 
with any of the exanthemata. (209.) They have, on the contrary, 
great analogy with the vesicular inflammations, from which, however, 
they differ in the characteristic size of their vesications ; bullae being 
always much more considerable than vesiculee. The accidental bullae, 
produced by the confluence of several vesicles, such as are occasion- 
ally observed in zona and other varieties of herpes, present a pecu- 
liarity of character that always distinguishes them from true bullae : 
their bases are constantly irregular, and seem composed of minute 
arcs of circles which proclaim the fusion of several smaller vesicles 
into one. 

286. The diagnosis of these inflammatory affections, necessarily 
uncertain when the bullae are not completely developed, or when the 
erythematous spots that precede the bullae alone appear upon the skin, 
may also become very obscure when the bullae are broken, their con- 
tents dried up, and they are succeeded by incrustations of variable 
thickness, by marks or by superficial sores or excoriations. The un- 
certainty can only then be dissipated by accurate information relative 
to the state of the skin previous to the formation of any scabs, marks 
or ulcers, or by a minute study of the form, the kind and the size of 
the alterations consequent on the different species of bullae. (Vide 
Pemphigus, Rupia.) 



PEMPHIGUS. 



Vocab. Bulla, Hydalides, Pemphigus, Pemphigoid fever, Pomphulix. 

287. Pemphigus is characterized by the eruption on several regions 
of the body of one or more large, yellowish and transparent bullae, 
which terminate by the effusion of the fluid they contain, and the for- 
mation of.a scab of variable thickness, or of a superficial excoriation. 

The various appearances which the age of the patient (pemphigus 
congenitus, pemphigus infantilis), the number of bullae (pemph. soli- 
tarius, pemph. confluens), their mode of appearing (pemph. simultane- 
ous, pemph. successivus), the greater or less rapidity of their course 
(pemph. acutus, pemph. chronicus), the existence or absence of febrile 
systems (pemph. pyreticus, pemph. apyreticus), &c, give to this erup- 
tion, have been the cause of a multitude of distinctions, which patho- 
logists have created to facilitate the study of the disease. I adopt, 
as fundamental distinctions, the two following : pemphigus acutus ; 
pemphigus chronicus. 

288. Acute pemphigus, (febris bullosa, febris pemphigoides, febris 
synocha cum vesiculis, fyc.,) is a rare disease. I have seen but a very 
few cases of it. It may be general or partial. It appears on every 
region of the body, most commonly on the lower extremities ; occa- 
sionally, however, also, on the arms, the trunk and the face ; it is very 
seldom seen on the soles of the feet, the hairy scalp or the genital 
organs. The bullae almost always stand apart from each other. 

The disease occasionally attacks without precursory symptoms ; but 
may also be preceded by a sense of general uneasiness, violent pru- 
ritus of the skin, and slight fever ; or otherwise it is ushered in by an 
irregular chilly fit, after which the skin becomes parched and burning, 
the patient complains of thirst and anorexia, and the pulse becomes 
excessively rapid. These symptoms last for one, two or three days. 
The eruption then shows itself by one or more circular or oval red 
spots, slightly prominent, and varying from a few lines to several 
inches in diameter. At first of a bright red, they soon turn to a more 
dusky hue. Their development is preceded and accompanied by 
pain and heat in the affected parts. The erythematous patches are 



92 



BULL.E. 



next transformed into true bulla, or blebs. A certain quantity of trans- 
parent strum, effused beneath the epidermis, raises it in the form of 
vesications which have with justice been compared to the blisters 
produced by the application of hot water or cantharides to the skin. 
The development of these bulla? often takes place almost immediately 
after the appearance of the erythematous blotches, the entire surface 
of which they rapidly cover ; a circumstance which has led some 
writers to suppose that pemphigus was not preceded by any redness 
of the skin. The existence of these red patches, however, is so posi- 
tive that bulla; occasionally appear surrounded by a distinct circular 
red border, which happens from the parts of those patches nearest the 
circumference, not being implicated in the bleb covering its centre 
and the greater portion of its superficies. 

The skin between the bulla? appears perfectly unaffected ; at least 
this is the case where the bullae do not approach very closely to each 
other, for where they do it may present a more or less decided erythe- 
matous blush. 

The number of bullae is in general so much the greater as the 
disease attacks a greater extent of the integuments. Occasionally, 
however, a small number of bullae have been seen disseminated over 
the entire surface of the body ; whilst in other circumstances they 
have been observed thickly congregated in a single district. Now 
and then there exists no more than a single large bulla (pompholyx 
solitarius, Willan). The development of this bleb, which rapidly 
acquires such dimensions as at length to contain several ounces of 
serum, is preceded by a sense of smarting in the part where it is to 
appear. This bleb bursts in the course of eight and forty hours. It 
often happens that a second bulla arises two or three days afterwards 
in the vicinity of the first ; and this may be followed in its turn by two 
or three voluminous bullae which are evolved in the same manner ; 
but the disease now generally becomes chronic in its nature. This 
variety is extremely rare. I have seen it occur on the leg of a young 
man convalescent ihom dothinenteritis. 

The bullae of pemphigus vary in size from that of a split pea or an 
almond to that of a hen's egg or a large blister. From the very mo- 
ment of their formation the bullae possess, in a great measure, the size 
they will attain at every subsequent period. Having reached their 
height, the greater number of them contain a serous fluid, which is 
transparent, and of a yellowish or yellowish-green colour, similar to 
the serum of an ordinary blister. When the primary inflammation of 
the skin is very acute, a quantity of coagulable lymph may be de- 
posited on the outer surface of the dermis. Plump and distended 
during their growth and at their acme, which usually extends over a 
period of two or three days, the bulla? of pemphigus then become 
flaccid, wrinkled and half full ; they form towards their most de- 
pending part a small hanging pouch in which the serum is mostly 
contained. At the end of from twenty-four to forty-eight hours the 
majority of them give way, and suffer the greater part of the fluid 
they contained to escape. 

After the bursting of the bullae, if the epidermis be detached by rub- 
bing, or in any other manner, excoriations result ; which are painful 
in a greater or less degree. Even more commonly, however, the 
bullae are replaced by lamellar incrustations, which are of a pale 
brown colour at first, and become gradually of a deeper hue as they 
grow older. When these scabs are in their turn detached, the skin 
remains marked with spots of a dusky red hue in those places where 
the bullae had been evolved. The duration of each bulla extends on 
an average to about seven days ; that of acute pemphigus varies from 
one to two weeks when the eruption is simultaneous, and from three 
to four weeks when it is consecutive. 

When the eruption of the bullae is simultaneous and confluent, or 
when pemphigus is complicated with another inflammatory affection 
of the skin, it is almost always attended by a febrile paroxysm ; if 
the eruption invades the mouth or the genito-urinary organs, if it be 
combined with a deranged or inflamed state of the digestive appara- 
tus, or of any other important organ of the body, the general symptoms 
may assume a character of considerable intensity. An acute pem- 
phigus, accompanied by a copious eruption, has been observed to 
produce delirium, extreme restlessness, and exhaustion in children, 
and in old persons to be followed by adynamic symptoms of such 
gravity, as in some cases to have even proved fatal. 



We occasionally observe bullae imperfectly developed. These 
appear under the form of circular and prominent erythematic patches. 
By passing the finger over their surface, the cuticle is felt to be 
loosened, and a slight effusion is perceived between it and the 
dermis. The loose portion of cuticle is detached at the end of a 
few days, and leaves exposed a red spot covered with a thin and 
glistening epidermic layer. 

289. Chronic pemphigus (rnaladie vesiculaire, dartre phlyctenoide 
confluente, Alibert ; pompholyx diutinus, Willan), is a much more 
common disease than acute pemphigus, from which it differs in the 
lono- continuance of the eruption, which commonly extends over 
several months, by the mode of development of the bullae, which is 
always successive, and by the absence of febrile reaction, at least 
during the earlier periods of the disease. 

290. Chronic pemphigus especially attacks men advanced in 
years ; occasionally, however, those in the prime of life suffer from 
it ; individuals of the male are much more frequently attacked than 
those of the female sex. The bullae of chronic pemphigus succeed 
each other at various intervals during from ten weeks to seven or 
eight months, and occasionally, even during several years. In one 
case they are confined to a single region, in another they invade 
every part of the body in succession. Several days before the first 
eruption of the bullae patients commonly complain of pains in the 
limbs, and feelings of lassitude and depression ; these sensations, 
however, are often so slight as to be passed over without attracting 
particular notice. Small red patches, preceded by smarting, show 
themselves on one or several regions of the body, from the centres of 
which the epidermis begins to rise whilst their circumference spreads, 
so that in the course of a few hours bullae are formed as large as fil- 
berts or even as walnuts, and by the end of two or three days, several 
acquire the size of a pigeon's egg. These bullae are either burst 
from being rubbed, or give way in consequence of mere distension. 
The raised portion of cuticle then sinks down and becomes wrinkled 
or lies in folds over the surface of the inflamed dermis ; or if it be 
removed completely, painful excoriations are left bare and unpro- 
tected, in the immediate neighbourhood of which the epidermis 
looks wrinkled, and subsequently undergoes a slight exfoliation. 
The bullae which have not been broken become turbid and sink 
down ; they assume a whitish colour, and by and by are replaced by 
flattened scabs, of little thickness and of a brownish hue. New 
bullae continue to arise in the neighbourhood of the old ones, and 
are sometimes preceded by prickling or smarting sensations, a 
febrile paroxysm, and violent lancinating pains, similar to those 
which herald the eruption of shingles ; I have heard several patients 
compare the pains they suffered to the impression of the electric spark. 

Such are the appearance and the most usual progress of chronic 
pemphigus; but they may be variously modified. 

The usual antecedent circular red patches, for example, are occa- 
casionally not visible except on the evolution of the first bulla?, or 
otherwise, only before the last crops of the eruption that happen. I 
have in several instances seen the bullae begin as vesicles no larger 
than lentils, which afterwards went on increasing till they attained the 
size of small eggs. Some bullae are surrounded by an areola, others 
are not. Most commonly disseminated and distinct, bullae are more 
rarely seen clustered together in irregular groups, or arranged in rings 
similar to those of two varieties of herpes. 

Bullae may be confluent or conjoined by their bases; in this case 
they are soon seen to contain purulent matter, and are succeeded by 
thin scabs, the intervals between them being occupied by squamae 
that lie in some degree over one another. This variety is most com- 
monly seen on the face. Occasionally the eruption fixes on a small 
surface, three or four inches in diameter; I have, however, seen it 
more frequently confined to the face, hands and forearms on which 
bullae continued to follow each other during several months; the 
affection has also been seen on the lower part of the leg. When the 
eruption is considerable the patient is sometimes obliged to keep his 
bed ; but there is rarely any degree of fever present, unless, indeed, 
the inflammation have been propagated to the mucous membranes. 
When the excoriations are numerous, patients often sink exhausted 
by pain and want of rest, or are cut off by dropsical affections and 
colliquative diarrhoeas. 






PEMPHIGUS. 



93 



221. Pemphigus affecting the skin may be preceded or accompanied 
by an inflammation the same kind of the mucous membranes of the 
alimentary canal or genito-urinary apparatus. This affection either 
shows itself under the form of circular red patches, or of flattened 
bullae on those parts that are provided with an epithelium. I had an 
opportunity of observing this extension of the disease to the mucous 
membranes, to a very great degree, in an old mayor of Paris, labour- 
ing under chronic pemphigus complicated with prurigo, whom I 
attended along with Messrs. Maury and Kapeler. On several different 
occasions we could perceive flattened bullae on the lining membrane 
of the mouth and pendulous velum of the palate, and in the last stages 
of the disease, which the most unwearied attention had no influence 
in checking, the inflammation extended to the great intestines, the 
bladder and bronchiae. 

Inflammation of the mucous membrane of the mouth and fauces is 
often seen allied with pemphigus of the face, of which disease, indeed, 
it is then a mere extension. Cceco-colitis, cystitis, and inflammation 
of the vagina frequently complicate the disease when it appears on 
the parietes of the abdomen, or on the upper and fore parts of the 
thighs. In these complicated cases, the functional disorders of the 
digestive organs and of the urinary passages are associated with the 
morbid phenomena induced by the inflammatory affection of the skin. 
The appearance of the bullae is preceded or accompanied by a state 
of langour and lassitude, by headache, sickness, dysuria, pains in 
the limbs, &c. Besides the gastric and intestinal disorders, which 
complicate pemphigus so frequently that they have even been regarded 
by M. Gilibert as one of its elements, other affections, and particularly 
several forms of skin disease, such as herpes and prurigo, are occa- 
sionally added to the list. Pemphigus may also occur in the course 
of vaccinia and scabies ; and it has sometimes appeared to decide the 
fate of internal inflammations, such as pneumonia and dysentery, and 
to replace rheumatic attacks. But M. Gilibert was, in my opinion, 
deceived when he regarded erysipelatous inflammations, presenting 
accidental phlyctenae here and there, as instances of this exanthema- 
tous disease, complicated with pemphigus. It is also necessary to be 
on our guard against confounding true pemphigus with the accidental 
bullae which are observed to occur in some old cases of scabies, or in 
consequence of oedema. Those writers have also done wrong, as I 
conceive, who have contrasted with acute pemphigus those usually 
flaccid phlyctenae half full of bloody serum, which occasionally appear 
on the buttocks and trochanters in the course of severe dothinenteritic 
affections. 

292. Structural Changes. — The alteration of the skin that occurs 
in pemphigus, is precisely similar to that which results from the second 
degree of burning, and the application of blistering plasters. In pem- 
phigus infantilis, the dermis is often ulcerated in the centres of the 
bullae (Case XXVIII). The mucous membranes of the nipple, of the 
vulva, of the lips and inside of the mouth, are all frequently the seat 
of true bullae. It was a mistake to suppose, as has been done, that 
the bullae of pemphigus could be evolved on the mucous membrane 
of the stomach and intestines, these parts not being provided with any 
epithelium; but it is certain that in chronic cases of pemphigus which 
have terminated fatally, the redness, thickening, softening, ulceration, 
and other changes induced by inflammation in mucous membranes, 
have frequently been encountered. The greasy liver has several 
times been found in individuals who have died from pemphigus. 

293. Causes. — These are in general very obscure. Pemphigus 
appears more particularly during the autumn and winter ; it attacks 
both sexes, and individuals of every age, but especially old men. It 
has also been seen as a congenital affection. The serous fluid of its 
bullae has been inoculated, but the punctures did not inflame. M. 
Garde and I tried the experiment on ourselves, performing the opera- 
tion with purulent serum from the bullae of a woman advanced in 
years, and affected with chronic pemphigus, but without other effects 
than such as follow a simple puncture. The process of dentition 
among infants ; excesses or irregularity in diet, and violent moral 
affections among adults; and amenorrhcea and d} r smenorrhcea among 
women, have all occasionally seemed to influence the development of 
pemphigus. Several authors have observed the disease as an epi- 
demic. 

Chronic pemphigus attacks those individuals especially whose 
24 



general constitutions have suffered ; living in cold and damp places, 
and on unwholesome food, seems also to favour its development, 
which, under other circumstances, is perfectly inexplicable. The 
blood is often found to be buffy during the continuance of the disease. 

294. Diagnosis.— When the bullae are distinct and unbroken, pem- 
phigus cannot be mistaken for any other disease. In an anatomical 
point of view, burns, attended with vesications, have some resem- 
blance to partial pemphigus, but the cause that produced the blisters 
enables us to distinguish the two affections. When a single bulla 
(pompholyx solitarius) constitutes the whole affection, and appears 
without an areola, it resembles in all respects the vesication produced 
by a blistering plaster, and the one does not in fact differ from the 
other, save in the exciting cause. I shall by and by have to relate a 
case of pemphigus simulated by means of the powder of cantharides. 
In rupia, the bullae, which are usually less numerous, smaller and 
flatter than those of pemphigus, are followed by true ulceration of the 
skin, and become covered at length with thick and prominent scabs. 

The bullae which we find now and then accidentally developed in 
erysipelas, differ from those of pemphigus by appearing on an exten- 
sive surface of a uniform red colour, with swelling of the subcutaneous 
cellular substance. 

When the bullae of pemphigus are small and clustered together, 
(Case XXX,) the eruption may be distinguished from herpes phlycte- 
nodes, by the circumstance of the bullae of pemphigus being always 
larger than the vesicles of the herpes, as well as by the former being 
uniformly accompanied by isolated blebs that sufficiently proclaim the 
nature of the general affection. 

The scabs of pemphigus are distinguished from those of impetigo by 
being thinner, less rugous, and shagreen like ; they are also generally 
bulging in the middles, wrinkled in their circumferences, and formed 
of a single piece that represents the extent and something of the form 
of the bullae to which they have succeeded. The scabs of acute 
pemphigus frequently present a perfectly characteristic disposition : the 
incrustation formed by the drying up of the fluid collected in the most 
depending parts of the bleb, is covered by a cuticular disc of a yellow- 
ish-brown colour, and of the size of the bullae. 

The marks which pemphigus leaves after the detachment of the 
scabs or cuticular discs, are separated from each other by healthy 
skin, of a dusky red colour ; they are of various magnitudes, and often 
bounded in their circumference by a very distinct epidermic border. 

295. Prognosis. — Acute pemphigus without pyrexia, ends naturally 
within two or three weeks. When the eruption is preceded, attended, 
or followed by febrile symptoms, the diseases assumes a character of 
gravity, great in proportion as it is complicated with nervous and 
adynamic symptoms ; this last complication is happily very rarely met 
with. 

Chronic pemphigus indicates a bad state of constitution ; it is al- 
ways a very obstinate affection, and proves troublesome in the same 
ratio as it is more extensive, more frequently renewed, or complicated 
with chronic bronchitis, inflammation of the bladder, &c. Pemphigus 
pruriginosus often proves fatal when it attacks persons in the decline 
of life. 

Several cases are related in which pemphigus seemed to have a 
beneficial influence on the course of some internal maladies. I once 
saw a man who, after having had several attacks of haemoptysis, be- 
came subject to chronic pemphigus of the legs, and from this period 
the bleeding from the lungs did not recur. The cure of pemphigus 
has, in some cases, been observed to be followed by various ill con- 
sequences. 

296. Treatment. — In acute pemphigus without fever, when the bulla? 
are few in number, and not of very large dimensions, the eruption 
may be left to itself, or at most, the serum of the vesications should 
be evacuated by one or two small punctures made in the epidermis. 

When the eruption in this form of the disease is more considerable, 
care is to be taken that the cuticle continues applied to the surface of 
the spots that have sustained bullae ; these are sedulously to be pro- 
tected from friction, and in case they should become denuded, are to 
be immediately dressed with a perforated rag (linge ftn'etre') spread 
with cerate. The general treatment may consist in the exhibition of 
diluents, — lemonade, and the vegetable acids, — milk diet, the anti- 
phlogistic regimen and an occasional warm bath. Should the erup- 



94 



BULLAE. 



tion have been accompanied or preceded by fever, or the inflammation 
of any internal organ, should the patient be of a robust constitution, or 
the bulla have followed amenorrhcea, bleeding from the arm or foot 
must be practised, or leeches applied in the vicinity of the part affected. 
When chronic pemphigus implicates but a small extent of surface, 
and the state of the constitution appears satisfactory, the disease will 
occasionally yield to the use of diluents, and of the warm or cold 
bath, either simple, or alternately with a tepid slightly alkaline bath, 
which is found greatly to relieve the accompanying pruritus and heat 
of the skin. 

In an adult, or one w r hose constitution does not appear to be sen- 
sibly deteriorated, should chronic pemphigus have invaded through a 
period of several months, almost the entire surface of the body suc- 
cessively, should there be at the same time fever, and numerous exco- 
riations scattered over the skin, and should the inflammation, in fine, 
have spread to the mucous membrane of any part, a general bleeding 
ought by all means to be practised, whilst the skin is covered with 
emollient gelatinous or oily applications. 

Emollient baths are often of service, but they must not be con- 
tinued too long, nor taken at too high a temperature. When the 
patient is too weak to use the bath himself, this means must be aban- 
doned, as painful excoriations are almost constantly produced by 
giving him any assistance out or in, or by helping him into his bed. 
In such circumstances the patient must be laid on an oil-cloth whilst 
the inflamed parts of the skin are covered by compresses, frequently 
renewed, wrung out of some emollient and narcotic decoction. 

Lastly, when the accompanying inflammatory affections of the sto- 
mach and bowels become very severe, and when blood-letting cannot 
be had recourse to on account of the weakness and state of exhaus- 
tion of the constitution, we turn to soothing and narcotic medicines, 
especially to such as contain neither wine nor alcohol, in graduated 
doses. When sickness or pain of stomach is excited by a draught of 
fluid, the drink may be administered by spoonfuls at a time to quench 
the thirst. 

Occasionally recourse has been had, with success, to a milk diet, 
which was subsequently changed by degrees for more nutritious food. 
In elderly persons, whose constitution did not appear to have suffered 
materially, and when there were no symptoms of irritation in the 
digestive organs, the acidulated decoction of bark, wine and water, 
bitters, chalybeate medicines, and a tonic regimen have all been found 
of advantage ; the mucous membrane of the digestive apparatus, 
however, so seldom escapes implication in this variety of pemphigus, 
that too much caution cannot be observed in the use of these medi- 
cines and remedial means. 

When the digestive apparatus is healthy, purgatives are sometimes 
beneficial. Sherbets prepared with the nitric and sulphuric acids con- 
tinued for several months, have also effected remarkable cures. 

Chalybeates, such as the subcarbonate of iron, in doses of half a 
drachm or two scruples, the sulphuret and carburet of iron, the vinum 
ferri, &c, are all very serviceable when the eruption has been pre- 
ceded by dysrnenorrhcea and amenorrhcea. 

The preparations of arsenic are always to be prescribed with great 
discretion, and only when the stomach and intestines appear perfectly 
free from actual disorder, (Case XXX,) or from predisposition to in- 
flammation. 

Pemphigoid inflammations of the mucous membranes occurring in 
old subjects where they have continued long, or been frequently re- 
vived, ought not to be treated by the detraction of blood, which only 
reduces the strength, without preventing the return of fresh eruptions. 
Soothing gargles, and such as are acidulated with the muriatic acid, 
or prepared with a solution of alum, often produce favourable modifi- 
cations in bullous inflammations of the mouth and pharynx. Diuretic 
drinks containing a portion of nitre, and emollient topical applications 
to the pubes, along with glysters of pellitory, often relieve the dysuria 
and check the haematuria that occasionally supervenes during the last 
stages of chronic pemphigus. The diarrhoea, which often precedes 
these symptoms, as well as the sleeplessness occasioned by the pain 
of the excoriations, and the accidental occurrence of prurigo are to be 
soothed by opium in one form or another. When the continued 
action of opium seemed to oppress the stomach, I have frequently, 
and with good effect, ordered half, or three-quarters of a grain, of the 



hydrochlorate of morphia to be applied to the abraded surfaces of one 
or more of the bulls. Dropsical symptoms occurring at this period 
are almost always the precursors of approaching dissolution ; the scene 
of pain and suffering, however, is more frequently terminated by an 
obscure affection of the lungs. 

Historical Notices, and particular Cases of the Disease. 

297. The account which Hippocrates 1 has left us of the pemphigoid 
fever is very obscure. Ch. Lepois 2 was the first who gave a clear 

description of pemphigus. 

A great many observations have been published on acute pemphi- 
gus, in which the eruption of bulla took place at once, 3 and on acute 
pemphigus with successive eruptions ; 4 on acute pemphigus complicated 
with intestinal, or as they are styled, biliary affections, 5 with gastro- 
enteritis, 6 with pneumonia f with symptoms of great depression, 8 with 
vaccinia, 9 and with prurigo. 10 

We possess a still larger mass of information in regard to chronic 
pemphigus, 11 to hereditary pemphigus, 12 and to the disease as it attacks 
the aged ; 13 we have also some remarks on the disease with a gangren- 
ous character, 14 which, perhaps, are rather applicable to rupia escha- 
rotica than to this complaint, on the pemphigus of camps, 15 on the 
complication of pemphigus with hysteria; 16 on the pemphigus of chil- 
dren, 17 of the foetus, and of the new-born infant ; 18 of pregnant women ;" 
lastly, we possess the researches of M. Brachet 20 on several different 
species of pemphigus. The facts collected by M. Ozanam 21 on 
epidemic pemphigus, and the critical and historical inquiries of M. 
Bidault de Villers, 22 will all be perused with interest. 

298. The following cases refer to several varieties of pemphigus. 
One of these is so rare as to have led many pathologists to question 
its existence ; this is pemphigus acutus ; another had never been 

' Hippocr. Opera. Ed. Ren. Charterii, t. ix. p. 38. — Foes. (Economia Hipp. Art. 

ntfj.<piywfci< nvpToi. 

* De morbis a serosa colluvie et diluvie ortis. Obs. 149. 

3 Delius Amacnitates medicse. Casus, ix. p. 71 (t'ebris catarrhalis vesicularis).— 
Seliger (Ch.). Ephem. nat. cur. decas, 1 ann. VIII. Obs. 56. — Hebreard. Observ. 
sur le pemphigus (Journ. gener., t. xlni. p. 376). — Gilibert. Munographie du pem- 
phigus, in-8. Paris, 1813. 

4 Dickson. Observat. on pemphigus (Transact, of Irish Acad. 1787, p. 47). — Hoff- 
mann. De affectu raro scorbutico pustulari. Suppl. ii. p. 2. — Miroglio (Journ. de 
med., t. Ixxxi. p. 221). — Gilibert. Adversar. medico-practica prima. Lugduni, 177 1, 
p. 183. — Vallot. Recueil periodique de la societe de med.de Paris, t. iv. p. 292. — 
Stewart (David). A case of the pemphigus major of Sauvages. (Med. and physic, 
comment, by a society. Edinburgh, vol. vi. p. 79.) 

6 Finke. De morbis biliosis anomalis, etc., p. 118. — (Jalabert. Journ. de med., t. 
lxxxii. p. 65.) 

6 Robert. Observat. sur une fievre vesiculate (Journ. de med., chir. et pharm. t. 
xxiii. p. 227). — Barbieux. Annates de la med. physiol., t. ii. p. 78. — Richard. Ibid., 
t. iii. p. 274. — Strambio. Bullet, des sc. med. de Ferussac, Mars. 1827, p. 248. 

7 Frank (J. P.). Epit. de cur. hom. morbis, lib. iii. p. 258. 

8 Savary. Journ. de med., chirurg. et pharm., t. xxii. p. 203. Sept. 1811. 

9 Husson. Recherch. hist, et medic, sur la vaccine, 3 edit., p. 884. — Fine. Obs. 
sur une eruption particuliere survenant pendant le cours d'une vaccine (Journ.de 
med. chirurg. et de pharm., t. i. p. 513). — Vide Vaccinia. 

10 Bateman. Delineations of cutan. diseases, PI. 33, fig. 2. 

ii Wichmann. Beylrage zur kenntniss des Pemphigus, etc. Erfurt, 1790.— Mouton. 
Observation sur une maladie vesiculate, t. xliii. p. 41. — Robert de Langres. Mem. 
sur le pemphigus (Journ. de med. et de chirurg., t. xxiv. p. 26). — Asdrubali. Archives 
gen. de med., t. xvii. p. 601. — Biett. Journ. hebd., t. viii. p. 46. 

u Jacquemin. Obs. sur uue maladie singuliere de la peau. (Journ. gen.de med., 
t. xxx. p. 264.) 

'» Macbride. Method. Introduct. to Medicine, 4to. Dubl. 1772. 

" Stokes. Annal. de lilterature medic, etrangere, an. 1810, Septemb. p. 225. 

'5 F. Thierry states that, in 1736, there reigned at Prague a contagious and very 
fatal disease among the soldiers. The bullae that rose upon the skin were as large as 
a hazelnut, and were very similar to the phlyctenas caused by blisters (Medecine 
experimentale, p. 134, 12mo. Paris, 1755). Langhans, under the title of pemphigus 
Helvelicus, has described a disease that reigned in Switzerland in 1752 (Acta. Helvet, 
vol. ii. p. 260). It is difficult to say whether these epidemics ought to be considered 
as a severe species of acute pemphigus which does not now occur, or referred to a 
dothinenteritic affection with eruption of bullae on the skin, a disease of which I have 
met with several cases. 

is Frank. Epitom.de cur. hom. morbis, lib. iii. p. 261. 

vf Bateman. Synopsis of cutan. diseases, 1829, p. 197. 

is Osiander. Denkwuerdigkeiten fuer die Heilkunde und Geburts-huelfe, B. 1, Si. 
2.— Lobstein. Journ. complem. des scienc. medic, t. vi— Hinze. Sur le pemphi»us 
des nouveau-nes. (Bull, des sc. med. de Ferussac, t. xi. p. 47.) ' 

'» Bunel. Diss, sur le pemphigus, in-4, p. 13. Paris, 1811. 

20 Rec. per. de la soc. de medec, t. ix. p. 55. 

21 Ozanam. Hist, des malad. epidemiques, t. v, p. 208. 

« Recherches et observ. sur le pemphigus, son histoire et sa synonymie (Recueil 
period, de la soc. de med. de Paris, t. ltv. p. 1.) * v 



PEMPHIGUS. 



95 



noticed until I described it, pemphigus circinnatus ; a third, pemphi- 
gus infantilis, differs so essentially from the other varieties of the 
disease, that Bateman, who has pointed out its characters but very 
imperfectly, was led to look upon it as a species of rupia. The others, 
also, have all some remarkable peculiarity to distinguish them. 

Case XXVI. Acute pemphigus , with simultaneous eruption of bulla 
on the right forearm ; annular erythema ; herpes phlyctenodes. A. B., 
twenty-three years of age and unmarried, had menstruated regularly 
since she was twelve years old. Had come to Paris three weeks 
ago, and entered the service of a restaurateur, where she had better 
food at her disposal than she had hitherto been accustomed to. No 
cause of moral nature appeared to have exerted any influence on the 
development of the disease for which she sought relief. Five days 
before entering the hopital St. Antoine this young woman felt such a 
sensation of itchiness in the lower part of the right forearm, and in 
the hand of the same side, as would have led her to scratch the parts 
violently, had she not resisted the impulse. A number of small red 
spots appeared on the parts mentioned, during the existence of which 
the pruritus continued. These were succeeded by small blebs which 
gradually became larger and increased in number. The patient hav- 
ing now observed several red spots of a similar kind on different parts 
of the body, sought admission to the hospital on the 21st of August. 
The right forearm and hand were both found evidently swollen, and 
considerably hotter than the same parts of the opposite extremity ; 
they presented several red points of a very small size, numerous bulla?, 
excoriations, incrustations, whitish spots that had been covered with 
scabs, and a few vesicles. 

The fingers alone exhibited any of the red spots mentioned ; they 
were not numerous, pretty regularly rounded, of the size of a small 
lentil, and disappeared momentarily under pressure ; bullae varying in 
size from that of a pea to that of an hazelnut were scattered over the 
lower part, and especially the inner surface of the forearm ; they were 
pretty closely crowded together; from twenty-five to thirty could be 
counted in a space scarcely so large as the hand. They were gene- 
rally very regular in their shapes, and as large at first as they became 
at any subsequent period ; some few, however, evidently, increased 
by the extension of their circumference. Those which were irregular 
in their outline, were so evidently in consequence of being formed 
by the fusion of several bulla? together, which, thus conjoined, as- 
sumed the form of the figure 8, or appeared like a string of beads. 
They were almost all without areola? ; some, however, were surrounded 
by a very conspicuous border. Through several of the most transpa- 
rent bullae the rosy colour of the cutis vera could be perceived. The 
want of transparency in others seemed to be owing to the formation 
of a very thin layer of whitish matter on the surface of the corion. 
The oldest bulla? had become perfectly opaque either in consequence 
of the formation of pus, or of the great thickness of the false membrane 
they contained. 

There were but a very few excoriated places consequent on the abra- 
sion of the cuticle. Here and there a few incrustations and cuticular 
lamina?, proceeding from the drying up of the blebs, were conspicuous. 
All of these adhered strongly to the skin ; several consisted in fact of 
nothing but a circular lamina of cuticle, which, after having been 
soaked with the yellowish serum or purulent fluid of the bulla?, sank 
down on its evacuation and became applied anew to the surface of 
the corion. These circular lamina?, usually of a yellowish-brown 
colour, were continuous with the healthy cuticle at theircircumference. 
Others of the scabs were more complicated ift their structure, and 
consisted, besides the cuticle, of a true, yellowish, rounded scab, half 
the size of the superposed cuticular lamina itself, and here occupying 
its centre, there one of its segments. These lamina? and scabs were 
generally thrown off in a single piece, and exposed the last traces of 
the disease, which consisted in rounded and not very numerous 
marks of the same size as the crusts that had been detached, and of 
a dull white colour, which formed a marked contrast with the natural 
rosy tint of the skin. A few crusts of the kind now described, existed 
on the fore part of the trunk. Besides these various organic changes, 
which were all proper to pemphigus, an erythematous patch was per- 
ceived in the form of an oval circlet perfectly regular in its outline, 
the centre being occupied by healthy skin. This ring was not covered 
by any vesicle. 



The skin covering the lower halves of several of the metacarpal 
bones, and first phalanges of the finger, was beset by a great number 
of vesicles, the size of a small pin's head, or of a split pea, here and 
there isolated, but in general congregated into irregular clusters. 
Several of these were surrounded by a border of a deep red colour. 
The general health of the patient was good. She was put upon diluents 
and spare diet, — lemonade and the quarter hospital allowance. 

23d. — Several bulla? which last evening were distinct had become 
joined by their edges and now communicated with each other; a cir- 
cumstance of which we were assured by making a puncture into one 
of them, and letting out the fluid which the whole that were so united 
contained. 24th. — The bulla? were all broken and covered either 
with the shrunk and wrinkled cuticle, or the peculiar incrustations of 
which mention has been made above. 29th. — No new bulla? had 
been developed. 30th. — A few marks, some of a dusky hue, from 
which the incrustations had been forcibly removed by the patient, 
others of a dull white, from which the scabs had fallen off of them- 
selves, were now the only traces of the disease remaining. The pa- 
tient had three-quarters of the hospital allowance, took a warm bath, 
and on the third of September left the hospital cured, although the 
circular marks on the forearm still proclaimed the nature of the affec- 
tion under which she had laboured. 

Case XXVII. Chronic pemphigus ; bullae, arranged in bands ; com- 
plication with herpes circinnatus ; Grainprot, sixty-eight years of age, 
entered the hopital St. Antoine on the 13th of August, 1828 ; of a 
naturally good constitution, this man had been living in the country 
during the last two months, and was habitually employed in garden- 
ing. In the month of June, 1827, when the heat was excessive, he 
states that he had the first attack of a disease similar to that under 
which he now labours, and from which he then recovered completely 
in five weeks. In the same month of the present year (June, 
1828,) a new eruption of bulla? showed itself, first on the wrist, and 
subsequently on other regions of the body. On the 15th of August 
they presented the following characters on the right arm: 1st, promi- 
nent red spots of various forms ; 2d, bulla? in different degrees of 
development; 3d, incrustations; and 4th, certain alterations that did 
not appear to be owing to the pemphigus. 

The spots were flat on the surface and of a deep red colour ; they 
varied from the size of a split pea to that of a shilling ; they were 
slightly raised above the level of the surrounding skin, and disap- 
peared for an instant when pressed on by the finger. They were 
distinct in several parts of the extremity, crowded together in others, 
and occasionally ranged one after the other, so as to resemble in 
some sort irregular curved bands of different breadths, some being 
but a few lines and others much more across. The red borders, with 
which these bands were furnished, terminated sharply in the healthy 
skin on the convex aspects, but on their concave edges they were gra- 
dually diffused and lost in the areola with which the bands were on 
this side surrounded. This arrangement, however, was not univer- 
sal ; and the bands in various places included patches of apparently 
healthy integuments within their concavity. The red patches gene- 
rally, were sensibly hotter than the neighbouring parts, and at a sub- 
sequent period became covered with bulla?. 

The disposition of the bulla? corresponded in general with that of 
the red spots and bands ; in other instances they surrounded the in- 
crustations about to be mentioned, and then they were much more 
minute. They varied in size from that of a split pea to that of a 
hazelnut Some of the bulla? were transparent; but in general, they 
were opalescent; almost all contained limpid serum and a false mem- 
brane of a dirty white colour, occasionally tinged with infiltrated 
blood, an appearance which was conspicuous in even the most re- 
cently formed bulla?. 

The greater number of the bulla? were full and tense ; others of 
older date were shriveled, and looked as if a part of the fluid they 
contained had been absorbed. 

If the bulla? were opened, their contents evacuated, and the false 
membrane, generally included, detached, the surface of the corion 
appeared of a rose colour similar to that of the primary patches 
on which the bulla? were themselves evolved. 

The scabs or incrustations, of the same dimensions as the bulla? to 
which they had succeeded, were like these, now isolated and distinct, 



96 



BULLAE. 



now congregated in stripes. They were of various hues, from a yel- 
low to a deepish brown, adherent to the skin, of considerable thick- 
ness in their centre, but much thinner towards their circumference, 
where they were squamous and consisted of the cuticle alone. If 
they were detached, the red surface of the corion was exposed, gene- 
rally dry, but now and then smeared over with a little sero-pumlent 
matter. 

Besides, the organic alterations, now described, proper to the dis- 
lliat immediately occupies us, a number of perfectly transparent 
vesicles of the size of large pins' heads existed on the right arm, 
mingled with the bullae of the pemphigus. A large phlyzaceous pus- 
tule with a hard and red base, the centre of which was covered by a 
brownish scab, was also developed on the outer aspect of the forearm 
near the elbow joint. 

The left arm also exhibited the eruption of pemphigus in all its 
stages ; and here the stripes or bands sometimes appeared completely 
annular, including circular portions of healthy skin; this appearance 
was even more frequent on several parts of the body. The bullae on 
this as on the opposite extremity were very numerous, and although 
completely transparent, included almost universally a false membrane, 
which, in the older ones, either presented spots of a dull white, or the 
sanguinolent infiltration of which mention has been made. 

It was on the right lower limb that the elevated red bands were 
most completely beset with bullae. One of these bands pursued the 
following course : from the level and vicinity of the trochanter major, 
it passed obliquely inwards towards the. scrotum ; turning back, it 
descended along the thigh to the fore part of the knee, which it sur- 
rounded in an imperfect manner; it then mounted, winding as it ad- 
vanced along the outer aspect of the thigh, till it attained the point 
from which we have traced it as commencing. This long band was 
made up of several smaller ones, which represented arcs of circles of 
various diameters. The area which this band circumscribed was 
occupied by healthy skin, beset here and there with red patches co- 
vered with blebs and vesicles. It was in the course of this great band 
so particularly described that the largest bullae of the pemphigoid 
affection were encountered ; so that this belt of bullae bore the most 
striking analogy to the groups of herpes circinnatus which existed on 
the other thigh and especially on the trunk. 

The bullae were more numerous on this extremity than anywhere 
else. Attacked more recently, it exhibited none of the incrustations 
described as existing on the arm, but it presented a new feature not 
observed elsewhere, namely a number of excoriations , the dimensions 
of which varied between that of a sovereign and a double sovereign 
piece. They were all superficial, the corion being destroyed in no 
one of them. 

The left leg exhibited no bullae, but in different places it presented 
several circular red bands which completely circumscribed portions, 
greater or less in extent, of healthy skin ; the diameters of these va- 
ried between that of a silver two-penny piece and that of a shilling. 
These rings were almost all covered with transparent vesicles the size 
of large pins' heads or small lentils (herpes circinnatus). 

The herpetic groups, well characterized in the region I have just 
mentioned, were still more so on the trunk. One was seated below 
the left breast, four on the epigastric, and many more on the hypo- 
gastric region ; they were, however, more numerous on the back than 
anywhere else. Three groups in this region placed one over the 
other, and joined by their edges, formed an elevated band between 
two and three inches in length, by six or eight lines in breadth, which 
presented three different circular patches of healthy skin ; the centre 
of one of these groups was occupied by a crust of ecthyma, more 
prominent than the red line by which it was surrounded ; a boil of 
considerable size was observed in the centre of a cluster situated over 
the right scapula. 

The pemphigus at length also appeared on the upper part of the 
throat and on the chin ; here the blebs were less regular ; the serum 
they contained became more speedily turbid ; and the scabs were 
thicker, and longer of drying than in other situations. Further, the 
hair-follicles of these regions inflamed and poured out a thick matter 
of a yellowish-green colour, which concreted into crusts, like those 
of impetigo. The other parts of the face, and the hairy scalp con- 
tinued free from eruption. 



All the parts affected were hot, and troublesome sensations of itchi- 
ness and smarting were complained of, especially in those points that, 
within a few hours afterwards, became covered with an eruption of 
blebs. These symptoms were so much the more violent as the erup- 
tion proved copious, or was actually confluent ; they were scarcely- 
felt in the right arm, which was the part first affected. 

The general state of the patient was rather satisfactory ; the thorax 
and abdomen were not affected ; the intellect alone seemed weakened, 
and the patient had long been in a state verging on fatuity. (Lemon' 
adefor drink, gum julep, and broths and soups for diet, were ordered ; 
and the excoriated parts were dressed with simple cerate.) 

Durino- the few first days Grainprot remained in the hospital, new 
bullae were successively thrown out, especially on the legs and trunk; 
but they always appeared upon prominent red blotches, which, iso- 
lated at first, soon united into the raised bands I have mentioned, and 
changed their shape. On the 20th, bread, gruel and vegetables were 
added to the diet, and a few cups of herb-broth (bouillon aux heroes) 
were taken during the course of the day. By the 22d, the original 
elevated bands which presented themselves the preceding days on 
the right thigh, were no longer visible. But new blebs, thrown out 
on spots prominent like the others, and assuming the same arrange- 
ment in bands, made their appearance on the left thigh. The cir- 
cular clusters increased in number on the dorsal region, which here 
and there presented bullae, mixed with vesicles evolved on the spots 
themselves. The patient complained of having had two loose motions 
the preceding evening. 

The red spots were more numerous than ever on the 23d ; on the 
inner side of the thigh an immense bleb, nearly as large as a crown- 
piece, its base surrounded by a red border which was well defined 
and distinct from the healthy skin in its neighbourhood, made its ap- 
pearance. A grain of tartrate of antimony was now added to the 
lemonade, and the quantity of food formerly allowed was diminished 
by one half. 

On the 25th, the erythematous rings, and round vesicular groups, 
were so greatly increased in number that the primary form of the 
inflammatory affection was masked. On the dorsal region, however, 
several circular clusters were still visible, which, uniting together, 
composed various figures, among which, many of the figure 8 were 
very distinct. The diarrhoea had increased ; the patient had lost flesh 
since his entrance into the hospital, and during the last two days, the 
pulse had become quick : the prognosis was less and less favourable. 
On this day the patient was induced to leave the hospital, and it is 
with regret I have to state, that no further information could be ob- 
tained as to the issue of the serious disease under which he laboured. 

It is worthy of remark that this patient had been for two years suc- 
cessively affected with pemphigus; on each occasion, too, during the 
hottest months of the year, and that it was only on the second attack 
that the eruption became general. 

Case XXVIII. Chronic Pemphigus presenting isolated bulla, and 
clusters of an eruption similar to that of herpes phlyctenodes ; amenor- 
rhcea ; recovery. Frances Richard, 42 years of age, and of a good 
natural constitution, had for some years past been subject to slight 
but frequent indispositions. The menstrual discharge had been al- 
most always irregular and scanty ; she was married at about twenty- 
two, and had had three children, who all died young. For fourteen 
years she had laboured under profuse leucorrhcea, the consequence 
of a clap. About five months ago, on the return of a menstrual 
period, she had a shivering fit, which lasted several hours, and was 
followed by febrile symptoms. Two days afterwards leeches were 
applied to the thighs; the menses did not recur, and an eruption of 
bullae, which appeared singly and in groups, came out successively 
on the thighs and trunk, and on the fronts and insides of the arms. 
The pruritus was excessive, and was increased by the warmth of the 
bed. The patient was brought to the hopital St. Louis, where she 
remained during several weeks under treatment, by means of baths of 
the decoction of bran, lemonade and sulphur pastiles. She left the 
house without benefit, passed some time at her own home, and obtained 
admission into the hopital de la Charite on the 6th of March, 1833. 

The upper extremities, especially the forearms, on their inner and 
anterior aspects, are covered with irregular groups of round, convex, 
semi-transparent bullae, the size of a pea, or larger, filled with a thin 



PEMPHIGUS. 



97 



and limpid fluid, separated from each other by very small spaces, in 
which the skin looks red and injected ; in some places the bullae join 
each other by their edges. Here and there, especially on the upper 
hp, inner aspect of the thighs, and lower part of the lumbar region, 
a few isolated bullae are to be seen. The bases of these isolated bulla 
are here sharply circumscribed by the healthy skin, there surrounded 
by a red circle, which is visible about all that occur in clusters. 
When the serum is evacuated and the cuticle is removed, the subja- 
cent dermis appears reddish, granular, moist, and but little inflamed. 
The patient having acquired the habit of pricking the blebs as soon as 
they appear, very few have been allowed to run their natural course, 
yet here and there scabs, formed by their contents, become dry, are to 
be met with ; these crusts are of rather a lightish brown colour; they 
are prominent, slightly conical, granular, unequal at their bases, and 
adhere pretty firmly to the skin, which appears either slightly excori- 
ated, or merely red. In other places the crusts are thinner and plain, 
or only very slightly convex; to conclude, no other traces of bullae 
remain in some places than a few slight epidermic exfoliations of a 
circular shape, adhering by one of their edges and covering reddish 
or brownish spots; these spots are most numerous above the right 
buttock. 

The bulla; always appear in successive crops, and the patient has 
fancied that she could perceive the skin of the places where they were 
about to appear to become redder than natural, and to be affected 
with considerable pruritus; each bulla rapidly attains its largest 
dimensions ; the itching is especially troublesome when the body 
becomes heated, by being warmly covered in bed, for example. 

The skin of the front and inner parts of the forearms, no point of 
which has escaped being the seat of bullae at one time or another, ap- 
pears to be thicker than natural. The principal functions of the body, 
respiration, digestion, and circulation are performed with perfect 
regularity; but the patient has had no return of the menstrual flux for 
several months. {Barley water, with half a drachm of nitric acid ; 
carbonate of iron, in doses of twenty-four grains.) The bowels had 
been constipated, but were relieved by two cold glysters. 

March 9th. — Several bullae on the forearm were touched with a 
solution of nitrate of silver ; sharp smarting pains during the day ; 
eruption of new bullae to which the caustic solution was also applied. 
10th and subsequent day. — The same medicines were continued ; 
great numbers of bullae appeared around the parts that were cauterized. 
On the 20th the use of the warm bath was begun, and regularly con- 
tinued every day till the 1st of April, at which date the dose of the 
carbonate of iron had been carried the length of thirty-six grains daily. 

The thighs now presented but a few isolated bullae ; the daily erup- 
tion on the forearms, though it still took place, was much less in amount 
than formerly. Alkaline baths were prescribed, each containing four 
ounces of carbonate of potash ; of these the patient took six in the 
course of eight days, but without any great benefit from their use. 

On the 8th the menses appeared for the first time during the last 
five months and flowed but scantily for two days. On the 12th, 
without any evident or known cause, the patient was affected with 
febrile symptoms for which blood-letting was deemed necessary and 
prescribed, although it was not practised ; by the 14th the fever had 
very much abated. The skin complaint now showed a great change ; 
the bullae were no longer transparent, but were filled with a sero- 
purulent fluid ; the skin of the forearms was greatly flushed, and the 
itchiness had given way to a sense of smarting. The patient took 
seven gelatinous baths, and internally a cup of decoction of endive, 
with the addition of two drachms of sulphate of soda occasionally. On 
the 21st the patient was much better, and no new eruption of blebs 
had occurred. Half a drachm of the solution of arseniate of soda 1 was 
now prescribed, and the dose afterwards carried to a drachm. The 
patient bore the medicine well ; no new bullae appeared, and the skin 
showed no symptoms of inflammation. The cuticle on the forearms 
began to be thrown off. On or about the first of May, a cluster of very 
small bullae was observed in the bend of the arm ; these contained 
but a very small quantity of serum, and disappeared at the end of a 
few days, without being followed by any more. The same medicine 

1 This solution is the liqueur de Pearson of the French. It consists of one grain of 
the arseniate of soda, in one ounce of water. — R. W. 

25 



continued. On the 8th the menstrual discharge set in and proved 
more copious and lasted longer than it had done for several years. — 
On the 15th the patient was discharged, and promised to return 
should her disease recur. She still continued well on the 15th of 
July. 

Case XXIX. Pemphigus infantilis ; ulceration of the skin ; gastro- 
intestinal inflammation. P. Francoise, weakly in constitution, seven 
months old, and already weaned three, was brought by the mother 
for advice on the 7th of July, 1828. Six weeks previously the infant 
had had an attack of ophthalmia, which got well without any treat- 
ment, and was speedily followed by a very remarkable disease of the 
skin, which appeared successfully on the chin and neck, and on the 
fore and back parts of the body. The different appearances that 
characterize it seem to form parts of the same malady, which, accord- 
ing to the mother's account, showed itself almost simultaneously on 
the different parts now affected, and without being preceded by any 
peculiar symptoms. 

This eruption consists of round bullae in different stages of red 
excoriations, circular in form, humid, and almost uniformly ulcer- 
ated in their centres, and of a few scabs which present peculiar 
characters. 

1. The bullae are pretty regularly round, the size of a large lentil, 
almost always distinct, and scattered over the surface of the trunk, 
but here and there congregated into irregular groups, especially upon 
the back, when they are surrounded by an areola, which disappears 
with pressure. The fluid of the bullae is opalescent and escapes 
when the cuticle is removed. The surface of the corion where 
exposed looks red, and the centres of the spots are almost always 
occupied by a small grayish-coloured ulcer, much inferior in extent 
to the excoriation itself. This small central ulcer, which might be 
covered with the head of a pin, corresponds to a point of the skin 
which is softened and infiltrated with a drop of purulent matter. — 
These hemispherical bullae with the ulcerated centres, had already 
lasted several days when they were examined. 

2. The excoriations consecutive to the bullae, when deprived of 
their cuticular covering, almost all present a central ulcer, which is 
generally larger and deeper than in the bullae just laid open. When 
the bullae have been crowded, these remaining sores have occasionlly 
spread into each other and formed small ulcerated bands, very analo- 
gous in appearance to those met with in some forms of syphilitic skin 
disease. The ulcers are of various depths, some penetrating through 
the whole thickness, others implicating no more than the superficies 
of the corion ; they are uniformly surrounded by red areolae. 

3. A few incrustations are observed here and there, between the 
bullae and the ulcerated parts. They look about the size of the 
original bullae, are yellowish in colour, of no great thickness, and 
adhere to the skin ; some of them have a slight depression in their 
centre of a lighter yellow, and corresponding to the seat of the little 
ulcer of which mention has been made. All the parts affected 
appeared to be very painful. 

Besides the skin complaint, the belly of the child has, according 
to report, been tense and voluminous for several weeks past; the 
tongue is slightly red, and there is rather a profuse diarrhoea. The 
sore places were dressed with fine linen spread with cerate, and protected 
with soft lint; demulcent drinks were ordered, light nourishment in 
smaller quantity than usual, and emollient baths. 

13th July. — New bullae have arisen ; several are of very recent 
date, and appear opalescent, not in consequence of the nature of 
their fluid contents, but from enclosing an opaque false membrane of 
a yellowish-white colour. When this exudation was removed, the 
papillary surface of the dermis looks as in the older bullae, of on 
uniform red colour, but the centre instead of a true ulcer, only 
presents a small whitish spot, which, however, marks the point thst 
at a later period was to become the seat of ulcerative absorption. — 
The bowel-complaint had ceased. Same treatment. 

15th. — No new bullae have been developed, but many of the old 
ones still continue ; the skin, indeed, over the scapulae and lower part 
of the left side of the thorax, is almost of one uniform red tint from 
the conjunction of the areolae that surround each of them or the con- 
sequent excoriation. These parts seemed also to be very painful. 
Four leeches were applied to a portion of healthy skin that occupied 



98 



BULLAE. 



nearly the centre of a group on the left shoulder-blade, and the former 
dressings and demulcent drinks were continued. 

20th.— The little patient appeared greatly better; there were now 
no more than three groups of ulcers on the lower parts of the chest. 
The scabs that have been detached from the single bullae have left 
small isolated and depressed cicatrices ; those that have followed the 
ulcerated bands are tortuous and irregular, and seen, for the first time, 
might very readily be ascribed to a very different cause than that to 
which they are due. By the 24th of July there were no symptoms 
remaining of the bullous inflammation with which the infant had been 
affected ; but on this day new signs of gastro-intestinal irritation were 
exhibited ; these, however, were successfully subdued by means of a 
warm bath and other soothing remedies. 

Case XXX. Chronic pemphigus of both legs, recovery under the 
use of arsenical preparations ; subsequent insanity. M * * *, nearly fifty 
years of age, was very ill in April, 1827. He then had sinapisms 
applied to his legs, which caused considerable inflammation, followed 
by some discharge, which continued for nearly two months. M * * * 
had occasion to travel to the south, and about the month of October, 
the legs, especially the calves, were attacked with chronic pemphigus, 
characterized by the eruption of bullae six or eight lines in diameter. 
Baths and emollient poultices, saturnine and sulphureous washes, were 
employed one after the other, without success. On returning to Paris 
on the 1st February, 1828, I was consulted. I found the disease 
principally seated in the posterior, outer, and fore parts of the right 
leg ; every point, however, was not affected in the same manner, nor 
in the same degree. I remarked, 1st, rounded, reddish eminences, 
the size of a French bean, which were painful and firm to the touch, 
and looked like flattened tubercles ; these elevations were the eruption 
in its first stage. Next day the eminences were changed into true 
bullae, filled with transparent serum. 2d. Several bullae, here at their 
height, round, and distended with transparent serum, there sunk down 
and flaccid, or ruptured, and empty. 3d. Flat, laminated and yel- 
lowish scabs proceeding from the drying up of the bullae. 4th. Red 
and bleeding excoriations, some circular like the distinct bullae ; 
others of different forms and broader, consequent on the junction of 
several contiguous bullae. Some of these excoriations had the ap- 
pearance of recently blistered surfaces, others that of a blistered part 
covered with a white or shriveled membrane. 5th. Between these 
different morbid changes, the skin was reddish in some places, and in 
others preserved its natural appearance. The inflamed parts were 
not very hot ; the pain only came on in paroxysms, and was excited 
by any attempt at walking, which, indeed, was nearly impossible ; the 
patient consequently kept his room. He called my attention to the 
circumstance that the painful paroxysms came on principally during 
the night, and that each new eruption of bullae was preceded by vio- 
lent pains in the calves. Speaking of the pain he endured, M * * * 
expressed himself nearly in the same terms as individuals use who 
are affected with bad shingles. The right leg was swelled, and infil- 
trated inferiorly. On the left leg alterations of a similar kind, but 
much less violent in their character, were apparent. 

The digestive organs were unaffected ; the bowels, however, were 
obstinately constipated, occasionally for four or five days at a time, 
despite the repeated use of lavements. The kidneys performed their 
office perfectly ; there was nothing amiss with the functions of respira- 
tion and circulation. The nervous system alone seemed affected. 
M * * * was excitable, very irritable, contentious, and eccentric ; he 
also occasionally complained of a sense of heaviness in the head. 

I directed the legs to be dressed with pledgets spread with saturnine 
cerate, and covered with soft lint, as if they had been affected with 
vesications after a scald. At each dressing the lint was carefully 
detached after being well wetted with decoction of althea ; every 
other day the patient took a gelatinous bath, and each day he drank 
a considerable allowance of veal broth. Under this treatment, which 
was continued for nearly three weeks, several bulla: dried up and 
were replaced by others; the patient was alternately better and worse. 
Almost regularly after coming out of the bath, the"legs became more 
distended, and after this afflux there was an evolution of one or several 
bull* : the patient consequently soon went into the bath with reluc- 
tance, as the skin only seemed to become more tender under its influ- 
ence. A blister had already been applied to the arm, and I now put 



the patient on the use of phosphate of soda, and then of calomel in 
purgative doses, but without deriving any benefit from the measure. 
Twenty leeches were next applied to"lhe right leg, and this step was 
attended with more harm than good, the bites becoming inflamed, and 
suppurating without any sensible amelioration in the state of the 
affected parts. 

The obstinacy of the disease, and the good state of the digestive 
organs made me resolve on trying the solution of arseniate of soda 
and the patient was put upon doses of this preparation, successively 
increased from six to eight, ten, fifteen, twenty-five, and thirty drops. 
There was a manifest improvement from the time that the doses of 
twenty drops were attained. The legs were completely cured at the 
end of a month, under the influence of the medicine, which, however 
was continued for a fortnight longer. Besides its effects ijpon the 
disease, this medicine caused some slight derangement of the diges- 
tive functions, but not to the extent of colic, or diarrhcea, or vomit- 
ing ; it also induced a slight puffy state of the countenance, with 
several erythematous blotches on the fingers. These inconveniences 
ceased of themselves on the use of the remedy being discontinued. 

At a later period this patient, who for a long time back had been 
observed to be very eccentric, was attacked with mania. After several 
bleedings had been practised without doing any good, M. Esquirol 
and I agreed to try the effect of a succession of blisters upon the parts 
that had been affected with pemphigus. These applications made no 
impression on the disease of the brain, which degenerated into de- 
mentia, and two years afterwards the patient died paralytic. 



RUPIA. 

Vocab. Rupia, Ulcers-atonic. 

299. Rupia is characterized by small isolated, flattened bullae, filled 
with a serous fluid which soon becomes opaque, puriform, or sangui- 
nolent, and to which succeed black, thick, and prominent scabs, whose 
bases conceal ulcers of variable depths. Three varieties are observed: 
rupia simplex, rupia prominens, and rupia escharotica. 

300. Symptoms. — Rupia simplex is commonly evolved on the legs, 
sometimes on the loins and thighs, and more rarely on the other 
regions of the body. It is proclaimed by one or more flattened bulk 
about the size of a shilling, which at first contain a serous and trans- 
parent fluid. This fluid, however, soon becomes turbid and purulent, 
it then grows consistent, and is finally transformed into scabs of a 
chocolate colour, thicker in their centres than around their circumfer- 
ences, their outer layer being continuous with the epidermis, which 
appears detached by the serum or pus in which their edges are bathed. 
Under these scabs, which are detached naturally within a few days, 
or are accidentally rubbed off, the true skin is found to be excoriated. 
This superficial sore, left to itself, either heals up, or is covered with 
another scab, which falls off at a later period, and this process may 
be repeated several times successively. After cicatrization is accom- 
plished, the skin retains for a very long time a livid, deep red colour. 

In rupia prominens the bullae are larger, the succeeding scabs 
thicker and the consequent ulcers deeper. Each bleb is preceded 
by a circular red spot, over which the cuticle is slowly raised by a 
blackish-looking, thick fluid, which soon concretes, and gives occa- 
sion to the formation of a scab, whose thickness and size increase for 
some days afterwards. The circumference of this incrustation is sur- 
rounded by a reddish border a few lines in breadth, the epidermis of 
which is raised by a fresh effusion of serous fluid, that forms a new 
incrustation, and adds to the extent of the one originally produced. 
The areola also spreads slowly around the base of the scab first formed, 
which itself increases in breadth and thickness during three or four, 
and sometimes even during seven or eight days. The scab then 
appears very broad in comparison with its thickness, and is often 
very aptly likened to an oyster shell. More commonly, however, the 
incrustation projects in the same degree as it spreads, becomes coni- 
cal, and bears the greatest resemblance to the shell of the limpet. 
The scab of rupia generally adheres firmly, and can only be detached 
with the assistance of moist and emollient applications The skin 
once exposed, appears ulcerated to an extent and depth that vary in 



RUPIA. 



99 



every instance. If the part affected remain exposed to the air, a new 
crust is either formed alter a greater or shorter interval, or the ulcera- 
tive process extends more deeply, and spreads till it sometimes ap- 
proaches the size of a crown-piece in breadth ; the sore in this case 
looks pale, and bleeds readily. These ulcers, which are usually cha- 
racterized as atonic, and the cure of which is only obtained with 
extreme slowness, are always succeeded by cicatrices, subject to 
break open afresh, the brownish livid hue of which continues for a 
very long time unchanged. 

3. Rupia escharotica is evolved more especially in cachectic infants, 
and occasionally in elderly persons, or in adults who have suffered 
from chronic rheumatism, or constitutional syphilis; it is most usually 
seen upon the legs, the thighs, the scrotum, the abdomen, the loins, 
the neck, the upper part of the chest, and but very rarely on any part 
of the upper extremities. It begins by one or two red and livid spots, 
over which the cuticle is soon raised by the effusion under it of a 
serous or sero-sanguinolent fluid. These bullae go on increasing in 
an irregular manner; the serum they contain becomes turbid, and 
acquires a blackish colour. By and by they give way, and the dermis, 
left naked, appears ulcerated, softened or gangrenous in different 
points ; a bloody and very offensive sanies bathes the surface of the 
sore, the edges of which are livid and not very painful. In adults I 
have seen rupia escharotica acquire the dimensions of rupia prominens, 
and small portions of the skin and cellular substance, stricken with 
sphacelus, become detached slowly from the surface of the ulcerated 
parts. In children the bullae of rupia escharotica do not generally 
acquire so large a size, but they follow each other in greater numbers; 
the succeeding sores become very-painful, cause fever and sleepless- 
ness, and may exhaust the patient in the space of two or three weeks. 
In every case the cicatrization of these sores is a very tardy process, 
and is always expected long before it happens. Ecthyma is a form 
of cutaneous disease that is often seen along with rupia simplex, but 
very rarely with rupia escharotica. I have seen many cases of rupia 
complicated with purpura and with chronic rheumatism, as also in 
individuals labouring under constitutional syphilis. 

301. Causes. — Scrofulous children, and the offspring of the poor, 
of delicate constitution, or who have been weakened by previous ill- 
ness, are predisposed to rupia. The disease shows itself particularly 
during the winter season among such as are insufficiently clothed, 
badly lodged and ill fed, more especially after any other form of in- 
flammation of the skin, such as variola, scarlatina, measles, &c. I 
have seen rupia, as just stated (300), complicated with purpura 
hemorrhagica. The disease also frequently appears among the aged, 
though those in the vigour of life are by no means exempt from it. 

302. Diagnosis. — The small flattened bulla? of rupia very commonly 
contain a turbid serous fluid. They cannot be mistaken for the large 
transparent and prominent blebs of pemphigus. Besides, the rough, 
thick, and often prominent scabs of rupia, and its succeeding ulcers, 
are very different and easily distinguishable from the laminated incrus- 
tations and superficial excoriations of pemphigus. Yet the pemphigus 
infantilis, in which the skin often appears ulcerated in the centres of 
the blebs, seems in some sort to form the link of connection between 
these two diseases. Rupia differs from ecthyma in its primary form, 
which is bullous, whilst that of ecthyma is pustular ; the base of the 
pustules of ecthyma is much inflamed, and the scabs, with which they 
become covered at a later stage of their progress, are hard, and, as 
it were set, or encased within the substance of the skin; the circum- 
ference of the bulla? of rupia does not present the same degree of 
inflammation, and their incrustations are much broader, more promi- 
nent, and less adherent than those of ecthyma. It must be allowed, 
however, that the bulla? of rupia become purulent very quickly, and 
that occasionally the diagnosis is rendered so much the more difficult, 
as the two eruptions are met with at one time in the same individual. 
Nevertheless, the prominent incrustations, and the deep, and often 
intractable ulcers of rupia are very different from the impacted scabs 
and slighter sores of ecthyma. It does not seem possible that rupia 
escharotica can ever be confounded either with anthracion, which is 
surrounded with a broad erysipelatous base, or with frost-bite of the 
hands and feet presenting bulla? and gangrenous spots. 

303. Prognosis. — Rupia is never a dangerous disease ; the escha- 
rotica species itself is only serious when the eruption is very abundant. 



When the disease appears on the legs it is always succeeded by 
intractable ulcers. The duration of the disease cannot be precisely 
calculated, but depends greatly on the age of the patient, the number 
and size of the bulla?, on the consequent sores, the degree in which 
the general constitution is affected, and the influence which certain 
concomitant maladies, such as scrofula, and chronic affections of the 
lungs and alimentary canal, may exert on its progress. 

304. Treatment. — The treatment of rupia is of a general and local 
nature. The object proposed by the first is to bring about a modifi- 
cation of the constitution acting faultily in a greater or less degree. 
The milk of a good nurse for infants at the breast, exhausted by 
hunger, and in misery, through want of proper care ; a nutritious 
meat diet — beef or mutton, and generous wine mixed with water for 
children and adults of lax fibre and a scrofulous habit ; a regimen 
adapted to any form of concomitant disease, if the general health has 
suffered, — such, in a general way, ought to be held the objects of 
primary and highest importance, (a) 

The local treatment may be as follows : 

The bulla? of rupia simplex are to be opened if they contain serum, 
and the parts covered with a soft rag and some lint, the dressings 
being kept in their places by proper bandages. 

After the fall of the scabs in rupia simplex and rupia prominens, 
the ulcerated skin is to be bathed with decoction of althea if it be 
painful; but if the inflammation appear indolent and below the pitch 
requisite for the production of a new epidermis, or the formation of a 
cicatrix, it may be stimulated with a wash of wine and water, or a 
weak solution of cream of tartar. I have been in the habit of order- 
ing the sores of rupia to be dusted with cream of tartar, and of all the 
topical applications I have tried, this is the one that seemed to me to 
answer best, (b) 

Rest, the horizontal posture of the body and limbs, and continued 
gentle pressure, assist the cicatrization of the ulcers. Sticking plas- 
ters may be employed in some cases where the legs are affected, and 
the blebs are isolated or few in number; but whenever the round 
shape of the ulcers is modified, it is proper to change the adhesive 
straps for a perforated rag and a compress of lint, maintained by a 
proper bandage. If the adhesive plasters be continued too long, the 
parts almost always grow livid and fungous, a state that requires the 
repeated application of escharotics. The best of these, when they do 
become necessary, is the nitrate of silver, and the use of this is often 
followed by good effects. In some cases the nitric or muriatic acid, 
or the acid nitrate of mercury may be advantageously employed. 

When the eruption extends to several regions of the body it will be 
necessary to resort to alkaline and sulphureous baths of regulated 
strength, alternating these with the simple warm bath. 

To cleanse the skin and get rid of the incrustations, as also to enable 
us the better to ascertain the state of the excoriations, I make it 
almost a general rule to order a warm bath for the patients we receive 
into our hospitals. For scrofulous subjects a sulphureous bath is 
usually substituted, and this is had recourse to again from time to time 
during the treatment. 

Historical Notices and particular Cases. 

305. There are but few individual cases of rupia recorded; yet the 
disease is perhaps more common than pemphigus. If it appear less 
familiarly known to practitioners, it is because the bulla? that charac- 
terize it are always few in number, and soon replaced by scabs and 
excoriations which have been described by many surgeons as atonic 
or incrusted ulcers, &c. Willan and Bateman were the first who gave 
a good account of this disease ; Lorry seems to have seen it. 1 A case 

(a) Mercury has been advised in some cases ; but it ought to be 
prescribed, if at all, as an alterative and not sialagogue. 

(6) Ointments of the protiodide of mercury (a scruple to the ounce, 
and of the biniodide of mercury 12 or 15 grs. to the ounce) have 
been strongly recommended by Biett. Mr. Wilson succeeded in an 
obstinate case with a strong solution of alum injected beneath the 
edges of the bulla?. 

' " Horret saepe cutis crustis superpositis.etrupium ad instar sese mutuoexcipenti- 
bus" (Lorry. De morb. cut., p. 81). Vid. p. 76: Nasci purtulas illicO cruore plenas,etc. 



100 



BULL/E. 



has been quoted by one writer which was aggravated by the use of 
mercury. 1 

XXX. Rupia of the legs in a child. I attended a child be- 
longing to poor parents", eight years old, of a fair and pale complexion, 
and lymphatic and scrofulous habit, in whom three flattened bullae* 
each the size of a six-penny piece, tilled with bloody serum and sur- 
rounded by an inllamed areola, were evolved on the lower and outer 
part of the right leg. Two other bullae having similar characters, 
were also observed on the same region of the left leg. These bullae, 
which had been evolved within four and twenty hours, burst on the 
day I was called, and were completely emptied of their contents. 
The day after, each of the bullae was replaced by a thin brown scab 
which adhered to the skin. (Hoptea ; bulla dressed with saturnine 
cerate spread on a perforated rag : fomentations with elder/lower water.) 
I saw the child eight or ten days afterwards. In this interval the 
incrustations had been repeatedly detached along with the stockings 
of the little patient. The dressings had not been regularly applied, 
and the scabs were always reproduced. I now recommended the 
incrustations to be got off by means of a soft poultice, the parts that 
were inflamed and deprived of cuticle to be covered with a pierced 
rag, spread with saturnine cerate, a little soft lint, and a firm bandage 
above all. Within a fortnight the child got well, but the skin long- 
retained a deep purple hue in those points where the bullae had ap- 
peared. 

Case XXXI. Rupia of the legs, ecthyma and petechia, oedema of the 
feet, use of the superiarlrate of potash. In the month of May, 1823, 1 
had a water-carrier under my care for an ecthyma,- the large pustules 
of which had principally appeared on the thighs. This man, who was 
in his sixty-sixth year, was pale and emaciated, and had a worn-out 
appearance. Ill clothed, ill lodged and ill fed, he was often exposed 
to cold and moisture ; he had suffered several attacks of bronchitis, 
and repeatedly laboured under diarrhoea. When I saw him, however, 
for the second time on the 2d of July, 1823, he showed no signs of 
either gastric or pulmonary affection. He applied to me on account 
of three flattened bullae, having a large and but slightly inflamed base, 
which had appeared on the lower and outer part of the left leg. Two 
days afterwards the blebs had changed into brownish incrustations, 
which increased in thickness for some time afterwards. Besides the 
bullae six or seven petechia were observed, and a small ecchymosed 
spot on the leg, near its articulation with the foot, which was cedema- 
tous. Having no expectation that cicatrization would go on readily 
under the scabs, I recommended them to be removed by means of an 
emollient poultice, and the superficial excoriations they covered to be 
then dressed with a piece, of linen pierced with holes, a compress of 
soft lint, and a firm retaining roller above all, extending from the ends 
of the toes to the middle of the leg. The dressings were not regu- 
larly attended to, and the patient continued to ply his ordinary occu- 
pation so long as his strength would permit him. The two excoria- 
tions became painful, bled frequently and began to spread ; a month 
was passed in this way. The patient at last consented to lay himself 
up. He was supplied with wholesome food; the leg was kept in the 
horizontal posture during a part of the day at least; the sore places 
were stimulated by being powdered with cream of tartar; a firm 
bandage was applied and regularly changed. Three weeks had 
hardly passed before the oedema of the food, the petechiae and the 
ecchymoses had disappeared, and the excoriations were replaced by 
two livid cicatrices. A laced stocking was subsequently put on in- 
stead of the roller. 

Case XXXII. Rupia escharotica. A woman twenty years of age, 
of a lax constitution, presented herself among the out-patients at the 
hopital St. Antoine, on the 22d of June, 1828, having an eschar, a 
little larger in size than a shilling, on the inner part of the left leg, 
around which the skin was a good deal inflamed, tense, shining, pain- 
ful and swollen. This eschar had been preceded some days before 
by a large bleb, which had burst, and been succeeded by a black 
scab. The disease was evidently a case of isolated gangrenous rupia. 
Co7npresses wet with cold decoction of althea during the day; emollient 
poultices through the night. 24th. The eschar began to be detached 
from the inflamed skin in its circumference ; the surrounding redness 

i Flumbe (Sam.). A pract. treat, on diseases of the skin, 8vo., Lond. 1824, p. 156. 



was greatly less. 2d of July.— The eschar was detached, and the de- 
structive process perceived not to have implicated the entire thickness 
of the skin in every part of the sore. Rest, and a few applications 
of powdered cream of tartar, caused the rapid cicatrization of the 
ulcer, which in this instance proved to be of a more purely local 
nature than rupia is in general. 

Case XXXIII. Rupia ; recovery, followed by febrile symptoms, 
relieved by blood-letting. Morreau, twenty-two years of age and of a 
bad constitution, was admitted into La Charite on the 24th of De- 
cember, 1832. When I saw him first he had been some days under 
treatment for a rupia, the bullae of which had already disappeared, 
and been succeeded by incrustations of a brownish hue, mixed with 
rather prominent yellow lines. In two points of the outer and lower 
surface of the right leg, the removal of these scabs had exposed as 
many oval-shaped ulcers about four lines in breadth, by nearly six 
in length : these sores were of no great depth, and of a pale reddish 
colour. 

The treatment after the 1st of January, was changed from emol- 
lients to dressings with a perforated rag and soft lint ; and subse- 
quently the sores were touched with a solution of nitrate of silver. 
This plan, aided by the use of sulphureous baths, hastened the cica- 
trization of the ulcers, which was almost accomplished by the 20th. 
Till this time the general health had been good ; but now, without 
any appreciable cause, beyond the drying up of his sores, the patient 
was attacked with irregular shivering fits, which continued the whole 
day long. On the evening of the 20th, heat of surface, and a general 
uneasiness, wandering pains of the lower part of the chest, headache, 
and frequency and force of pulse were superadded. The nights of the 
20th and 21st were passed without sleep. On the visit of the 21st 
the face was flushed, though the headache was less severe ; but the 
sense of constriction about the chest was as violent as ever ; at one 
time crepitation was supposed to have been heard at the base of the 
right lung, but further examination did not confirm the suspicion. 
The patient had a little cough, and the chest sounded well on percus- 
sion ; he had no expectoration whatever. The tongue was moist and 
natural ; the epigastrium and rest of the abdomen were not painful on 
pressure. The patient had had a motion the preceding evening ; the 
pulse was full, bounding and frequent; the skin hot and the thirst 
considerable [barley-water, low diet, vents, ad Sxii). Evening of 
the 21st. — Headache less ; other symptoms the same ; 22d, the patient 
had slept for two hours and was better [the same treatment continued). 
In the evening there was a marked exacerbation. These febrile 
symptoms continued till the 24th, after which they declined consider- 
ably ; the patient felt his appetite returning, and on the 26th he was 
so far recovered as to be allowed some solid food. On the 28th the 
patient w r as dismissed, cured. The ulcers of the rupia w^ere com- 
pletely cicatrized, but the skin that covered them still retained a livid 
or blue colour. 



artificial or accidental eullous inflammations. 

306. Under this head I arrange vesications, blisters and other wa- 
tery blebs, produced by local and evident causes. 



AMPULLJE OR VESICATIONS. 



Vocab. Ampulla, Blister, Vesication. 



307. This title has been given to the blisters which arise on the 
hands and feet, in consequence of violent and long-continued pressure, 
rubbing, pinching, &c. These blisters are preceded by redness, and 
heat and painful swelling of the skin ; a serous fluid is then effused 
under the cuticle, which becomes raised in the shape of a rounded 
bleb of variable size, the sense of touch in the part being very much 
obscured or altogether destroyed. 




BLISTER. 



101 



whole of the thick and unyielding cuticle of the heel is sometimes 
seen raised in one large and uneven blister, which, indeed, is only per- 
ceived by the lookers-on from the more regularly rounded figure and 
greater size of the part than naturally belong to it ; to the patient their 
existence is always sufficiently indicated by the tensive and acute 
pain they occasion. 

Left to themselves, blisters of the hands and feet disappear slowly, 
the serum they contain is either absorbed, or escapes by a natural 
rent or an artificial opening made in the cuticle. The spontaneous 
rupture of blisters of the heel is always very long of happening; 
their fluid contents become brown and exceedingly fetid, and at last 
flows out by small openings in the thickened, macerated and partly 
destroyed epidermis. 

308. Blisters of the hands and feet are only liable to be confounded 
with those that follow burns and frost bite. To distinguish them it 
is enough to mount to the cause which has produced them, when 
their situation is not of itself a sufficient index of their origin. 

309. The best mode of treating ampullae is to prick them in several 
places as soon as they are formed, and thus to evacuate the serum 
they contain ; when they are very large, it is even better to lay them 
open through their whole extent. When this practice is not followed 
in regard to blisters of the heel, they are apt to be followed by small 
fistulae, from which a very fetid ichor oozes out. In this case it 
is necessary to remove the flap of cuticle which is detached, to apply 
an emollient poultice upon the exposed surface, and then to cover 
the whole heel with a compress, wetted with a solution of acetate of 
lead. The inflammation subsides in a few days and a new cuticle is 
produced. 



310. The name of blister has been especially given to the large 
bullae, now commonly produced in the practice of medicine, by the 
application of cantharides to the skin. This form of inflammation is 
so usually looked on as a remedy, that some may be surprised to find 
me here speaking of it as a disease. The study of blisters, in a 
pathological point of view, however, appears to me a subject of so 
much the more importance as they occasionally give rise to serious 
consequences. 

311. The formation of the vesication of a blister is rapid in the 
same proportion as the irritating matter employed is more energetic 
in its action. The serum effused between the cutis and cuticle is of 
a pale straw or citrine colour, and transparent: it has sometimes, 
however, though rarely, the consistence and appearance of a kind of 
yellowish jelly. After having by a small opening evacuated the 
serum of a blister completely, if the epidermis be pressed accurately 
down, it will by next day appear to be incorporated again with the 
general integument, and a new cuticle will be formed under the old 
one, which is detached at a later period. If, on the contrary, the 
cuticle be removed from the blistered surface entirely, the contact of 
the air with the inflamed skin causes pain of so severe a kind that it 
is often compared to the sensation produced by a scald. After the 
rupture of the bullae the skin appears injected, and covered with 
small red points, which probably correspond with the papillae. 
When the exposed surface of the skin is systematically irritated, or a 
blister is kept open, the part often becomes covered with a whitish- 
looking false membrane, which cannot be removed without causing 
the flow of some drops of blood, and to which a cicatrix, or a new 
cuticle would speedily ensue, did not renewed irritation cause the 
formation of pus. The false membrane which is here formed is 
composed of fibrin like those of the serous surfaces, but it differs 
from these inasmuch as no traces of organization have ever been 
detected in it. When the skin has been long kept in a state of in- 
flammation, it bleeds often and readily, and occasionally becomes 
covered with exuberant fleshy growths or granulations in the form of 
tubercles separated from each other by fissures. These growths are 
owing to a true hypertrophy of the papillae of the skin. 

Blisters may also ulcerate in several points of their surface : a 
patient at La Charite, whose forearms were paralyzed in consequence 
of repeated attacks of lead-colic, was treated successfully by gradually 
26 



increased doses of strychnine applied upon two blistered surfaces on 
the dorsal aspects of the forearms ; these blisters, however, were not 
long of becoming painful, and then exhibited several small ulcers 
which appeared to implicate almost the whole thickness of the corion. 
I have often since made use of the strychnine in the same manner, 
but have not seen any similar consequence ensue. 

When the ulcers have not implicated the entire thickness of the 
dermis, the cicatrices that follow them have a pitted appearance 
which recalls the natural disposition of its parts when minutely ex- 
amined. 

Blisters have a livid appearance and bleed readily in some serious 
diseases. They also occasionally become gangrenous. 

The pigmentum, the sebaceous follicles, the hair-bulbs, and the 
hairs themselves, sometimes become unnaturally developed in conse- 
quence of the application of blisters. 

Blisters often cause troublesome pruritus, pain, and sleeplessness, 
especially in children. They may also give rise to painful inflamma- 
tion of the lymphatic glands of the axilla, neck and groin, when they 
are applied to the arm, nape of the neck, or thigh. The inflammation 
in these instances even extends to the neighbouring regions and to 
the subcutaneous cellular substance. Blisters of a very large size are 
almost always followed by some degree of febrile reaction ; like burns 
they may excite inflammation of the digestive organs, irritation of the 
brain and nervous system, &c. ; their application in acute diseases is 
almost always followed by a temporary increase in the severity of the 
symptoms. M. Richard has seen an intermittent fever brought on by 
a blister, each paroxysm being preceded by acute pain in the inflamed 
portion of skin. I have myself seen the same thing: having ordered 
the application of a blister to the forearms of a man labouring under 
paralysis from lead, the pain and inflammation of the skin produced a 
violent paroxysm of fever which was even accompanied by fainting. 

Corvisart thought that the secretion from blistered surfaces might 
be so profuse as to exhaust the strength of some patients ; the same 
remark has been made in reference to the discharge from extensive 
burns. 

512. The bullae produced by the application of blistering plasters 
may be distinguished by the special nature of their cause from those 
that follow burns and frost-bite, or that are characteristic of pemphi- 
gus. Independently of other circumstances derived from their form, 
situation and extent, blisters in a suppurating state, or dried up and 
covered with scales, differ in their mode of formation from the super- 
ficial ulcerations or excoriations, and circumscribed squamous patches 
which follow certain bullous and vesicular inflammations. 

When blisters have been long kept open, or when they have had 
good effects, whether on the constitution at large, or on the progress 
of a local affection, they are of the number of those inflammations 
which it is dangerous to suppress on a sudden. Notwithstanding this, 
however, when the disease which induced their application is cured, 
if it be not constitutional, hereditary, or liable to return, it is proper 
to bring about the cicatrization of the secreting surface by dressing it 
either with some soothing cerate, or simply by abstaining from irri- 
tating it longer. If the intestinal canal be healthy, one or several 
successive doses of purgative medicine are then generally prescribed 
with great propriety. 

Excessive growths from blistered surfaces are to be kept down by 
the application of some escharotic, or removed entirely with curved 
scissors. 

Sulphureous baths hasten the absorption of the pigmentary marks 
produced by blisters. 

Historical JVbtices and particular Cases. 

313. Blisters have of late been studied in an anatomical point of 
view by M. Villerme 1 and by M. Gendrin; 2 Messrs. Brandes and 
Reimann have analyzed the fluid of the vesications ; 3 and Broussais 
has satisfactorily proved that blisters employed as revellents in 
chronic affections of the stomach are more frequently noxious than 

i Villerme. Ait. fausse membrane, Die. des sc. medicates. 

2 Gendrin. Hist. anat. des inflammations, t. i. p. 416, in-8. Paris, 1826. 

3 Bulletin des sc. medic, t. x. p. 330. 



102 



BULUE. 



beneficial. 1 They may also cause ill effects in a greater or less degree 
under a great variety 'of other circumstances. 

The powder of cantharides applied to the skin with a view to feign 
disease, may prove a cause of error in diagnosis. See Case XXXVI. 
Cask XXXIV. Intermittent fever produced by a blister: (Richard, 
iu the Annates de. la Midecine Physiologique, torn, iii.) M. X * * *, 
an officer of light troops, came under my care for wandering pains of 
the chest, dependent, apparently, on the fatigue induced by severe 
riding. There was no symptom of any considerable affection of the 
thoracic viscera ; and the accession of a slight catarrh alone induced 
the patient to enter himself on the sick list. Regulated diet and de- 
mulcent drinks were employed for some time, but these not having 
answered the expectations of the patient, a few leeches first, and then 
a blister were applied to the left arm. On my return, after an absence 
of three days, I learned that M. X * * * had every day suffered a rather 
violent attack of fever regularly at the same hour on each accession : 
I learned further that the discharge from the blister appearing insuffi- 
cient to the dresser, he had taken it on him to stimulate the part by 
the application of fresh cantharides, and that the violent pain which 
followed this measure was the prelude to the febrile paroxysm. — 
Having no doubt of the irritation produced by the blister being the 
cause of the fever, I directed the application of a poultice moistened 
with laudanum, to the suppurating surface, and from this time the pain 
ceased, and the fever did not return. 

Case XXXV. Eczema of the arm produced by a blister. M. 
Ch. * " *, aged thirty-two, of a sanguineous temperament, had been 
subject during several years, to a chronic coryza, which gave rise to 
an habitual and very copious discharge of a serous and mucous fluid 
from the nostrils. This flux was continual ; so that M. Ch. * * *, when 
he was engaged in writing, was often obliged to keep a handkerchief 
under his nose to catch the fluid that distilled from it. When this 
flux, which appeared in the first instance to have been brought on by 
the habitual use of snuff", happened accidentally to be suppressed, M. 
Ch. * * *, who at other times enjoyed good health, was immediately 
taken with aching and a sense of weight in the head, symptoms which 
, immediately disappeared on the return of the morbid secretion. After 
having tried various remedies for this inconvenient malady, M. 
Ch. * * * resolved on applying a blister to his arm ; this rose perfectly, 
and began to suppurate as usual on the two following days. 

Several days afterwards, M. Ch. * * * requested me to call on him 
and examine an eruption that had appeared around the blister, and 
caused so violent a pruritus that he found it impossible to resist 
scratching the parts. The inflammation extended over almost the 
whole anterior and outer parts of the arm. It consisted of vesicles 
and superficial excoriations; of the vesicles but few had escaped lace- 
ration ; they were very minute, scarcely visible to the naked eye, and 
bathed by an abundance of yellow-coloured serum which exuded from 
the denuded skin. The excoriations had the precise characters of 
acute and ulcerated eczema, — a red uneven surface, with minute 
drops of blood scattered over it, and small distinct circular red points 
corresponding to the ruptured vesicles. The blistered surface was 
hot, bleeding and painful [crum of bread poultice, with decoction of 
althea ; cooling and emollient 10 ashes ; warm bath; antiphlogistic 
regimen). In spite of this treatment the eczema spread on the follow- 
ing days as high as the bend of the arm. The itching was intolerable. 
The secretion from the nose still continuing, I healed up the blister 
a fortnight after its establishment. The eczema, however, still con- 
tinued for twenty days longer, at which period a slight redness of the 
skin was all that indicated its previous existence. A seton having 
been inserted into the neck, the flux from the nose was arrested. 

Case XXXVI. Pemphigus simulated by the application of powder 
of cantharides. Frances Bouillot, aged fifty-nine, was received into 
the hopital St. Antoine, on the 6th of April, 1828, complaining of 
frequent fits of vomiting, pain of the epigastrium, and habitual consti- 
pation. She was put on the regimen pursued in cases of gastrointes- 
tinal inflammatory affections, and took several doses of hemlock. 
Under this treatment the sickness and haenaatemesis with which it was 
at times attended, left her entirely, and a hematuria, to which she had 
become subject, ceased nearly at the same period. A short time after- 

' Histoire des phlegmasies chroniques, t. iii. p. 0G, in-8. Paris, 1822. 



wards she had a pretty severe attack of erysipelas of the face, which was 
speedily subdued by the general abstraction of blood ; but the sides of 
the puncture in the arm, though it had been made with a clean and 
sharp lancet, afterwardsinflamed, and the irritation extended to the sur- 
rounding subcutaneous cellular substance. Leeches were applied, 
and the arm was enveloped in a poultice. Over all the parts so 
covered, a very plentiful crop of vesicles was soon observed to have 
arisen, which, bursting almost immediately after their formation, left 
the dermis beneath naked and exposed. This first eruption was before 
long succeeded by another, the bullae of which varied in size from 
that of a pea to that of an almond, and only presented this peculiarity: 
that they either formed portions of an arc of a circle, or were too 
minute to be distinguished as possessing any determinate figure. These 
bullae were almost always developed around the margins of the primary 
excoriation, which only spread in this way. The successive erup- 
tions of bullae had followed each other so quickly, that on the 6th of 
September, in spite of four bleedings of fourteen ounces each, in all 
of which the buffy coat was observed in as great perfection as it 
appears in articular rheumatism of the most violent kind, and two 
applications of leeches in the neighbourhood of the eruption, the 
excoriated surface resulting from the rupture of the bullae, was from six 
to seven inches in length, by about three in breadth. Around the 
edges of the sore, sometimes separated from it by a narrow stripe of 
sound skin, sometimes touching it on one side, new bullae of various 
shapes and about the size of hazelnuts, were still arising. The 
excoriated surface was slightly raised above the proper level of the 
integuments and mamillated ; it secreted a considerable quantity of 
pus ; here and there it was covered with patches of false membrane, 
and in other places with points of newly-formed cuticle. When the 
mamillated parts were pierced with a needle, or squeezed between 
the ends of the fingers, a small quantity of serum was expressed. 
The whole excoriated surface was excessively painful, and each dress- 
ing was followed by a violent shivering fit, which lasted two or three 
hours, and then gave way to a hot stage of some intensity. The 
pain came on in paroxysms, very commonly about midnight. The 
countenance of the patient was pale, the tongue slightly furred, the 
abdomen was free from all complaint but constipation. The mildest 
dressings were applied to the sore, the patient took the warm bath 
repeatedly, and the antiphlogistic treatment was enforced ; neverthe- 
less there was a fresh crop of bullae almost every day, which was 
always preceded by violent pain in the arm, so that the patient, before 
the dressing was commenced, could predict the appearance or non- 
appearance of a new eruption, and even point out the places, where, 
in case of its having happened, the bullae would principally be found. 

At different times the sore put on a better appearance, and showed 
a disposition to heal, but on a sudden this favourable state of matters 
passed away, and our hopes were disappointed. No change of the 
dressings seemed to do any good, and nothing was gained by any 
form of lotion or fomentation. 

After the 8th of October the arm was firmly rolled from the fingers 
to the shoulder, and the excoriation became completely skinned over, 
so that up to the 17th no new bullae had appeared ; but in the night, 
between the 17th and 18th, according to the patient's account, the 
pain returned with so much violence, that she was forced to undo 
the bandage, and next morning the parts first affected were found 
covered with an immense number of bullae, of large size, and full 
of transparent serum. These vesications were all opened, and the 
roller re-applied. Several brown points being observed upon the 
skin when the dressings were removed on the 24th, a suspicion arose 
that they consisted of powder of cantharides, and on the 27th, a 
quantity of this article, easily recognizable by the changing bright 
green and brown colour of its particles, was discovered on the 
shoulder of the patient. The bedding being now carefully searched, 
two ounces of flour of mustard and a broad piece of cloth sprinkled 
over with cantharides in powder, were discovered. The woman, 
when questioned, acknowledged that she had applied these sub- 
stances to excite new bullae, undoubtedly with a view to prolong her 
stay in the hospital. A few days of uninterrupted watching, and the 
careful application of the roller, after this discovery, sufficed to heal 
up the excoriation completely, and to prevent the appearance of any 
more vesications. 



HERPES. 



103 



314. Other causes, besides those now specified, may give rise to 
the development of artificial bullae. M. Brachet informs us that he 
induced a pemphigoid eruption on the arm of a man affected with 
paralysis, by exposing it to the current, from a powerful galvanic 
battery. Wichmann, 1 and Messrs. Bourdois, Thillaye, and Guerin, 2 
have seen erysipelatous and bullous eruptions, produced by the rhus 
toxicodendron and rhus radicans. 

315. Lastly, M. G. Pelletan has published a case in the Journ. de 
Chimie Medicate, 3 in which a bullous eruption was produced on the 
fingers, by handling balls for poisoning rats, prepared with nux 
vomica in powder, cheese and bitter almonds. 



VESICUL^], OR VESICULAR INFLAMMATIONS. 

Vocab. Vesiclt. 

316. This group is characterized by vesicles, or small serous and 
transparent elevations, differing from bullae in nothing but their 
smaller size, and formed by a globule of serum with or without 
coagulable lymph, effused beneath the cuticle. These minute drops 
of serum may be either re-absorbed, or shed upon the surface of the 
skin after the rupture of the vesicles, which are succeeded at length 
by desquamation, superficial excoriation, or small thin and laminated 
crusts or scabs. 

Five forms of vesicular inflammation of the skin are reckoned : 
Herpes, Eczema, Hydrargyria, Scabies, Miliaris sudatoria, and Suda- 
mina; to these, however, must be added vesicular syphilis, and 
artificial vesicles. 

317. The vesicular character of scabies has been disputed by 
Bateman, who ranks it among the pustular affections. The mistake 
he committed has been exposed by M. Biett. (a) On the other hand, 
Bateman has classed vaccinia, aphthae, rupia, and varicella, among 
the vesicles. But the vaccine pock is indisputably a. pustule; aphtha? 
cannot be counted among the diseases of the skin ; and rupia is a 
bullous affection. With regard to varicella, I grant that of the three 
or four varieties which the disease presents, severally designated 
under the names chicken-pox, swine-pox, and modified small-pox, one 
at least, the chicken-pox, is perfectly vesicular in its form ; but it is 
also certain that the other varieties mentioned, and particularly the 
modified small-pox, are invariably pustular diseases. Varicella, there- 
fore, by this double character, may be regarded as forming the link 
of transition from vesicular to pustular eruptions. Feeling myself 
free to attach it to one or other of these groups, I have preferred 
classing it among the pustules, with a view of approximating it to 
variola, of which it is a mere modification. 

Vesicles are sometimes accidentally developed in the course of other 
diseases ; but they are then few in number, and form true complica- 
tions of the original malady. 

318. The evolution of vesicles upon the skin is not preceded by 
any appreciable degree of redness in scabies, or in sudamina. On the 
other hand a great degree of redness precedes the eruption of herpes, 
eczema, hydrargyria, and sweating miliaria. It shows itself under 
the form of red points or spots of greater or less extent, on which the 
vesicles subsequently arise. The size of the vesicles in several varie- 
ties of herpes is rather considerable. In eczema, on the contrary, the 
vesicles are so minute that they are only distinctly visible under the 
magnifier. Occasionally it is even impossible to perceive that an 
elevated patch is vesicular without pricking it with a needle, when 

(a) Justice is not done to Bateman in these observations of M. 
Rayer. The former defined scabies to be, " a contagious eruption of 
minute pimples, papular, vesicular, pustular, or intermixed according 
to circumstances, and terminating in scabs." 

1 Wichmann. Idean zur Diagnostic, 1. B. p. 75. — Nouv. mem. de l'Acad. de Berlin, 
177. 

2 Gaz. medicate, t. iii. p. 493. 

a Journ. de chimie medic, t. iv. p. 482.] 



the escape of the serum proclaims its nature. The forms assumed by 
vesicles are not less various than their sizes. Those of miliaria are 
globular, those of herpes labialis, broad and flat, those of itch, acu- 
minated, &c. 

Vesicles may appear thinly scattered, or congregated into thickly 
set groups or clusters ; their evolution is at One time simultaneous, at 
another successive, and the duration of each new crop may vary from 
a period of a few hours to one of several days in extent. 

319. Vesicles may terminate, 1st, by the re-absorption of the fluid 
they contain, and a slight desquamation ; 2d, by the transformation of 
this fluid into pus, and at a later period into thin laminated scabs, 
under which a new epidermis is produced ; 3d, by the excoriation of 
the skin, which, becoming raw, first pours out a sero-purulent secre- 
tion, and then continues habitually subject to desquamation; 4th, and 
very rarely, by ulceration, as in zona and vesicular syphilis. 

The vesicles in sweating miliaria never terminate but in the first of 
these modes; in herpes they often end in the second; and there is 
none of them in which eczema is not occasionally manifested. 

The vesicular phlegmasia; may be complicated with exanthematous, 
pustular, and other forms of inflammation. Two of them, itch and 
sweating miliary, are contagious ; the others are uninfectious, and 
their etiology is often involved in great obscurity. 

320. The vesicular are very different from the exanthemtaous inflam- 
mations. They are less unlike the bullous, from which, however, 
they are distinguished by the inferior size of the vesications that 
characterize them. The large bullae of pemphigus cannot be con- 
founded with the minute vesicles of eczema, of hydrargyria, and of 
sweating miliaria. Further, each of these diseases has its own 
peculiar and distinguishing characters. 

The characters that distinguish vesicles from papulae, tubercles, &c, 
have been already indicated (8), and by and by will be more particu- 
larly set forth. 

The incrustations, the furfuraceous scales, and the red marks that 
follow some vesicular diseases, are distinguished with greater difficulty 
from alterations of an analogous kind, succeeding eruptions of a differ- 
ent nature. When speaking of each particular form of inflammation, 
I shall give the elements of the diagnosis in these difficult cases. 

In the two-fold point of view of prognosis and treatment, vesicular 
inflammations present no common and generic characters for the guid- 
ance of the practitioner. 



HERPES. 



Vocab. Herpes, Dartre, Tetter. 



321. With Willan and Bateman I designate, under the name of 
herpes, a genus of cutaneous inflammations, not contagious in their 
nature, characterized by clusters of distinct vesicles inflamed at their 
bases, separated from each other by intervals of healthy skin, and 
drying off respectively and becoming covered with crusts in the course 
of one or two weeks. The different species of herpes, which resem- 
ble each other in the circular form generally assumed by their clusters 
of vesicles, differ in their seat (herpes labialis, herpes prceputialis), in 
the arrangement of the several groups, which now appear scattered 
and far apart (herpes phlyctenodes), now disposed in the shape of a 
half girdle (herpes zoster), or in that of a ring (herpes circinnatus), 
and lastly, in the colour of the areola which surrounds them (herpes 
iris), (a) 

(a) " Herpes 1 is a non-contagious affection of the skin, character- 
ized by the eruption of clusters of globular vesicles upon inflamed 
patches of an irregular or rounded form, and of small extent. The 
eruption rarely presents any remarkable degree of severity ; it is not 
usually accompanied by symptoms of constitutional disturbance ; and 
it lasts for a brief period only ; rarely longer than two or three weeks. 
Each vesicle runs a course of about ten days, and terminates either 
by absorption of its contents, by desiccation without rupture, or by 
rupture, and the formation of a thin, brownish scab, which speedily 
falls. 

4 Der. ip7r«iv, to creep. 



104 



VESICUL/E. 



Taken in the above acceptation, the word herpes, which has become 
classical, is not synonymous with the vague and indefinite name, tetter 
and dartre, by which the older English and French pathologists ren- 
dered it. It" designates a class of affections, in the majority of in- 
stances, different from those which Lorry and some other pathological 
writers of the last and even of the present century, have grouped 
under the title herpes; it is now understood in a precise and rigorous 
sense which it does not possess in the nomenclature of the authors 
alluded to. (6) 



HERPES ZOSTER OR ZONA. 
Vocab. Zona, Herpes Zuslcr, Shingles, Ignis sacer, <5fC. 

822. Herpes zoster, zona or shingles, 1 is so denominated from the 
disease usually attacking one side of the body in the shape of a semi- 
circular belt or band formed by several clusters of agglomerated vesi- 
cles, which occasionally appear transformed into irregular bulla? by 
their conjunction, and the cure of which is commonly accomplished 
within two, three or four weeks. 

323. Symptoms. The eruption of herpes zoster may be distinct, and 
characterized by scattered and not very numerous clusters of vesicles ; 
more generally it is confluent, so that the vesicles of the various groups 
touch each other, or become mingled by their corresponding edges ; 
in this case the epidermis may be detached over a considerable surface 
of the skin, as it is in extensive vesications from scalds or burns. 

I have never met with zona as a chronic disease, and Willan makes 
no mention of this variety which is admitted by Lorry and Alibert, and 
of which Burserius quotes a case : — "Hanc speciem tamen diutinam 
non vidi, nisi semel invetula quam stigmata pustularum sub omoplata 

" The varieties of herpes derive their designation either from the 
form and arrangement of the clusters, or from the locality of the affec- 
tion. In reference to their general characters, these varieties admit 
of a natural division into two groups, a phlyctenoid group, and a 
circinnate group. The phlyctenoid group is characterized by the 
irregularity of form and distribution of the clusters of which it is 
composed ; it is typified by the variety of herpes phlyctenodes, and 
embraces all the local forms. The circinnate group, on the other 
hand, is remarkable for the circular arrangement or form of its clus- 
ters ; hence, the herpes zoster consists of irregular clusters disposed 
in a circular form around the trunk of the body; herpes circinnatus is 
eharacterized by the disposition of individual vesicles in the form of a 
circle ; and herpes iris presents the same peculiarity in the form of concen- 
tric circles. In a tabular plan, the varieties maybe thus arranged: — 
"1. Pldyctenoid group. 2. Circinnate group. 

H. phlyctenodes, H. zoster, 

" labalis, " circinnatus, 

" nasalis, " iris." 

" palpebralis, 

" auricularis, 

" prseputialis, 

" pudendalis. (Wilson, op. cit. p. 157, Am. Edit.) 
Dr. A. T. Thomson believes that there are only two distinct species 
of herpes, viz. herpes phlyctenodes and herpes iris. All the other 
forms, generally regarded as species, are, in the view of this experi- 
enced writer, mere varieties of herpes phlyctenodes, how r ever they 
may differ in the figure of the clusters, or in the parts on which they 
appear. 

(b) Diagiiosis. Herpes, says Dr. A. T. Thomson, is distinguished 
from pompholyx by the vesicles appearing in groups or patches on 
an inflamed base ; and from erysipelas by the vesicles not being pre- 
ceded by redness and tumefaction; by their distinct yet clustered 
characters, and the state of the skin between the clusters. Neither 
eczema nor impetigo assumes the purely vesicular form, nor runs the 
same regular progress within a limited period ; and both of them form 
their plates or semi-pellucid crusts, from under which a thin acrid 
fluid exhales, instead of the dry, hard scab which characterizes herpes. 
1 Zona, cingulum, a girdle. 



sinistra ad aliquot menses summo cruciatu atque ardore pertinaciter 
divexarunt." 2 

324. Zona may be developed on any region of the body ; it is most 
frequently seen on the trunk, occasionally on the neck, face and scalp, 
on the scrotum and on the extremities. Like erysipelas it is occa- 
sionally preceded by a shivering fit, by headache, restlessness, in- 
somnia, sickness of stomach, thirst and loss of appetite ; the pulse is 
accelerated, the tongue is covered with a brownish or whitish fur, the 
patient is disinclined to exertion, &c. More frequently, however, 
the disease appears without any of these precursory symptoms. The 
evening before the eruption shows itself, the patient complains of 
prickling or smarting sensations, of burning heat or acute pain in the 
region which the zona is about to occupy. 

In a previous edition of this work I remarked that of ten cases of 
zona which occurred, eight would be found on the right side of the 
body, without our being able to assign any cause for this anatomical 
disposition ; and, since then, Messrs. Cazenave and Schedel have 
said, that nineteen in twenty of the cases of zona encountered, would 
be found occurring on the right side of the body. At present these 
statements do not seem to me based on fact : of fifty-three cases of 
zona which I have seen during the last few years, the eruption was 
developed on the right side in thirty-seven only. I may further add, 
that Reil tells us he has almost always seen zona invading the left 
side ; and that out of twenty-five cases, Mehlis noticed sixteen on the 
left, and only nine on the right side. The discrepancy of these con- 
clusions shows that accurate results will only be obtained when cal- 
culations have been made from data much more extensive than any 
that have yet been used. 

1st. Zona of the trunk is the most common of all the varieties of 
this disease. The parietes of the abdomen are more frequently its 
seat than those of the thorax. The disease begins in some point of 
the mesial line, and proceeds outwardly and around the body till it 
approaches the plane of the vertebral column, forming in this way a 
sort of half girdle to the body. I have never seen zona form a com- 
plete belt; in such a case it would be almost impossible to distinguish 
the disease from herpes phlyctenodes. Pliny, Turner and Roussel 
have mentioned this disposition of zona ; but they have neither given 
nor referred to any authentic instance of its occurrence. The case 
published by Mr. Montault, deserves to be quoted: 3 P * * *, aged 
twenty-six years, complained of symptoms of gastric disturbance ; on 
the seventh day he felt a violent pain in the right side, without cough 
or affection of his breathing ; three days afterward there appeared on 
the right side, below and to the outside of the axilla, a number of 
erythematous patches, in the middle of which small whitish vesicles 
were before long evolved ; from this point the eruption spread suc- 
cessively to the front of the chest, then to the back part of the body, 
and lastly to the left side. 

Zona of the trunk, at its height, presents itself under the form of a 
semi-circular belt of variable breadth, formed by several rounded or 
oval groups of silvery gray or yellowish-coloured vesicles, occasionally 
mixed with irregular bullae, surrounded by a red areola, and filled 
with a serous fluid either transparent or sanguinolent in its appear- 
ance. The eruption of these vesicles is preceded by irregular blotches 
of a rather vivid red colour, which sometimes show themselves at the 
two extremities of the belt, and are afterwards united by intermediate 
red patches, generally of an inferior size. These patches are soon 
crowned by numbers of small white silvery-looking and transparent 
vesicles of the form and size of seed pearls ; in the course of three or 
four days they acquire the volume of a small lentil or large pea. The 
patches upon which the vesicles are evolved then become more florid, 
and the redness extends a few lines beyond the circumference of each 
particular group. At the end of five or six days the fluid contained 
in the vesicles assumes an opalescent appearance, becomes sero-puru- 
lent, and, when the inflammation runs high, is changed into true pus. 
Some of the vesicles burst spontaneously on the second, or from that 
to the fourth day, and pour out a little limpid and inodorous serum ; 
the cuticle is detached, and the vascular rete of the corion being ex- 
posed, suppurates for a few days. Others, and indeed the greater 
number of the vesicles, dry up and become covered with small yel- 

2 Burserius. Institut. med., vol. ii. p. 39. 

3 Journ. hebd. 2e serie, t. iv. p. 259. Zona formant une ceinture autour du Ironc. 



HERPES ZOSTER. 



105 



lowish or brownish incrustations, usually lamellar in their texture, 
occasionally prominent, arranged in the form of a band, like the ori- 
ginal eruption, and detached before long from the skin ; others in fine 
shrivel up and disappear, the fluid they contain being reabsorbed. 

The greater number of the vesicular groups of zona appear in 
succession, one after the other ; whilst those that were first evolved 
are drying off and becoming purulent, new clusters arise in the 
intervals between them, and pursue the same course. When the 
disease affects the parietes of the thorax, the new groups occa- 
sionally spread across the shoulder so as to form a sort of T., by 
their junction with the others. A similar disposition of the vesicular 
groups is observed when the parietes of the abdomen are the seat of 
the disease, and the new crops of vesicles extend to the thigh of the 
corresponding side. 

After the lapse of eight days at soonest, and of three weeks at 
latest, dating from the period of the attack, the whole of the incrus- 
tations of distinct zona are detached. The disease then leaves no 
traces of its existence, except marks of a deep red colour, which 
disappear by slow degrees, the peculiar oblique and belt-like dis- 
position of which long reveals the nature of the eruption that has 
produced them. 

The eruption does not terminate so speedily when the vesicles are 
confluent, and the skin that supports them is very much inflamed ; in 
drying they are then covered by very adherent incrustations of a 
yellowish-brown hue, under which the skin occasionally becomes 
ulcerated and cicatrizes slowly. 

Another and more disastrous consequence is occasionally ob- 
served : the part of the skin covered with vesicles on the posterior 
aspect of the trunk, is stricken with gangrene or a softening of its 
texture, whether from the effects of the inflammation, or in conse- 
quence of the continued pressure which this portion of the integu- 
ment endures in the supine position of the body is uncertain. The 
eschars that then result have ragged and irregular edges, and do not 
always extend to the whole thickness of the skin, as I have many 
times ascertained by passing a probe over every part of the surface of 
the succeeding ulcer. The eschars are thrown off with greater or 
less celerity, according to their extent and thickness, and according 
to the age and vigour of the. patient. If the skin be minutely ex- 
amined after the -fall of the sloughs, it appears as if a layer of the 
dermis had been removed with a shaving implement, leaving the 
part that remains white, and sown over with small red points ; these 
seem owing to the penetration of the cellular prolongations and minute 
vessels that permeate the interstices of the tissue. When the erup- 
tion has been confluent, the skin that surrounds the excoriations 
remains red for a great while, and the cure is long looked for in vain. 
The cicatrices of these ulcerated spots are indelible ; I have seen 
several which resembled the scars remaining after the cure of exten- 
sive burns. 

The general symptoms that accompany the development of zona, 
the fever, thirst, headache, &c, commonly decline in severity, and 
occasionally cease entirely on the appearance of the eruption. Local 
pain, however, which is at times very intense in its character, and of 
the smarting kind, continues to the end of the disease, and occasions 
distressing insomnia. This pain is now and then complained of, 
even several weeks after all traces of inflammation have gone from 
the integuments affected. I have remarked it constituting the prin- 
cipal feature of a zona that aborted, or was imperfectly developed ; 
this was in a patient who carried a single group of the vesicles of 
herpes zoster under the shoulder blade, and who complained at the 
same time of a very acute pain confined entirely to the left side, and 
extending like a belt from the spine to the sternum. 

2d. Zona of the neck is more uncommon than zona of the trunk. 
I have seen this variety accompanied by very acute inflammation of 
the sub-mastoid lymphatic glands. 

3d. When zona is developed on the face, the inflammation fre- 
quently extends to the mouth, one side only of which it likewise 
attacks. An old man, seventy years of age, was received on the 7th 
of January, 1827, into La Pitie, labouring under a chronic bronchitis; 
on the 13th of the same month, a vesicular eruption was thrown out 
on the left cheek, which, for three or four days previously, had been 
the seat of acute pain, shooting in the direction of the branches of 
27 



the portio dura. The skin of this side of the face presented a 
number of small red and slightly livid spots, which disappeared with 
pressure at first, but soon became changed into groups of vesicles 
similar to those of zona of the trunk of the body. Before long, the 
mucous membrane of the alveolar arch of the upper jaw, which was 
without teeth, and the inner surface of the left cheek were covered 
with vesicles, isolated or in clusters, and with several irregular bully 
of various dimensions, similar to those of the face. Vesicles of the 
same nature were also discovered on the left arch of the palate. On 
the last-mentioned part they were most numerous in the vicinity of 
the alveolar arch ; they were all of irregular shapes, round, oval or 
elongated, and appeared to be surrounded by slight areolae. This 
affection was preceded by prolonged shivering fits and constipation 
of the bowels. On the 14th, the fluid of the vesicles near the nose 
was partly changed into yellowish crusts ; other vesicles that were 
just appearing were more prominent; of these, one small cluster 
was situated over the temple. The patient had complained, the 
evening before, of very violent pains in the left side of the face, and 
of a severe aching in the same side of the head. On the 26th, the 
vesicles of the temple, and of the external surface of the cheek, which 
were the first that appeared, were dried up ; those of the interior of 
the mouth w r ere yet distinguishable ; the pain, still confined to the 
left side of the head and face, had recurred and continued through 
the whole of the night. On the 17th, the clusters of the face were 
succeeded by brown scabs, thin, where the vesicles were isolated, 
and distinct, thick, and analogous to those of impetigo, in those 
places where they had been confluent. Those of the inside of the 
mouth that had disappeared after an exfoliation of the epithelium, 
were replaced by small red spots. 

4th. Zona attacks the hairy scalp still more rarely. A. B., forty- 
seven years of age, on the 27th of October, 1827, felt a severe 
smarting pain in the left eye and eyebrow, which soon spread to the 
forehead and cranium of the same side, without extending down- 
wards to the face. Twelve hours after the commencement of the 
pain, vesicles, disposed in clusters, began to appear on the eyelids 
of the affected side, which were closed, and from between the edges 
of which a serous fluid kept distilling. Next day the left side of the 
forehead, and head generally, as far as the lambdoidal suture, was 
covered with small clusters of vesicles, similar to those of the eye- 
lids, none of which passed the median line to trench upon the opposite 
side. On the 30th, these small clusters, scattered over the forehead 
and hairy scalp, presented the following appearances: the vesicles 
that had been formed most recently were not larger than the head of 
a pin, and contained a very transparent and limpid, yellow fluid ; 
others were primarily of a larger size, or had become so by the 
fusion of several smaller ones; lastly, those that had been earliest 
evolved were completely dried up, and covered by a small black 
scab, set, as it were, within the substance of the skin around. All 
the remaining clusters dried up, as they do after their development 
on other parts of the body. 

5th. Zona perpendicular or parallel to the axis of a limb is not of 
such rare occurrence as has been supposed; I have met with several 
cases of the kind ; and others may be found recorded in periodical 
publications. When the disease attacks one of the lower limbs, the 
groups of vesicles are commonly scattered over the right or left lumbar 
region, the thigh, leg and foot. 

1 have, also, although rarely, seen zona developed on one side only 
of the skin of the penis, scrotum, groin, and verge of the anus. 

7th. To conclude this enumeration, Marcus 1 speaks of a case of 
zona which appeared over the whole of one side of the body. 

325. Zona seldom shows itself as a perfectly simple or uncompli- 
cated disease. Psydraceous pustules occasionally occur in the midst 
of the vesicles that particularly distinguish it. The lymphatic glands 
of the axilla are often inflamed in zona of the thorax ; this form of 
the disease I have seen complicated with pleurisy of the same side, 
a condition that was overlooked at first, the cough and local pain 
appearing to be sufficiently accounted for by the inflammation of the 
skin. I have, also, on many occasions, seen zona of the thoracic 
parietes, accompanied by bronchitis, of various degrees of intensity. 

1 Entwurf einer speciellen Therapie, B. ii. S. 213. 



106 



vesicul^:. 



Amonc the internal affections that may be connected, or that may 
coincide with zona, there is, perhaps, none of more common occur- 
rence than disorders of the stomach and bowels. Besides the pre- 
cursory phenomena of zona being generally linked to symptoms of 
previous derangement in the alimentary organs, these often continue 
many days after the complete development of the eruption. I may 
add that other morbid conditions almost always accompany this 
vesicular inflammatory affection of the skin. One of these is a kind 
of neuralgia of the intercostal nerves which occurs in zona of the 
thoracic parietes; of the lumber nerves, in that of the abdominal 
parietes ; of the crural or the sciatic nerves, in that of the lower 
extremities, and so on. This neuralgic affection varies in intensity, 
and not only always precedes the development of the vesicular in- 
flammation of the skin, but occasionally continues for several months 
alter it is gone, and even requires particular medical treatment. 

In this respect, as well as in the particular of their external form, 
there is a certain analogy between the vesicles of zona and those of 
the herpes labialis, occurring in intermittent fever. Another condi- 
tion is a huffy state of the blood, which I have remarked in almost 
all the patients affected with zona, for whom I have had occasion to 
prescribe venesection. 

326. Alterations of structure. — The anatomical structure of the 
vesicles and vesications of herpes zoster may be studied during life 
by opening them with the point of a pin or lancet. It will then be 
seen that besides serum the greater number of them contain a small 
piece of false membrane, which adheres very firmly to the vascular 
rete of the true skin below. The rete, of a vivid red colour, with 
small granulations formed by the papillae scattered over its surface, 
occasionally presents minute points of a violet hue, especially under 
those vesicles that have been filled with bloody fluid. The quantity 
of serum effused is sometimes exceedingly small. In elderly persons 
I have observed the following disposition to obtain : the clusters well 
raised above the skin, distinct or confluent, and of the size of the 
largest vesicles seen in zona, were of a livid colour, flat on their 
surface, and so tough and firm that they did not give way under the 
pressure of the finger. By the eye it was impossible to judge 
whether they contained fluid or not ; but a drop of limpid serum 
always escaped when the epidermis was pricked or raised by the 
point of a pin ; and it was then evident that the violet tint and the 
hardness of the eruption were owing to a true elongation of the 
papillae. In a case where the patient died, I had an opportunity of 
ascertaining that the vessels which penetrate the dermis were very 
much injected in the points corresponding with those on which the 
vesicles had been evolved. 

The false membrane either does not exist, or is less apparent in 
those vesicles and vesications which have passed into suppuration. 
Those whose surface has become gangrenous, or that have been 
followed by excoriations, present different conditions, which I had 
an opportunity of examining at leisure, in the body of an elderly 
woman, affected with confluent zona of the upper part of the chest, 
who died towards the decline of the disease at the hopital St. Antoine, 
of inflammation affecting the mucous membrane of the alimentary 
canal and air-passages. The excoriations were jagged, very irregu- 
lar, and interspersed here and there with minute islets of skin, which 
appeared healthy, or simply red on its surface. The skin was destroyed 
to unequal depths on the excoriated points; in all it was softened, 
presenting in several a consistence no greater than currant jelly; the 
reticulated fibres of the dermis could not be distinctly made out ; in 
sundry other places the skin, detached from the subjacent cellular 
membrane, was seen pierced with a few holes ; in other places, again, 
it was completely destroyed through a considerable extent. The 
cellular substance only showed traces of inflammation here and there. 
The subcutaneous nerves, especially those which are supplied by the 
cervical plexus, examined with the greatest care, exhibited no appre- 
ciable alteration. The disease of the skin, though confluent, had 
not been accompanied by much pain. 

327. Causes. — The causes of herpes zoster are little known. The 
disease is more frequent in summer and autumn, especially when the 
temperature is variable, than at other seasons. I saw a very great 
number of cases during the summer and autumn of 1827. Geoffroy, 
on the contrary, saw a great many patients labouring under the 



disease in the month of March, 1778. Adults are more, frequently- 
attacked than children and elderly persons. I have known several 
persons suffer repeated returns of the disease in the space of seven 
or eight years, just as others are liable to renewed attacks of erysipelas, 
urticaria, &c. It has been observed as a hereditary disease ;' it is 
neither contagious, nor has it been seen as an epidemic. Geoffroy, 2 
indeed, says, that " many persons were attacked with zona in March, 
1778," but he observes, at the same time, that the prevalent diseases 
were catarrhal affections of the head and chest. Very lately this 
cursory remark of Geoffroy, and several cases of the disease which 
had been accidentally collected within the same hospital, have been 
quoted as instances of the epidemic prevalence of zona. True 
epidemic diseases attack large masses of the population, not a few 
individuals. 

328. Diagnosis. — The clusters of vesicles which characterize herpes 
phlyctenodes differ from those of zona in this, that they always 
appear on several regions of the body, such as the nape of the neck, 
the parotid regions, the ears, the sides of the chest, the axillae, &c, 
and never assume the regular arrangement in a semi-cincture like 
zona. Several other particular characters further distinguish herpes 
zoster or zona, from herpes phlyctenodes, and the other varieties of 
this vesicular disease. The vesicles of almost all of these are smaller 
in size, and are never followed by the deep excoriations, nor the 
eschars occasionally observed in zona. With erysipelas, zona has 
only the functional derangement of the digestive organs, which so 
often accompanies both, in common ; in the external and general 
characters of erysipelas, none of the local and particular symptoms of 
zona are to be discovered. Notwithstanding this fact, herpes zoster 
has actually been described by some authors as a species of erysipelas, 
probably because the surface affected by the latter is occasionally 
covered with a few phlyctenae. But it seems impossible to confound 
the clustered vesicles of zona with the irregular and often very large 
bullae observed in erysipelas. It is, indeed, true that the vesicles 
of zona, when they are confluent, occasionally change into irregular 
vesications; but then they are surrounded by areolae that extend in 
proportion as the disease advances, and the vesicles and bullae 
approach the period when they dry up and become converted into 
scabs or incrustations. Moreover, zona constantly appears in a form 
that is every way different from erysipelas. In the latter, the swelling 
of the skin, always much more remarkable than in zona, is accom- 
panied by a tumid or puffy state of the subcutaneous cellular mem- 
brane. Erysipelas ends in a general desquamation of the surfaces it 
had affected, whilst the fall of the incrustations of zona is limited to 
the points that had been immediately occupied by its vesications and 
groups of vesicles. The form assumed by zona suffices to distin- 
guish it from pemphigus. Zona only attacks a stripe or band of the 
skin ; pemphigus is characterized by a single large bulla, or by 
numerous bullae scattered over different regions of the body, which 
never extend in the form of a girdle. In zona, the accompanying 
redness spreads in a large areola around each cluster more and 
more widely as it advances toward suppuration, whilst in pemphigus, 
very slight and narrow areolae are alone observed ; occasionally, 
indeed, no areola whatever is visible ; the redness of the skin in 
pemphigus, too, when it does occur, diminishes as the bullae extend 
or dry up. 

329. Prognosis. — Zona is never a serious disease among children 
or adults ; in the aged it may be succeeded by sloughing and gangre- 
nous ulceration, and these are accidents that always prove formidable. 
Langius 3 cites two cases in which this disease was fatal. Platner 
and Hoffmann have unquestionably alluded to cases of the same 
character when they speak of zona as a dangerous and malignant 
malady. Lorry, Burserius, Geoffroy and others have not noticed any 
cases of this description, which must, therefore, generally speaking, 
be held as exceptions ; these authors do not see any thing alarming 
in zona. Of several hundred cases I have treated mysellf, I do not 
remember more than five or six that proved fatal, and the subjects of 
these were constantly aged persons. If Pliny, the naturalist, says 
that this disease becomes mortal when it forms a belt completely 

1 Lond. Med. Gazette, vol. ii. p. 632. 

2 Mem. de la Societe roy. de Medecine, t. 2, 1778. 

3 Epist. Med., p. 110. 



HERPES ZOSTER. 



107 



round the body, the opposite statements of Turner, and the observa- 
tions of M. Montault, prove the assertion to be incorrect. 

^ Herpes zoster sometimes forms the crisis of more serious affections. 
The interesting case related by W. Gulbrand, de vertigne periodica 
per zonam solutd is well known. An instance of pleurisy consequent 
on the healing up of an ulcer, relieved by the eruption of herpes 
zoster, has been recorded. 1 In this case, however, the symptoms and 
characteristics of pleurisy are not rigorously set forth. On the other 
hand, the progress of zona may be modified by existing or intervening 
diseases. Two females, placed under the care of Dr. Recamier, were 
attacked with sciatic neuralgia : groups of vesicles, resembling those 
of herpes zoster, appeared here and there upon the thighs and legs of 
the attected side ; but instead of increasing in size, of attaining ma- 
turity, and, in a word, running the usual course of zona, they became 
flaccid almost immediately after being thrown out, and soon dried up, 
so that after the fourth or fifth day no farther traces of the eruption 
were visible. 2 

330. Treatment. — When zona is preceded by severe pain, heat 
of skin, and acceleration of pulse, a bleeding from the arm, or the 
application of a number of leeches to the verge of the anus, or to the 
epigastrium, is often a useful measure ; these symptoms, however, are 
commonly soon abated by rest, spare diet, and cooling drinks. The 
primary symptoms may either decline immediately, or continue with 
nearly the same intensity during several days, and compel us again to 
have recourse to the lancet, especially when the blood at first ab- 
stracted has been buffy. I have by this means treated successfully 
the insomnia and pain attending zona with fever, in a considerable 
number of cases. When the patients have refused to be blooded, I 
have ordered the application of a line of leeches along the most pain- 
ful parts, and an anodyne draught to be taken at night. The speedy 
relief that is so speedily obtained in this way, is always looked for 
several days before it arrives, when the treatment is limited to the 
purely expectant method. In general, blood-letting, which is pre- 
judicial in the cases of elderly persons, and unnecessary in those of 
persons in the vigour of life, when the eruption is inconsiderable in 
extent, and not very violent in character, is very beneficial in cases 
of zona that are accompanied by violent pain and high fever, when 
the age and the constitution of patients warrant us in having recourse 
to the measure. 

I have frequently seen the tartrate of antimony prescribed in the 
beginning of shingles, and I was myself for several years in the habit 
of employing this medicine, when the disease was accompanied by 
symptoms of gastric derangement; but I am now satisfied that the 
complaint went on, unmodified for the better, even to the time of the 
complete desiccation of the vesicles; the purely expectant method 
was even more fertile in results, (a) 

Emollient topical applications hinder the vesicles from drying up, 
and seem rather to induce than to prevent excoriations. Opiate lini- 
ments have the same ill effects, but they allay pain, and induce sleep, 
when they are applied to the ruptured vesicles, or excoriated surfaces. 
They never cause the recession of the disease, which several writers 
have apprehended. 

When the disease is confluent, and the cuticle is raised or removed 
from a great extent of surface, or, otherwise, when patients do not 
consent to keep their beds, it is proper, if the vesicles be not touched 
with any escharotic substance, to protect them from the friction of the 
clothes," by powdering them with starch, or covering them with tissue- 
paper, impregnated with oil and laudanum, or a piece of soft lint 
spread with cerate, retained in its place by a light bandage. 

Patients, and especially such as are advanced in life, ought to be 
careful to lie habitually on the unaffected side, a precaution without 
which they will run the risk of inducing gangrene in one or several 

(a) Associated as this, and the other species of herpes, often are 
with derangement of the digestive functions, the judicious use of laxa- 
tives, including calomel, followed by salines and magnesia, and, if 
the disease should persist, of sulphur, and of syrup of sarsaparilla with 
iodide of potassium, will be powerful aids in the treatment. 

1 Pleurisy, with an eruption of herpes apparently critical. (London Med. Gaz., v. 
1, p. 707. 

2 Revue Medic, t. xxv. p. 435. 



of the clusters. Should any of these small eschars chance to be 
formed, they are to be covered with a piece of sticking-plaster until 
they are thrown off, when the ulcerated or perforated skin is to be 
dressed with camphorated ointment, and a soft compress of dry lint. 
If the sloughs are large and penetrate deeply, they are still to be 
dressed in the same way, with the greatest care and regularity. A 
slight application of the nitrate of silver, at intervals, often hastens the 
process of cicatrization. Internally wine, or wine and water, should 
be allowed ; wine and the decoction of bark are the diet drinks of the 
aged. 

Turner recommended the vesicles of shingles to be denuded of their 
cuticle ; M. Serres proposes to cauterize them, with a view to shorten 
the period of the eruption, and to lessen its attendant pain. I have 
tried the plan ; the first five cases were not favourable in their results; 
all the patients complained that the process was very painful, and it 
did not seem sensibly to shorten the disease. I have, however, varied 
the mode of procedure of late, and I find now, 1st, that if, after having 
opened the vesicles, or removed the cuticle by excision, their bottoms 
be very lightly touched with the nitrate of silver, in the same way as 
is often done in aphtha?, the duration of shingles is abridged, and 
that, on the contrary, it is prolonged, if the escharotic be too freely 
and carelessly applied ; 2d, that the vesicles, when properly cauter- 
ized, are more rarely followed by excoriations, or by eschars, than 
those that are left to themselves, especially in elderly persons, and 
when they are situated upon the posterior parts of the body ; 3d, that 
this system, which may be omitted in slight and distinct cases of 
shingles, ought to be put in force whenever there seems reason to 
apprehend excoriations or eschars in any of the groups on the body, 
face, &c. ; 4th, that in touching slightly the red patches which precede 
the eruption of the vesicles, and especially those which appear subse- 
quently to the first crop of clusters, their further development is almost 
always arrested, but that the acute pain which accompanies them is 
not modified or abated. 

As to the subcutaneous pains, which in various degrees of severity 
occasionally continue several months after the disappearance of shin- 
gles from the parts it had invaded, they are commonly relieved by 
the exhibition internally of hyoscyamus, belladonna, and powdered 
stramonium seeds; (a) by the use of local vapour baths, or of a suc- 
cession of blisters along the course of the affected nerves. An old 
woman who suffered much from a neuralgic affection of this kind, 
was speedily cured by taking a drachm of the subcarbonate of iron 
three times a day. I have, however, met with many of these neural- 
gic affections which neither yielded to any of the remedies mentioned, 
nor to many more besides that were tried. I cannot better compare 
these obstinate pains which supervene after shingles, than to certain 
cases of tic-douloureux whose resistance to therapeutical agents of 
every kind is often truly deplorable. (6) 

(a) Or, still better, of the extract of stramonium. More than mere 
analogy will direct the use of colchicum in these cases ; also decoc- 
tion of dulcamara. 

(b) The following observations by Mr. Plumbe (op. cit. p. 214) 
are worthy of notice in the present connection. "Like the prickly 
heat, the eruption of herpes can never be checked [repelled?] by 
any medicine or medicinal application ; and those, therefore, which 
relieve the sufferings of the patient, ought not to be neglected. Solu- 
tions of ceruss. acet, or the liq. plumb, acet. dil., with the addition 
of alcohol, may be applied with advantage by means of wetted linen ; 
they lessen the pains in question, but never check the eruption in its course. 
The vesicles ought not to be cut or rudely broken, such a proceed- 
ing generally rendering the separation of the scab considerably more 
tedious than it would otherwise be; but if care be taken to puncture 
each individual vesicle early, so as to allow of the free escape of 
the fluid, the pain is much diminished, and the irritation sooner sub- 
sides." Dr. Mackintosh says that, in herpes zoster, leeches on the 
inflamed part, if early applied, will arrest the further progress of the 
disease. Plumbe has found blisters near the inflamed spot exert a 
similar effect. 



108 



VESICULiE. 



Historical Notices and particular Cases of the Disease. 



331. Celsua signalizes the principal characters of herpes zoster in 
his description of the first species of ignis sacer, " Exasperatumque 
per pustulas continuas, quarum nulla altera major est, sed phuinue 
perexiguae. In bis semper fere pus, et saepe rubor cum calore est, 
serpitque id nonnunquam sanescentre eo quod primum vitiatum est, 
nonnunquam etiam exulcerato, ubi ruptis pustulis ulcus continuatur, 
humorque exit qui esse inter saniem et pus videri potest. Fitmaxime, 
in pectore aut lateribus, etc." 1 Scribonius Largus considers it as a 
species of herpes, and distinguishes it from the ignis sacer "Zona, 
quam Graci e^tt^ra dicunt." 2 Pliny entitles the disease zoster. 3 
Several other names have been given to it in modern times, such as 
zona ignea, zona serpiginosa (Schwarz), herpes zoster (Willan), erysi- 
•< zoster (Sauvages), erysipelas phlyctenodes (Cullen), dartre phlycte- 
■/<• en zone (Alibert), cingulam, shingles, &c. 

Schenckuis' relates a case of zona of the loins and thigh that was 
cured by a bleeding from the foot. Tulpius 5 has given a good de- 
scription of zona of the trunk. Turner 6 has published observations 
on shingles of the neck, of the trunk, and of the limbs. In the first 
edition of this work I gave an account of the disease affecting the 
face and mouth. Bergius, 7 Jos. Frank, 8 and M. Cazenave, 9 have 
each published notices of the disease affecting the head and hairy sculp. 
Hoffmann tells us that he had seen the eruption of zona preceded by 
anxiety and delirium. 10 Messrs. Serres, 11 Bedor, 12 Em. Geoffroy, 13 
Velpeau, 14 &c, have written in favour of the cauterization of the 
vesicles of zona. Pinel 15 and M. Louis 16 have given us histories of 
cases in which the pain continued for several years after the disap- 
pearance of the eruption ; M. Molinie" and M. Lesenecal, 18 have 
inserted in their inaugural dissertations, the histories of many cases of 
zona of the trunk and extremities. In the two following cases the 
disease appeared in quarters where it is very rarely seen. 

Case XXXVII. Herpes zoster of the left side of the face, and of the 
inside of the mouth. M. M * * *, twenty-seven years of age, and of 
regular habits, entered the Hotel Dieu on the 29th of March, 1826. 
On Thursday the 23d, without known cause, this patient felt slight 
shooting pains in the left ear, which became more severe on the 24th, 
and extended to the neck. Whilst smoking, as usual, on the 25th, 
he felt severe prickling pains in the tongue, which one of his friends 
examined, and told him it was white. In the night, between Saturday 
and Sunday, a number of small blisters were developed on the left 
cheek close to the ear, which on Monday and Tuesday became more 
numerous and spread over the chin. On Wednesday the patient went 
out and got chilled ; on returning home he continued to shiver for 
three hours. This cold fit was succeeded by a burning heat that 
lasted the whole night. The patient did nothing for himself until 
Sunday, when he had a little olive oil dropped into the ear that was 
painful, and washed his mouth repeatedly with vinegar and water. 
Wednesday, 29th of March, the day of the patient's admission into 
the hospital, the disease was in the following state : 

The left cheek is swelled, hard and hot. From the ear to the chin, 
over a surface about three fingers' breadth in extent there is a band of 
bullae and rounded vesicles, of different sizes. The vesicles are from 
half a line to a line in diameter, and are separately disseminated, or 
gathered together in clusters. The bullae are much more voluminous 
than the vesicles, but much fewer in number; they are from four to 

1 Celsus. De re medica, lib. v. cap. 28, § 4. 

2 Scribonius largus. De composit. medicam., cap. 99, 100. 
a Nat. hist., lib. xxvi. cap. 11. 

« Obs. med., in-fol., lib. v. p. 639. 

s Obs. med., lib. iii. cap. 44 (Excedens proecordiorum herpes). 

e On diseases of the skin, chap. 5, p. 80. 

» Eph. nat. cur. dec. ii., an. 3, obs. 171. 

8 Act. clinic, vol. iii. p. 22. 

9 Journ. hebd., t. i. p. 317. 

"> Bergius. Insiit. med. De igni sacro, t. ii. p. 34. (Hoffmanni Observatio.) 

I' Journ. des hupitaux, in-fol., pp. 41, 62, 89. 

M Journ. hebd., 2e serie, t. i. p. 271. 

"3 Revue med., t. x. p. 50. 

14 Nouvelle biblioth. ined., t. iv. p. 435. 

is Xosog. philosoph. Arl. zona. 

ic Journ. hebd., I. vi. p. 361. 

i" Molinie. Diss, sur le zona, in-8. Paris, 1803. 

>9 Lesenecal. Diss, sur le zona, in-4. Paris, 1814. 



six lines in diameter. Many vesicles appear about their circumference. 
Several of the bullae and vesicles are transparent, and contain a limpid 
tluid ; others are of a dull white colour, and are filled with what ap- 
pears to be purulent matter. Both bullae and vesicles are mingled 
with many irregular yellowish and soft incrustations. 

There is a copious secretion of pus from the meatus auditorius ex- 
ternus. Neither redness nor ulceration are apparent in this part; but 
the concha is covered with several small vesicles. 

The left half of the tongue is swelled, thick, red, and covered with 
soft whitish plates of an irregular shape. Some of them are of the 
size of the vesicles, others nearly as large as the bullae that exist on 
the skin. These plates appear to be about as thick as a sheet of 
paper. Several of them formed of the epithelium thickened, are 
almost detached. White patches or spots of a similar kind are ob- 
served on the inferior surface of the tongue, on the inner side of the 
left cheek and left half of the gums and lower lip ; but none are to 
be seen on the palate, nor on the upper lip. Lastly, the affection 
appears to be limited in the most precise manner by the median line : 
the right half of the mouth and particularly the right half of the tongue, 
have their natural colour and appearance. 

The saliva, which is abundantly secreted, is ropy; the breath is 
offensive, but has nothing of the mercurial odour. The patient 
neither complains of heat nor unpleasant taste in the mouth. The 
pain of the ear is much less to-day ; he does not complain of head- 
ache, has no cough, little inclination for food, less thirst; the bowels 
have been locked up during the last three days ; the abdomen is not 
tender, even on pressure ; the urine is natural ; the pulse strong and 
full, not febrile in its character. (Venes. ad §xii ; veal broth for 
drink ; lavement, gargle of barley water with honey and roses ; spoon 
diet.) March 30th. — The vesicles and bullae which were plump last 
evening, are changed into yellow scabs. Five new vesicles, as large 
as pin's heads, have been formed during the night. Several of the 
white plates that adhered to the tongue are detached. The pulse is 
quicker than it was yesterday, but not so full. ( Veal broth, gargle, 
spoon diet.) April 5th. — There is now no trace of the white specks 
in the mouth. The left margin of the tongue presents a longitudinal 
furrow, bounded above and below by a prominent red line. The 
upper surface of the left side of the tongue is still red and uneven. 
When the patient thrusts his tongue out of the mouth, the point 
deviates to the right side. The secretion of saliva is much less 
copious than it has hitherto been; the left cheek is less tense; it is 
now neither injected nor hot. The scabs that have followed the 
bullae and vesicles of the chin bear a slight resemblance to those of 
impetigo fgurata. Three scabs are observed, differing from all the 
others, near the concha of the ear; these are brown, dry, like a 
small portion of horn, and are a little under the level of the skin. 
To these a poultice was applied. April 28th. — All the scabs have 
been thrown off'. The skin of the chin, in several places, is callous, 
indurated, and covered with tubercles like those that succeed men- 
tagra. From this time the patient continued quite well, and soon 
left the house. 

Case XXXVIII. Herpes zoster of the left side of the face, neck, 
meatus auditorius externus, and part of the hairy scalp. — B. Lambert, 
seventeen years of age, presented himself among the out-patients ot 
the hopital St. Antoine, on the 24th of August ; on the 19th, this 
patient had complained of heaviness of head, and heat in the regions 
that were now covered by an eruption of herpes zoster, which, in 
clusters of various sizes, extended upwards from above the clavicle 
on the left side to behind the ear, to the cheek, and parts covered by 
the beard, and downwards over the fore and outer parts of the chest. 
The clusters are everywhere of a bright red colour, which disap- 
pears under the pressure of the finger, and re-appears immediately 
on its removal. On several of them, less advanced than the rest, 
small vesicles are seen situated upon and projecting in a slight degree 
from the surface of a red patch of skin underneath. On the right 
side, behind the ear, and upon the scalp of the same side, these 
vesicles are more apparent than those of the groups scattered amidst 
the beard and over the chin. The patient assures us that these last 
have appeared since yesterday. One cluster is conspicuous in front 
of the meatus auditorius at the root of the hair; another is seen 
within the meatus itself. 



HERPES PHLYCTENODES. 



109 



The parts covered by the eruption are not particularly painful; the 
state of the general health is good, and the patient complains of no 
want of appetite. 

The patient was not restricted in any way ; at the end of the second 
week a few livid spots of the same shape as the previous clusters of 
vesicles were all that told of the existence of this eruption. 



HERPES PHLYCTENODES. 
Vocab. Herpes miliaris, Herpes phlyctenodes. 

332. Herpes phlyctenodes is characterized by clusters of globular 
and transparent vesicles, as large as millet-seeds, or the smallest 
peas, which appear in variable numbers upon red patches, usually of 
a circular form, and disseminated over different regions of the body. 

333. Symptoms. — This species of herpes, which is excellently 
described and represented by Bateman, is occasionally developed on 
the forehead, the cheeks, and the neck exclusively; more frequently 
it appears first on the extremities, whence it spreads to various other 
quarters. Willan and Bateman conceive that herpes phlyctenodes is 
always an acute disease. I have seen it assume a chronic form, one 
crop of vesicles being evolved after another. 

A sensation of tingling, of itchiness or painful smarting and pun- 
gent heat in the parts where the eruption is about to appear, is fol- 
lowed by the formation of minute and almost imperceptible red points 
clustered together, so as speedily to compose an irregular coloured 
patch, the breadth of which varies between that of a half-crown 
piece and that of the palm of the hand. Some hours afterwards, or 
next day at farthest, a number of hard, shining and globular vesicles, 
varying in size from that of a millet-seed to that of a small pearl or 
pea, arise on the inflamed patches. These are filled with serum, 
which is usually colourless, or of a pale citrine tint, but occasionally 
presents a brownish hue in the aged. The vesicles themselves occur 
in irregular clusters of different magnitudes, but consisting in general 
of from a dozen to about fifty vesicles. To these primary clusters, 
which are often not more than one or two in number, several similar 
groups succeed. The integuments preserve their natural appearance 
between the different clusters, but seldom between the several vesicles 
composing the particular groups. The tingling and smarting sensa- 
tions are increased by augmentations in the external temperature and 
by the warmth of the bed during the night. The size of the vesicles 
in general increases with rapidity; some of them even acquire rather 
considerable dimensions, and appear formed by the confluence of 
several into one. Twenty-four or thirty-six hours scarcely elapse 
after the appearance of the inflamed patches, before the fluid in the 
vesicles becomes turbid. The smaller assume a milky hue; the 
larger turn brown and are filled with sanguinolent serum. The 
whole decline, or are broken, from the sixth to the tenth day, during 
which interval new clusters continue to arise. The fluid of the very 
minute vesicles is occasionally reabsorbed, and many clusters seem 
to miscarry ; the fluid they contained is rapidly turned into yellowish 
or blackish scabs, which are usually loosened from the tenth to the 
twelfth day. The parts of the skin that have been affected retain 
for some time a red or livid colour ; and a painful sensation of prick- 
ling or smarting, very similar to that which follows shingles, occa- 
sionally continues for some time after the eruption has disappeared. 
Several weeks after the cure of the vesicles, small circular yellow 
stains still show the points they have occupied. 

Between the irregular clusters of the herpes phlyctenodes a few sin- 
gle vesicles, and occasionally a few pustules, make their appearance. 
In some rare cases the clusters of herpes phlyctenodes have a regular 
circular form, and the areas of the patches are covered by distinct, not 
confluent vesicles. This variety, which in England is known under 
the name of the nirles, is always attended with violent pain, and a 
notable derangement of the general health. 

The appearance of phlyctenoid herpes is occasionally connected 
with some slight disorder of the digestive organs, proclaimed by tar- 
dy digestion of the food, by thirst, heat and oppression of stomach, 
tumid state of the abdomen, &c. In some cases this internal affec- 
tion even attracts our attention more than the outward malady. Seve- 
28 



ral other symptoms precursory to the eruption, are also frequently 
observed : one patient complained for two days of acute pains similar 
to those of rheumatism or sciatica, and anon the disease made its ap- 
pearance upon the two lower extremities. It may also occur in indi- 
viduals labouring under other diseases: in an individual affected with 
a pulmonary catarrh, I have seen herpes phlyctenodes evolved on the 
face, the front parts of the thorax, under the axilla?, on the extremities 
and on the scrotum ; in this case the vesicles were preceded by red 
patches several inches in diameter, slightly raised above the level ot 
the skin, and were so minute that they could scarcely be distinguished 
by the naked eye. Among the clusters on the scrotum there were 
several that might very readily have been mistaken for something else, 
without attention to the nature of the neighbouring groups. The cuta- 
neous eruption in this case had no influence either salutary or noxious 
on the progress of the bronchial affection. 

The duration of herpes phlyctenodes varies considerably ; usually 
lasting three weeks, it is occasionally much more protracted ; the spots 
that follow the vesicles often continue visible for several months. 

334. Causes. — Like those of shingles, the causes of herpes phlycte- 
nodes are exceedingly obscure. The disease occurs more frequently 
in persons of mature age than among children and the aged ; it is 
often observed to follow night watching, moral affliction, and other 
acts that powerfully excite or modify the nervous system. (a) 

335. Diagnosis. — Herpes phlyctenodes cannot be confounded with 
pemphigus: the former being characterized by an eruption of vesicles, 
the latter by one of bullae. Several circumstances, however, may 
conduce to obscure the distinguishing features of these two diseases. 

In the first place we see that M. Alibert formerly described pemphi- 
gus under the name of herpes phlyctenodes or dartre phlyctenoid e ; but 
this is not the first occasion on which two different diseases have been 
called by the same name : to avoid error it is in this instance enough 
to be informed of its existence. On the other hand, the practice of 
employing the words bulla and phlyctena as synonymous terms, ought 
to have led Bateman to avoid the use of the appellative phlyctenodes, 
which is calculated to continue the confusion of names. The old 
denomination of miliaris — herpes miliaris, or any other that bore 
reference to the size or disposition of the vesicles would certainly 
have been preferable. 

Herpes phlyctenodes approaches pemphigus in its characters when 
the bullae are of small size, as they are often observed to be in the 
variety designated pruriginosus ; the bullae of pemphigus, however, 
are seldom seen in groups. Farther, the bullae in pemphigus pruri- 
ginosus are small, round and mixed with papulae, whilst in herpes 
phlyctenodes, when the vesicles are large, they are angular or irregular 
in shape. When herpes phlyctenodes is complicated with accident- 
ally occurring bullae, it may be confounded with pemghigus conjoined 
to an herpetic affection ; these two conditions form a sort of transition 
reciprocally from the one disease to the other. The bullae of acute 
pemphigus differ too widely from the vesiculae of herpes phlyctenodes 
to make the diagnosis in this case either uncertain or difficult. 

In eczema the vesicles are rarely seen in clusters ; I have, however, 
met with a few instances of this arrangement. The vesicles of eczema 
are always smaller and less prominent than those of herpes. 

336. Progiiosis and treatment. — Herpes phlyctenodes, the dangers 
of which have been strangely exaggerated by some pathologists, sel- 
dom appears on a great many regions of the skin at once. When it 
occurs, as it almost always does, with the acute type, it gets well of 
itself in the course of one, two or three weeks, in individuals of sound 
constitution. Its period may be shortened by cauterizing the vesicles. 
I always find it yields readily to cold or tepid bathing, to cool emollient 
and soothing lotions, to diluents and the antiphlogistic regimen, with- 
out having recourse to blood-letting. Nevertheless, in herpes phlyc- 
tenodes, as in shingles, when the patients are strong and the eruption 
is abundant, and so painful as to cause sleepless nights, a bleeding 
from the arm never fails of giving great relief. The blood abstracted 
under these circumstances is often found to be buffy. 

Any increase of temperature adds to the pain and uneasiness. Cold 

(a) Plumbe points out the fact, which must have been noticed by 
other practitioners, of the frequent occurrence of this disease in chil- 
dren during the period of dentition. 



110 



VESICUL^E. 



lotions and cold poultices applied to those clusters that are very much 
inflamed, occasionally give ease ; but as they prevent the scabbing 
over of the vesicles, they are in general rather injurious than bene- 
ficial. 

When the disease appears in children, Underwood recommends the 
juice of the Pastinaca sativa, in doses of from one to five tablespoon- 
Yuls, mixed with a small quantity of milk. 

In brief, when the disease is acute, but inconsiderable in extent, it 
may be left to itself, for it gets well spontaneously in no long space 
of time ; this at least may always be done when children are affected, 
as the application of escharotics alarms them greatly ; but when adults 
are attacked the vesicles should be slightly touched with lunar caustic, 
and, if need be, a small quantity of blood abstracted. When the 
disease assumes the chronic type, and the vesicles appear in success- 
ive crops, a case which very rarely happens, experience shows that 
the use of purgative medicines contributes essentially to its cure, as 
it does to that of those eruptions generally, the development of 
which appears occasionally to depend on a buffy state of the blood. 
The violent pains that so frequently follow shingles, occur more rarely 
after herpes phlyctenodes, which also leaves cicatrices of the parts it 
has invaded less commonly than the herpes zoster. 

Historical Notices and particular Cases of the Disease. 

337. Bateman believes that it was this variety of herpes that Galen 
meant to designate, when he spoke of the i%Hr t s xiyxe,ias [herpes miliaris). 
The passages quoted by Foesius, 1 and all those I have consulted with 
the assistance of the novus Index in omnia quae extant Galeni opera, 
foi., Basil. 1562, appear to me too vague to be capable of any rigor- 
ous and precise interpretation. I even perceive as many of the cha- 
racters of eczema as of those proper to herpes, in this author's account 
of the Roman matron who laboured under a herpes of the ankle. 2 
yEtius 3 repeats Galen. And the same vagueness of description, and 
the same uncertainty pervade the whole of the notices of herpes 
miliaris we meet with until the time of Turner, 4 who specifies the 
characters of the disease with precision. Willan and Bateman 5 have 
described it still better than Turner, and have figured it fairly. Rus- 
sell 6 speaks of it under the very objectionable title of herpes excedens. 
Jos. Frank's 7 account of the disease is not marked by exactness, and 
is even obscured by false contrasts with other affections. Underwood 8 
has spoken of its occurrence among children, and Alibert has de- 
scribed this variety of herpes under the name of olophlyclide miliarc. 

Case XXXIX. Herpes phlyctenodes of the face, preceded by pleu- 
risy and erysipelas. Rogers, admitted into La Pitie, on the 14th of 
January, 1826, labouring under pleurisy, which was arrested by the 
general and local abstraction of blood. A few days afterwards an ery- 
sipelatous inflammation attacked the face, for which sixteen leeches 
the one day and eight the next, were applied behind the ears and to the 
temples with the effect of immediately cutting short the disease. On 
the 12th of February an eruption of herpes phlyctenodes appeared 
on the skin of the face which was then losing its cuticle. Several 
clusters of vesicles were situated over the malar bone and masseter 
muscle of the left cheek, and on the frontal, temporal and nasal regions 
of the right side. The greater number of these vesicles were about 
a line in diameter, others were somewhat larger. They were unsur- 
rounded by any red border, contained a whitish and semi-transparent 
serum, and were only distinguished at first sight from the rest of the 
skin by their white and silvery aspect. In the intervals between them 
the skin retained the pallid hue it had assumed ever since recovering 
from the erysipelas. The vesicles were developed without heat o'r 
pain of the skin. The tongue appeared a little red, yet the digestive 
functions were regular and the sleep was natural. 'On the 18th the 
vesicles had dried up and were succeeded by small scabs, in general 
of a thin texture and brown colour, though some of them were thicker 

' CEconomia Hippocratis, art. Efw?,-. 

:!eni meth. med. in fol. Basil., lSfil, t. iii. p. 184. 
I jEuus. Tetrab. serm. 2, cap. lx. p. 73. 
' ^ 'realise of diseases incident to tlie skin, in 8i-o. London, 1731, fifth ed, p. 74. 

* Delineations of cutaneous diseases, pi. xlix. - 

• De herpetibus, in 8vo., p. 29. 

I Praxeos univ. medic, praecepta. Art. herpes miliaris. 
» On the diseases of children. Eighth edit., in 8vo. p. 162. 



and of a yellow hue. An inflammatory affection of the gastric and 
bronchial mucous membrane succeeded this slight disease of the skin, 
and the patient continued for some time longer in the hospital. 

Case XL. Herpes phlyctenodes of the body, face and lower extremi- 
ties, preceded by catarrhus vesica, and followed by bronchitis. Pierre 
Fort, aged 71, of good constitution, but with a yellow and bilious 
look, consulted me on the 19th of March, 1826. Three weeks pre- 
viously he had had symptoms of retention of urine, which on the 14th, 
in consequence of some freedom in diet, became complete ; fever set 
in and continued for eighteen hours, at the end of which time, and 
after drinking copiously of linseed tea, &c, he began to pass his urine 
without the use of the catheter. Since then P. F. makes water six 
or seven times a day. He complains of no pain in the hypogastric 
region, and shows none of the symptoms of chronic inflammation of 
the bladder. The object of his visit was to seek advice for another 
disease, herpes phlyctenodes complicated with bronchitis, which had 
first appeared on the 17th of March, during the violent sweating fit 
that terminated the febrile paroxysm brought on by the retention of 
urine. During the night between the 16th and 17th, several clusters 
of vesicles were observed on the front and lateral parts of the chest ; 
a few vesicles were also evolved on the lips, alas nasi and ears, during 
the course of the 17th. Next day he complained of tinglings in the 
buttocks, on which he could not rest without pain: the eruption had 
in fact extended to these parts. 

19th. Many distinct and unbroken vesicles were seen on different 
parts of the face ; several clusters in different stages were remarked 
on the chest, some of them transparent, others turbid, and filled with 
sero-purulent fluid; on the buttocks there were two distinct clusters, 
of rather larger dimensions than they possessed in other situations. 
These vesicles were everywhere of a much larger size than those of 
eczema; their base was very slightly inflamed, but still surrounded 
by a narrow red border. Besides the disease of the skin, I detected 
an affection of the bronchi. The inclination for food w r as not great; 
the sleep was interrupted by fits of coughing (pectoral tisan, linctus, 
vegetable diet). 24th. — The great number of the vesicles were now 
dried up ; such as were not so far advanced, had a small yellow point 
in their centre ; and others had been destroyed by rubbing. 26th. — 
The vesicles that had escaped destruction were transformed into black 
scabs, of an oval shape, and of the size of small grains of rice. 28th. 
— Small red spots indicated the points from which the scabs had been 
detached. The bronchial affection continued for some time longer 
than the disease of the skin. 



HERPES CIRCINNATUS. 



Vocab. Herpes Circinnatus, Ringworm. 



338. Herpes circinnatus, or vesicular ringworm, is characterized 
by an eruption of small, globular, and very closely crowded vesicles, 
arranged in the form of rings, or completely circular bands. The 
portions of skin included within these are usually healthy, and the 
edges, more particularly, or the circlets, are seen to be studded with 
vesicles, and of a red colour of greater or less intensity. The dura- 
tion of this eruption extends necessarily to no longer a period than a 
week or two, but it may be greatly protracted beyond this interval 
when the eruption of the vesicular rings is successive. It appears on 
the neck, cheeks, arms, shoulders, and other places, under the form 
of red and inflamed oval or circular spots, from half an inch to two 
inches in diameter, the evolution and continuance of which are ac- 
companied by a very troublesome sensation of itchiness and smarting. 
The redness is less vivid in the centre than towards the circumference 
of the smaller spots. It is entirely wanting in the areas of the larger 
patches, within which the skin preserves its natural appearance. 
Small globular vesicles very closely set, whose bases are slightly 
inflamed, and which contain a transparent fluid, are rapidly developed 
around the circumference of the patches, at the same time that their 
areas become temporarily of a deeper red colour. From the fourth 
to the sixth day of the eruption the redness declines ; the vesicles of 
the circumference become turbid, and then either burst, or are covered 
by small brownish scabs of extreme tenuity, which in their turn are 



HERPES LABIALIS. 



Ill 



detached between the tenth and fifteenth day ; at the same time a 
slight desquamation takes place from the centres of the spots when 
the redness has spread to them. Occasionally the fluid of the vesicles 
is reabsorbed, in which case they sink down, and are followed by 
an almost imperceptible exfoliation of the epidermis. The circlets of 
small diameter, covered with extremely minute vesicles are those 
especially that terminate in the manner just indicated ; those of a 
larger size, and crowned Avith vesicles of greater dimensions, scab 
and scale off like herpetic eruptions in general. 

Herpes circinnatus is never accompanied by any general functional 
derangement, — always understood that it is not complicated with 
another disease. It may be protracted for several weeks, when the 
patches and vesicles that characterize it are evolved in succession on 
different parts of the body. I have seen some of these ring-like 
vesicular clusters of the skin, surmounted by the bullae of pemphigus. 

Several of the children in the same school, or in the same family, 
are occasionally attacked with herpes circinnatus at one time ; this 
circumstance has led some writers to conclude that the disease was 
contagious ; the simultaneousness of evolution, however, may depend 
on other causes, such, for instance, as the impression of cold. 

English authors having treated of the herpes circinnatus under the 
name of ring-worm, a title by which a variety of favus or scall, 
(porrigo scutulata,) undoubtedly a contagious disease, has also been 
designated, this confusion in the nomenclature has probably tended 
to keep alive the opinion that herpes circinnatus could be communi- 
cated from one individual to another. Herpes circinnatus cannot be, 
and never is, propagated by inoculation. 

Herpes circinnatus is observed more especially among children, 
young people, women, and those whose complexion is fair, and skin 
is delicate. The causes of chronic herpes circinnatus, marked by its 
successive eruptions, are as completely unknown as are those of 
herpes phlyctenodes, or of pemphigus, when these diseases assume 
the same peculiar character. 

Herpes circinnatus being the only disease of the skin which shows 
itself in the guise of an erythematous patch surrounded by an areola, 
or ring of vesicles, is easily distinguished when these are not destroyed. 
Should the vesicles, however, be shrunk, and replaced by a slight 
exfoliation of the epidermis from an exactly circular ground, this 
state may be confounded with erythema circinnatum towards its de- 
cline, or with a patch of lepra vulgaris freed from scales. In the 
first case some remains of vesicles on one or another of the rings 
will clear up the diagnosis; in the second, mistake seems next to 
impossible, for the erythematous rings of lepra vulgaris on the way 
to recovery disappear with extreme slowness; and it is very seldom, 
indeed, that there are not at the same time other leprous spots to be 
found stationary, or whose cure is less advanced. As to favus in 
patches or rings — porrigo- scutulata, or pustular ring-worm — this is a 
contagious disease, of long and uncertain continuance, and covered 
with scabs, which present peculiar and distinguishing characters. 

Bateman recommends washes of sulphate of zinc, or borax, or 
alum, to soothe the itching that attends the formation of the vesicles 
in herpes circinnatus. The application of a linen rag dipped in plain 
cold water, and frequently renewed, answers the same end completely. 
Alkaline baths and saline lotions have likewise been successfully 
employed in this complaint. I am in the habit of recurring to slight 
cauterization with the nitrate of silver, with very good effects. In a 
word, the mode of treating herpes circinnatus does not differ from 
that which has been recommended in herpes phlyctenodes. 

Historical JYotices and particular Cases of the Disease. 

329. Celsus, after having evidently spoken of herpes zoster under 
the name of ignis sacer, adds, Alterum autem est in summce cutis 
cxulceratione, sed sine altitudine, latum, sublividum, incequaliter tamen, 
mediumque sanescit, extremis procedentibus, ac scape id quod jam sanum 
videbatur, iterum exulceratur. 1 This passage, which, in Bateman's 
opinion, refers to herpes circinnatus, is not to be interpreted in any 
very precise sense ; but it seems to me rather to bear upon a variety 
of palmar psoriasis, which Alibert has described as a dartre squameuse 
■centrifuge, than to the variety of herpes we are now discussing. 

1 De re medica, lib. v. sect. 28. 



Turner has indicated this variety of herpes in a perfectly clear and 
positive manner, under the titles of serpigo and ring-ivorm. 2 In the 
fourth volume of the Journal Hebdomadaire, p. 197, and in the 
Lancette Franchise, vol. v., p. 9, some observations may be found 
on herpes circinnatus. I have given an instance (Case XXVII), ot 
its complication with pemphigus. 



HERPES LABIALIS. 
Vocab. Exanthema Labiale, Hydrcca Febrile, fyc. 

340. A slight degree of local heat, followed, before long, by a 
feeling of burning and tension, precedes and accompanies the formation 
of the clusters of vesicles that characterize herpes labialis. These 
clusters commonly form a sort of irregular ring, the circumference of 
which extends unequally towards the chin, the cheeks and alas of 
the nose. The fluid contained in the vesicles, transparent at first, 
becomes turbid in the space of twenty-four hours, and then presents 
a yellowish-white colour, which ultimately merges into a puriform 
aspect. From the fourth to the fifth day of the eruption the vesicles 
burst or dry up ; the fluid they contain escapes, or is changed into 
brownish or blackish scabs, which are commonly loosened about the 
eighth, or from that to the twelfth day, at which epoch there usually 
remains no further traces of this trifling inflammation beyond a slight 
red mark on the skin. If the scabs be picked off before they are 
completely dry, and a new epidermis is formed underneath, others 
are produced, the desiccation and detachment in which are much 
longer in taking place. This eruption is always attended with some 
degree of swelling of the affected parts. 

Herpes labialis may be produced directly, by the action of external 
causes upon the skin of the lips, such as the impression of cold, occa- 
sioned by passing from a high temperature into a cold and damp air, 
the contact of acrid or irritating substances, &c. The complaint often 
appears during the course or towards the decline of an inflammation 
of the mouth, of a coryza, an angina, a catarrh, or a pneumonia ; more 
frequently still does it follow an attack of intermittent fever, a circum- 
stance that has not been noticed sufficiently by those who have treated 
of this slight complaint. All, however, have observed, that it was 
often preceded or accompanied by aphtha?, or vesicles in the mouth. 
I have seen the variety of herpes we are describing thrown out in the 
cavity of the mouth, and on the arch of the palate, accompanied by 
difficulty of swallowing, pains in the epigastrium, eructations, nausea, 
&c. Its appearance is occasionally observed to coincide with the 
decline or cessation of an inflammatory affection of the viscera. 

Herpes labialis cannot be confounded with any other affection of 
the lips. The disposal of the vesicles in isolated groups, the con- 
siderable size which several of them attain, and their desiccation under 
the form of crusts, are so many particulars that preclude the possibility 
of confounding this disease with eczema occurring on the same parts. 
It is sometimes more difficult to distinguish this herpetic affection 
from vesicles artificially excited on the surfaces it usually invades. 

Herpes labialis is at times a symptom of favourable augury in fevers, 
and the herald of a speedy recovery : In febricantibus assidue fiunt 
pustulce circtt labia et nasum juxtd, febris solutionem. 3 As in many 
other translations and Latin works, the word pustulce is here used 
instead of vesicuke. 

This affection of the skin, which of itself is totally free from danger, 
rarely requires any other treatment beyond that indicated in the diseases 
which cause its development. Where the vesicles are numerous and 
confluent, however, and the pain, heat and swelling are considerable, 
cold and soothing lotions procure the relief, which the trifling nature 
of the malady often prevents patients from seeking. To hasten the 
desiccation of the vesicles, they may also be slightly touched with 
the nitrate of silver ; [but if they be pricked with a fine needle on 
their first appearance, and the fluid they contain be squeezed out, 
they will be arrested in their progress, and scarcely show any scab 
afterwards, the unseemly appearance of which will consequently be 
avoided.] 

2 De morbis cutaneis, p. 73, 8vo. Lond. 1736. 

3 iEtius. Tetrabib., sermo 1, p. 234. 



112 



VESICULiE. 



Historical Notice* of the Disease. 

341. Hippocrates certainly knew, and alludes to this eruption. 1 
red hv all, it has been described of late both by Willan and 
others have noticed it under the names of eruption of the 
ranthema labiate (Jos. Frank), olophtyctide labiate (Alibert). I 
shall not give any particular case of this slight affection, which pre- 
sents few points of interest; many pathologists, indeed, have only 
mentioned it as a symptom common to several acute diseases. 



HERPES PRJEPUTIALIS. 



Vocab. Aphthae, Vlcusculu prxpulii. 



342. Herpes prceputialis is characterized by one or more groups of 
small globular vesicles evolved on the outer or inner surface of the 
prepuce, occasionally on both surfaces at the same time, and which 
disappear usually within the space of a fortnight. 

The disease begins in one or several patches, six or eight lines in 
diameter, accurately circumscribed, and of a pretty vivid red colour. 
These arc attended with a slight feeling of itchiness, more particularly 
towards their centre, upon which, between the second and fourth day, 
arise a number of small globular vesicles, containing a serous and 
transparent fluid, and, from their extreme tenuity, appearing to have 
the same colour as the parts upon which they are developed. The 
heat and itching increase and become more troublesome ; the size of 
the vesicles augments, and on the third or fourth day the fluid they 
contain grows turbid and acquires a puriform appearance. When the 
eruption takes place on the inner surface of the prepuce, the rupture 
of the vesicles frequently happens as early as the fourth day; the 
epithelium is then detached, leaving the inflamed vascular rete of the 
corion exposed. A superficial sore is thus established, which, from 
the red or whitish colour it presents, and the character of its edges, 
which are but little raised, has often been mistaken for a syphilitic 
ulcer. 

The character of this herpetic eruption is less equivocal when the 
vesicles are developed on the outer surface of the foreskin. The 
fluid they contain is either reabsorbed, or dries up on the fifth or sixth 
day ; in the latter case it is changed into small dry scabs, lamellar or 
conoidal in their structure, which, being thrown off about the eighth 
or tenth day, completes the cure, if the parts have not been irritated 
by rubbing. It does not often happen that the accompanying inflam- 
mation is of violence enough to cause an enlargement of the lymphatic 
glands of the groin. Mr. Evans, however, has seen several cases of 
such a complication ; but the inflammation of the glands never ended 
in suppuration. 

The continual excitement to which the organs of generation are 
exposed, and the contact of fluids secreted by the vagina and uterus 
affected with chronic inflammation, are, of all the causes assigned for 
the production of this disease, those whose influence appears to be 
most fully established. I have thus seen the complaint reproduced 
again and again in the same individual. In similar cases, Mr. Pear- 
son believes it may be caused by the use of mercurial preparations. 
Others imagine that they have observed it occurring most frequently 
in subjects who have had one or two attacks of venereal disease. Mr. 
Copland thought it occasionally symptomatic of an irritable state, or 
of actual stricture of the urethra. Mr. Evans and Mr. Plumbe, on 
the other hand, affirm, that it is often connected with a deranged state 
of the digestive organs. All are agreed that herpes prceputialis is 
not a contagious complaint. Mr. Evans, it is true, mentions the cir- 
cumstance of a friend of his having inoculated himself in the arm 
with the fluid of a vesicle developed on the prepuce, with the effect 
of exciting in the spot a much larger vesicle than the one that had 
furnished the poison. This experiment, however, repeated several 
times, not having been attended with the same consequences, and 
being in other respects inconclusive, the production of the variety of 

' Febres in quibus ulcerantur labia fortassis intermittentes. (Hippocrates, a Van 
der Linden, 1. 1. p. 821.) v rr 

1 On the diseases in London, p. 6, 1801. 
3 Journ. gen. de medecine, U xxxii. p. 240. 



herpes under consideration, even from Mr. Evans's showing, must be 
held to be independent of any specific cause. 

The vesicles of herpes prcrputialis cannot be confounded with the 
syphilitic pustules and tubercles which are occasionally formed on the 
prepuce : each of these forms of inflammation has its own peculiar 
and distinguishing features. The venerola vulgaris of Mr. Evans is, 
of all the diseases of the organs of generation, that which might most 
readily be confounded with herpes prceputialis. The venerola, how- 
ever, commencing by a single pustule, and herpes being first perceived 
as a cluster of small vesicles, the two complaints may always be dis- 
criminated. Farther, the thin, scaly incrustations of herpes praeputialis 
can never be confounded with the thick scabs of venerola vulgaris. 
The diagnosis is, indeed, more difficult when these affections occur on 
the inner surface of the foreskin, and have passed into the excoriated 
state. The patients are generally unable to say whether the inflam- 
mation was at first vesicular or pustular. The prepuce, too, may be 
in such a state of accidental inflammation, when affected with herpes 
praeputialis, as to make the diagnosis uncertain for several days. The 
superficial excoriations of the herpes, however, are very different 
from the ulcers of syphilis, remarkable for their depth, their hard and 
raised edges, and the small gray-coloured false membrane that covers 
their bottom. In fine, the small, thin, flattened incrustations of the 
herpetic affection cannot be taken for the scabs of syphilitic pustules. 

Herpes praeputialis is a disease of no severity, and gets well com- 
monly in the space of a week or two. When evolved on the outer 
surface of the foreskin, it is seldom that we are consulted by patients, 
unless, indeed, the vesicles have been excoriated or inflamed by the 
rude contact of the clothes, or the improper use of some irritating 
local application. It is generally best to leave the eruption to itself, 
only protecting the part against friction, inasmuch as all that inter- 
feres with the desiccation of the vesicles delays its cure. Mr. Evans 
knew a case in which this was prevented for six weeks, in consequence 
of the pains that were taken, by a variety of applications, to hinder 
the little vesicles from becoming covered with scabs. When the 
vesicles are situated on the inner surface of the prepuce and have 
become excoriated, their cure may always be brought about by the 
introduction of a small quantity of lint between the glans and the 
foreskin, or by the use of simple cold water, or acetate of lead washes. 
Herpes prceputialis may recur repeatedly, at intervals so close together 
as to present all the characters of a continued chronic affection ; in 
this case we often find a chronic inflammation of the urethra existing 
at the same time. The duration of herpes prceputialis may be short- 
ened by cauterizing the vesicles superficially. 

Historical JYotices and particular Cases. 

343. Herpes praeputialis, vaguely signalized under the names of 
aphtha and ulcuscula preputii, which were also applied to aphthae or 
solitary vesicles, has been in more recent times carefully described by 
Royston, 4 Mackechnie, 5 and Evans. 6 I shall give a single case ; others 
have been published in different periodicals and works of the day. 7 

Case XLI. Herpes prceputialis : slight inflammation of one of the 
glands of the right groin. M. N * * *, forty years of age, married, 
and never having had any venereal affection. His wife has, for 
years, been subject to leucorrhcea, which is always more copious 
than usual after the menstrual periods. On the 3d of August, 1820, 
M.N*** came to ask my advice for an inflammation of the prepuce 
that had continued three days, and presented the following characters: 
on the exterior of the prepuce there were three small clusters of 
from eight to a dozen of rounded and semi-transparent vesicles; 
several other minute vesicles, and slightly excoriated points, were 
also seen on different parts of the inner surface of the prepuce, each 

4 History of an eruptive disease of the integuments of the penis. Medical and 
Physical Journ., vol. xxiii. 

6 Observations upon herpes of the prepuce. (The Edinburgh Medic, and Surgical 
Journal, vol. vii.) 

6 Pathol, and pract. remarks on ulceration of the genital organs. Lond. 1819, 
p. 27. 6 

7 Journ. Hebdom., t. vii. p. 436. Journ. Complement, t. xli. p. 438. Several re- 
marks on the complication of the disease with stricture of the uretha, may be found 
in the Revue Medic, pour Juin, 1830. Observations on the use of Lactucarium in, 
the affection, by M. Rothalius, are contained in Ferussac's Bullet, des Sciences Med., 
t. xxii. p. 105. 



HERPES IRIS. 



113 



of which might have been covered with the head of a pin. The 
inner surface of the prepuce was more inflamed than the outer. The 
subjacent cellular membrane was itself a little swollen, and the fore- 
skin could not, without pain, be retracted towards the base of the 
glans. One of the lymphatic glands of the right groin was slightly 
swelled and painful. All the other organs of the body seemed 
healthy. No change was made in M. N * * * 's mode of living. 
The affected part was wrapped in soft linen to prevent it from being 
rubbed. The vesicles burst two days after I first saw the case, and 
for the most part, became covered by small, thin, blackish incrusta- 
tions. A slight degree of excoriation succeeded the vesicles on the 
inner surface of the prepuce. This excoriation was washed with 
decoction of althea, and on the 15th of August the affection of the 
prepuce and the swelling of the gland in the groin had both disap- 
peared. 



HERPES VULVARIS, HERPES AURICULARIS, HERPES PALPEBRALS, &C. 

344. Vesicles of a kind similar to those of herpes prceputialis, are 
occasionally developed on the upper eyelid in certain cases of oph- 
thalmia, on the concha of the ear, in external otitis, and on the labia 
majora in women labouring under leucorrhoea, during pregnancy, 
or after delivery : a young woman had been confined a month ; the 
labour and all besides had been prosperous; the lochia had disap- 
peared on the fifteenth day, but a slight mucous discharge had still 
remained. This young woman took a very long walk, and the same 
day began to complain of uneasiness in the upper parts of the thighs, 
and of darting pains in the vagina, which wholly prevented her from 
sleeping. About the parts where the labia majora are continuous 
with the skin of the thighs, I observed two groups of vesicles, the 
greater number of which were globular like small peas, transparent, 
and so closely connected as to form little irregular bulla?. A plentiful 
secretion of mucus was pouring from the vagina, which was affected 
with shooting pains, over the labia and parts affected. A few hip 
baths, and the use of emollient and saturnine washes, soon put an end 
to these symptoms. 

I also, on one occasion, had a young tradesman under my care, on 
the back of whose hands a great number of vesicles, similar to those 
of herpes labialis, had appeared. When I first saw him several of 
these vesicles had dried up, but others contained a sero-p undent 
fluid. An eruption of a like kind was repeatedly produced on the 
hands of a lad whose occupation was grinding colours, and who was 
in the habit of washing in water made very acid, after rubbing his 
hands over with soft soap. I have seen the same sort of eruption on 
the palms of the hands, and on the cushions of the fingers without 
any assignable cause. In these cases the fluid of the vesicles being- 
covered with a very thick cuticle was in part reabsorbed. 



HERPES IRIS. 

345. Herpes iris is distinguished by small groups of vesicles sur- 
rounded by four concentric erythematous rings of different shades of 
colour. Patients affected with this eruption often compare it to small 
party-coloured cockades. 

Herpes iris occurs most frequently on the backs of the hands, on 
the instep, olecranon, ankles, and similar parts. It commences with 
small circular red spots, composed of concentric rings of various 
shades, and which spread by degrees from two to perhaps eight lines 
in diameter. In the centre of each of these spots, from the second 
to the third day, there appears a flattened vesicle of a yellowish 
white colour, surrounded itself by several others of a smaller size, 
arranged in a ring. The central vesicle is surrounded by a first circle 
of a dull brown colour; this by a second, more external, and nearly 
of the colour of the central vesicle ; this second is in its turn sur- 
rounded by a third circle of a deeper red; the third circle by a 
fourth, the areola around which is formed on the seventh, the eighth, 
or the ninth day, and presents a rosy hue which melts insensibly into 
the natural complexion of the skin. Of all these rings the third is 
usually the narrowest; they may all become covered with vesicles; 
29 



the first is most generally found so circumstanced. From the tenth 
to the twelfth day the fluid of the vesicles is reabsorbed, or it escapes 
and dries off under the form of superficial scabs, which are detached 
before the end of the second week. 

Herpes iris has been observed to occur most frequently among 
children and females, either by itself or along with some of the 
other varieties of herpes. It is, however, very different from every 
one of these, and is the only form of cutaneous disease that is sur- 
rounded by several concentric rings. When the central vesicle has 
been destroyed, and the rings are not well marked, the disease is apt 
to be mistaken for roseola annularis ; this, however, differs from the 
herpetic affection by the greater breadth of its discs, which occa- 
sionally extend beyond the space that would be covered by a crown- 
piece, and by the absence of vesicles or any remains of vesicles. 

Herpes iris gets well spontaneously in the course of a week or a 
fortnight. Its period may be shortened by touching the vesicles 
slightly with the nitrate of silver. When blood-letting has become 
necessary on account of some co-existing affection, this evacuation 
has been found to shorten the continuance of the eruption, (o) 

Historical Notices and particular Cases. 

346. Herpes iris was established as a distinct species by Dr. Bate- 
man, who has given an accurate description, and published a good 
figure of the disease. Dr. Marshall Hall 1 has given a lengthened 
history of its progress ; and M. Ledeboer 2 has related the circum- 
stances attending a hereditary cutaneous disease which he thought 
analogous to the herpes iris. Alibert classes this eruption with his 
group of olophlyctides. 

Case XLII. Herpes iris affecting the regions of the olecranon and 
patella. — Michel, twenty-seven years of age, was admitted a patient 
to the fourth Dispensary on the 9th of March, 1826, and placed 
under my care and that of my colleague, M. Bayle. On the 5th and 
6th of March, Michel had felt pains of the hips, elbows, hands and 
knees. On the following days these different parts became covered 
in succession with a vesicular eruption ; but the patient continued at 
work as usual. The patient appears stout, of a sanguine and bilious 
temperament, and tells us he had an attack of the same kind last 
October, till which time he never suffered from any disease of the 
skin. On the 9th, vesicles, which had been thrown out on the lips 
six or seven days previously, were covered with thin brownish incrus- 
tations, and presented the characters that belong to those of herpes 
labialis. A single vesicle, situated on the upper lip, still contained 
fluid. The eruption over the olecrana and knee-pans, consisted of 
the herpes iris, and had only appeared within the last four days. The 
vesicles, which are about twenty in number on the right arm, less 
numerous on the left, are of the following description : in the centre 
of an inflamed surface, from four to six lines in diameter, a small 
vesicle, of a yellowish white colour, containing a little serum, and 
beginning to dry up, is perceived. The central point now described, 
is surrounded by a first ring of a reddish-brown hue, this by a second, 
nearly of the same pale yellow colour as the middle vesicle ; a third 
ring, which is the narrowest, succeeds, and is of a deep red; and 
four days later, a fourth and more eccentric ring surrounded the 
whole, the rose red colour of which was insensibly lost in the natural 
colour of the neighbouring skin. 

The vesicles about the knees were precisely similar in their cha- 
racters. I ought to add, however, that upon the back of the right 
hand, and in the vicinity of the vesicles developed on the elbows and 
knees, there existed a small number of globular vesicles similar to 
those of herpes phlyctenodes, and containing a little limpid and trans- 
parent serum. These vesicles were all affected with a severe tingling, 
smarting pain. (Venes. ad gyi ; bath; barley-water for drink.) The 
desiccation of the vesicles was completed on the succeeding days, 



(a) With Dr. Thomson, we are disposed to think well of moderate 
and gentle aperients in this species of herpes ; to be followed by 
Fowler's solution and vegetable decoctions. A small piece of soap 
plaster is a useful topical application. 

' Case of a particular eruptive disease. (Edinburgh Med. and Surg. Journ., 1820.) 
2 Bulletin des Sciences medicates de Ferussac, t. xviii. p. 70. 



114 



VESICULJE. 



and on the 15th of the month a few circular red slains upon the 
parta that bad been affected were all that remained of this slight 
disease. 

X 1 ,1 1 1 . Inflammation of the mouth ; herpes iris. — Fr. Germain, 
aged nineteen, of a lymphatic temperament, came into the hopital de 
la Pitie on the 15th of April, 1826, on account of an inflammatory 
affection of the mouth, and a disease of the skin. In the month of 
April, last year, the patient had had an attack in the skin similar to 
the one lie now lahours under. 

April Kith. On the legs and arms a number of spots are observed, 
the diameters of which vary from two to eight lines; one of them, 
nearly the size of a six-penny piece, is situated on the lower and 
outer part of the left arm; another at the bend of the arm ; six more, 
two of which are as large as lentils, occur on the forearm, and a 
greater number are scattered over the left lower extremity. Two of 
those on the upper and outer part of the thigh are very close together; 
on the opposite lower limb several spots of the same kind occur, and 
two are visible on the buttocks. The greater number of these spots 
are formed by several concentric rings of a red or pink colour, each 
by its difference of shade rendered distinct from the others. The 
centres of all are occupied by a small, thin, brown scab, proceeding 
undoubtedly from the desiccation of a vesicle, from which, indeed, 
the patient says he evacuated the fluid by scratching the spots, which 
he knows made their appearance very lately, though he cannot tell 
precisely when. The spots are circular ; the dimensions of the con- 
centric-coloured rings vary, but are in proportion to that of the spots. 
Round the yellow central point there exists a first circlet of a deep 
red colour; this is inclosed within a second, more eccentric ring of 
a pink hue ; these two rings are further surrounded by a third, of a 
deep and dusky red like the first ; lastly, a fourth ring of a rose tint, 
which is gradually lost in the skin about it, encircles the whole. In 
the course of the next and succeeding days the second ring became 
covered with vesicles, and of a white colour, but the patient soon 
tore it with his nails, when a few drops of serum escaped. The 
whole of the spots were excessively itchy. By the 20th the little 
scabs in the centres of the spots had fallen off and exposed the pink 
surface of the corion, covered with a new epidermis. 

The affection of the mouth had begun nearly twelve days before 
the patient sought admission into the hospital, by the development of 
aphthae and an increased secretion of saliva. Two days afterwards, 
the swelling of the lips was followed by that of the tongue, and anon 
by inflammation of the throat. Deglutition became difficult and pain- 
ful. The lips were covered with brownish or yellow incrustations. 
April 16th, the commissures of the lips are bleeding and inflamed ; 
their mucous membrane, as also that of the gums, cheeks and palate, 
are covered with aphthae or white prominent spots accurately defined 
on the inflamed mucous surface. The tongue is moist, and its upper 
surface is covered with a thick and whitish mucus. The mouth feels 
clammy, tastes bitter, and is so violently inflamed that the patient can 
scarcely unlock his jaws. The epigastrium is painful ; there is con- 
siderable thirst ; the bowels are constipated ; there is no fever. (Low 
diet, soothing gargle, barley-water for drink.) 17th. — Greater swelling 
of the lips than yesterday ; white confluent patches on the inner sur- 
face of the cheeks. (Prescriptions as before.) 18th. — The inflamma- 
tion of the mouth has abated, and the secretion of saliva is less profuse 
than it was; bowels still unmoved. (A glyster ; a bath; broth and 
milk for food.) 19th. — Desquamation over the upper surface of the 
tongue, which appears of a bright red colour, as in convalescence from 
scarlet fever. 20th.— The patient could open his mouth without pain; 
the inflammation declined gradually, and the patient was quite well by 



the 30th. 



ECZEMA. 
Vocab. Eczema, Dartre, Gale, Tinea. 



. 347. Eczema is a non-contagious inflammation, often confined to a 
single district of the skin, characterized in its commencement by an 
eruption of rery minute and not prominent vesicles, which are com- 
monly very closely set or crowded together, and terminate either by 
the reabsorption of the fluid they contain, or by the formation of 



superficial moist excoriations; to which succeed furfurae and squamae, 
or renewed eruptions of vesicles of the same nature as those that had 
preceded. 

Although commonly limited to a single part of the body, eczema 
may become general, and appear simultaneously or successively in 
different districts. It seems in general to attack those regions in 
which the follicles are numerous and particularly apparent, such as 
the hairy scalp, the ears, more rarely the face, the trunk, the roots of 
the nails, the backs of the hands, and the superior extremities gene- 
rally. It occasionally extends to the mucous membranes. In men it 
is often seen on the inner parts of the thighs, on the scrotum and verge 
of the anus ; in women, it is occasionally developed on the mucous 
membrane of the nipple, vulva, and rectum; in children it particu- 
larly affects the face and hairy scalp, and occasionally extends to the 
inside of the mouth, to the nasal fossae and external ear. 

Eczema is acute or chronic in its type. In every case the disease 
is distinguished by the occurrence of one or several successive crops 
of eruption on the same region, or on different parts of the body. 
The vesicles themselves are agglomerated in broad patches, or ar- 
ranged in irregular clusters; they very rarely take the form of bands 
in their disposition. When eczema is general, the whole of these 
varieties are occasionally witnessed in the same individual, in dif- 
ferent degrees and in various stages of their progress. Under other 
circumstances one of them only is displayed with all its distinguishing 
characteristics. 

348. Symptoms. — In acute eczema the eruption of the small vesicles 
that characterize the disease is announced by a sensation of smarting 
and sometimes by actual pruritus. They appear with or without red- 
ness, heat or tension of the skin, and present three varieties which are 
well described by Willan : 1st. Eczema simplex. 2d. Eczema rubrum. 
3d. Eczema impetiginodes. 

1st. Eczema simplex. In this generally very mild variety, the skin, 
covered with vesicles, almost always preserves its natural colour be- 
tween the clusters. There is neither heat nor tumefaction ; the vesicles, 
extremely minute, contain a globule of limpid serum, and usually 
correspond with the minute projections whence the hairs issue, and 
which may be very distinctly seen by examining the insides of the 
arms and thighs with attention. When the serum of the vesicles is 
reabsorbed, the cuticle that concurred in their formation shrivels, and 
is detached in the shape of a very minute plate or scale. More fre- 
quently still, the vesicles, after having existed for several days, burst 
or are ruptured by scratching, when the drop of serum escapes and 
gives place to a yellowish-coloured speck which, being before long 
thrown off, leaves a little pink spot, now dry, now moist and sur- 
rounded by a whitish circle, upon the skin. When the spot is moist, 
a very minute pore is perceived, whence a small quantity of serous 
fluid distils, which drying up forms a scab the size of a pin's head. 
Occasionally also, layers of the cuticle, altered in their nature, and 
thickened from the adhesion of the dried fluid of the vesicles, are 
detached from the skin. And it is at this stage that frequently, and 
without known cause, a new eruption of vesicles takes place, which 
follows in every particular the course of the first, when the eczema 
becomes chronic. 

A variety of eczema simplex has been described by one of my pupils, 
Dr. Levain, which is not noticed by Willan, nor by any of the other 
pathological writers who, since his time, have given particular attention 
to the diseases of the skin. This variety is distinguished by clustered 
patches of vesicles, the dimensions of which vary from those of a 
sovereign to those of a two sovereign piece. The vessels of these 
clusters are numerous, very small, and in all respects similar to those 
of the other varieties of eczema, consequently they are much more 
minute than those that characterize herpes phlyctenodes. The clusters 
are scattered over the skin, which only appears red in the places 
affected. On the red patches covered with vesicles, the cuticle may 
sometimes be raised and removed in a single piece. Its inner surface 
looks moist, and covered with small whitish or deep yellow points 
produced by the fluid of the vesicles. The corion beneath is red, 
but not ulcerated ; the clusters of vesicles here bear a resemblance to 
those of the herpes prceputialis ; and the variety of eczema we are 
describing, seems the link of connection between these two genera of 
vesicular eruptions. 



ECZEMA. 



115 



Eczema simplex often extends to the whole surface of the body, 
especially in children, young persons, and subjects of an irritable con- 
stitution. The disease in general soon gets well, and relapses are not 
frequent. The diseases with which it may most readily be confounded 
are certain vesicular eruptions, artificially produced by the action of the 
sun's rays, and lichen simplex. To avoid mistakes in regard to the 
latter, it is enough to remember that the vesicles of the eczema con- 
tain serum, whilst the elevations of lichen are solid and yield a drop 
of blood when they are punctured. 

2d. The inflammation of the skin is occasionally more intense 
than in the variety just described, and the disease is then entitled 
eczema rub rum. The part which is about to be affected with this 
eruption, swells, becomes hot, red and shining as in erythema and 
erysipelas. It is soon covered with small confluent vesicles, trans- 
parent at first, but speedily becoming milky, which burst anon, and 
pour out a little red-coloured serum. At a later period the cuticle, 
saturated with this fluid inspissated, becomes softened in some points 
and detached in others, when it dries into yellowish laminee of little 
thickness, which are soon replaced by slight incrustations proceeding 
from the drying of the fluid poured out by the diseased surfaces. 
Lastly, the skin here and there presents small pink points around 
which the cuticle forms a true border with a jagged edge, indicative 
of the dimensions of the vesicles. 

When eczema rubrum is very intense, the heat, redness and ten- 
sion continue or even increase during several days ; the vesicles are 
evolved, and burst with great rapidity ; the fluid they pour out irritates 
still more the parts already very painful, and by its contact gives rise 
to excoriations of varying extent. The skin, stripped of its cuticle, 
and inflamed, appears beset with a multitude of pores each of which 
might be covered with the head of a small pin, from whence a red- 
coloured fluid exudes, sometimes in such profusion as to soak the 
clothes of the patient. 1 At other times the small vesicles unite, become 
blended together and form irregular bullee analogous to those observed 
in certain cases of erysipelas. The epidermis, detached over a con- 
siderable space, bursts at length, a torrent of serum escapes, and the 
sub-epiderrnic layer now exposed and greatly swelled, besides the 
pores that have been already mentioned, presents false membranes of 
a whitish colour and soft consistency, which adhere slightly to the 
structures beneath. The serous exudation soon becomes less in 
quantity and ceases entirely ; the cuticle, moist at first and slightly 
adherent, becomes of a yellowish or greenish colour, by being soaked 
in the fluids exuded ; it then dries, falls, and is replaced by other 
laminated incrustations of a firmer and more permanent description. 
The skin loses by insensible degrees its tension and increased heat ; 
the redness also declines, and the parts slowly recover their natural 
condition, the return to this being announced by the formation of a 
new and healthy cuticle. It frequently happens, however, that fresh 
eruptions break out, and the eczema rubrum becomes chronic. 

3d. Eczema and impetigo have between them many strong points 
of resemblance, as well in reference to the parts of the body most 
commonly affected, as perhaps in regard to the constituent element 
of the skin, the follicles, in which they are both evolved ; it is not, 
therefore, uncommon to meet in the same individual with impetigo 
affecting one quarter, and eczema developed in another. It often 
happens also that we find a mixture of the vesicles of eczema and of 
the pustules of impetigo covering surfaces of the integuments of greater 
or less extent, and still more frequently do we find the vesicles of 
eczema becoming purulent and giving occasion to an anomalous 
variety of the disease which has been described by Willan under the 
title of eczema impetiginodes. When this variety makes its attack in 
an acute form, the tension, heat and redness are considerable ; it is 
not now mere tingling and itching that are complained of, but shoot- 
ing and violent smarting pain. The vesicles now pass rapidly into 
the purulent state ; the cuticle, raised in large flaps, is impregnated 
with the fluid effused, and acquires the appearance of greenish-co- 
loured laminated scabs, which being before long detached, a surface 
is exposed of as bright a red as carmine. When the eruption is con- 
siderable, the ichorous fluid secreted is so profuse that dressings of 
every kind, and even the bed-clothes and bedding become drenched 

1 The disease in this form is described by French authors under the title of dartre 
humide. 



with it ; the smell of this matter too is as offensive as possible ; it is 
faint and sickly, and something like that which a large burned sur- 
face, in a state of suppuration, diffuses. Around these impetiginous 
eczemas we commonly observe a tumid red circle, the surface of 
which is studded with small vesicles, transparent, milky or dry, ac- 
cording to their ages, and in all respects analogous to those that 
characterize eczema rubrum. The A r esicles and incrustations are 
occasionally renewed successively and the disease becomes chronic. 

Eczema impetiginodes may last several weeks, be transferred from 
one place to another, or lastly attack almost the whole surface of the 
integuments ; most commonly, however, it implicates but a single 
region. When it shows no tendency to pass into the chronic state, 
all the symptoms decline, the inflammation lessens, the laminated in- 
crustations fall off", the cuticle is reproduced, and the skin, of a violet 
colour, is unaffected afterwards, save by a slight exfoliation. 

The three acute forms of eczema that have now been described, 
present shades of extreme variety. Most usually the morbid symp- 
toms do not extend beyond the parts affected, or the structures in the 
immediate neighbourhood of these. Nevertheless when the eruption 
is very extensive, it is accompanied by disordered actions of a general 
nature ; the pulse becomes frequent ; there are thirst, anorexia, and the 
sleep is disturbed. The pain is increased by the heat of the bed ; 
motion at times is impossible or attended with extreme suffering. The 
most common complications are inflammations of the lymphatic glands 
in the vicinity of the affected parts, and in some cases, especially in 
children, inflammatory disorders of the stomach or intestines. 

4th. Chronic eczema. The three varieties of inflammation of the 
skin which constitute acute eczema may occur with the chronic cha- 
racter ; this is even, it must be noted, the tendency of the varieties 
entitled rubrum and impetiginodes. After the bursting of the vesicles 
the inflammation often increases in severity, extends to the deeper 
structures of the skin, and even to the subcutaneous cellular tissue. 
Irritated by repeated eruptions of vesicles, and by the contact of an 
acrid ichor, the skin becomes excoriated, and presents chaps and 
fissures which every movement tends to make deeper and more 
extensive, especially if the disease occurs between the fingers, on the 
nipples, verge of the anus, or in the popliteal regions. In the greater 
number of cases the affected districts of skin present at first the appear- 
ance of a blister in a state of suppuration, and pour out a purulent 
serous fluid, of a disagreeable smell, which quickly penetrates ad- 
dressing that may be applied. These humid eczemas occasion in- 
tense pruritus, accompanied by severe smarting pains; the skin, 
highly jnflamed, is stained with blood, looks of a violet colour, and 
seems beset with an infinity of minute pores, from which a sort of 
serous dew distils. Tormented by pruritus of the most violent de- 
scription, patients thus affected talk of nothing but heat of blood, 
inward fires, &c. They cannot forget themselves in sleep ; their 
sufferings, lulled for an instant, often return suddenly and without 
appreciable cause; nothing can then prevent or moderate the energy 
with which they begin to scratch themselves ; a bloody serum flows 
from the torn surface of the skin; but, nothing assuaged, the pruritus 
continues as unbearable as before, particularly when the perineum, 
orifice of the vagina, or verge of the anus is the part affected ; 
when left to itself, this cruel state often continues for months and 
even for years. 

When the inflammation declines in severity, chronic eczema assumes 
another character. After the lapse of a longer or shorter interval, the 
vesicular, or vesiculo-pustular eruptions become rarer, and even end 
by not appearing at all ; the scabs, at first moist and thick, and repro- 
duced as soon as detached, grow thinner and thinner, drier, and more 
adherent to the skin, which at length appears covered by small, yel- 
lowish-coloured scabs, — the dartre squameuse ou furfurach of some 
authors — among which, several bloody incrustations, the consequence 
of the excoriations caused by the nails of the patient, may be detected. 
The serous exudation is replaced by a simple epidermic exfoliation, to 
a greater or smaller amount. The more severe these eczemas have 
been, and the longer they have continued in this state, the longer is 
their complete disappearance expected, even after amendment has 
begun, and longer still are certain sequelae, by which the previous 
existence of the disease may be certainly recognized, of being com- 
pletely obliterated. Should a fresh eruption of vesicles chance to 



116 



VESICULtfJ. 



appear on surfaces which either have been or are still affected with 
eczema, the new eruption bursts more quickly than that which is 
evolved on regions that have never before been attacked ; these fresh 
crops scarcely continue entire above five or six hours in the former of 
these cases, a circumstance which is undoubtedly owing to the tenuity 
of the newly-formed epidermis. Lastly, it happens occasionally that 
slight vesicular eruptions are thrown out under the epidermis, thick- 
ened and altered by prolonged disease. 

3 19. Having now described in a general way the acute and chronic 
states of eczema and the chief varieties presented by the affection, I 
shall proceed to speak of the peculiarities presented by the disease as 
it affects different regions of the body. 

1st. Eczema of the. hairy scalp (teigne muqueuse, Alibert ; porrigo 
larvalis, Willan). Extremely frequent among children at the breast, 
of three, five, and eight months old, and at the period of the second 
teething, it not uncommonly attacks young persons of both sexes, 
especially such as have fair hair and a fine and delicate complexion, 
with a scrofulous taint and lymphatic constitution. This variety, which 
has been separated erroneously from the group of eczemas, and vari- 
ously placed among the tineas and poriigos, appears at one time on a 
portion, and at another invades the whole surface of the scalp, ex- 
tending occasionally even to the ears, nape of the neck, forehead and 
face. In very young infants the vesicles of this eczema spread over 
the scalp and temples, and soon become covered with thin scabs that 
increase in thickness as the exudation continues. The swollen hairy 
scalp, indeed, pours out a profusion of a viscid fluid which glues the 
hair into masses or layers, and in drying, forms yellow or brown lamel- 
lar incrustations. In this acute state the head is hot, and the scalp 
appears injected and tense ; children are then tormented with a pru- 
ritus of the affected parts, the violence of which cannot be expressed 
by words, and which seems to gain in intensity when their heads are 
uncovered and exposed to the air; they rub them violently upon their 
shoulders, and, if their hands be at liberty, they scratch themselves 
with the greatest imaginable eagerness, though the blood constantly 
follows the nail. 

When the hair has been cropped with care, and the scabs got rid 
of by means of emollient poultices, the hairy scalp appears to be 
covered with a sort of cheesy matter. Occasionally the inflammation 
extends to the subcutaneous cellular membrane, which forms small 
prominent tumours attended with very severe pain, usually ending in 
suppuration. The lymphatic glands of the nucha and parotid regions 
swell and grow painful. In some cases the vesicles of the eczema 
are mixed with the pustules of impetigo, and the incrustations 
formed are then much thicker and more adherent than wont. An 
immense quantity of pediculi usually appear on the scalp at the same 
time. 

Eczema of the hairy scalp often extends to the forehead, temples, 
face, nape of the neck and shoulders. 

If the children attacked with this disease be carefully attended to, 
if the incrustations be gently removed by means of lotions and soothing 
cataplasms, the inflammation of the scalp declines, and the exudation 
from its surface usually ceases within one or two months at farthest. 
If these measures be neglected, the caps and other articles applied to 
the head become impregnated with the fluid secreted by the inflamed 
surface and increase the pruritus ; the inflammation becomes chronic, 
and extends more deeply ; the bulbs of the hair inflame, and often 
cease from their functions over a considerable extent of surface; the 
scalp at the same time assumes a furfuraceous appearance on some of 
the inflamed points (teigne furfur acee, Alibert). 

When the ichorous exudation ceases suddenly, either naturally, or 
in consequence of ill-timed medication, and the incrustations grow 
hard and friable, children become dejected, taciturn, restless and 
evidently unwell. On the other hand, when the exudation is very 
abundant, the principal functions are frequently performed with the 
most perfect regularity, and the health of the little patients seem oc- 
casionally even to improve during the whole period that the disease 
continues I shall add further, that those children who labour under 
eczema of the face and hairy scalp whilst they are teething, rarely 
suffer trom convulsions or obstinate diarrhoeas. This remark is in 
accordance with the result of M. Billard's observations, who tells us 
that, at the Foundling Hospital of Paris, he noticed a considerable 



number of infants at the breast attacked with eczema of the scalp 
{teigne muqueuse), who, after the slow and natural cure of the disease, 
were remarkable for the freshness of their colour, and their excellent 
state of health. _ Among adults, chronic eczema of the scalp seizes 
particularly on individuals of a lymphatic and scrofulous habit of 
body. Women at the critical period of their lives are more frequently 
attacked than men. The greater number of these cases of eczema, 
humid and secreting at first, become at a later period squamous and 
furfur acous ; the swelling, redness and heat of surface are then almost 
wanting, and the scalp freed from the squama; that covered it, appears 
somewhat red and shining. The squamae are occasionally of a silvery 
and pearly lustre, and very much resemble the pellicles that envelop 
the sprouting feathers of young birds. Occasionally tufts of five or 
six hairs are bound together, as it were, at a short distance from their 
roots and free ends by these squamae. In this state the disease is not 
accompanied by any great degree of itchiness, and the head has no 
particular odour. 

Chronic eczema of the scalp now and then spreads to the ears and 
eyebrows ; it also occasionally attacks the margins of the eyelids, 
causing the fall of the eyelashes, and a chronic ophthalmia of a very 
intractable description. 

Eczema of the hairy scalp is a disease that is very rarely met with 
among the aged, in consequence probably of the alterations that have 
taken place in the organization of the skin. I have oftener than once 
seen the disease coincide with a more than usually copious secretion 
of cerumen, (a) 

2d. Eczema of the face. In young children eczema of the face 
often accompanies that of the hairy scalp and of the ears ; many 
authors have described the affection under the title of crusta lactea. 
It usually appears on the forehead, the cheeks and the chin ; the small 
vesicles that characterize it, are arranged in irregular clusters, and 
scarcely rise above the level of the skin, which soon assumes an ery- 
thematous blush ; within four or five days these vesicles burst, and 
pour out a viscid and yellowish fluid which concretes and turns into 
thin yellowish-green coloured scabs ; fresh vesicles are before long 
developed around the circumference or in the immediate neigh- 
bourhood of these clusters ; the fluid they contain is shed on the sur- 
face of the skin, at the same time that a considerable exudation takes 
place below the first formed squamae or scabs, which adds farther to 
their thickness and extent. If this disease be left to itself many erup- 
tions occur one after another, until the whole countenance is covered 
with yellowish laminated incrustations. The serous or sero-purulent 
fluid secreted, is often very copiously shed under the laminae and 
scabs ; the skin is of a vivid red, and appears beset with a multitude 
of minute pores which are covered with slight false membranes of 
a milky white colour; it becomes chapped and excoriated on the 
cheeks, at the angles of the mouth, and in the furrow between the 
lips and the chin, and these tender places are all made worse by the 
act of sucking, crying, and the contact of the tears ; the disease in 
this state, has all the distinguishing features of eczema impetiginodes. 
At a still more advanced period, eczema of the face presents all the 
characters of a chronic inflammation ; the vesicles are few, the dis- 
charge becomes smaller in quantity, ceases at length, and the skin is 
endued with dry and grayish-coloured scabs, which are thrown off 
without being reproduced; the diseased surfaces, covered with a 
cuticle of extreme tenuity, continue long to show an erythematous 

(a) " Of the diseases of the scalp which I have been called upon to 
treat during the last twenty-eight months, amounting to above 280 
cases, more than 180 were cases of eczema; seven were cases of 
herpes ; sixty-five were cases of impetigo ; six were pityriasis ; eight 
were cases of psoriasis, or lepra ; and eleven only were cases of 
porrigo. From inquiries I have made among persons whose oppor- 
tunities of observation have been favourable, I am inclined to think 
that the proportion shown in my own experience is about that which 
is usually observed. It is true that now and then the proportion 
would seem to be different; but the variance is unquestionably owing 
to particular circumstances. Porrigo has broken out in a school or a 
family, and has been rapidly communicated by contagion, so as to 
swell the proportion of the latter disease." (Mr. Phillip's Lect. on 
surgery, in Med. Gaz., 1840.) 



ECZEMA. 



117 



blush, and are then affected with a furfuraceous desquamation, which 
also ceases at last. The excoriations and fissures which attend 
eczema of the face never leave cicatrices behind them. Those that 
do occasionally remain are effects of the wounds which children inflict 
on themselves with their nails ; to prevent them from doing mischief, 
therefore, it is proper to confine their hands during the night, for 
without this precaution I have seen many who made their faces bleed 
with scratching. 

Eczema of the face sometimes spreads to the margins of the eye- 
lids, to the mucous membrane of the mouth and nasal fossae, and to 
the conjunctivae; the epithelium, where it exists, is rapidly destroyed, 
and is replaced by small patches of whitish false membrane. When 
the eczema of the eyelids extends to the conjunctivae we have all the 
symptoms of acute ophthalmia: the eyes become red and injected, 
watery, and sensible to light; the free edges of the eyelids are swollen 
and cedematous. When eczema occurs in the nasal fossas, it causes 
a very troublesome sense of itching, and a very copious flow of a 
serous fluid. This disease seldom attacks the mouth; I have seen it 
confined to the under lip, round which it formed a kind of ring; it 
happens occasionally that the mucous membrane of the mouth, which 
appears to be generally red and swollen, presents here and there 
small superficial ulcers like aphtha?, and children then excrete a great 
quantity of saliva. 

In adults, eczema rubrum and impetiginodes of the face are often 
attended by a general swelling of the features, and an cedema of the 
eyelids similar to that which is observed in phlegmonous erysipelas. 
Eczema of the face differs from this form of inflammation by being 
essentially a disease of long continuance, and by the skin, instead of 
exhibiting a simple exanthematous inflammation complicated with 
occasional phlyctenae, presenting a vesicular, or a vesiculo-pustular 
eruption, generally accompanied with a severe itchy heat of the sur- 
faces affected. When eczema of the face has passed to the chronic 
state, the serous exudation is almost insensible, the face becomes 
covered with bran-like scales, which fall off, and are renewed re- 
peatedly ; the eyebrows and eyelids now and then lose their hairs. I 
have seen this variety, which is very intractable, more especially in 
young girls of a lymphatic temperament, whose menstrual discharge 
is irregular, or in whom this evacuation is not yet established. It is 
A-ery seldom seen among the aged. 

3d. Eczema aurium. — This is one of the varieties most commonly 
met with in the two sexes at all ages. It often occurs to women at 
the period of the menstrual cessation. Lorry has specified its charac- 
ters accurately (de auribus suppurantibus). Infants are attacked with 
the disease at a very early age ; and it frequently coincides with 
eczema of the scalp, or face, the development of which it occasionally 
precedes or follows. It must not be confounded with intertrigo, a 
kind of erythema of the posterior parts of the ears, attended with 
chapping, and some slight exudation. I have also seen many cases 
of this affection among young women from fifteen to twenty years of 
age, who either had not yet menstruated, or who had menstruated 
very irregularly. When this eczema appears with the acute character, 
the ears become red and swelled to such a degree that their size is 
often doubled ; a reddish fluid flows rapidly from the vesicles, chaps 
and fissures are formed, and the inflammation is propagated to the 
meatus auditorius, around which small purulent abscesses are occa- 
sionally formed that prove excessively painful. The sense of hearing 
is either perverted or lost for a time ; the lymphatic glands in the 
vicinity swell. This eczema most usually becomes chronic; the 
skin is covered with lamellae of a deep yellow colour, very similar to 
cracked strata of yellow bees- wax; a reddish fluid, the flow of which 
is increased by pressure, exudes from the fissures. Often, when the 
diseased parts appear to be returning to their natural state, all at once 
and without known cause, a new eruption appears. 

Eczema of the ears is usually a very obstinate disease when it at- 
tacks females at the critical age ; it gets well, on the contrary, readily 
and naturally in children, when it has broken out during the process 
of teething. Pieces of sponge or tents of lint have by some been 
recommended to be placed in the meatus auditorius to prevent the 
contraction of this passage ; but the precaution has more inconveni- 
ences than advantages. When the eczema is acute in its character, 
more good is done by blood-letting, the application of leeches, and the 
30 



use of pediluvia and aperients; and when the disease is of a chronic 
nature, the swelling of the subcutaneous cellular membrane seldom 
goes so far as to make any precaution of the kind mentioned necessary. 
It rarely happens that eczema of the ears does not extend to the 
parotid regions and hairy scalp ; the two ears are also most commonly 
affected at the same time ; but the disease seldom attains the same 
degree of severity in both. 

4th. Eczema mamillarum. — Eczema of the nipple is a much more 
uncommon disease than the varieties I have hitherto described ; I hare 
never met with it in young children. M. Levain has collected several 
cases of its occurrence in young women who were nursing for the first 
time. It is of consequence not to confound this affection with erythe- 
ma and chapping of the nipples, which are much more frequent com- 
plaints with young nurses. It is occasionally observed, especially in 
the chronic form, in young girls and grown women who have never 
given suck. The inflammation is at times transferred from one nip- 
ple, to the other ; very violent itching is felt, and a yellowish or red- 
dish serum flows abundantly from the affected parts, and rapidly 
penetrates any dressing that maybe applied. The mucous membrane 
of the nipple, inflamed over its entire surface, although in an unequal 
manner, presents small excoriations like linear scratches ; some points 
are of a bright red, moist, studded with sero-sanguinolent drops; others 
are covered with yellowish scabs, which are thick in the middle, and 
decrease towards their circumference. This complaint is usually 
attended with severe pruritus, which increases on the approach and 
during the continuance of menstruation. The nipples remain scaly 
for a long time after the inflammation has subsided : they are moist 
and exuding one day, dry and scaly the next. At length, after many 
recoveries and as many relapses, the pruritus ceases, the serous exu- 
dation appears no more, and the parts are covered with a new epithe- 
lium, smooth and uniform like that which covers the healthy surface. 
I have never observed eczema of the nipple in the male. It is 
important, as I have already said, to distinguish eczema of the nipple 
from simple chapping or cracking of the part ; and above all, not to 
mistake it for a syphilitic affection ; it is usually very intractable, may 
continue for years, and requires active treatment on its first invasion. 

5th. Eczema wmbilicalis . — The skin of the umbilical region bears 
great affinity to that which surrounds the natural openings. Eczema 
of the umbilicus consequently very much resembles that of the nipple 
and vulva. It has been mistaken for a syphilitic blenorrhcea. In 
newly-born infants, the pulling which the cord has undergone, the 
ligature of this part and the use of unguents, give rise now and then to 
the development of minute vesicles and to slight excoriations, distin- 
guished from those of true eczema by their short continuance. 

6th. Eczema of the insides of the thighs, prepuce, scrotum, verge of 
the anus, and lower end of the rectum in the male. — These varieties of 
eczema are all very rare in early life ; they are more frequently met 
with between the thirtieth and fortieth year than at any other age. 
The eczema may begin in any one of these regions, and then creep on 
to the others in succession, or else attack them all at the same time. 
The sleep is broken ; tormented by incessant pruritus, the patients 
become restless and irascible ; the vesicles either break or are vio- 
lently torn at the moment of their formation, so that it is often impos- 
sible to find a single one untouched ; the skin is bedewed with an 
ichorous fluid ; the patients tear themselves with their nails ; crevices 
are formed from which a sero-sanguinolent exudation takes place ; 
the penis, scrotum and perineum are extensively excoriated ; the lint 
and dressings applied to these parts are speedily soaked with dis- 
charge ; walking, and the friction of the clothes, the heat of the bed, 
and occasionally the presence of pediculi, add to the amount of irri- 
tation, which is already excessive ; erections, and the act of emptying 
the bladder and rectum, are often attended with pain. In the great 
majority of cases, this form of eczema becomes chronic. It proves 
at all times a protracted and obstinate disease, and one in which 
patients are willing and eager to submit to the most energetic treat- 
ment, in order to get rid of their misery ; there are cases, however, 
in which this ought to be employed with great discretion. One of my 
patients, who had laboured under a chronic eczema of the margin of 
the anus for twenty years, became accidentally affected with a very 
severe inflammation of the gastric and pulmonary mucous membrane, 
which yielded to a rigid adherence to low diet, the use of asses' milk, 



118 



VESICULiE. 



mucilaginous diluents, amd the insertion of an issue. During the 
■ul most severe period of this disease, the eczema of the fun- 
dament disappeared completely, but broke out again after the cure of 
the gastro-pulmonary inflammation. This interchange of internal and 
externa] inflammations is well worthy of engaging the attention of the 
pathologist and therapeutist. 

Eczema of the scrotum, perineum, &c, and especially the fissures 
it occasions in the skin, have occasionally been confounded with 
lichen agrius and syphilitic sores. 

7th. Eczema of ' the inner parts of the thighs, of the vulva, of the 
i f the anus, and of the mucous membrane of the vagina and rec- 
tum in the female. — Children are seldom attacked with eczema of these 
regions. In the adult female the disease may commence in any one 
of them and be propagated successively to the others ; or it may 
seize on all of them at once. Like the disease in the male it begins 
with heat and intolerable itching; the vesicles burst as soon as 
formed ; the pain becomes unbearable, excoriations take place, the 
disease spreads to the labia majora, to the mucous membrane of the 
vagina, to the verge of the anus and to the rectum. The scalding 
heat and pruritus are extremely violent ; the passage of the urine is 
painful ; a discharge of an offensive smell takes place from the exter- 
nal organs of generation. The vagina and inner surface of the labia 
present slight superficial excoriations ; patients occasionally addict 
themselves to masturbation with a sort of fury as in prurigo pudendi ; 
the sexual act is either impossible or exceedingly painful. 

This variety of eczema has been sometimes taken for a syphilitic 
affection ; and it is often difficult, when it is accompanied with a leu- 
corrhceal discharge, to determine whether this flux be the cause or the 
effect of the vesicular eruption. Discharges from the vagina, however, 
give rise much more frequently to intertrigos than to true eczemas. 

8th. Eczema of the upper and lower extremities. — Eczema of the fore- 
arm, of the arm and of the thigh present nothing peculiar; those of 
the legs, in elderly persons, have been described under the title of 
tcttery sores (dartres ulcereuses). They usually begin in a chronic 
form, and are occasionally accompanied with varices of the veins and 
with ulcers. Eczema of the legs often presents the characters of 
eczema rubrum. The skin, of a livid hue, tense, not very hot, and 
sprinkled with numerous pores that pour out an ichorous reddish 
fluid, presents excoriations of a bright red, the surface of which is 
dotted over with points of a deeper shade of the same hue ; other 
parts present yellowish laminated incrustations, fissures or extensive 
excoriations. The vesicles are very rarely to be seen entire. The 
eruption is occasionally propagated to the dorsal aspect of the feet, to 
the toes and the integuments between them, and then the same phe- 
nomena are observed as when the disease attacks the hands and 
fingers. Farther, it is requisite to distinguish a primary form of 
eczema followed by sores, from those vesicular eruptions that are 
produced by the contact of discharges from ulcers of an older date. 
The cure of these eczemas is accomplished with difficulty ; and even 
when the excoriated places are healed up, when the serous exuda- 
tion no longer takes place, and the fall of the scabs has been com- 
pleted, an epidermic exfoliation and scaly state of the skin continue 
for a long period; the skin too retains a reddish, livid and shining 
appearance, and the slightest irritation brings back the disease in 
greater seventy than it possessed even on the first invasion. 

9th. Eczema of the bend of the arm, of the axilla and hams. — 
These varieties, in their evolution and in their progress, have a great 
resemblance to those that appear about the margin of the anus and 
vicinity of the genital organs in either sex; they are, however, much 
less painful. Those of the axilhe are the most uncommon, and have 
frequently the appearance of the eczema impetiginodes . In these 
regions the heat is usually considerable; they are in an habitual state 
of moisture ; the follicles are numerous, and the motion of the parts 
incessant: hence the violence of the pruritus, the copious discharge 
of serous fluids, and the occurrence of excoriations and chaps so diffi- 
cult to cure. It is important to distinguish these varieties from con- 
fluent lichens. 

10th. Eczema of the hands. — Eczema simplex occasionally appears 
between the fingers, on the backs of the hands and on the anterior 
parts of the wrists. I have seen the vesicles of this disease as large 
and as pointed as those of scabies, so that it was matter of difficulty 



to distinguish between them. It is true that one of these affections 
is contagious and the other is not ; but the experiment that must be 
made to establish this diversity of character cannot, of course, be 
recommended to be instituted on purpose. Eczema rubrum very 
frequently occurs on the backs of the hands and fingers ; occasionally 
between the fingers and around the nails ; the vesicles being extremely 
crowded in these cases may give rise to the formation of bullae of 
various dimensions. When confined to the circumference of the 
nails, as I have several times seen the disease, it simulates onychia 
very closely; and when it gets chronic in its nature, the skin on the 
backs of the hands becomes covered with large thick scabs of a 
yellow or brown colour, and the spaces between the fingers present 
deep fissures, the bottoms of which are highly inflamed, whilst their 
edges are covered with laminated scabs. From these fissures a sero- 
purulent fluid is continually exuding, especially when the parts are 
bent, or used in any way. When the hand is passed over the dis- 
eased surfaces, they appear as rugged as the bark of an aged oak. 
Long after the disease is to all appearance cured, the skin remains 
hard, dry and scaly, and is very liable to chap and split. 

In general eczema, after several successive crops of eruption have 
been evolved, the inflammation occasionally spreads to the palms of 
the hands. The fluids effused are then detained under the thickened 
cuticle, and not shed upon the surface, a circumstance that modifies 
the appearance of the eruption notably. 

Eczema of the nails will be described in another place. See 
Onychia. 

350. Complications. — The numerous cases which I have watched 
myself through all their stages, prove that eczema may co-exist with 
the greater number of the diseases that attack the external integu- 
ments. Pustules of impetigo are very commonly seen in the middle 
or near vicinity of a district attacked with eczema ; this is even the 
most natural, as it is the most frequent complication. I have seen 
eczema coincident with lepra. The vesicles were disseminated in 
the intervals between the scaly patches, and got well, whilst the 
leprosy continued unchanged ; as if these different affections had 
severally depended on some peculiar and distinct condition of the 
system. I have seen a young woman labouring under very extensive 
psoriasis guttata and a moist eczema of the face and ears at the same 
time. I have observed eczema co-existing with scaly syphilitic affec- 
tions. The bullae of rupia, the pustules of ecthyma, and boils are 
occasionally observed in individuals labouring under chronic eczema 
of different districts of the body. Certain forms of eczema of the 
sexual organs and hairy scalp are attended with the production of 
pediculi, which incessantly excite the patients to scratch themselves. 
Eczema is occasionally observed to precede scabies ; at other times 
it seems to be induced by the unguents employed in the treatment oi' 
this disease. 

Among children, inflammatory affections of the mucous membranes 
frequently coincide, or alternate with the development of this erup- 
tion. When it is general, and the secretion is abundant and con- 
tinues long, cough and diarrhoea are apt to supervene, especially 
among the aged, and individuals weakened or worn out by previous 
disease. I have seen eczema of the scalp, ears and face spread to 
the mucous membranes of the eyes, meatus auditorius and nostrils, 
causing intense ophthalmia, severe otitis, and chronic coryza followed 
by profuse and fetid discharges. Pregnancy may cause the develop- 
ment of eczema, and complicate or stand in the way of its proper 
treatment ; occasionally, also, the disease has appeared in nurses, as 
a consequence of weaning. Among children it now and then appears 
on the mucous membrane of the mouth. Eczema of the legs in old 
people is rather frequently accompanied with the appearance of 
petechia? around the inflamed parts of the skin, also with oedema, 
varicose tumours, and ulcers which protract or impede its cure. 1 
have seldom seen eczema occur among the consumptive; on the 
other hand it frequently coincides with gastric, enteritic and bronchial 
inflammations, especially among children, in whom it is often replaced 
by convulsions. The practical inferences to be deduced from these 
observations are, that the treatment of eczema is to be modified 
according to the ages and the idiosyncrasies of individuals, and 
above all, according to the nature and the intensity of its different 
complications. 



ECZEMA. 



119 



351. Alterations of structure. The follicles of the skin are the 
parts essentially affected in eczema. And we observe, in fact, that 
if the disease may and does attack almost every district of the integu- 
ments, it shows itself in preference on the inside of the thigh, at the 
bend of the arm, in the hams, the axillae, the groin, on the scrotum, 
labia, margin of the anus, and generally in those situations in which 
the follicles are the most largely developed, and the most numerously 
bestowed. The disease is very frequent in the scalp among children, 
and there, in early life, the follicles are very numerous and very 
large; in this situation, on the contrary, it is rarely met with among 
the aged. Farther, the disease seldom appears in districts where the 
existence of follicles is matter of doubt, as in the palms of the hands 
and soles of the feet, the neighbourhood of the patellae and olecrana. 
And to conclude, in eczema simplex the affection of the follicles is 
evident to the eye. In eczema simplex the papillary body does not 
appear to be injected ; it is so, however, in the variety entitled rubrum, 
in which the deep layers of the corion and the subcutaneous cellular 
tissue are also occasionally inflamed. When excoriated, the skin 
may become covered with pseudo-membranous deposits, analogous 
to those which are observed on blistered surfaces. I have even seen 
the skin of the leg, in old subjects labouring under eczema rubrum, 
presenting small holes which might have been filled with the head of 
a pin, and little sinuous ulcers, very irregular in their course, which 
did not interest the whole thickness of the corion ; the skin had an 
appearance very similar to that which a piece of mahogany board 
worm-eaten on its surface might be supposed to present. In chronic 
impetiginous eczema I have noticed small nipple-like projections on 
the surface of the skin which were owing to a sort of elongation of 
the natural papillae. The cuticle itself undergoes various alterations 
in this disease. In the chronic forms it is resolved into a kind of 
farinaceous dust, or is thrown off in little laminae, the centres of 
which, of a yellowish-gray colour, are more adherent than their cir- 
cumferences. In certain eczemas of the hands the cuticle becomes 
dry and falls off in large yellow scales which are thick in proportion 
as they have been infiltrated with diseased secretions. Lastly, the 
cuticle is entirely destroyed in certain cases, and the corion is either 
exposed or is covered by incrustations of various thicknesses. The 
fluid secreted by the diseased surfaces, serous, limpid and almost 
inodorous in one case, is turbid, yellowish or greenish, and more or 
less consistent in another ; it has a faint and sickly smell in eczema 
impetiginodes, especially when pustules of impetigo occur mingled 
with the vesicles of the eczema. In drying, this secretion gives rise 
to the formation of scabs which have some resemblance to those of 
impetigo. When the inflammation runs high, it may implicate the 
bulbs of the hair and the matrix of the nails, and cause these append- 
ages of the skin to be detached. In brief the primary seat of eczema 
is in the follicles of the skin ; but other elements of this tissue are 
affected in eczema rubrum and impetiginodes. The papillae, the entire 
thickness of the dermis, the subcutaneous cellular membrane and the 
lymphatic glands are occasionally affected one after the other : hence 
those small abscesses that form in children who are attacked with 
eczema of the head, and those painful inflammatory swellings of the 
glands which occasionally end in suppuration. Other diseases of 
the skin (acne, rosacea, mentagra, and impetigo), also affect, and, 
indeed, more evidently affect the follicles than eczema. There are 
consequently essential differences between the various diseases of 
the skin which must be sought for elsewhere than in the immediate 
affection of the several anatomical elements of which this tissue is 
composed. 

352. Causes. — I have met with several cases of eczema that ap- 
peared exclusively during the period of uterine gestation, that yielded 
with this state, that returned in a second and third pregnancy, and 
got well immediately after delivery, although various plans of treat- 
ment had been vainly tried before this event. Among children the 
process of teething and the quality of the nurse's milk, among women 
the states of amenorrhcea and dysmenorrhea frequently exert a notable 
influence upon the development of eczema. 

Our inability in a multitude of cases to discover any evident, or 
even probable cause of the disease, often leads us forcibly to the con- 
clusion that eczema is most generally evolved and kept up by some 
hidden alteration of the fluids and solids. In this disease, as in 



almost all inflammatory affections, independent of external causes, 
the blood is buffy. 

If a patient who has recovered from one attack of eczema is seized 
a second time, it is almost certain that the disease will be of the same 
genus and species as before. This speciality in the form, and proba- 
bly in the nature of relapses, has been observed in pemphigus, in 
favus, and in several other diseases of the skin. 

In infancy and youth, eczema appears more particularly on the 
head ; in riper years on the breast and belly, but especially on the 
genital organs; and in advanced life, on the lower extremities and 
about the margin of the anus. According to Billard, eczema is also 
frequently observed on the trunk and extremities of the newly-born 
infant ; he tells us he has seen the disease in infants scarcely a day 
old. M. Levain having delivered a woman labouring under impeti- 
ginous eczema of the whole body, observed that the child two days 
afterwards presented several clusters of vesicles on the left forearm, 
on the neck, and in the hams, and by and by eczema rubrum appeared 
on the forehead and hairy scalp. It is at the periods of the first and 
second dentition that children are more especially attacked with 
eczema. Women are more subject to the disease than men, particu- 
larly at the critical period of life. Chronic eczemas of the hairy scalp, 
ears, eyebrows, and eyelids, are common in scrofulous subjects. 
Eczema is not a contagious disease, but under certain circumstances, 
especially when the discharge is copious, the contact of the secretion 
may determine vesicular eruptions upon healthy parts. M. Levain 
has seen acute eczema of the labia in a woman whose husband had 
long laboured under a similar eruption of the scrotum; the woman in 
this case had a rapid recovery. I have collected several cases of the 
same kind. 

Relapses are observed to happen in almost all diseases, but in none 
are they more frequent than in eczema. I have collected many in- 
stances of unlooked-for returns of the complaint in consequence of 
variations of atmospheric temperature, errors of diet, affections of the 
mind, &c. I have seen the disease get well and recur twelve or 
fourteen times within the space of a few months, in despite of the 
most scrupulous and undeviating attention to regimen. These relapses 
happen particularly among individuals of an irritable and nervous 
constitution. 

353. Diagnosis. — Eczema is of all the diseases of the skin that 
which presents the greatest variety in its appearance, for as it is acute 
or chronic, simple and unmixed, or complicated with pustules, it may 
be characterized by vesicles with or without redness, by moist or 
running excoriations, by laminated incrustations, or by small furfura- 
ceous scales. 

Willan and Bateman have both connected to the group of eczemas 
several artificial or accidental vesicular eruptions, which both in their 
nature and means of cure are totally distinct. Such is the sun-fret 
(eczema solare of these authors), which is observed among labourers 
in the time of harvest, and the inhabitants of towns who flock into 
the country during the fine season of the year. The skin of the face, 
neck, hands, and other parts usually left uncovered, is attacked with 
erythema, to which succeeds a plentiful eruption of vesicles, analogous 
indeed in appearance to those of eczema, but speedily ending in a 
slight furfuraceous desquamation of the cuticle. 

Some preparations of mercury excite a vesicular eruption which 
has been connected with eczema, and which resembles this disease 
considerably in its external characters ; but in its nature and progress 
it bears a much nearer affinity to inflammations artificially produced. 1 
Various other substances, such as Burgundy pitch, adhesive strap, 
plasters of cicuta and opium, the juices of certain plants of the family 
of euphorbiaceae, the oil of the croton tiglium, sulphureous lotions, 
diluted acids, &c, have also the property of causing minute vesicles 
to be developed on the skin, which in their form, arrangement and 
size approach more or less nearly to the eczemas. All these vesicular 
inflammations, however, differ essentially from this group in their 
nature, and get well with an ease and a rapidity that make a strong- 
contrast with the inveteracy and tendency to return of eczema. 

The vesicles of herpes are globular, and arranged in clusters sur- 
rounded by an inflammatory areola, of much greater extent than that 

1 Vide sub. Hydrargyria. 



120 



vesicul^:. 



of eczema. The minute serous vesicles that are occasionally observed 
with rheumatic affections, puerperal peritonitis, the furuncular 
e of the bowels (dothinenteritis), &c, are devoid of inflam- 
s, and are very different from the vesicles of eczema. 1 
When eczema simplex appears between the fingers, on the wrists, 
bends of the arms, hams, and fore parts of the belly, it is at times 
difficull to distinguish it from scabies : it was a mistake to say that the 
es of eczema were always flat and agglomerated. I have seen 
those of scabies, dispersed and separate like them, 
and like them, too, a little pointed : but scabies is essentially contagious, 
i is not ; this is almost always acute, that as constantly chronic 
in its nature; the pruritus of eczema is accompanied with a kind of 
smarting, that of scabies is rather a pleasant than a painful sensation. 2 
The small, red, solid and itchy papulae of lichen do not contain any 
serum like the vesicles of eczema simplex. In confluent and inflamed 
lichen (lichen agrius, Willan), when the papulae, crowded together in 
large patches have been torn by the nails, the skin, in a raw and 
bleeding state, pours out a sero-sanguinolent fluid which, in drying, 
assumes an appearance intermediate between squamae and scabs, that 
might readily cause the disease to be mistaken for eczema rubrum. 
This advanced and very severe form of lichen has consequently been 
approximated by M. Alibert to the excoriations of eczema, and mixed 
up with his description of the Dartre squameuse humide. The small 
psydracious pustules of impetigo, from their very first appearance, 
contain a thick, greenish-yellow fluid. Eczema impetiginodes in its 
commencement either presents transparent vesicles which become 
rapidly purulent, or, more rarely, a mixture of the proper vesicles of 
eczema and of the pustules of impetigo. The scabs of eczema impe- 
tiginodes are not so thick, but drier, and more compact than those 
that follow the rupture of the pustules of impetigo, the scabs of which 
are of a greenish-yellow colour, rough and uneven aspect, and not 
very unlike the masses of gum that concrete upon the cherry-tree. 
Eczema of the labia and vagina causes a discharge that might be 
mistaken for a gonorrhoea ; it is rare, however, that a few untouched 
vesicles may not be discovered in the neighbourhood of the affected 
parts to serve as guides in the diagnosis, (a) 



(a) The following contrasted characters, given by Mr. Phillips, 
(Lect. on Surgery, Med. Gaz., 1840,) will aid the student in the diag- 
nosis of eczema : " As you see, it would not be difficult to mistake 
these affections for scabies. Like it they are often developed without 
inflammation — like it they often affect the wrists and sides of the 
fingers — like it, they produce great itching; but, then, the vesicles of 
eczema are flat, those of scabies are conical-acuminate : those of 
eczema are agglomerated, those of scabies are distinct and isolated. 
The itching of eczema is stinging, that of scabies is rather an agree- 
able sensation. Scabies is essentially contagious ; eczema is either 
not at all, or very little so. Eczema rubrum sometimes bears a resem- 
blance to miliaria ; but, then, in miliaria the vesicles are never con- 
fluent — they are larger, and there is more general excitement. The 
eczema impetiginodes can scarcely be mistaken for impetigo : the 
surface occupied is usually large. Impetigo pustules never, at their 
commencement, contain a transparent serum ; they have a large base, 
and a thicker fluid. Eczema is, at first, always vesicular, and never 
contains true pus, but a yellowish sero-purulent fluid. Then, im- 
petigo produces true thick scabs, yellowish and rugous ; in eczema 
we see only thin squamae. When the disease is chronic, it may be 
confounded with lichen. For instance, here is lichen agrius ; it is 
accompanied by an exhalation of serum, followed by scales ; but they 
are larger, thicker, yellower, than those of eczema. More like scabs, 
they do not leave after them a red, smooth, shining, or slightly ex- 
coriated surface, but a surface chagrined by small prominent points 
— papulae ; and, then, in lichen we can always find some papulae, 
where eczema would present vesicles. However, where it occupies 
the hands, much attention is sometimes necessary. Again, it may be 
confounded with psoriasis. Here, again, the surrounding vesicles 
will be wanting. There may be no weeping ; and, after the scales 

1 Vide sub. Sadamina. 

* James the First of England and Sixth of Scotland, held that kings alone were 
worthy to have the itch, the pleasure of scratching was so supreme.— R. W. 



The absence of pruritus in syphilitic affections distinguishes these 
sufficiently from the eczemas of the sexual organs, in which the 
itching is almost insufferable. It is occasionally difficult to discrimi- 
nate between chronic eczemas grown scaly, and old lichens and pru- 
rigos, situated on the genital organs. Lorry appears to me, indeed, to 
have confounded these three obstinate forms of cutaneous affection in 
his description of prurigo pudendi ; nevertheless, before falling into 
the chronic state, eczema of the genital organs is attended with a co- 
pious exudation which is never observed in the other diseases just 
mentioned. Eczema of the scalp in the state of desquamation is not 
always easily distinguished from psoriasis and pityriasis capitis; it is, 
however, seldom that no remains of yellowish incrustations and scabs, 
characteristic of this disease, are to be seen on any part of the scalp, 
or ears, or person at large, a circumstance never observed in pity- 
riasis, a disease essentially furfuraceous and one that is never accom- 
panied with a discharge. 

354. Prognosis. — In children eczema of the scalp and face is often 
a salutary eruption. When it appears during the process of teething, 
it will hardly yield to treatment until the teeth have appeared. In 
young women whose menstrual function is irregular, eczema of the 
ears and scalp is an intractable malady, and seldom gives way before 
some favourable change is effected in the state of the general health. 
The disease is always subdued with difficulty in women arrived at 
the critical period of life; and when it appears during pregnancy it 
can rarely be subdued until after delivery. When eczema is heredi- 
tary the cure of the disease is very frequently followed by a relapse. 
Eczema of the hands among cooks, hat-makers, dyers, &c, is always 
difficult of cure. In elderly persons eczema of the legs, attended with 
cedema, and a varicose state of the veins, is often altogether incurable. 

exfoliate, instead of a smooth, red, elevated surface, as is seen in 
psoriasis, we find a cracked one." 

And again: "You have found a vesicle; the disease is vesicular; it 
must be, then, herpes or eczema : your first idea would be eczema, 
because for every single example of herpes, you will see from twenty to 
thirty cases of eczema. Herpes circinnatus is a circle, or, as it has been 
termed, a " ringworm'''' — eczema never so. Herpes only affects one 
or more points : eczema often the whole scalp ; add to these the dif- 
ferential characters I formerly pointed out, and you can have no diffi- 
culty in making out the vesicular diseases which affect the scalp." 

Of eczema impetiginodes, Dr. Carswell ( Clinical Lectures, Lancet 
1839), thus speaks: "And, in the first place, what are the ele- 
mentary characters of eczema impetiginodes? This disease, as the 
term implies, is a compound of two diseases, — of eczema and of 
impetigo. Now, each of these, in its separate state, has its own 
elementary character — a vesicle in eczema, and a pustule in impetigo. 
In eczema impetiginodes we have both the vesicle and the pustule ; 
the vesicle, however, being the primary element, and generally pre- 
dominating during the early stage of the disease. And, besides, the 
pustular character of this affection always succeeds to the vesicular, 
and can easily be traced during its progress to a change in the con- 
tents of the vesicle, which consisting, at first, of a clear yellow- 
coloured serosity, afterwards becomes milky-looking, opaque, and 
puriform. In most cases, however, of eczema impetiginodes the 
pustular element is much less perfect than the vesicular, the contents 
of the former consisting of a sero-purulent rather than of a purulent 
fluid. But in cases in which the inflammation is more severe than 
usual, the perfect impetiginous pustule is formed ; that is to say, the 
small, psydraceous pustule, characteristic of impetigo, and even the 
large or phylaceous pustule, characteristic of ecthyma. 

" Such are the special and distinctive characters of eczema impeti- 
ginodes. The pustular character of this form of eczema distinguishes 
it from the other forms of the disease, viz., from the eczema simplex, 
which is a purely vesicular eruption, neither preceded nor accompa- 
nied by redness of the skin ; and from eczema rubrum, which is 
always distinguishable by the bright red colour of the skin, and the 
number of minute vesicles by which it is covered. To distinguish 
eczema impetiginodes from some other diseases of the skin is not 
always so easily accomplished, and this is more especially the case in 
that form of scabies, called scabies purulenta, affecting the fingers 
and hands, parts, also, often affected with eczema impetiginodes." 



ECZEMA. 



121 



Eczema resists curative means so much the more obstinately as it 
occupies a more extensive surface, as it is of older date, of a severer 
kind, and as it appears on the lower extremities or on the hairy scalp. 
When children and the aged are the subjects of eczema, it often 
proves a disease which it is dangerous to cure. 

355. Treatment.— -In calling to mind the influence which teething, 
amenorrheea, dysmenorrhoea and pregnancy exercise on the produc- 
tion of certain eczemas, we are naturally" led to the indications of 
cure. Some varieties of the disease get well in time under the in- 
fluence of a regulated diet ; others require means of greater potency; 
and there are a few which are either intractable, or which it would 
be dangerous to interfere with. 

A considerable number of cures attributed to the use of medicines 
of little power, ought to be almost entirely ascribed to the influence 
of regimen, rest and time, which are frequently very powerful, espe- 
cially among the poorer classes leading laborious lives, who are 
mostly admitted as patients into public hospitals. 

I have seen children at the breast attacked with eczema of the hairy 
scalp who recovered by changing the nurse. I have seen many per- 
sons of mature years labouring under chronic eczema of the scrotum, 
verge of the anus and other parts, whose malady was constantly aggra- 
vated by the slightest irregularity in point of diet. It would be idle 
to ascribe too great an influence to the farrago of cooling and cleansing 
decoctions and drinks so constantly recommended in cutaneous affec- 
tions, and especially in eczema; but, on the other hand, it is perhaps 
not going too far to affirm that, of late, these means, or rather the diete- 
tic plans of which they formed a part, have been too much neglected. 
In no case, however, would it be reasonable to restrict individuals, 
otherwise in perfect health, to a lowering system of diet ; their con- 
stitution might suffer from such a course. 

I have met with several cases of eczema in which a vast variety of 
therapeutic agents had been fruitlessly employed, whilst the patients 
went on with their usual avocations, and took active exercise, but 
which were successfully attacked by the same remedies, from the 
moment that these individuals consented to lay themselves up. Time 
also modifies eczema at length, and occasionally accomplishes its 
cure ; so that individuals labouring under the disease in a chronic 
form, have now and then got well without recurring to any medical 
treatment whatever. 

The simple or emollient cold or tepid bath is frequently of the 
greatest service in the different acute species of eczema, even when 
the affected parts are not immersed in the water. In the decline of 
these diseases, when stiffness and dryness of the skin are alone com- 
plained of, and in the chronic eczematous affections of the backs of the 
hands, fingers, &c.,the vapour bath, and, better still, the steam douche 
to these parts is found to be useful. When eczema has passed into 
the squamous state, the warm sea, and alkaline bath are efficient in 
freeing the skin from the layers of epidermis accumulated on its sur- 
face ; but they almost always increase the redness, and the squamae 
are rapidly reproduced. Local baths repeated several times a day, 
and fomentations of decoction of linseed, marshmallow flowers, poppy- 
heads, and milk, are often of advantage in eczema of the genital or- 
gans ; in these cases the tepid hip-bath twice every day, always gives 
the greatest relief. If the disease have extended to the mucous mem- 
brane of the vulva, injections of althea-root decoction, with or without 
the addition of a little acetate of lead, are generally found to be sooth- 
ing. Sulphureous baths have also been tried in the advanced stages 
of eczema, especially when the aged and enfeebled were the subjects 
of the disease. These occasionally cause new eruptions, and have 
been found effectual in restoring eczema, the disappearance of which, 
either spontaneously or obtained by art, has been followed by unplea- 
sant or serious symptoms. The waters of the baths of Louiische have 
been frequently recommended with effect for this purpose. They 
have also occasionally seemed to make old standing eczemas run their 
course more rapidly, and thus to hasten their cure. I have seldom 
found artificial sulphureous baths produce such good effects, except 
in the chronic eczemas of elderly people, and some middle-aged 
persons, when they now and then seemed to lessen the redness and 
discharge from the skin, after having exasperated these morbid states 
for a time ; scrofulous subjects alone received invariable advantage 
from the use of these baths. I have occasionally seen beneficial effects 
31 



from the use of a sulphureo-alkaline ointment. Sulphur exhibited 
internally has never seemed to me to exert any appreciable influence 
on chronic eczema, except when it acted as a purgative. 

In running eczemas of small extent, emollient fomentations have 
been found of service. When the disease is followed by painful and 
extensive excoriations, and the skin is red and swollen, or covered by 
yellowish-looking scabs of considerable thickness, soothing-washes 
must be replaced by poultices of floury potatoes, of ground rice, and 
of crumb of bread, softened still farther with decoctions of althea and 
poppy-heads. These cataplasms are greatly preferable to such as are 
prepared of linseed meal, which are observed occasionally to induce 
artificial vesicular and even pustular eruptions. When the parts of 
the skin affected are covered with hair, these various topical applica- 
tions must be used folded up in a fine muslin rag. 

When poultices are employed in the treatment of children labouring 
under eczema of the hairy scalp and of the face, care must be taken 
to keep the head well covered, especially during the first few days, a 
precaution without which otitis and ophthalmia of greater or less 
severity are extremely apt to supervene. Depilation is an absurd and 
cruel practice during the acute period of eczema of the hairy scalp ; 
neither is it ever to be recommended even when the inflammation has 
passed into the chronic state. 

Moderate compression by means of a roller properly applied, is often 
employed with advantage in the cases of elderly persons affected with 
eczema rubrum of the lower extremities, when the disease is compli- 
cated with cedema or a varicose state of the veins, or when patients 
are obliged habitually to keep the erect posture without much motion. 

Slight escharotics, solutions of the nitrate of silver, diluted muriatic 
acid, $r.,have been recommended with a view to change the actions 
of the skin, when eczema has passed into the scaly state, and has 
continued for several months or years. With like intentions ointments 
of the red precipitate, of the lesser celandine, clematis, spurge, Sfc, 
and even blisters have been applied to the whole of the affected sur- 
face of the skin. If the cure of circumscribed chronic eczemas have 
occasionally been obtained by such means, these diseases have also 
been frequently and seriously aggravated by them. In general, when 
eczema has passed into the squamous or furfuraceous state, soothing 
ointments are the best local applications ; the good effects of the oint- 
ments of oxide of zinc, and of the protochloride of mercury are cer- 
tainly due in great part to the hog's-lard with which these substances 
are then largely incorporated. 

M. Alibert has given the details of a case in which the disappear- 
ance of an eczematous eruption {dartre squameuse) was followed by 
insanity. I am in the habit of employing issues in obstinate eczema 
of the hairy scalp, and genital organs; and when we have succeeded 
in bringing about or are anxious to accomplish the cure of the eczemas 
of elderly persons, which have existed long, or of individuals who 
have previously suffered from a chronic affection of the viscera, it is 
advisable to institute and keep open an issue or a blister in one of the 
arms. If the theory of counter-irritation still requires clearing up, it 
is enough that by the practice we can relieve the mind of the patient 
especially, from doubts and fears, and therefore it ought not to be 
neglected. 

I have said that eczema of the scalp, face and ears was occasionally 
a salutary disease in childhood. It is therefore proper to inquire in 
the first instance whether it might not be dangerous to attempt its 
cure ; the best and safest termination being that which is accomplished 
naturally. Facts enough prove the danger of discussing these erup- 
tions. On the other hand, inflammatory affections of the eyes, ears 
and viscera have been seen to disappear on the eruption of certain 
eczemas ; in such cases it would be improper to attempt the cure of 
the cutaneous affection in any other than the slowest and most gradual 
manner. These remarks also apply to other ages, when the disease 
appears under similar circumstances. 

The vegetable acids, diluted with water ; sherbets of the sulphuric 
and muriatic acid, with or without the addition of gum ; or milk mixed 
with barley-water or gruel, for those individuals with whom acid 
drinks do not agree, are usually recommended in the treatment of 
acute eczema. Such means are of less avail when the disease is 
chronic in its nature. W'hen eczema is acute, and the pruritus is 
exceedingly troublesome, and the inflammation runs high, as in the 



U 1 



VESICULiE. 



,-uvi or imp , it may be necessary to abstract blood 

it oftenet. I have had occasion to prove the utility of bleeding 
in a gfeai number of cases, even of chronic eczema. When one 
bleeding bas been followed by a notable improvement in the symp- 
toms, it is commonly an inducement to repeat the operation after a few 
days have elapsed. I frequently make such experimental bleedings 
in "the treatment of diseases of the skin. Cases of eczema, however, 
frequently occur, which resist this powerful means, or which even 
continue to advance in spite of its employment. It is, therefore, diffi- 
cult to lay down precise rules for the management of every case, or 
to specify those in which blood-letting will be found serviceable or 
detrimental. It is almost always hurtful to individuals of an irritable 
constitution and spare habit, and in whom the cutaneous affection has 
supervened or been increased after some violent affection of the nerv- 
ous system. Hereditary eczema is usually a very obstinate complaint, 
and we must beware of persisting in endeavours to effect its cure by 
means of blood-letting. In adults and individuals of mature years, 
the general is constantly to be preferred to the local abstraction of 
blood. The last is the only form of blood-letting that can be prac- 
tised in regar-r to young children. In eczema of the face and scalp, 
of the pudenda and margin of the anus, a number of leeches are often 
applied with good effect in the neighbourhood of the affected parts. 
The aged bear bleeding badly ; yet the measure occasionally becomes 
necessary when the parts implicated are severely excoriated and dis- 
charge abundantly, and when the disease is accompanied with violent 
pain and sleepless nights. 

In chronic forms of eczema, especially affecting the scalp and face, 
the waters of Seidlitz and Balaruc, the sulphates of soda and magnesia, 
or the tartrate of potash administered so as to procure one or two 
liquid evacuations daily without inducing colic, or even exhibited in 
cathartic doses twice a week during two or three months, are found 
to be useful when they only cause a temporary state of irritation in 
the digestive passages, without exerting any lasting ill effect on the 
state of the general health. The use of these remedies must be im- 
mediately suspended when pain, a continual feeling of uneasiness, 
and febrile symptoms give us reason to fear the excitement of inflam- 
mation in the stomach or alimentary canal. 

Purgatives are constantly had recourse to in the treatment of the 
eczemas of childhood. They are injurious to women who are preg- 
nant or nursing. Individuals of a nervous temperament, and habitu- 
ally confined in their bowels, always derive benefit from this class of 
medicines. Calomel alone, or in combination with jalap, is a good 
form of purgative ; when prescribed in frequent small doses, however, 
its use is almost constantly followed by painful inflammation of the 
mouth. Eczema, in some of its forms, is so painful a disease, and 
causes such distressing insomnia, that recourse must often be had to 
medicines of a narcotic character. 

Carrere and Bertrand-Legresie have greatly extolled the effects of 
the dulcamara in the treatment of eczema. The expressed juice, the 
decoction and the extract of this plant were prescribed by both of 
these practitioners, combined with purgatives, particularly a compound 
of the blue pill, with aloes, scammony and aromaties. After having 
fruitlessly tried the dietetic, the antiphlogistic and purgative plans of 
treatment in obstinate cases of eczema, about the verge of the anus 
and the genital organs, I have occasionally made successful use of 
the decoction of bitter-sweet, with the addition of a quarter of a 
grain of sublimate to each dose ; but this practice has its dangers, 
or at all events its inconveniences, even when it is not pushed to 
extremes. 

The preparations of arsenic are occasionally the only medicines 
-which can be successfully administered in chronic and rebellious 
eczema of the scrotum, pudenda, verge of the anus, &c. I shall 
not repeat what I have already said, 188-192, of the modus agendi 
of this class of remedies, and "of the precautions which are necessary 
to be observed in their administration. I shall only farther add, that 
the best advice which can often be given to patients advanced in life 
and of infirm constitution, is not to attempt the radical cure of such 
an infirmity as chronic eczema, if the disease be at all endurable. 
I he removal of these natural drains of the system is often followed 
by serious symptoms of a different kind; or, if no ill consequence 
ensues, the cure seldom proves permanent, the disease generally 



returning within a few months after the use of active medicine has 
been abandoned, (a) 



Historical Notices and particular Cases of the Disease. 

356. According to iEtius, 1 the Greeks characterized, under the 
name of eczema, those itchy vesicles that were not followel by ulcera- 
tion. In later times Willan 2 restored the term, using it to designate 
a vesicular non-contagious eruption, various forms and different termi- 
nations of which had been improperly described as particular diseases 
under what were deemed appropriate titles. 

Several cases of eczema simplex have been detailed under the 
names of rubores cum vesiculis et pruritu. 3 

An immense number of cases of eczema rubrum, impetiginodes and 
fluens, have been recorded by French pathological writers under the 
titles of dartre vive, 4 dartre squameuse humide, 5 herpes fongeuxf dartre 
avec ampoules ou vesicules ; 7 and we must even arrange several 
descriptions of scabies fera* and of agria under the single head of 
eczema. 

Several cases of eczemata in their last and furfuraceous stage, have 
been described under the names of dartre furfuracee, and others 
under those of dartre erysipflateuse (eczema rubrum) and milky erup- 
tion (eczema simplex), 9 terms which correspond to the running scall, 
humid tetter, fyc, of English writers. 

Eczemata of the face and hairy scalp, in their acute states, have 
been described as crusta lactea, 10 tinea mucosa, 11 porrigo larvalis, 12 
scabies faciei, 13 and itch of the face and head of young children: 14 the 
scurfy state and asbestous appearance of the dermis which this disease 
occasionally present in its last stage, have been described under the 
titles of tinea furfur acea, 15 and tinea amiantacea, 16 (teigne furfurach, 
teigne amiantacie.) 

Of late several cases of eczema have been published in different 
periodical publications. 17 

In the same works, also, may be found cases and remarks illus- 
trative of the efficacy of the ointment of cantharides in restoring 
eczematous eruptions which had disappeared, and had been followed 
by ill effects, on the virtues of the cicuta, 18 on the inconveniences of 
oiled silk coverings in eczemata of the hairy scalp, 19 on the properties 
of the diachylon gum plaster, 20 of the dulcamara, 21 of emollients, and 



(a) See, in a subsequent note, cases illustrative of the value of the 
arsenical treatment. In some of the more obstinate cases of chronic 
eczema, recourse may advantageously be had to Donovan's solution of 
the iodide of arsenic and mercury, in a dose of five drops gradually 
increased. 

1 Eas £«{^«t« ab ebulliente fervore, Groeci vulgo appellant. Tetrabib. iv. seruio 
1, cap. 128. 

= Batem. Synopsis. Art. Eczema. 

s Schenck. Obs. medic, rar., etc., fol., p. 749. 

4 Berlrand-Lagresie. Essai sur le trait, des dartres (Obs. i. iv. v. vi. vii. x. xix. 
etc). 

s Alibert. Precis sur les maladies de la~ peau, 2 vol. 8vo. t. i. p. 224.— Deleau. 
Ann. de la med. physiol, t. vii. p. 271. 

6 Rasori. Rec. period, de la soc. de med., t. lx. p. 367. 

7 Bertrand-Lagresie. Op. cit. (Obs. iii.) 

8 Plater. (F.). Praxeos, t. ii. p. 672. 

' Puzos. Traite des accouchemens, 4to. 376. 

,„ ,0 ,I isc J? er • , De morb - cutan> s P ec> '• Gaming., 1765 (crusta lactea adultorum).- 
Wolff. Diss, de crusta lactea. Jenae, 1793. 
" Alibert. Op. cit. p. 35. 

12 Willan. On cutan. diseases, 4to. Art. Porrigo. 

13 Rec. des actes de la soc. de sante de Lyon, t. i. p. 331. 

14 Mauriceau. Traite des maladies des femmes grosses, etc., 4to. Paris, 1740, t. 
i. p. 510. 

13 Alibert. Op. cit. Obs. iv. p. 25. 
16 Alibert. Op. cit. Obs. ii. p. 31. 

" Journ. hebd., t. iv. pp.77, 78;— t. viii. p. 44— Revue medic, Juin, 1830, p. 343.- 
Journ. complem., t. xni. et xxxvi. p. 85.— Ibid., t. xxxix. p. 37.— Lane, franc, t. v. p. 

OS) loo I . 

18 Labonardiere. Rec. period, de la soc. de med, t. 1. p. 263. 
' 9 Lespine. Rec. period, de la soc. de med, t. xxxviii. p. 437 
*° Labonard.ere. Rec. period, de la soc. de med, 1. 1. p. 2G1.-Rec. per. de la soc. 
de med , t. lvn. p. 292. v 

2' See the observations of Carrere, Crichton, &c, quoted § 202. 



EC2EMA. 



123 



of blood-letting, 1 of the white precipitate, 2 of the rhus radicans, 3 of 
lotions of sublimate, 4 of the sulphuret of potash, 5 &c. 

Poupart has given us several cases of recovery from affections, 
which he characterizes as dartres vives (eczema rubrum), which were 
followed by serious consequences of various kinds. 6 

The Essay of M. Levain, on the subject of the eczemata, is also 
deserving of a perusal. 7 

Confusion in the language employed, and in the arrangement of 
the facts observed, so conspicuous, has arisen not only from the dis- 
crepancies of our medical nomenclature, but also in some degree 
from the error into which the greater number of pathologists have 
fallen, of considering as distinct diseases the degrees and even the 
different terminations of eczema, the various modifications and suc- 
cessive transformations of which they had not studied with sufficient 
care. I regret that the nature of this work will not allow me to 
give a great number of particular cases of a disease the external 
phenomena of which are so varied, and whose treatment so frequently 
presents such insurmountable difficulties. 

Case XLIV. — Chronic eczema of the right breast, cured by Seidlitz 
water and an alkaline liniment. A young woman of a sanguine and 
lymphatic temperament had laboured under a chronic affection of the 
skin of the right breast for three months. Instead of being soft and 
pliant as in the natural state, the mucous covering of the nipple, and 
the neighbouring skin were covered over a space three inches in 
diameter, with grayish or yellowish epidermic laminae. Those to- 
wards the centre of the nipple were thicker than those in its circum- 
ference. The squama? were furrowed with many superficial chaps, 
from which a reddish-coloured serous fluid exuded. No vesicles 
were to be discovered ; these had all been destroyed. The patient 
stated that during the first stage of her disease the parts affected had 
poured out great quantities of red water. The nipple was the seat of 
rather violent pruritus, which became intolerable during the periods 
of menstruation. I recommended her to be purged once a week 
with a bottle of Seidlitz water, and the diseased surfaces to be anoint- 
ed gently three or four times every day with a liniment composed of 
two parts of olive oil and one of lime-water, the quantity of the latter 
to be subsequently increased till it equaled that of the oil. The 
pruritus was notably lessened by a few applications of this mixture. 
After the fifteenth day of treatment it had entirely subsided, and 
within six weeks the cure was complete. 

Case XLV. — Chronic eczema of both mammae; cure accomplished by 
the use of the ointment of red precipitate. Madem'lle N * * *, nine- 
teen years of age, of a sanguine temperament, applied at the fourth 
Parisian Dispensary, 21st November, 1825. Up to the beginning of 
this year the patient had enjoyed good health. At this period, how- 
ever, she was attacked, without assignable cause, with eczema of the 
nipple of the right breast, and two months afterwards with the same 
affection of the corresponding part of the left breast. An abundance 
of reddish or yellowish-coloured serum flowed from the parts in the 
first instance ; the local disease was unconnected with the slightest 
apparent derangement of the functions generally. For these com- 
plaints the patient had had recourse to a variety of remedies, general 
and topical, without deriving permanent relief from any one of them. 

November 21st, 1825. — There is now no vesicle to be distinguished 
on the surface of the parts affected. The mucous covering of the 
nipples is entirely but unequally inflamed, and presents a number of 
small excoriations in the form of scratches and linear chaps. The 
epithelium is even destroyed in several places, which are of a very 
bright red colour, moist, and covered with minute points of blood. In 
several others it is thickened, and somewhat reddish: towards the 
circumference it is whitish and thinner. The surface of the nipple, 
in fine, bears a great resemblance to a blistered surface beginning to 
dry up which has been scratched, or, rather, the disease is in that 
state which has been so frequently designated under the title of scaly 

1 Bobillier. Rec. per. de la soc. de med., 2e seYie, t. xxxi, p. 135. 

2 Vacquie. Journ. com pi., t. xxxi. 257. 

3 See the remarks of Dufrenoy, quoted § 207. 

■• Vincenzo Compagnero. (Gaz. med., 1831, p. 433.) 
6 Bertrand. (Rec. per. de la soc. de med., t. xlviii. p. 369.) 

6 Traite des dartres, 12mo. p. 86. Paris, 1784.— Des maladies internes que les 
vices dartreux produisent. 
' Lerain (J.). Essai sur l'eczema, Paris, 1830. 



tetter or dartre squameuse by the writers both of France and England. 
The surface of the nipple instead of being smooth and soft, is rough 
and uneven to the touch. The pruritus is at times unbearable ; fre- 
quently, when the patient has successfully resisted the strong desire 
to scratch the affected parts through the day, during the night when 
half asleep, she tears the nipples with her nails. The inflammation is 
evidently superficial and does not extend to the subcutaneous cellu- 
lar membrane. (Diluted sulphuric acid, warm bath, Goulard's wash.) 
These remedies were tried for a month without other advantage than 
a slight diminution in the inflammation. The acid was first omitted, 
and then discontinued from its having caused colicky pains of the 
bowels. The nipples continued squamous as before, discharging one 
day and becoming hard and dry the next. I now advised gentle 
frictions night and morning with the ointment of the red precipitate 
of mercury, to be discontinued should the nipples become very much 
irritated, and resumed when the state of excitement passed off. This 
plan was soon followed by the alleviation of the pruritus, the disap- 
pearance of the discharge, and the formation of a new epithelium, 
smooth and uniform as it is in a state of health. A relapse, however, 
occurred without any evident cause, and recourse was again had to 
the red precipitate salve. At length, after the cure had been appa- 
rently accomplished several times, and relapses, successively, how- 
ever, of less severity, had happened as often, the eczema was finally 
and completely cured towards the latter end of March. The patient 
was kept on the books till the 4th of May, 1826, in order to be cer- 
tain that no new relapse, occurred. 

Case XLVI. — Chronic eczema rubrum and impetiginodes of the left 
hand. Venesection, sublimate and dulcamara. N * * *, a straw-hat 
maker, thirty-six years of age, of a lymphatic constitution, consulted 
me in the month of February, 1822, on account of an impetiginous 
eczema of the left hand. The disease had appeared about three 
months previously, and in despite of a variety of remedial measures, 
had been growing continually worse. When I saw the patient first, 
the dorsum and metacarpal region of the left hand were painful, red, 
excoriated and pouring out abundantly from a great many places a 
viscid and very fetid ichor, so that dressings were speedily soaked 
and subsequently stiffened by the drying of the discharge. The 
patient had been obliged to discontinue her usual occupation five 
weeks back. Towards the circumference of the excoriation several 
small yellowish scabs, and a number of red patches appeared within 
the last few days, upon which a great many minute transparent vesi- 
cles were observed. Next day the majority of these vesicles were as 
large as pins' heads, and the fluid they contained was opaque and 
milky. Several small psydracious pustules, slightly prominent, and 
a few small transparent vesicles were thrown out on the sides of the 
fingers, the divisions between which were inflamed, excoriated and 
painfully chapped. The whole of these parts were affected with an 
intolerable pruritus, and the patient, in spite of herself, scratched them 
every instant. The patient's general health was good ; the men- 
strual periods were regular. (Venes. ad Sviii. Fomentations with 
decoction of bran, cataplasm of rice flour ; a quarter of a grain of 
sublimate in a cup of milk every morning fasting ; three glasses of the 
decoction of dulcamara daily, the tepid bath every fourth day.) These 
measures were speedily followed by a decrease of the inflammation 
and of the morbid secretion which accompanied it; I was even 
tempted to think the cure at hand towards the end of the third week ; 
the skin of the back of the hand was whitish and covered with 
squamae, but it was without redness, chaps or discharge, and no new 
eruption either of vesicles or pustules had appeared upon the fingers. 
On a sudden, however, an eruption of vesicles took place over the 
same parts that had already been affected, accompanied during the 
first few days with a copious exudation and intolerable pruritus. The 
same plan of treatment was still pursued without apparent injury to 
the digestive organs; the new eruption ran through the periods more 
rapidly than the first; and by the 25th of March, 1822, the patient 
had completely recovered ; nor has she had any relapse since this 
period. 

Case XLVII. — Chronic eczema of both legs. Madame * * *, thirty- 
eight years of age, of a mixed sanguineous and nervous temperament, 
had never been particularly indisposed until she was attacked, with- 
out any assignable cause, with eczema of both her legs in the month 



124 



VESICUL.E. 



of March, 1822. After a violenl sensation of smarting, tingling, and 
pruritus, a large red patcb appeared on the outer part of the left leg, 

upon which with the naked eye, and better, with the aid of the mag- 
nifier, an innumerable quantity of minute vesicles were observed. 
On the following days several new spots, also covered with -vesicles, 
made their appearance on the inner part of the leg, from the whole of 
which before long a yellowish and glutinous serum began to be dis- 
charged by an infinity of minute pores, in such abundance that every 
thing put about the limb was speedily saturated. The motions of the 
limb were performed with difficulty and pain, and the diseased sur- 
faces were affected with pruritus of the most intolerable description. 
The right leg also became affected, but the vesicles here w y ere much 
fewer in number, and the parts on which they were thrown out, in- 
flamed in a much inferior degree. The general health of the patient 
was not deranged in the slightest degree. ( Venes. ad 3xii. ; the warm 
bath; whey for drink.) The legs were dressed with saturnine cerate 
spread on a perforated rag, with compresses of soft lint to absorb the 
discharge. These dressings and the medical treatment gave relief, 
so much the more remarkable as Madame * * * had hitherto done 
nothing but apply fine linen and tissue paper to the inflamed skin, 
and the violence necessarily employed in changing these simple 
dressings had caused painful excoriations, from which drops of blood 
distilled every time they were renewed. The same plan of treat- 
ment was continued for two months, the disease at one time getting 
nearly well, at another becoming exasperated by the development of 
fresh crops of vesicles. The disease continued in this state for five 
months, the patient all the while leading the most regular life, and 
having used the warm-bath more than one hundred times, when at 
length it disappeared to return no more. 

Case XLVIII. — Chronic eczema of the verge of the anus and of the 
scrotum; psoriasis palmaris and plantaris ; various plans of treatment 
fruitlessly pursued ; cure obtained by arsenical preparations. So long 
ago as the year 1805, N * * * suffered from extreme itchiness of the 
inner parts of the thighs. In 1810 the disease had spread to the im- 
mediate vicinity of the anus, and surrounding parts of the buttocks. 
The lower part of the intestine at length became the seat of intole- 
rable pruritus which occasioned the patient the greatest distress on 
going to stool. From the year 1822 the parts mentioned had the 
appearance of a kind of large open blister ; and the patient was com- 
pelled to go about with an abundance of lint between the buttocks, to 
absorb the scalding serum which was discharged from the inflamed 
surface of the skin. In 1824, the patient was attacked with large 
pustules on the arms similar to those of ecthyma, which only got well 
slowly and reluctantly. Towards the end of the same year, the 
scrotum became implicated in the first affection, and caused such 
excessive pruritus that the patient was continually tearing his skin 
with his nails ; a serous, yellow-coloured discharge exuded from an 
infinity of minute pores on the inflamed surface, upon which I was 
never able to detect any vesicles ; but the progress and the seat of 
the disease, as well as the copiousness of the discharge, induced me to 
regard this scaly running tetter, this dartre squameuse humide, rather as 
a chronic eczematous affection than as a lichen agrius, a presumption 
that was greatly strengthened by the existence of several small vesi- 
cles, similar to those of eczema on the inner and upper parts of the 
thighs. In addition to the chronic eczema, the patient was also 
attacked with psoriasis of the palms of the hands and soles of the feet. 
This new affection first appeared on the right hand between the 
thumb and forefinger, then on the palm of the left hand, and lastly 
on the soles of the feet. (Gelatino-sulphureous baths; three glasses 
of the^ decoction of dulcamara ; lotion with the alcoholic solution of 
corrosive sublimate, diluted; soft lint between the buttocks.) This 
treatment had produced some amendment within a few days. The 
vesicles on the inner parts of the thighs were touched with nitrate of 
silver and soon got well. Before a month had elapsed the inflamma- 
tion of the scrotum, as well as that of the lower and posterior part of 
the raphe had subdivided; but the parts about the anus still con- 
tinued red, slightly chapped, and dischargino-. 

The inflammation having returned, the application of the oxide 
of zinc ointment was substituted for the lotion with the solution of 
corrosive sublimate. On the 18th of June the pruritus was excess- 
ively violent; the compresses of lint were dipped in a lotion contain- 



ing twenty-four drops of laudanum. The psoriasis of the hand was 
also worse. The patient called my attention to several fresh patches 
of a red colour on the palm of the left hand. These were neither 
covered with papula*, vesicles, nor pustules; the epidermis, over the 
parts of the skin affected, acquired a yellow colour; at length, after 
the lapse of rather more than twenty days from the attack of the 
pruritus and heat, it split into fissures. June 29th. — No new vesicles 
have been evolved, but the skin of the upper and inner parts of the 
thighs is still red and inflamed. A fissure has taken place in the 
direction of the median line, and several phlyzacious pustules have 
appeared upon the upper part of the buttocks. They are as large as 
small boils, from which, however, they differ by being covered with 
a firmly adherent scab, and exhibiting no sign of a sloughy core in 
their centre. The psoriasis is better. The pruritus about the verge 
of the anus has increased, and seems to be excited by emollient 
fomentations. July 1st. — The patient complains loudly of the pruri- 
tus of the margin of the anus, which was excessively troublesome 
during the night. I applied the nitrate of silver to those points of 
the inflamed skin between the buttocks, which appeared to have lost 
their cuticle. Bathing the affected part with a solution of sublimate, 
having on former occasions given great relief, I recommended N**** 
to make use of a wash of this kind four or five times a day; and with 
the same advantage as before. July 2d. — Five or six small round 
tubercles, which had existed for several weeks on the scrotum, ter- 
minated in suppuration. The patient was going on better, but from 
the 10th of July to the 15th of August, when he seemed to have 
completely recovered, he endured several unexpected and severe 
relapses. N**** now went to sea-bathing quarters, from whence he 
returned in the month of October, with the skin about the anus 
covered with squamee. These were got rid of by steam douches to 
the parts several times a day, by which the skin regained its pliancy. 
Another relapse now induced me to propose arsenic to the patient, 
to the use of which he consented. On the 10th of November he be- 
gan taking six drops of the solution of the arseniate of soda; 1 the dose 
was gradually increased, and carried at last to the length of thirty-four 
drops. The medicine caused neither diarrhoea nor vomiting; but on 
two or three occasions it excited shivering fits, a slight dry cough, 
and general uneasiness, which ought to have induced the patient to 
abandon it for a time. Up to the 15th of May, 1826, ten grains of 
the arseniate of soda had been taken, and the recovery was complete, 
at least in appearance, for the skin possessed its natural colour, and 
was covered by a smooth and supple epidermis, like that of the 
integuments in a state of health. 

Case XLIX. — Chronic eczema of the hairy scalp, ears and cheeks, 
cared by the decoction of dulcamara, solution of corrosive sublimate, 
and oxide of zinc ointment. — A. B., thirty years of age, asked my 
advice on account of an extensive eczematous affection of both ears, 
on the 5th February, 1826. This disease made its first appearance 
on the occipital region, after severe labour, and incessant watching 
during the illness of one of her children. A month afterwards it 
spread to the right ear, and from thence to the neighbouring regions; 
the affected parts, according to the patient's report, had repeatedly 
discharged great quantities of a reddish fluid. This discharge ceased 
occasionally, and then returned more copiously than before. It was 
accompanied by intolerable pruritus. The patient's nights were 
sleepless, and she had lost flesh, but in other respects she was well. 
Feb. 5th.— The skin of the right side, affected with eczema, which 
has spread over the whole of the ear and a great part of the cheek, 
has a marbled and variegated and moist look, in one place exhibiting 
small red patches, where the corion is exposed ; in another, being 
covered with thin, yellow, laminated and strongly adherent scabs; 
and in a third, haying little points of blood scattered over an exco- 
riated surface, amidst blackish incrustations which scarcely rise above 
the level of the integuments. The whole of this surface exhaled a 
sickly and very unpleasant odour, and a yellowish serous fluid exuded 
from the points which were most violently inflamed. On the left side, 
the cheek and ear were very similarly affected. Every part impli- 
cated was the seat of the most violent pruritus. No derangement of 
the digestive, nor of any other apparatus, could be detected. [Three 

' This is the liqueur or solution de Pearson of French writers.— R. W. 



ECZEMA. 



125 



glasses of decoction of dulcamara, and a spoonful of the liquor of Van j 
Swieten, (a solution of sublimate, a quarter of a grain to the oz. of 
fluid) every morning, fasting.] These medicines were not taken 
without some inconveniences, which were relieved, however, by the 
use of the warm bath, and, at the end of a month, the disease had 
almost entirely disappeared ; a few yellowish laminated crusts alone 
remained, which were soon thrown off, after a few applications of the 
oxide of zinc ointment. The cure in this case was completed without 
any relapse. 

Case L. — Eczema of the hairy scalp (teigne muqueuse), with pediculi; 
subcutaneous abscess, gastro-enteritis : recovery under the use of the 
warm bath, local bleedings, and emollient applications. — I was called 
to see a little boy, five years of age, on the 6th of January, 1826, 
the occipital region of whose head discharged a yellowish viscid 
fluid abundantly, which glued the hair together. I found the child 
affected with eczema of the scalp, and acute inflammation of the 
gastric and intestinal mucous surfaces. A straw-coloured fluid ex- 
uded from numerous points of the skin ; other parts were covered 
with soft, yellow scabs, stuck amongst the hair. The head rested 
on the left shoulder; upon the occipital region several small subcu- 
taneous phlegmonous tumours were detected by the touch, which 
were extremely painful. One of them, situated on the left side, near 
the mastoid process, heing felt to fluctuate, was opened, and a tea- 
spoonful of laudable pus evacuated. A chain of inflamed and swollen 
lymphatic glands could be felt along the lateral and posterior parts of 
the neck. Rather acute pain in the epigastric region, occasional 
efforts to vomit, dotted redness of the tip, and whiteness of the base 
of the tongue, obstinate constipation, an accelerated pulse, heat and 
dryness of the skin, added to great prostration of strength, were the 
principal symptoms of gastro-intestinal inflammation. The breathing 
was unaffected. {Five leeches to the epigastrium, mucilaginous drink, 
emollient cataplasm to the occipital region.) The leech-bites bled 
freely. From the 7th to the 13th, the gastro-intestinal symptoms 
were treated by the warm bath, administered twice a day, and by 
emollient cataplasms and glysters. The little patient, mean time, was 
supported with gum-water, and milk and water mixed. On the 15th 
he was convalescent. During all this interval the affection of the 
scalp showed no improvement under the continued application of 
emollient cataplasms. The mother even assured me that the disease 
of the scalp had got worse since the inflammatory affection of the 
gastro-intestinal membrane supervened. I now removed the hair 
from the affected parts ; the soothing poultices were continued ; a 
blister was applied to the left arm, and twenty-five days afterwards 
the scalp was completely whole. 

Case LI. — Repeated attacks of acute eczema rubrum at irregular 
intervals during a long succession of years. — The following interesting 
case is given by Dr. Marcet, in the second volume of the Medico- 
Chirurgical Transactions : 

I was called, he says, to attend a gentleman, about thirty years of 
age, rather of a spare habit, and pale complexion, for the first time, 
in March, 1808, on account of a complaint in the skin, which is apt 
to recur at irregular periods, and to which he has been subject, more 
or less, ever since the age of sixteen. 

The attacks of the disease are generally preceded for a few hours 
by what the patient calls a twinging sensation at the pit of the sto- 
mach, but without nausea, fever, or even loss of appetite. He then 
begins to feel a sense of stiffness and heat in the various parts of the 
body; these parts, in a few hours, are observed to become red, and 
to swell rapidly to a considerable degree. The hands, the feet, the 
ears and the lips, are the parts which the disease principally attacks. 
But it also frequently appears in the face and eyes, and sometimes 
even in the hairy scalp. Indeed, in the severest attacks, there is no 
part of the body which can be said to be totally exempt from it. 
The extremities, however, especially the hands and feet, are by far 
the most conspicuous seats of the complaint. 

When the parts are attentively examined on the second or third 
day of the disease, the cuticle appears to be raised in innumerable 
small vesicles, some of which are distinct, so as to give a roughness 
to the surface, though most of them are confluent, forming an uniform 
swelling, with a shining appearance. Soon, however, on the swell- 
ing abating, which commonly happens on the third or fourth day, the 
32 



cuticle begins to crack, and to rise in patches, discovering an in- 
flamed surface, with numerous small superficial ulcerations, from 
which there oozes a fluid, having a strong disagreeable smell. On 
the extremities, and in the bends of the toes and finger-joints, pretty 
deep fissures or ulcerations are formed, which, however, heal readily, 
and in a day or two the cuticle falls off in large patches, sometimes 
as large as the hands, presenting an appearance wdiich may be best 
compared to that of the trunk of the plane-tree when casting its bark. 
Sometimes the nails themselves are cast off, the new nail gradually 
pushing up the old one, which appears dead and withered. A few 
days after this, however, the new cuticle, which is at first red and 
inflamed, generally assumes its natural appearance, so that in the 
course of about a fortnight or three weeks from the beginning of the 
attack the complaint is commonly entirely removed. But at other 
times, and at the moment when the patient thinks himself convalescent, 
the new cuticle becomes hard and dry, and cracks again as in the 
first instance, producing a repetition of the symptoms just described. 

When I saw this patient for the first time, (in March, 1808,) it was 
on the 4th or 5th day of the attack, which happened to be one of the 
most violent he had experienced for some years. The swelling was 
still conspicuous in many parts, and these were in both his hands, 
particularly in the palms, where the cuticle is the thickest, and 
between the fingers, deep cracks and ulcerations. He had, however, 
no fever, no thirst, no quickness of pulse, and he complained only of 
a sense of weight, heat, and stiffness in the affected parts. The 
corners of his mouth, the ears and the feet were this time but slightly 
affected. 

Finding that amongst a variety of remedies and applications, which 
he had tried at various periods, with a view to relieve the immediate 
symptoms, he had never made use of poultices, I recommended a 
linseed-meal cataplasm, with twenty drops of the extractum litharg. 
acetat. to be applied to the hands. This produced a sensible diminu- 
tion of the tension and swelling, and upon the whole, great relief was 
obtained by this application. But soon after the removal of the 
poultices, the heat and stiffness gradually returned, so as to require a 
repetition, and an almost uninterrupted use of the same application ; 
and even during his convalescence (which took place in three or four 
days), and when the parts were fast returning to a natural state, he 
still found it expedient to have, occasionally, recourse to a poultice 
in order to remove uneasy sensations. 

With regard to internal medicines, having no distinct precedent to 
assist me in the choice of any particular treatment, and seeing evi- 
dently, from my first visit, that the patient was gradually recovering, 
I contented myself with regulating the state of the stomach and 
bowels. But with a view to prevent the recurrence of similar parox- 
ysms, I suggested that he should try a course of sarsaparilla, that he 
should make frequent use of neutral salts, and above all, that he 
should give a full trial to the warm bath, a remedy which, to my 
great surprise, had never been recommended to him before. 

Upon inquiring into the general history of this uncommon disorder, 
I was informed that the attacks had of late years recurred two or 
three times in each year, and appeared to have no connection with 
particular seasons. Some of these attacks have been very slight, and 
they have sometimes been so partial as to be confined to one hand, 
or even to one finger. In these instances the patient thinks that the 
progress of the disease has been prevented by the use of nitre and 
aperient medicines. 

This gentleman's general constitution appears to be delicate, 
though, excepting the complaint above described, he is not subject 
to any habitual ailment. In general he sweats easily and profusely 
upon the slightest exertion when in health ; but, at the time of the 
attacks, he complains rather of a deficiency in that secretion. His 
diet is moderate, and he has in vain tried to trace his complaint to 
peculiarities of regimen. 

Two years had elapsed, when, about the middle of last May, the 
same gentleman desired that I should see him again. I found him 
in a state perfectly analogous to that which I have just described, but 
with symptoms more severe than in the former instance, though still 
unattended with fever or other obvious constitutional affection. The 
desquamation of the cuticle all over his body was such, that on rais- 
ing his bed-clothes the spot where he lay was found literally strewed 



126 



VESICULjE. 



•with scak-s, and I do not overrate the fact in saying, that a handful 
d ighl easily have been collected. The hands, feet, lips, 
face and even the eyes, especially the outer corners of the eyelids, 
were the pails most "severely affected. The cuticle of the heels in 
particular, and that of the soles of his feet, came off in patches as 
as the palm of the hand. This attack had begun about twelve 
days before 1 saw him, with a sense of oppression in the pracordia, 
and it was immediately preceded by, and (he thinks) obviously con- 
nected with, his having been exposed to a severe shower of rain. 
After raging for a few days the complaint had in a great degree 
subsided, but had broken out again just before I saw him, with 
redoubled violence. 

I had the satisfaction of finding, upon inquiry, that with the excep- 
tion of some slight threatening*, this was the only attack which he had 
experienced for the last two years, and he ascribed his having been 
so much more free from his complaint, during that period, to the 
frequent use of the warm bath, and to the great attention he had paid 
to the state of his bowels. He had occasionally used cold sea-bathing 
with apparent benefit. 

The same local treatment was adopted, as in the former instance, 
namely, the application of poultices to the hands and feet; and with 
regard to internal medicines, I ordered a saline antimonial mixture, 
which, by exciting a moisture on the surface, appeared to allay the 
tension and uneasiness. In the course of a week he was in a state 
of full convalescence. 

Since writing the above, I accidentally met, a few days ago, (June, 
1811,) the gentleman whose case I have related ; he informed me that 
he had within these few weeks experienced another attack of the dis- 
ease, perfectly similar to those I have described, though in a slighter 
degree. 

March 1st, 1813. On inquiring into the state of my patient, of 
whom I had lost sight for the last twenty-one months, I found him 
just recovering from a severe attack of his complaint, with his cuticle 
partly renewed, partly falling off in large patches, of which he showed 
me a handful which he had just collected. He informed me that he 
had had eleven attacks of his disease since we had met last, that is 
about one every two months, some of which, however, had been very 
slight. The only additional particulars, I collected from him, were 
that he had found a brisk purgative more useful in mitigating the 
symptoms on their first appearance, than any other kind of remedy; 
and that, during the severer attacks, he had noticed a sensation of 
heat and irritation in his urethra, with some difficulty in passing his 
urine. His looks and general health are not materially impaired. 

Case LII. — Congenital ophthalmia, aphthous inflammation of the 
■mouth, roseola, strophulus, sordes of the scalp, slight eczema impetigi- 
nodes. Madame A. B. was delivered, towards the end of March, 1826, 
of a female child, well formed, but with the conjunctiva? of both eyes 
slightly inflamed. This child was confided to a nurse of a delicate 
constitution, whose milk, though abundant, did not seem greatly to 
benefit the infant. Despite a variety of measures — soothing collyria, 
counter-irritants behind the ear and to the nape of the neck, and the 
warm bath persisted in for the space of a month, the affection of the 
eyes did not yield before the end of the seventh week. From the 
twelfth day after birth, the lips, the edges of the tongue and the inner 
surface of the cheeks were attacked with the pultaceous inflammation 
peculiar to new-born infants, and characterized as aphthous. The 
suckling was temporarily suspended, and the child fed on milk and 
water. Nearly at the same time the body became covered with a 
roseolous eruption so general that the nurse and the parents believed 
the infant to be attacked with measles. This affection disappeared 
completely in the course of the third day. The aphthous affection 
did not extend beyond the mouth ; the evacuations of the infant, how- 
ever, showed considerable disturbance of the primae vi<e. The suck- 
ling was recommenced with a strong nurse as soon as the child could 
take the breast without pain. The child seemed at first to suffer from 
griping in the bowels; and a number of laree papal* were evolved 
on the thighs and buttocks (strophulus) ; the child slept little, but took 
the breast freely, and the discharges from the bowels soon became 
natural. A slight discharge took place from behind one of the ears, 
which was rather encouraged, and at length a cluster of small yellow 
pustules appeared on the right cheek, and another of larger dimensions 



on the parietal region of the same side. Both of these clusters of pus- 
tules speedily became covered over with a moist yellow incrustation 
which dried up in a few weeks afterwards, — that of the face falling 
off spontaneously and leaving a small red blotch upon the skin, (hat 
of the hairy scalp being removed by means of a softening poultice. 
By the same means a thick yellow, and, as it were, imbricated and 
very adherent scurf or sordes, which, since the period of birth, had 
formed a sort of covering to the scalp, was removed from its surface. 
The skin under this deposit, which extended some way over the naked 
part of the forehead, was quite healthy, and did not appear ever to 
have been inflamed. During the whole of the treatment the infant 
was put into the warm bath almost every day. 

Case LIII. — Inveterate eczema impetiginod.es ; remarkable modifica- 
tions in the appearance of the eruption (furfuruceous or squamous state 
of the face, hairy scalp, and palms of the hands). P. B., a hackney 
coachman, fifty years of age, in the habitual enjoyment of good health, 
though he occasionally indulged in wine and brandy to excess. Dur- 
ing the month of August, 1832, several small vesicular spots appeared 
on the right forearm. Feeling some uneasiness in the lumbar region, 
the patient applied a Burgundy pitch plaster to the part; the applica- 
tion was followed by an eruption that spread in the course of a few 
days to the thighs and legs, accompanied with severe itching, espe- 
cially during the night, but which even in the day was occasionally so 
annoying as to oblige him to get down from his box that he might 
scratch himself more at his ease ; this indulgence was accompanied 
and followed by the discharge of a quantity of reddish serum, which, 
concreting subsequently, formed scabs upon the diseased surfaces. 

On his entry into the Hopital de la Charite on the 11th of March, 
1833, the legs were covered with thick yellowish or dirty gray-coloured 
incrustations, rough, laminated, and irregularly cracked in the course 
of moist and ragged-looking chaps of the skin. On the thighs, fore- 
arms, and lumbar region, the surface of the dermis under the incrus- 
tations was moist and excoriated, and sprinkled with points of a very 
vivid red, from which the discharge appeared to exude. The pruritus 
was not now much complained of; the patient's health was good, he 
slept quietly, and was free from any derangement of the principal 
functions (twelve grains of the sulphuret of antimony ; sulphureous baths, 
mucilaginous lemonade, the three quarters hospital allowance of food). 
March 15th. — The sulphuret of antimony was carried the length of 
fifteen grains at each dose without producing uneasy feelings or mov- 
ing the bowels. The sulphureous baths had modified the appearance 
of the eczema ; the incrustations had partially disappeared ; the exposed 
dermis was red and moist (alum washes ; alum Ei, water lbs. ii.). The 
alum washes occasioned severe scalding pains, and had to be discon- 
tinued after the second day. March 19th. — The patient was bled ; the 
blood was not buffed, but very much cupped. The sulphuret of 
antimony in doses of thirty-six grains was continued to the 21st with- 
out inducing catharsis or any other appreciable effect on the system. 
Eighty grains of black hellebore produced no purgative effect, which 
speedily followed the exhibition of a few pills containing half a grain 
of the tartrate of antimony. These pills and the sulphureous baths 
were continued. One grain and a half of the tartrate of antimony, 
made up into three pills, and taken in the course of the twenty-four 
hours, kept the bowels constantly open up to the 14th of April, at 
which time the medicine began to cause vomiting, and the eczema, 
treated besides by compression, did not appear "to be making any 
progress towards recovery. Its appearance varied exceedingly from 
day to day ; the legs were alternately dry and scaly, or running and 
excoriated ; the general health had suffered no change. 

After being left quiet for a few days, the patient was put upon the 
solution of arseniate of soda in doses of thirty drops daily. About the 
18th of April the appetite fell off remarkably, an occurrence which was 
followed by a notable exacerbation of the eczematous affection. On 
a sudden the pruritus became more troublesome, and the skin redder 
and covered with vesicles, from which an abundance of reddish serum 
was poured forth to concrete into scabs of considerable thickness, 
especially on the legs. The pruritus was now exceedingly severe, 
and was accompanied by a very painful sensation of heat in the dis- 
eased surfaces ; the pulse became quicker, the sleep was disturbed, 
the appetite failed entirely. A copious bleeding gave an immediate 
check to these symptoms. The blood was buffed. Large cataplasms 



ECZEMA. 



127 



were applied to the inflamed surfaces. Cold bathing was substituted 
for the sulphureous baths, and the patient was put upon whey. A 
few days of this regimen and treatment sufficed to allay the general 
excitement of the system and to lessen the inflamed state of the skin. 
Barley water, acidulated with nitric acid, was prescribed, and the 
arsenical solution recommenced. On the 6th of May the legs were 
free from scabs, and the skin had lost its redness ; the excoriations 
were paler, but dotted with points of blood as if the skin had been 
slightly abraded by the action of a rasp. This improvement, however, 
did not continue long ; renewed febrile symptoms were followed by a 
reappearance of the eruption. The patient was bled again, and again 
put upon the whey diet and the use of the cold bath. The blood was 
still buffy. The legs were gently anointed with lard, and covered 
with emollient cataplasms. 

At this period the face was attacked with an eruption of a similar 
kind, followed by furfuraceous desquamation principally from the parts 
that were covered with hair. Small impetiginous scabs were also 
formed upon the eyebrows. The hairy scalp, especially its anterior 
part, was soon covered with a very abundant white and glistening 
desquamation, the scales of which clung to the hair. The skin, when 
rubbed and freed from this species of scurf, did not appear much 
inflamed. 

On the palmar aspect of the hands, the desquamation had a differ- 
ent character. Large flaps of cuticle were detached from the skin, 
which appeared humid and red underneath them. The cold baths 
and whey diet were continued till towards the end of May, a period 
at which the eczema of the legs had a favourable aspect. The scabs 
were no longer reproduced, the discharge had almost entirely ceased, 
and the general state of the patient was satisfactory. June 11th. — 
The nitric acid sherbet was resumed, and the bathing continued. Lard 
was ordered to be rubbed upon the tender surfaces, and the disease 
appeared stationary ; but on the 12th, the skin of the legs in several 
places again took on an inflammatory action, and became covered 
with impetiginous incrustations ; the patient was bled for the third 
time, and after a few simple baths, improved once more. The patient 
left the hospital on the 24th of July, 1833, not completely well ; the 
disease, however, had become supportable ; the general health was 
good ; the micaceous desquamation of the scalp still continued abun- 
dant, without itchiness or unpleasant sensations. («) 



(a) A good clinical lesson is conveyed in the following case, 
recited by Dr. Carswell (ut supra). " We now come to the con- 
sideration of the second case of eczema impetiginodes, which is one 
of considerable interest, even in a diagnostic point of view, owing to 
the unusually obscure and complicated appearances which it presented. 
I shall first read you the history of this case, taken from the case-book, 
before offering you the explanatory observations which it suggests. 

" History of case. — John Smith, set. 35, admitted December 4th, 
1838, formerly a groom, but for the last three years has been em- 
ployed as a gardener ; he is of a sanguine temperament, tall and mus- 
cular, married, and of regular habits ; parents are living, and generally 
healthy ; his own health has always been remarkably good. Fourteen 
years ago (before his marriage) he contracted gonorrhoea, and got 
well in about a fortnight by the use of internal remedies. He declares 
he never had any venereal complaint since, nor, indeed, ever been 
in "harm's way." In the summer, six years ago, he had an erup- 
tion of small pimples all over his body, on glans penis and scrotum, 
as well as on other parts. These were attended with very little itching, 
and died away spontaneously towards winter; they have returned 
every summer about June. The eruption was supposed, by his 
medical attendant, to be syphilitic, and the patient was salivated 
three times within the twelve months, three years ago. At this time 
he states that he had a small swelling in the groin, which, however, 
soon subsided after leeching and rest. After the first salivation the 
eruption assumed a new form ; the pimples broke and discharged a 
yellow fluid, which concreted into thick scabs. Similar pimples 
now began to appear on the scalp and face, being preceded by severe 
headaches. Each pimple broke, enlarged, joined with neighbouring 
ones, and formed large discharging surfaces, which afterwards gradu- 
ally healed at the centre, on various parts of the head, trunk, and 
extremities. His throat became sore ; there were large ulcers formed 



Case LIV. — Eczema of the navel; rapid spontaneous cure folloioed 
by chronic gastritis ; good effects of a blister and an issue in the original 
seat of the eruption. F. J. M., forty-six years of age, was admitted 

in it, and it continued in this state for two months. He became gradu- 
ally worse and worse, and was, as stated, admitted the 4th December. 

" Present symptoms. — His face is nearly covered with the erup- 
tion ; the patches are irregular in size, but generally assume a circular 
form ; some parts are erythematous, covered with a furfuraceous de- 
squamation, and around the margins of these patches, which have 
healed in various degrees in the centre, the still discharging eruption 
forms scabs and crusts of a yellow colour, by the concreting of the 
matter furnished by the pustules. There are numerous patches on 
the head, behind the ears, &c. &c. ; the margins of the patches are 
not raised, but the skin around is red and shining ; the eruption heals 
in the centre of the patches, and the parts, once the seat of the disease, 
do not again become affected. The affected parts are hot, itch, and 
smart, and heat only makes them worse. There are several large 
patches on the back, and on the front of the chest, one on the left 
scapula, and one on the right breast, forming a complete ring. Ano- 
ther very large one is situated just below the knee, healed in the 
centre, the skin there being of the natural colour, and another patch 
under the left thigh, four inches in breadth. There are small red 
papulae, containing fluid of a yellow colour, like impetiginous pustules, 
diffused over the body in various parts. 

" The upper lip is much swollen and protruded ; the eyelids are 
thickened ; there are lippitudo and coryza ; the sight is dim and im- 
paired, and the eyeballs bloodshot. 

The skin is, at times, very hot and dry ; he is very much weakened 
by the disease; appetite is pretty good; thirst; sleep bad ; very little 
perspiration; bowels regular; urine high-coloured, and rather increased 
in quantity; tongue clean and natural. 

" The history of this case suggests two inquiries : first, the nature 
of the eruption considered in itself; and, secondly, its remote cause 
or origin. As to the eruption, it presented far from common appear- 
ances, both as regarded its general characters and the great extent of 
the surface which it affected ; in some of its characters it bore a faint 
resemblance to psoriasis, particularly in the redness of the inflamed 
surfaces and the presence of the furfuraceous desquamations, or, 
rather, thin whitish, transparent, laminated scales, which covered a 
great part of these surfaces. It was, however, only in these respects 
that it had any resemblance to psoriasis, and that but a very imper- 
fect one ; for, in this disease, the squamae are white and opaque, and 
are not only accumulated into thick rugous masses, in chronic cases, 
such as that of our patient, but the inflamed cutis is thickened, hard- 
ened, and fissured, which in this case was smooth and shining. 
Besides the somewhat scaly or squamous character of the affection, 
which gave to it a resemblance to psoriasis, there was also another 
circumstance calculated to lead astray, viz., the tendency of the large 
patches to heal in the centre ; but this circumstance is observed in 
other and different cutaneous diseases, and particularly in that with 
which this patient was affected. 

" Besides these negative characters of the disease, there was one 
of a positive nature, which at once served to distinguish it from psori- 
asis, viz., the incrustations, or scabs, which occupied principally the 
outer margin or circumference of several of the patches on different parts 
of the body. These were of a yellowish or yellowish-brown colour, 
obviously formed by the concretion of a viscid secretion, such, in fact, as 
is observed to occur in impetigo or eczema impetiginodes. No such 
kind of crust or viscid discharge occurs in psoriasis, although in some 
cases of psoriasis, inveterata, after an exacerbation of the inflammatory 
excitement, a slight discharge may take place; but even here the 
resemblance to impetigo is extremely remote in this as well as in 
many other circumstances. 

" Could there have been any doubt as to the character of the dis- 
ease, as indicated by the general appearances of the patches, and 
particularly by that of the scabs, this would have been removed by 
the presence of the impetiginous pustules on several parts of the 
body. 1 

" ' A model in wax of a part of the body affected with the disease was exhibited 
and described. 



128 



VESICULrE. 



into the Hopital de la Charite* on the 3d of Juno, 1833. 1 ive years 
prior to this date he had been troubled with an eruption over a space 
U broad as the palm ot'the hand around the navel, accompanied with 
smarting and pruritus, from which a quantity of red fluid was dis- 



"This form of impetigo is, as I have already said, far from being 
common. It is observed in persons of a lymphatic or scrofulous con- 
stitution, and most frequently as a sequela of venereal infection, and 
possibbj in those on whose constitutions mercury exercises an injurious 
influence. It is stated that this patient had a gonorrhoea fifteen years 
ago, which was removed in the course of about a fortnight after the 
use of internal remedies, probably no mercury having been employed. 
Nine vears after he had, in summer, what appeared to have been a 
papular eruption over the whole body, including the glans penis, and 
which disappeared spontaneously towards the winter, and which had 
returned every summer since. This eruption was supposed, by the 
medical attendant of the patient, to be syphilitic, and three years ago 
he was salivated three times within the twelve months. Instead of 
this treatment having been of any service to the patient, the disease 
with which he was afflicted became worse after \he first salivation. 
Instead of a papular there now appeared a pustular eruption, occupy- 
ing first the head and face, and accompanied by severe headache. It 
was at this time, also, that the throat became affected, and was the 
seat of ulceration for about two months. From this period, also, the 
cutaneous disease increased in severity until it had arrived at that 
stage at which you saw it when he was admitted into this hospital. 

" When I first saw this patient I did not attach much importance 
to the venereal origin of his disease, nor was this to me a matter of 
consequence, as the treatment employed was that which has been 
found to be, in most cases of this nature, by far the most efficacious. 

" You have heard that he had fifteen years ago only a gonorrhoea, 
although our evidence on this point is by no means conclusive. How- 
ever, were his statement correct, it would not be a solitary instance 
of syphilitic eruptions succeeding to gonorrhoea after intervals of many 
years. I have myself witnessed cases of this kind, in which the 
cutaneous affection itself, either of a scaly, vesicular, pustular, or 
tubercular character, bore sufficient evidence of its origin ; and Biett, 
of the Hospital of St. Louis, of Paris, who has had the most extensive 
opportunities of investigating this subject, long since informed me that 
the occurrence of syphilitic eruptions after gonorrhoea was far from 
being uncommon. 

" Numerous experiments, particularly those of M. Ricord, have, 
indeed, lately demonstrated that the primary affection of the mucous 
membrane is, in many cases of gonorrhoea, of the same nature as in 
chancre, the puriform discharge in these cases, when introduced into 
the cutis, being followed by the formation of a true venereal sore, or 
chancre, and its constitutional consequences. From a review of the 
history of this patient's case, therefore, you will no doubt be disposed 
to consider the vesiculo-pustular affection which he presented of 
syphilitic origin. The sore throat, combined with successive attacks 
of the cutaneous affection, would, by most physicians, be considered 
conclusive evidence in a case of this nature. 

" The treatment in this case was in the highest degree successful ; 
how far the cure will be permanent is yet a question. However, the 
further use of mercury in a case of this kind would have, I am certain, 
as it already had done, acted most injuriously. Indeed, I may say, 
that almost all the bad cases of syphilis which I have seen, more 
especially when the throat was extensively ulcerated, the nose de- 
stroyed, nodes of the bones, excruciating pains, &c, have occurred in 
persons who had undergone repeated courses of mercury, and without 
imputing this to the deleterious operation of the mercury alone, it is 
no less an important practical fact that such consequences too fre- 
quently follow the operation of this medicine in constitutions con- 
taminated by syphilis. 

" The following was the treatment adopted in this case : — 

"Dec. 4. Venesection Sxii ; sol. of hyd. of potash 1 3 ss thrice a 
day ; middle diet. 

" 6. Blood buffed and cupped ; skin less hot. 

i The solution of the hyd. of potass, employed in the hospital contains one drachm 
to the ounce of water. 



charged ; this in all likelihood was a cluster of edematous vesicles. 
After continuing a month, the disease very quickly disappeared, with- 
out any kind of very active treatment having been employed for its 
cure. Previously to this attack the patient had never been affected 
with any symptoms of indigestion ; but from this time he began to 
complain of a feeling of weight and a disordered state of the stomach 
and bowels. He now felt sick, and showed some inclination to vomit. 
Several days of rest, demulcent drinks, and leeches to the epigastric 
region subdued these unpleasant symptoms; but the digestive func- 
tions continued weak; the patient could not eat of every thing indif- 
ferently ; he was only comfortable when taking milk and light broths ; 
meat and wine were excluded from his regimen. The patient, after 
suffering in this way for fifteen months, got a little better, but the 
improvement did not continue long, and the former symptoms re- 
turned ; he therefore sought admission into the Hotel Dieu, where he 
was bled twice with leeches from the anus, and ordered to take the 
bath several times. He left the hospital in a fortnight very little 
relieved. 

When M. entered La Charite, he looked pale and was considerably 
reduced. The tongue was white in the centre, and rather red at the 
tip ; the epigastrium was painful. He complained of distaste to food, 
of flatulence, a painful sense of constriction across the stomach, espe- 
cially after taking certain articles of food, amongst which fresh vege- 
tables were particularly mentioned ; he had also acid eructations, and 
a sour taste clung about the gums ; he was occasionally sick and had 
a more copious secretion of saliva than proper. The stools were 
natural, the respiration was free, the pulse good ; there was no heat 
of surface. The patient, however, was habitually dejected and 
melancholy. (Demulcent gummy drink ; beef tea, soup and milk for 
diet ; and with a view to restore the eruption of the navel, the recession 
or suppression of which seemed to have preceded all the gastric symp- 
toms since endured by the patient, a blister was applied over the umbili- 
cus.) June 9th. — The patient, whose sensations appear to be very 
acute, complained of his inability to bear the pain of the blister; one- 
half of the blistered surface was therefore allowed to heal up ; the 
other was kept open, and so long as the artificial inflammation thus 
excited was maintained, the stomach felt less oppressed and the 
digestive powers appeared stronger. The patient, however, made 
new complaints of the blister, and it was healed up on the 16th, but 
replaced on the 18th by a small issue established above the navel. 
After the 25th the improvement was remarkable. The tongue became 
less loaded, and the countenance wore a better aspect. Milk, and a 
very small quantity of solid food, now composed the diet of the 
patient. On the 5th of July he requested to be discharged. The 
digestive functions were then greatly improved ; the appetite was 
better, the patient ate and digested without difficulty the quarter hos- 

" R. Creasote, one drop ; 

Water Evj ; a lotion for the affected part. 

" 8. Lotion caused some smarting, and was decreased in strength ; 
two ounces additional of water. Increase solution to two scruples. 

"11. Heatand itching less ; eruption paler. Sol. of hyd. of potass. Z'\. 

" 15. Improving rapidly. Sol. of hyd. of potass. 3£ scruples. 

" 18. Much less redness, heat, and smarting; lotion diminished in 
strength from its causing too much tingling. Sol. of hyd. of potass. 
four scruples. 

"22. Eruption still less red and tingling ; patient feels much easier, 
but had an attack of headache and sickness, from having taken 3ss 
of the solution, by mistake, more than was ordered. 

" 25. Venesection 3vj ; sol. of hyd. of potass. 3iss. 

" From this period up to the 10th of January, the general health of 
the patient and the cutaneous affection gradually and steadily im- 
proved. 

" The use of the creasote lotion was continued, with some varia- 
tion in its strength, and the solution of the hydriodate of potash 
gradually increased to 9 v. A few days after the patient was allowed 
a more generous diet. On the 22d he was nearly well, desirous of 
returning home ; and on the 24th was discharged cured, the only 
remains of the cutaneous disease consisting in a reddish discolora- 
tion of the parts of the skin which were affected by the eruption." 



ECZEMA. 



129 



pital allowance, and could even take a little wine without incon- 
venience. He was discharged with a recommendation to keep the 
issue open, (a.) 

(«) The following cases related by Mr.Erichsen (Med. Gaz., May, 
1843), will illustrate the value of the arsenical treatment. 

" The only disease," says Mr. E., " amongst thevesiculse thatcan 
ever necessitate the employment of arsenic is chronic eczema. This 
is more particularly the case when this affection, as has already been 
stated, has assumed a furfuraceous or scaly condition, closely resem- 
bling some forms of psoriasis, or pityriasis, and indeed in some 
instances, as Biett has shown, actually passing into these diseases; 
the scales becoming dry, laminated, and of a whitish, grayish, or 
yellowish-gray colour ; the subjacent skin being red, thickened, 
cracked, and inflamed ; the vesicular element, however, reappearing 
in the progress towards a cure. However obstinate this form of the 
disease may usually be, it becomes particularly intractable when 
affecting certain regions of the body, as the scrotum, labia, and inside 
of the thighs, and will, when of old standing in these situations, sel- 
dom yield to any remedy but arsenic. The following is a case in 
point : — 

" Mr. W. B., set. 49, of relaxed debilitated habit of body, applied to 
me, in October last, for a disease of the scrotum, thighs, and breast, 
under which he had been labouring between four and five years. He 
ascribed his complaint to his having drunk some porter when over- 
heated, soon after which act of imprudence he experienced considera- 
ble irritation about the scrotum and thighs, on which parts a vesicular 
eruption made its appearance : this was followed by a scaly condition 
of the parts, and the affection, after a time, spread to other parts of 
the body, as the arms and chest. He has been subjected to a variety 
of treatment, and has been salivated twice, but without deriving any 
benefit. When he applied to me, the scrotum and inner aspect of 
the thighs were covered by a number of thin, flimsy, yellowish-gray 
scabs, from under and between which an occasional exudation of a 
serous fluid took place ; the subjacent skin was red, inflamed, and 
fissured, and there were several patches of a similar character upon 
the chest, occupying a space of about the size of the hand, as well as 
one on the right arm. The itching and tingling in the affected parts 
were severe, so much so that it was with difficulty that he could keep 
his hands from tearing them. When I first saw him his mouth w r as 
sore from the effects of some mercurial that had been ordered by the 
physician who last attended him, and by whom he was sent to me. 
He was, therefore, in the first instance, merely directed to take some 
aperient medicines, and to make use of soothing applications to the 
affected parts. On the 4th November he was put upon a course of 
Fowler's solution, beginning with two and a half minims twice a 
day, and increasing the quantity up to six minims three times a day ; 
this was continued, with two intermissions on account of constitu- 
tional disturbance, up to nearly the end of December, when the 
disease was entirely cured. The external applications that were had 
recourse to were, in the first instance, the ointment of the white pre- 
cipitate, which was, as the disease became more passive in its 
characters, changed for that -of the biniodide of mercury, diluted with 
four parts of spermaceti ointment. 

" Useful as the solution of the arsenite of potassa unquestionably is 
in cases similar to the preceding one, it is equally serviceable in dry 
chronic eczema affecting other parts of the body, as the following 
instance will illustrate. 

" Eliza Penny, aet. 16, of a lymphatico-bilious temperament, came 
under my care on the 17th November, 1842, for a disease of both 
arms under which she had laboured from the very earliest infancy 
(from the age of three months). The affection in question was clearly 
eczematous. The diseased integument appeared thicker and rougher 
than natural, was covered with flimsy exfoliations of the epidermis, 
was exceedingly irritable, itching and tingling to an intense degree 
when the patient got warm, and was much fissured about the bends 
of the elbows and wrists. There was every now and then an exacer- 
bation of the disease with a distinct eruption of vesicles. The patient 
complained much of languor and lassitude, was pale, or rather sallow- 
in complexion, and menstruated somewhat irregularly. She was 
ordered the diluted mineral acids internally, with the oxide of zinc 
33 



ointment to the affected parts, and the pil. aloes cum myrrha,to regu- 
late the bowels and menstrual functions. Under this plan of treat- 
ment the general health improved somewhat, and the irritability of 
the affected skin was subdued. She was then, on the 2d January, 
ordered to begin the solution of the arsenite of potassa in two-minim 
doses; these were gradually increased to five, and subsequently to 
seven and a half minims, three times a day : this she continued lor a 
space of two months and a half, until the middle of March, without 
being obliged to intermit its use for a single day, at the expiration of 
which period the arms had assumed a healthy appearance, the skin 
being smooth, soft, and supple, perfectly free from scales, and without 
any harshness; it was, however, owing probably to the very long 
time it had been diseased, of a yellowish or tawny colour, darker than 
that of the rest of the body. The only external applications used were, 
in the earlier stages, the ointment of the oxide of zinc, with occa- 
sional fomentations during the exacerbations of the disease. These 
were followed by the ointment of the white precipitate, and subse- 
quently by a lotion of the sulphuret of potassium, in the proportions 
of a drachm of the salt to a pint of water. The local disease was not 
only cured, but the general health very decidedly improved by the 
administration of the arsenic ; the patient having gained flesh and 
strength, acquired a good colour, and declared herself to be in better 
health than she had ever enjoyed." 

In support of a different mode of practice, and as a lesson in diag- 
nosis, I introduce the following " Aggravated case of eczema rubrum 
on the genital organs, mistaken for syphilis. By W. Jlcton, Esq., 
Surgeon to the Islington Dispensary. (Read before the Westminsf ■ 
Medical Society.) 1 A child, nine weeks old, was brought to me by 
its mother, in great alarm, in consequence of having been told by a 
medical man that the complaint was venereal. 

" The child was a fine stout boy, but very fretful. The eyebrows 
presented distinct vesicles of eczema. The inside of the mouth and 
lips free from disease, but just at their margins, and extending for 
the space of an inch and a half, completely encircling the mouth, the 
skin presented a dusky hue, and appeared covered with a thin, shining, 
dry pellicle, like a recent blistered surface, interrupted with cracks 
and crevices, without exudation, except beneath the chin, where the 
capstring had irritated the surface ; and here a serous-looking fluid 
exuded, and excoriated the surrounding parts. Beyond this, distinct 
and separate clusters of vesicles could be seen, presenting a dusky 
hue. On the arms and chest a few small patches of these vesicles 
were apparent. The disease, however, seemed to have settled prin- 
cipally on the lower part of the abdomen, scrotum, thighs, and nates. 
The entire surface of these parts presented a shining, but dark o r 
dusky-red surface, as if covered with a thin pellicle, similar in ap- 
pearance to that found on a healing blistered surface. The tempera- 
ture of the surface was much above that of the surrounding parts ; no 
vesicles could be detected ; this unhealthy-looking skin was creased 
and plaited, with a disposition to crack; in many places large thin 
flakes could be detached ; every movement the child made appeared 
to cause great pain. 

" The mother states that her other two children are, and have been, 
quite healthy; her husband has never complained of illness; she has 
suckled her own child, which has never been out of her sight; has 
never nursed any other woman's infant. The child enjoyed good 
health until three weeks old ; at this period it was seized with thrush ; 
the throat became affected, and soon after an eruption appeared around 
the arms, which has gradually spread over the parts now affected. 
For some weeks the child was under the care of her usual medical 
attendant, and treated with powders and ointment; the mother, finding 
the complaint getting worse, consulted another medical man, who, 
after looking at her boy, told her not to be offended, but her child 
had the venereal disease, and mercury was necessary for its cure. 
He prescribed a gray powder twice a day. The terror of the mother 
was, as may be supposed, great, when made acquainted with her 
child's complaint ; for herself she could reply, and as to her husband':: 
conduct she never had entertained the least suspicion. The medical 
man was no less positive, and further enjoined her not to suckle the 

1 Lancet, Jan. 1845. 



I 10 



VESICUUE. 



the should herself become infected: the friends in the 
becoming alarmed, recommended her to take a third 
opinion. 

"On seeing the child I felt no hesitation in stating that it suffered 
an aggravated form of eczema rubrum — a complaint which I 
more than once have seen mistaken for syphilitic disease; and as it 
sveral features of great interest, 1 have brought it forward 
this society as one illustrating the diagnosis of a most interest- 
iss of infantile diseases, not usually dwelt on in books on that 
subject, yel leading to most lamentable consequences in practice. I 
presume the dusky colour of the skin, the obstinacy of the complaint, 
and the possibility of the father having been infected with venereal 
in his youth, may have imposed on this practitioner, as it has done 
on others, who have characterized similar complaints, syphilitic. My 
own opinion was formed on the following data : — The general appear- 
ance of the child, strong and plump for its age, contra-indicated any 
syphilitic taint; in almost all cases, previous to secondary symptoms 
appearing, we find children fall away. The skin presents generally 
an earthy hue, and before syphilis has existed six weeks, the infant 
is reduced to a skeleton. The dusky colour of the eruption on the 
child certainly might lead to the suspicion that the complaint was 
syphilitic in the minds of those who place much dependence on colour 
as a criterion of syphilitic eruptions, but most modem writers agree 
in this test being very fallacious, as no recent eruption of a syphilitic 
character is copper-coloured, and many old and non-specific diseases 
of the skin take on a bluish or livid character. Moreover, the vesicu- 
lar form of secondary symptoms is a very uncommon affection ; those 
who have had the greatest opportunity of witnessing venereal diseases 
not having met with more than one, or at most two, instances of the 
disease. The only affection, then, that this disease could be con- 
founded with, would be that form of the complaint shown in the plates 
(which I pass round); but it will be seen that it there assumes a 
flattened, tuberculated form: in this instance no elevations could be 
seen or felt. The severity and duration of the disease equally bespeak 
the case to be one of eczema rubrum, as that complaint is well known 
to be very rebellious to ordinary treatment, unless a correct and even 
appropriate treatment is recommended, for an exactly opposite one is 
requisite in the one and the other disease. 

"In this case the first indications of treatment consisted in attempt- 
ing to reduce the temperature of the part, and to apply locally a 
soothing application. I recommended the mother to place the child 
in a bran bath, night and morning; to be careful not to employ soap, 
or dress the child in front of a fire ; to keep fine linen rags, damp with 
Goulard's lotion, constantly to the child's nates and scrotum, reap- 
plying them as often as they became dry ; to protect the infant from 
catching cold, by enveloping it with flannel, so as to maintain the 
general temperature of the surface. 

"I am prepared to hear this treatment caviled at as one fraught 
with danger, and the probability of inflammation attacking some 
internal organ. I can only say that where ordinary precautions are 
taken to exclude air, no apprehensions need be entertained. I have 
infants like the present very speedily cured, when all other 
means have failed, and in old people, much reduced, no ill conse- 
quences have followed, although, as in this instance, the surface con- 
stantly kept wet has been considerable. 

"All kinds of ointments or greasy applications are, as in this case, 
prejudicial; they soothe the part for a moment, but seem then to 
increase the temperature, are liable to become rancid, and frequently 
occasion a relapse of the complaint. 

" As the child had taken three gray powders, (its bowels, previ- 
ously regular, having become relaxed,) I did not order any physic, 
being determined to watch the effect of simple local treatment. The 
mother was desired to give the child the breast, as in its present con- 
dition it would be difficult to find any other person to suckle it, for 
fear of infection. I desired her, however, to live regularly, abstaining 
from cheese and raw vegetables, or any thing that might disagree with 
the stomach. 

" Nov. 25.— On the next morning the mother came to me delighted ; 
her child had been much less fractious, and slept for several hours 
after the bran bath ; she had constantly kept the lotion applied by 
means of a damp lawn handkerchief, completely enveloping the parts 



HYDRARGYRIA. 



Vocab. Hydrargyria, Eczema Mercuriale. 

357. Hydrargyria is a cutaneous eruption excited by the internal 
or external administration of mercury, characterized by an evolution 
of vesicles, with or without fever, upon red and inflamed patches of 
various sizes. Dr. Alley, who has written expressly on this subject, 
has described three varieties of the disease : hydrargyria mitis ; hy- 
drargyria febrilis, and hydrargyria maligna. 

358. Symptoms. — 1. Hydrargyria mitis at first sight, appears to 
consist of a slight rosy efflorescence ; but by placing the parts affected 
between the eye and the light, and looking narrowly, or using a 
magnifier, they are seen to be covered with transparent and exceed- 
ingly minute vesicles. The eruption of these vesicles is not pre- 
ceded by any appreciable disturbance of the constitution. They 
principally appear about the upper and inner parts of the thighs, the 
scrotum, the groins and lower parts of the abdomen, situations in 
which their coming is announced by feelings of violent heat and 
smarting. Dr. Alley has seen this eruption spread to the whole sur- 
face of the body. The smarting pruritus with which the eruption is 
accompanied, occasionally returns in paroxysms, causing greater red- 
ness of the skin, and increased frequency in the pulse. The colour 
of the parts affected diminishes under pressure, and returns on the 
instant it is discontinued. If the use of mercury be persevered in the 
eruption is increased. When the vesicles are well developed the 
skin feels rough under the finger. The efflorescence occasionally 
fades without any sensible desquamation of the cuticle following it ; 
in other cases, in which desquamation happens, the skin is very long 
of regaining its natural colour. 

Hydrargyria mitis frequently degenerates into hydrargyria febrilis, 
and hydrargyria maligna, when mercury is continued after the erup- 
tion has appeared, or more commonly still, should this medicine be 
resumed at too early a period after convalesence, or, lastly, should 
the patient be kept confined within a mercurial atmosphere. Under 
such circumstances several individuals have experienced a second 
eruption of the same nature and sometimes of greater severity than 
the first. Alley gives two cases in which the relapses that occurred 
could not be attributed to the renewed employment of mercury. Of 
these two patients one was seized anew with ptyalism, the inflamma- 
tion of the gums having persisted till after the period of the second 
attack. The second patient having, through necessity, continued 
in a mercurialized atmosphere, exhibited febrile symptoms from the 
first appearance of the eruption, and in the interval which elapsed 
between the disappearance and the return of the disease. Pearson 
informs us that he has even seen such relapses happen after patients 
had left the hospital, and were living in an uncontaminated atmosphere. 

2. In hydrargyriayeJW/i's the eruption is preceded by langour, rest- 
lessness, and shivering fits; and is attended with itching and heat of 
the skin, the surface of which is rougher to the touch than in the 
efflorescence of the first species. 

This eruption, which is always accompanied by a greater or less 
amount of fever, resembles measles so much during the two first days, 
that it would be difficult to distinguish the one from the other, in 
attending only to their external characters. At the end of the second 
day, the patches of hydrargyria febrilis, at first isolated and distinct, 
usually become confluent; they get united into red patches of various 
forms and sizes, larger than those of measles, and not arranged in 
small irregular clustered arcs of circles like these. On the third and 
fourth day, in the severer cases, the greater part of the surface of the 

affected. The temperature of the skin is now natural, the dusky 
colour of the surface disappearing, and large portions of a thin pellicle 
are peeling off; motions continue still unhealthy; so continue the 
same treatment. 

" 27th. — The skin is resuming its healthy structure ; here and there 
are a few creases, which exude a thin serous fluid. 

" 29th.— All traces of the disease have disappeared, except red 
marks, which the creases, now rapidly healing, have left. Ordered 
to leave off the lotion, but to continue the bran baths, night and 
morning; the child's bowels have become quite regular." 



HYDRARGYRIA. 



131 



body becomes of as bright a red as in the first variety. In men, the 
eruption usually begins on the scrotum and insides of the thighs: 
occasionally, however, it makes its appearance on the backs of the 
hands and arms, and still more frequently, on the back and belly simul- 
taneously. Dr. Duncan speaks of a case in which the disease began 
in the face, which is generally one of the parts last affected. The 
vesicles are more apparent in hydrargyria febrilis than in hydrargyria 
mitis, especially at the beginning of the eruption ; at a later period, 
the contact and friction of the clothes are apt to destroy them. Very 
small and transparent at first, and surrounded by a red circle, the 
vesicles of hydrargyria febrilis, before long, acquire the size of pins' 
heads, and become opaque and purulent. When the eruption begins 
to disappear, it bears a strong resemblance to the efflorescence of 
scarlatina anginosa on the decline ; hydrargyria, however, always 
preserves a deeper shade of colour. 

The heat of the skin occasionally reaches to the thirty-eighth 
degree of the centigrade scale ; in no disease perhaps is it so inces- 
sant and so distressing. When the eruption extends in large patches, 
a thick and very offensive discharge takes place from the parts where 
two surfaces of the skin come in contact, such as the axillae, the 
groins, the upper and inner parts of the thighs, &e. The desquamation 
rarely begins at a later period than the fourth day after the appear- 
ance of the eruption. The slighter the disease has been, the sooner 
does the exfoliation of the epidermis commence ; it is thrown off in 
larger pieces in the febrile than in the mild variety of the disease. The 
desquamation is generally preceded by some soreness of the throat, 
which appears to be the cause of the detachment of the epithelium of 
the velum palati and pharynx. 

A second exfoliation of the cuticle occasionally happens, and the 
skin then appears as red as before the first took place ; it is only after 
repeated falls and renewals of the epidermis that the skin in many 
cases at length regains its natural colour; when this is once removed, 
the cuticle is no longer detached. This peculiarity has been observed 
especially in those cases in which the use of mercury was continued 
after the appearance of the disease. 

Headache, nausea, a foul white state of the tongue, constipation, a 
sense of oppression, violent cough and difficulty of breathing, — such 
are the general symptoms most usually observed on the breaking out 
of the eruption ; the pulse beats from a hundred to a hundred and 
thirty times in a minute, the thirst is unquenchable, and the patients 
call incessantly for acid drinks. At the epoch of the eruption the 
urine is scanty and high-coloured ; it becomes more copious, and 
deposits a furfuraceous sediment towards the decline of the disease; 
there is generally either constipation or diarrhoea, and these may 
alternate with the eruption. 

In one case, observed by Alley, the stomach continued irritable and 
threw off fluids of every description taken into it during the whole 
course of the disease. 

The fever declines when the period of desquamation arrives, and 
usually terminates towards the eleventh day. 

3. The most common cause of hydrargyria maligna is the continued 
use of mercury, or its absorption by the lungs, after the appearance of 
the first vesicles. A patient labouring under hydrargyria mitis, was 
subsequently attacked with the malignant form of the disease from 
having remained in the ward of an hospital of Dublin where mercury 
was administered to others. Many similar facts demonstrate that 
mercury may in this way act upon or be absorbed into the system. 

However this may be, hydrargyria maligna is characterized by the 
following symptoms : the heat of the skin often rises as high as the 
42d decree of the centigrade scale ; the throat and tonsils are extremely 
painful ; the eruption is of a deep or purple red colour ; the face is so 
much swelled that the features are obscured ; the eyelids, completely 
closed, are lost in the general tumefaction ; and when the vesicles 
break and discharge, the eyes become excessively painful. The skin, 
swollen and very tender, is covered with vesicles of greater size than 
in the other varieties of the disease, which pour out a large quantity 
of acrid fluid. The vesicles are so closely crowded together that the 
whole epidermis is detached as in variola complicated with measles. 
The odour of the discharge is characteristic, and by one writer (Spens) 
has been compared to that exhaled by putrid fish ; it is so disagreeable 
that it makes the patient himself as well as the attendants sick. In 



one case related by Alley, in which the cuticle was detached from the 
back, a discharge of blood instead of serum took place. 

The epidermis is thrown off at a much later period in this than in 
either of the two former varieties, and scarcely happens before the 
fortieth day from the date of the eruption. The cuticle occasionally 
falls entire from the hand like a glove. Thick yellow scabs follow 
the detachment of the epidermis, which peel off in layers ; a fresh 
incrustation succeeds a fresh flow of serum, and each new desquama- 
tion discovers a surface less and less red ; at length, no further discharge 
takes place, and a natural healthy cuticle is reproduced. The skin 
may, nevertheless, continue rough and scaly. The nails of the feet 
and hands are occasionally detached at the same time, or a little later 
than the epidermis. In a case, related by Pearson, not only were the 
nails lost, but such as replaced them were imperfect and deformed, 
like those of persons who have laboured under eczematous onychia. 

Whilst the exfoliation of the cuticle is taking place in one district, 
a serous or purulent discharge is often going on in another; and when 
the disease has disappeared from almost the whole surface of the body, 
a single part may remain painful and inflamed ; such was the case in 
a patient spoken of by Carmichael; the eruption vanished everywhere 
except from the arms and hands, which remained red and painful, and 
continued to discharge for three weeks after all the rest of the surface 
was whole ; such was also the case with a young man, treated by Spens, 
in whom the disease, after having invaded the lower part of the abdo- 
men, the genital organs, the upper and inner parts of the thighs and 
the hairy scalp, continued long on the latter part, after having rapidly 
got well on all the others. 

As after-consequences of hydrargyria maligna, we often observe 
painful inflammatory affections of the lymphatic glands, large abscesses 
of the axillae, and boils on other parts of the body. The skin may 
also become greatly altered in its external layers. One patient, on his 
recovery from an attack of hydrargyria maligna, was found to have 
lost all traces of the small-pox, with which he had been marked before. 
Pearson has seen the hair of the head, beard, axillae, pubes, and, in 
great part, of the eyebrows fall off; the eyelashes are more rarely 
lost, even when the eyelids have been inflamed. 

The fever of this form of hydrargyria, usually attended with great, 
depression, difficulty of breathing, troublesome cough, fixed pain in 
the chest, and occasionally with spitting of blood and a sense of 
suffocation, is generally high in the same proportion as the external 
inflammation is violent. The pulse is hard and full as it is in pneu- 
monia ; the throat is very sore ; the voice occasionally hoarse ; the 
tongue, at first white, soon becomes yellow and brown at the base ; 
in one case, however, mentioned by Spens, it continued moist and 
clean during the whole course of the disease. 

Alley only met with a single case in which the appetite was undi- 
minished, but Mullins speaks of an individual attacked with the 
disease in its severest form, who was hardly satisfied with double the 
usual hospital allowance of food. 

During the whole continuance of the disease patients complain 
greatly of weakness and depression ; their sleep, too, is interrupted, 
and opium only brings short intervals of forgetfulness. The pain 
endured is occasionally extreme ; words convey no expression of its 
amount. One of Spens' patients, speaking of what he suffered, said 
he felt "as if his flesh were torn from his bones!" In the severest 
cases, a copious and fetid diarrhoea, delirium and coma precede the 
fatal termination. 

The anorexia is commonly as strongly marked in hydrargyria 
maligna as in ordinary febrile affections. One of Alley's patients 
suffered from convulsions, another passed his urine and feces in- 
voluntarily. 

Chilly and painful sensations of the skin usually denote an in- 
crease or a relapse of the disease, and each renewal is accompanied 
with the same kind of inflammatory fever as that which ushers in the 
first attack. 

Gangrenous sores, fistula in ano, phthisis pulmonalis, marasmus, 
&c, have been observed to follow in the train of hydrargyria ma- 
ligna. 

These are the three principal forms or varieties of hydrargyria 
which have been described ; I ought to say, however, that the "dis- 
ease has been seen to begin in a manner little severe in appearance, 



132 



vesicul^e. 



a later period exhibit the most alarming symptoms ; I have 
• thai relapses are more serious and continue longer than 
first attacks ; that the febrile symptoms do not always correspond with 
the intensity oi the outward inflammation; and lastly, that the erup- 
tion, though partial, may be followed by painful and repeated desqua- 
mations of the cuticle. 

' tes. — I have seen, and have myself treated a considerable 
number of patients in whom the exhibition of calomel and the inunc- 
mercurial ointment were followed by profuse salivation. I have 
mI a great many water-gilders under my care affected with mer- 
curial trembling or shaking of the limbs ; but in all the twenty years 
I have been engaged in the study of my profession, I have only seen 
i if hydrargyria. How is it, then, that this disease is so rare 
in France? The disease is incontestably produced by the exhibition 
of mercury, and the simple discontinuance of this substance often 
checks its progress, whilst the continued use of the medicine cer- 
tainly aggravates the symptoms, as its recurrence is induced by too 
speedy a resumption of the remedy after convalescence from an attack. 
It would appear, therefore, that some predisposition in the skin or 
general constitution, or some combination of circumstances, little un- 
derstood, was required for the production of this disease. We know 
that certain individuals are extremely unsusceptible of the action of 
mercury in every shape, whilst others cannot make use of even the 
smallest quantity of any of its preparations without experiencing its 
peculiar effects. 

Some of those who have suffered from hydrargyria have only had 
one attack of the disease, although they have undergone several 
courses of mercury ; others after having been affected with the erup- 
tion at the beginning of a course, have been enabled to renew it after 
a time without further inconvenience; in others, in fine, the eruption 
lias only broken out after salivation and the usual signs of the mercu- 
rial action have been induced, or in consequence of exposure to cold 
or some other accidental cause, (a) No age appears to give immunity 
from the disease, although Pearson remarks, that he never met with a 
case in a patient above fifty. 

The disease is occasionally benign in its character, although a large 

(a) Mr. Colles (Practical Observations on the Venereal Disease, and 
on the use of Mercury), tells us that all danger of hydrargyria is removed 
after ptyalism is fully established. 

" What is most worthy of remark is this, that we never find this 
eruption to make its appearance while the system is under the influ- 
ence of ptyalism. So that, after we have ptyalism fully established, 
we may dismiss all our fears on account of this rash. But let us not 
be lulled into a false security merely because this symptom may not 
appear in the early part of a mercurial course: for in some instances 
it does not appear until the mercury has been used for a considerable 
time. 

" I recollect the case of a young woman affected with an induration 
of one of her breasts, for which I had directed small doses of pil. hydr. 
combined with extr. conii. No sensible mercurial effect having been 
produced at the end of three weeks, I increased the dose of the pills ; 
the result was very speedily a slight degree of ptyalism, and with it 
very full eruption of mercurial erythema, which proved tedious, obsti- 
nate, and alarming. 

" In this case it is obvious that the eruption attended that slight 
febrile excitement of the system which mercury so generally occasions 
when it is just about to act on the constitution. During the first three 
weeks of its use, the mercury had not produced any sensible effect, 
and therefore had not excited this eruption. We may in fact declare, 
that at whatever period of a course of mercury the mercurial fever is 
first suddenly excited, there is danger of the erythema. Hence it 
should be a rule with those who are conducting a course of mercury, 
to watch carefully the earliest effects of each increase in the doses of 
the medicine, and to question the patient minutely, that he may get 
the earliest notice of the presence of this affection. When once the 
first burst ot mercurial fever is over, and ptyalism has been fairly 
established, then the surgeon may carry on the mercurial process to 
ogth oi time necessary, (provided he do not allow the action of 
the mercury to subside,) and yet be under no apprehension of an 
attack of this ras 



quantity of mercury has been used previously to its invasion ; in 
other instances, it is malignant and severe alter the employment of a 
comparatively very small portion of the metal, and even before what 
is called the mercurialization of the system can be supposed to have 
taken place. An adult became affected with hydrargyria after having 
taken two grains of the protochloride of mercury (calomel) for two 
days. (Alley, case IV.) Dr. Duncan saw the same thing happen to a 
girl nine years of age. Three grains of calomel, administered to 
a child seven years old as a purgative, have produced the mercurial 
eruption. (Alley, case III.) The father of this child had been at- 
tacked with hydrargyria maligna, twenty years before, whilst pursuing 
a mercurial course on account of venereal symptoms. Two sisters 
became affected with the disease in the Dublin Lock Hospital, after 
having rubbed in three drachms of camphorated mercurial ointment. 
(Alley, cases I and II.) One of the severest cases seen by Alley was 
produced by a single blue pill. Lastly, Pearson informs us, that he has 
seen the disease brought on by the simple contact of the mercurial 
ointment, and even by that of a few grains of red precipitate. 

At Dublin, mercurial frictions appeared more frequently to induce 
the disease than any preparation of mercury administered internally. 
Alley supposes that the quantity of camphor which enters into the 
mercurial ointment (scr. ii to i oz.) used at the Dublin Lock Hospital, 
is not perhaps without influence in the frequent occurrence of the 
disease in that establishment. 

The symptoms of bronchial affection observed during the course of 
the disease, induced Dr. Gregory to suppose that cold was one of the 
potential causes of hydrargyria. A correspondent of Spens', who 
writes from Madras, also informs him, that the complaint is very fre- 
quent among the natives there, who can with difficulty be persuaded 
to clothe themselves properly during a mercurial course. On the 
other hand, however, the same catarrhal symptoms have been ob- 
served to accompany the disease, under the influence of a very mild 
temperature. 

Men appear to me more subject to this affection than women: 





Hydrarg. 

mitis. 


Hydrarg. 

febrilis. 


Hydrarg 
malig. 


Total. 


Died. 


Cured. 


Men. 
Women. 


C 
4 


12 

7 


10 
4 


28 
15 


G 
2 


22 
13 


Total. 


10 


19 


14 


43 


8 


35 



The whole of the cases in the preceding table were seen by Alley 
within ten years : in three instances only did he meet with the 
disease in children, in none of which was mercury administered for 
a venereal cause : in the greater number of adults, the mineral was 
employed in the treatment of primary or secondary syphilitic symptoms. 

360. Diagnosis. — To distinguish hydrargyria from other diseases, 
it is enough to remember that this vesicular affection is induced by 
mercury ; that the eruption and the fever are isochronous, that the 
inflamed skin in different places secretes a fluid, the odour of which 
is characteristic ; that the desquamation, preceded by pain of the 
throat and tonsils, occurs from the fourth to the eighth day, &c. It 
is true that eczema rubrum has all the external characters of hydrar- 
gyria, the same redness of the skin, and the same form of vesicles. 
But eczema, unlike hydrargyria, acknowledges no special cause, 
neither is it, but very rarely, so general ; neither is it attended with 
inflammation of the mouth, sore throat, or salivation. Hydrargyria 
is essentially an acute disease ; eczema rubrum is almost uniformly 
chronic in its character. Hydrargyria is still more easily distinguished 
from the discreet pustular affection which is often produced by the 
friction of rancid mercurial ointment upon parts covered with hair; 
and it will not readily be confounded with any other form of artificial 
inflammation of the skin. It is well known that mussels, bitter almonds, 
raushroons, lobsters, pickled salmon, &c, may cause eruptions which 
bear some resemblance to scarlatina, erythema, or hydrargyria. Pe- 
culiar eruptions have also been observed among the natives of differ- 
ent coasts, who live much on particular species of fish. Alley saw 
a vesicular eruption of the colour of a boiled lobster, caused by eating 
a spoiled mackerel. General eruptions have also been seen to fol- 
low the administration of camphor and several other medicines. A 



HYDRARGYRIA. 



133 



knowledge of these facts, and of the circumstances under which 
hydrargyria is developed, makes mistake all but impossible, (a) 

361. Prognosis. — In two cases of gonorrhoea, Alley tells us that 
the discharge ceased on the appearance of hydrargyria, and did not 
recur after the cure of this eruption. This suspension or disappear- 
ance of symptoms is not confined to those of a syphilitic nature only. 
One patient who commenced rubbing in mercurial ointment on account 
of a hepatic affection, was soon after attacked with hydrargyria, and 
the disease of the liver disappeared ; another who had taken a solu- 
tion of the bi-chloride of mercury, (corrosive sublimate,) under the 
care of a quack, for a similar affection, suffered in the same way, 
with the same fortunate result. These cures, however, which are 
mentioned by Alley, were only observed to follow when the mercu- 
rial affection appeared under the febrile or the malignant form. 
Hydrargyria mitis produces little or no abatement in the symptoms of 
syphilis, whether the affection be local or constitutional, nor in those 
of any other disease. It has also been observed, that when primary 
syphilitic symptoms appear to be removed on the occurrence of hydrar- 
gyria, they almost always reappear after the diminution of the fever 
which accompanies the mercurial eruption. This is a circumstance 
which has been remarked by more than one practitioner. 

Hydrargyria, being a modification of the constitution other than 
that generally effected by the action of mercury, Alley, Crampton, 

(a) Mr. Colles (op. cit.) thinks it necessary to establish a diagnosis 
between hydrargyria (erythema mercuriale) and another more partial 
eruption also induced by mercury. 

" We should carefully distinguish between erythema mercuriale 
and another but more partial eruption arising from the use of mer- 
cury. They both come on under similar circumstances ; both seem 
to be excited by the first impression of mercury on the general system. 
Our attention is attracted to this latter eruption by our patient inform- 
ing us that he fears he has got the itch — that he could scarcely get a 
wink of sleep for one or more nights preceding. He then exhibits 
on his hands and wrists an eruption beginning with small but very 
distinct red papulae, some of which, in a more advanced stage, have 
vesicles on their apices : they chiefly occupy the anterior surface of 
each wrist, and of the forearm half way up to the elbow ; the backs 
of the hands and fingers are also thickly beset with them. On first 
view, this eruption closely resembles a form of itch, in which the 
vesicles are small ; but, on more careful examination, you discover 
that the clefts between the fingers are altogether free from the former, 
while they are known to be the principal seat of the latter. This 
eruption is accompanied by a slight degree of fever, and generally by 
marks of commencing ptyalism. 

" I cannot say what changes or effects on this eruption would be 
produced by persevering in the use of mercury, because all the 
patients in whom I witnessed this symptom were also affected with 
a smart degree of fever, and complained so bitterly of the itching and 
of the restlessness caused by it, that I felt afraid to go on with the 
mercury until the irritation of this eruption had subsided. A few 
days' use of the antiphlogistic regimen, and abstinence from mercury 
at the same time, were sufficient for the desquamation of the pustules, 
and the removal of this rare effect of the mineral. 

" I need hardly observe that this eruption differs from the mercurial 
erythema, by the early appearance of the vesicles — by the eruption 
being much more distinct, and less thickly set in the skin — by the 
parts of the body which it affects, and, we may add, by its not extend- 
ing to the other parts of the body, and not seizing on the angles of 
flexion in the limbs, where two skins occasionally lie in contact with 
each other. I suspect this effect of mercury is observed only in cases 
where the patient is using mercurial frictions. Here, as well as in 
mercurial erythema, we observe a decided improvement in the primary 
symptoms uniformly to occur. 

" Having for some time noticed this eruption only among the sol- 
diers under my care in the hospital, I at first suspected that it was 
produced in a great degree by the oatmeal diet, to which they are so 
much accustomed ; but subsequent observation has removed this 
error, and convinced me that it is attributable solely to the use of 
mercury. Of course the use of mercury must be resumed as soon 
as the itching has ceased, and the eruption begins to desquamate." 
34 



and Willan, conceive that the appearance of this eruption ought to 
have no influence on the duration of the treatment requisite in vene- 
real cases. Several practitioners have, however, been of a contrary 
opinion, and have stated, that only a very small quantity of mercury 
became subsequently necessary for the cure of these affections. 

Messrs. Garnett and Wilmot, surgeons of the Lock Hospital, never 
saw hydrargyria so violent as to cause serious fears for the patient's 
safety, a circumstance which they attribute to their constant rule ot 
immediately suspending the mercury on the first appearance of the 
disease. Crampton never saw the disease prove fatal, except in a 
few cases, in which the patients, the eruption being held venereal, 
persevered in the use of mercury. According to him, the fever 
which accompanies the eruption, whatever its degree of violence, is 
never important ; the danger of the secondary fever which is lighted 
up when the skin becomes affected with a purulent discharge, is in 
proportion to the extent of the denuded and secreting surface. The 
fever occasionally then loses its inflammatory type, and assumes the 
hectic character. The patients are seized with shivering fits and 
tremors of the limbs ; they complain of extreme weakness, and show 
a greater degree of emaciation than can be laid to the score of the 
discharge, (a) 

362. Treatment. — To effect the cure of hydrargyria mitis, nothing 
more is necessary than to suspend the use of mercury, to abstract the 
patient from the influence of a mercurial atmosphere, if he be ex- 
posed to one, and to prescribe diluents, a gentle aperient or two, and 
an occasional warm bath. Pearson was occasionally induced, by 
considerations unconnected with the best treatment of the affection, 
to order the mercury to be continued in despite of its appearance. 
When the disease is on the decline, the use of mercury r may occa- 
sionally be resumed with advantage, to combat the syphilitic affec- 
tion for which it was first prescribed : in Davidson's case, related by 
Dr. Spens, the medicine was given under these circumstances, and 
the cure of the eruption advanced with not the less rapidity on this 
account. Another patient who had an ulcerated bubo in the left 
groin, was attacked with hydrargyria: when the eruption began to 
give way, a blue pill was prescribed night and morning, and the 
bubo got well without the affection of the skin being aggravated. 

In the febrile and malignant species of hydrargyria, nothing could 
warrant the continuance of mercury in any form. By abandoning its 
use at once, an attack of hydrargyria, which commenced with violence, 
has occasionally been disarmed of its formidable aspect ; the neglect 
of this simple precaution, on the contrary, has in some unfortunate 
cases, rendered the most energetic subsequent treatment unavailing 
in warding off a fatal termination. Like salivation, hydrargyria once 
established, seems to have a kind of necessary course to run. Pearson 
and Alley, therefore, agree in believing that though the more painful 
symptoms of the affection may be soothed by appropriate remedies, 
yet that no treatment is adequate to check it in its progress. 

In hydrargyria febrilis and hydrargyria maligna, cold ablution or 
sponging, allays the distressing sense of heat which attends the erup- 
tion. The tepid or cold bath is also extremely useful when the con- 
dition of the patient does not prevent its repetition at short intervals. 
One of Spens' patients found the warm bath extremely soothing; but 
it could not be repeated on account of the syncope it produced. Next 
to frequent immersion in cold or tepid water, purgatives are the best 
means of diminishing the excessive heat of skin which accompanies 
hydrargyria. Crampton was in the habit of ordering powder of jalap 
combined with some of the neutral salts ; Spens' medicine was the 
electuary of senna with an equal quantity of sublimed sulphur; Alley 
believed the super-tartrate of potash a preferable purgative to either 
of these formula?. Mercurial purgatives ought, of course, to be 
avoided. 

When the pulse is full and frequent, blood ought to be taken away, 
especially when any bronchial affection complicates the mercurial 
diseases. Alley saw one patient lost through want of recourse to this 
measure. The mercurial pulmonary affection, however, will also 
frequently be found to yield to purgatives. 

Blisters are occasionally indicated, and may prove useful; but 

(a) Mr. Colles, in his large experience, only saw one case in which 
the fever lasted more than eight days. 



134 



VESICULiE. 



rs are afraid to resort to these upon surfaces so highly 
inflamed and covered with vesicles, as they are in hydrargyria. 

Those cases in which the tartrate of antimony might prove a useful 
medicine, have nol been well determined. 

niiM is best allayed by acidulous drinks. 

Peai i mends opium to procure sleep, lessen pain, and check 

the diarrhoea, which almost always occurs during the secondary lever. 
( Opiates and Peruvian bark are occasionally exhibited along with some 
generous wine during the continuance of the purulent discharge in 
hydrargyria maligna. 

To prevent the absorption of the discharge into the system, and to 
promote the formation of a new epidermis, some drying powder, such 
;is fmely powdered charcoal, and liniments containing lime-water, 
have been advised. Alley was no advocate for any form of topical 
application containing lead. 

To recapitulate, cold lotions, tepid baths, bland diet, purgatives 
and opium are the usual remedies in hydrargyria; blood-letting and 
tonics are only required in the severer, and happily the rarer, cases 
of the disease, (a) 

Historical Notices and particular Cases of the Disease. 

363. Among the writings of Th. Bonetus, 1 and in those of B. Bell, 2 
several passages occur that evidently refer to hydrargyria. Jussieu 3 
mentions an eruption of pustules affecting the skin of the workmen 
employed in the quicksilver mines of Spain. Cullerier, 4 and M. 
Lagneau 5 seem to refer to hydrargyria under the title of erysipelas 
caused by mercury. 

The medical practitioners of Dublin having had the most frequent 
opportunities of studying this disease, their writings, and especially 
the works of Alley, have supplied the greater part of the information 
here laid before the reader. Dr. Burrowes, Physician to the House 
cf Industry, Dublin, the late Dr. Gregory, Professor of the Practice 
of Medicine in the University of Edinburgh, and Mr. Dease, Professor 
of Surgery to the Royal College of Surgeons in Ireland, were the first 
who recognized mercury as the cause of this disease, to which Dr. 
Stokes, of Dublin, called the attention of his pupils during his course 
of 1798. Dr. Alley" was the first who published a good special 
treatise on the affection. Three months after the appearance of this 
publication, Dr. Moriarty 7 gave the results of his own and of Dr. 
Whitley Stokes' experience in the disease, which he describes under 
the title of Mercurial Lepra. Dr. Thomas Spens, in the Edinburgh 

(a) " With respect to local treatment, I believe," says Mr. Colles, 
"that dusting the excoriated parts with any of the mild drying pow- 
ders, will be found to afford as much relief as any other application. 
Sometimes the application of cloths, wetted with the black wash, has 
procured relief, and has appeared to promote the formation of cuticle. 
In a very severe case it will be necessary to have the sheets in which 
the patient is laid prepared so as to prevent them from sticking to the 
skin ; I think that this is very effectually done by a mild ointment of 
rather a stiff consistence. The common one, made of equal parts of 
suet and beeswax, spread as thin as it can be spread by holding the 
spatula on its edge, will answer extremely well. I do not pretend to 
say that some other composition may not be discovered which will 
better promote the healing of the excoriated surface, but whatever it 
be, I should recommend it to be made of a firm consistence, for the 
softer ointments, by the heat of the body, are found to run quickly 
ihrough the sheets, and consequently to leave the surface which is 
applied to the body nearly dry. 

" I may next remark, that an obvious amendment takes place in 
the symptoms of the venereal disease, on the first appearance of this 
eruption, and that in a degree more striking than that which attends 
so slight a degree of ptyalism." 

i Medicin. septentrion.. vol. ii. p. 384, folio. Geneve, 16*4—1656. 

- Treatise on the ? onorrh«ra virulenta, etc.. vol. ii. p. 227, 8vo. Edinburgh, 1703. 

JKmoures de 1 Academie des sciences de Pans 1719 
« Dicuonnaire des sciences raedicales. An. Mercure! 

Lxpos6 de la maladie vencrienne, 8vo. 1818, 5 edit. p. 440. 
1 An e^av on a peculiar eruptive disease ->i-;o;.,_ <■ ' \i_ i ■> ■ - 
i>,,hi,n l-ru niK.r,. ,„ ,»,„ i , e msease arising from the exhibition of mercu rv. 

UuDlin, l&lM. — uoserv. on the hydrargyria or thai n. B i-ni^ jv • c V 

exhib.tion of mercury. London". lSlcT ves >cular d.sease ansing from the 

A description of the mercurial lepra. Dublin, 1804. 



Medical and Surgical Journal, No. 1, 1805, and No. 7, 1806, under 
the name of .Mercurial Erythema, gave three cases of the disease which 
occurred in the Royal Infirmary of that town. Dr. Mullins 8 published 
a translation of his inaugural dissertation defended at Edinburgh in 
1S05, in the same periodical. Dr. John Pearson" subsequently gave 
an exact description of the disease under the name of eczema mercu- 
riale, or eruption produced by the use of mercury. For additional 
information on the disease, the writings of Jos. Frank, 10 and a variety 
of papers by Bacot, 11 Lawrence, 12 Crawford, 13 and Johnston, u mav 
be consulted. 

Case LV. — Hydrargyria occasioned by mercurial frictions. Madame 
C * * *, thirty-four years of age, came to Paris from the neighbour- 
hood for medical advice, on account of an enlarged state of the 
lymphatic glands of the neck and abdomen, and a chronic gastric 
affection. Madame C * * * was recommended by the practitioner she 
consulted, to rub in half a drachm of the strong mercurial ointment on 
the insides of her thighs every day. On the fifth day after this pro- 
cedure was adopted, a very copious eruption of vesicles, each as large 
as a small pin's head, took place upon the upper and inner parts of 
the thighs. The skin in these situations was red, hot and extremely 
itchy. Next day the vesicles became confluent, the skin burning, 
and the legs stiff; febrile symptoms also set in, and the night was 
passed without sleep {Cold baths, cold washes with decoction of althea, 
lemonade and broth for diet). On the following or third day a plenti- 
ful discharge of yellowish serum took place from the parts affected ; 
the greater number of the vesicles were ruptured, the patient having 
passed the night in tearing with her nails the districts of skin that 
were inflamed. Had not the patient been much reduced by the 
chronic affection of the abdomen, already of several months, standing, 
I should certainly have taken away blood at this stage. Under the 
circumstances, I was compelled to be satisfied with recommending 
the cold bath and emollient lotions. No incrustations were formed 
on the vesicles ; the reddish serous discharge which was poured out 
abundantly for five days, was absorbed, by the cloths kept constantly 
applied to the parts. The continual use of the cold bath and the 
lotions undoubtedly prevented the parts from scabbing over. By the 
end of the second week the inflammation of the skin had disappeared, 
and nothing more than a pretty abundant furfuraceous desquamation 
then took place from the internal parts of the lower extremities, (a) 

(a) An instance of the extreme susceptibility of the system to 
mercury, and to the production of hydrargyria occurs in the following 
case : 

"Mr. R. applied to me, 12th August, 1813, for the cure of a 
chancre. I had treated him in 1810 for a similar disease, and was 
then made fully acquainted with his extreme tendency to mercurial 
erythema. Having premised a tepid bath, and some active purging 
m-edicine, I commenced by directing a pill of hydr. acet. gr. ss. and 
pulv. antim. gr. ij. to be taken every night. On the second day a 
slight rash appeared on the inside of his thighs ; of course the mercury 
was withheld for a day. No improvement in the chancre attended 
this eruption. The pills were continued sometimes every day, some- 
times every second day, (according to the appearance of the rash,) 
until the middle of September, when the chancre took an unfavoura- 
ble turn, and showed a tendency to slough. Then the mercurial 
medicines were entirely discontinued. The rash having disappeared 
for four days, the state of the ulcer induced me to recommend the 
ordinary black wash (calomel and aq. calcis). This had been applied 
for one day only, when the rash reappeared, and with increased 
severity. On resuming the mercury on Oct. 3d, I directed hydr. 
acet. gr. ss., and extr. cicutee gr. i." No rash appearing, the dose of 
the pills was doubled: the rash appeared on 11th Oct. After this 
the dose was cautiously increased to three, and ultimately to four pills 
per diem. The chancre was very slow in healing, hut was completely 
healed on the first of November. The mercury was continued some 

8 An essay on the erythema mercuriale, 1605. 

9 Obs. on the effects of various articles of the materia medica on the cure of lues 
venerea. 2d edit., p. 167. 

i° Prax. Univ. Med.— Acta clinica, vol. iii. p. 22. 
" Lond. Med. Gaz., v. iii. p. 347. 

12 Lond. Med. Gaz., vol. v. p. 742. 

13 Edinb. Med. and Sur?. Journ., v. xvi. p. 37. 

14 Ibid., vol. xxxi. p. 169. 



SCABIES. 



SCABIES. 



Vocab. Itch, Psora. 



364. Scabies or Itch is an inflammatory affection of the skin, un- 
accompanied with fever, contagious, and characterized by an erup- 
tion of pointed vesicles, transparent on their summits, filled with a 
viscid and serous fluid, and constantly attended with pruritus. This 
eruption is liable to appear on every part of the body, but is seen 
more especially upon the abdomen, about the bends of the different 
articulations and between the fingers. I must say, however, that I 
have never seen itch affecting either the face or hairy scalp. 

365. Symptoms. — When itch has been communicated, the party 
contracting the disease is sensible a few days afterwards of a slight 
pruritus in the parts which have been most immediately exposed to 
the infection. The pruritus is increased through the night by the 
warmth of the bed, and during the day by indulgence in spirituous 
liquors, spiced food, and by every cause that produces an afflux of 
blood towards the surface. A number of small spots or points, 
elevated, but in so slight a degree as scarcely to rise above the level 
of the skin, now make their appearance ; this eruption usually takes 
place in children, four or five days after exposure to the contagion ; 
in adults it appears from the eighth to the fifteenth or twentieth day, 
and in the aged and those affected with chronic diseases, occasionally, 
a month or more after the infection. 

The vesicles of scabies appear first on the parts that have been 
immediately exposed to infection: the hands in tailors and dealers in 
old clothes, the breech in infants at the breast, &c. The eruption 
has at first a rosy red hue in the youthful and florid ; but it more 
usually preserves the common colour of the skin, especially among 
valetudinarians. It spreads gradually to the parts in the neighbour- 
hood of those on which it first appeared. The proper character of 
the eruption soon becomes apparent, — small acuminated vesicles are 
perceived upon every red point. If the vesicles be few in number, 
they occasion but little pruritus, and long preserve their primary form. 
If, on the contrary, they be very numerous, the skin between each 
participates to a certain extent in the inflammation, and the pruritus 
is greater and less endurable. The vesicles are then most usually 
torn by the nails, and allow their viscid, serous contents to escape, 
which, concreting, form small thin scabs, flimsy in their texture and 
but slightly adherent to the skin. Should the patients have used 
considerable violence in scratching, the scabs are black and analo- 
gous to those observed in prurigo. 

In the sanguine and robust, and those addicted to the use of stimu- 

days longer, although a slight return of the rash again obliged us to 
desist for a day occasionally. During this lengthened course of 
mercury Mr. R's general health continued good. No ptyalism was 
induced ; the gums were not made sore, but the inside of the cheeks 
assumed a leaden colour, and became a good deal swollen during the 
last fortnight of the treatment. 

" Mr. R. gave me the following account of the effects of mercury on 
his system. Previously to the year 1806, he had used mercury for 
cure of a chancre, and did not then experience any but the ordinary 
effects from the use of this medicine. In 1806, he again had occa- 
sion to use it for cure of a chancre, and then he employed it both 
internally and externally in very large doses. On this occasion it did 
not affect his mouth ; but immediately after he had laid aside the 
medicine he was attacked with mercurial erythema, which affected 
him in a very severe and dangerous degree. Since that period (and 
never before) he has experienced an extreme susceptibility to the 
action of mercury in producing this rash ; for example, a very small 
portion of mercurial ointment rubbed on the pubes, for the purposes 
of cleanliness, has more than once produced it. A grain of calomel 
combined with purgatives has had the same effect. 

" In this case I would remark, that the venereal symptom did not 
improve on the appearance of the rash as it does in less susceptible 
constitutions. The mercury had not the effect of producing ptyalism, 
though used for such a length of time. The effects of the topical 
application of black wash affords the strongest proof of the great sus- 
ceptibility of this individual." (Mr. Colles ut supra.) 



lants, itch, if left to itself, by spreading till almost the whole surface 
of the body is infected, may give rise to symptoms of considerable 
severity: the vesicles become more and more violently inflamed, and 
acquire at length the character and appearance of true pustules (scabies 
purulenta, Bateman) ; boils, and accidental pustules, like those of ecthy- 
ma, are also occasionally developed in their interstices, under these 
circumstances. 

366. In southern climates, during the spring and summer seasons, 
in youth, and among individuals of a sanguine and robust constitution, 
the vesicles of scabies run rapidly through their periods when they 
are not torn by the nails ; their progress is slower in the north, during 
the winter and autumn, and among the aged and infirm. 

Scabies is a disease which left to itself never gets well : it might 
continue through the lifetime of the individual who should neglect 
all means for its cure. Its usual duration is from twelve days to a 
fortnight, when it is properly treated. Occasionally, it may be seen 
disappearing for a few days under the influence of some intervening 
acute disease, without the symptoms of the latter being sensibly 
modified by the circumstance. Sabatier mentions the case of a man 
labouring under an old and well-marked itch, in whom the vesicles, 
without any kind of treatment, sank and disappeared on his being 
attacked with inflammation in both lungs, nor did the eruption appear 
again until a fortnight after this disease began to yield, and when con- 
valescence was already well established. On the other hand, Rammaz- 
zini, Testa, and several others, tell us they have seen hematuria, affec- 
tions of the heart, and several other serious diseases, follow retrocession 
of the itch. I have not myself met with any similar occurrence, and 
such cases must be very rare. 1 From a superficial study of symp- 
toms, and the inherent deficiency of our medical nomenclature, conse- 
quences have been attributed to the disappearance of itch, which are 
owing to the retrocession of true eczematous eruptions described under 
the name of scabies. 

367. Scabies may be complicated with other cutaneous diseases, 
and its diagnosis thus be occasionally rendered obscure. Yet is it 
seldom that other vesicular eruptions are met with on the skin at the 
same time as itch. When ecthyma occurs along with scabies, it is 
almost always after the employment of stimulating washes or unguents. 
I have, however, seen vesicles similar to those of eczema, and true 
vesications like those of a blister, on the backs and palms of the hands, 
when these happened to be the seat of a large crop of scabious vesi- 
cles. It is almost always with papular eruptions that scabies is com- 
plicated. When the vesicles of scabies are widely and plentifully 
disseminated in a young and hardy individual, they often occasion the 
development of a lichenous eruption, the papulae of which are either 
separately scattered or collected into clusters. Prurigo is also occa- 
sionally evolved among subjects who have long suffered from scabies ; 
a circumstance which has given rise to the erroneous supposition, 
that itch occasionally degenerates into a papular disease. When 
the irritation of the skin becomes excessive, pustules of ecthyma, and 
even furuncles may be seen associated with the vesicles of scabies. 

Scabies, when it is extensive and severe, and has continued for a 
very long time, is now and then seen accompanied or followed by an 
inflammation of a portion of the mucous membrane of the gastric and 
pulmonary passages. 

In individuals labouring under diseases of the digestive organs or 
lungs, who contract scabies, the vesicles are flaccid, and either de- 
cline or die totally away, when the primary diseases get worse or are 
temporarily aggravated from any cause, — errors in diet or otherwise 

368. Scabies is scarcely modified in its course by scrofula or sy- 
philis. In unhealthy subjects the vesicles assume a livid hue, and 
when they appear congregated in large numbers in particular regions, 
they are there often seen complicated with ecthyma cacliecticwn. 

369. Causes. — Scabies is one of the most universally disseminated 
contagious diseases known ; the most momentary contact of the fluid 
secreted by its vesicles is enough to communicate the infection ; it is 
observed in every climate, during every season of the year, attacking 
all ages, and persons in every rank of life, without discrimination. It 
is most commonly observed, however, among the poor and wretched, 

' Dr. Hahnemann, the noted head of the Homoeopathic school, and his disciples, are 
of a different opinion; they seem to ascribe nineteen in twenty of the ills that flesh is 
heir to, to latent psora in the constitution. — R. W. 



136 



YESICULiE. 



and those who a, ill of cleanliness. When it does appear in 

the families of the affluent, its importation may generally he satis- 
Sailors, soldiers, work-people, and those who are 
crowded together in manufactories, prisons, barracks, hulks, &c.,are 
% civ frequently affected with this disease. Itch is neither an endemic 
epidemic disease iii the usual sense of these words: it is not 
gated by causes peculiar to the climate, nor to the situation 
where it appears ; it spreads by the mere effects of contact and want 
anliness. All tends to show that those epidemic scabicsot which 
Frederic Hoffmann and several other writers have spoken, were 
ular eruptions referable to distinct and different genera. 
Some pathologists, among others Fabricius Hildanus, Lazarus 
Uivciius and Pnngle, have supposed that scabies might be sponta- 
neously developed under particular circumstances, and as crises in 
several acute and chronic diseases. They would persuade us that 
patients who had long suffered from severe affections, have been 
cured by the spontaneous appearance of this eruption. I have never 
met with any instance of this kind ; and we may, perhaps, be allowed 
to suppose that certain vesicular and papular eruptions, such as 
eczema and lichen, were mistaken for itch, in times when the dis- 
tinguishing characters of the different diseases of the skin were not 
very generally known. 

Several instances of itch, transmitted from animals to the human 
species, have been cited ; but the greater number of the diseases to 
which veterinary practitioners have given this name (ox-itch, horse- 
itch, dog-itch, hog-itch, &c), are very inaccurately described, and 
many of the cases of these affections which have been shown to me, 
analogous to lichen and eczema in their external characters, have still 
left me in great doubt as to their actual nature ; and although their 
transmission be an asserted fact, which cannot be positively denied, 
neither can it be satisfactorily demonstrated. M. Mouronval instances 
several cases, in which the itch was communicated from the dog to 
the human kind. On the other hand, that skilful veterinarian M. Le- 
blanc, showed Messrs. Sabatier, Littre, and myself, several dogs la- 
bouring under the disease called itch, in which we could distinguish 
a number of small acuminated vesicles, perfectly analogous to those 
of scabies in the human kind, upon the upper and inner parts of the 
thighs and various other regions of the body, calling our attention to 
the fact, that the man by whom these animals were rubbed and tended 
had not contracted any disease, not only in the present instances, but 
in many preceding ones ; whilst a dog, from having slept on some of 
the straw which had littered one of the mangy brutes, was seized 
shortly after with the same disorder. 

340. Several authors of modern times, have reported that they had 
discovered an apterous insect, almost invisible to the naked eye, 
within the vesicles of scabies, which they have described under the 
name of acarus scabiei. Ingrassias and Jobertus hint at the existence 
of such an insect ; but it is in the Theatrum Insectorum of Moufet 
that it is mentioned with a few particulars for the first time. Haupt- 
mann was the first who published a figure of one of these acari, drawn 
from nature, as he says, and represented with six feet. Additional 
observations by Redi seemed to put the existence of this insect be- 
yond doubt: " Whilst under your auspices and led by your views, I 
was engaged in making experiments on insects, I saw by accident, 
that the ciro was a very small worm, formed under the skin of those 
affected with scabies, whose bite occasioned extreme itchiness. 
Having since found, that Giuseppe Lorenzo had adopted the same 
opinion, I was curious again to examine the fact myself. I commu- 
nicated my purpose to M. H. Cestoni, who informed me he had 
several times seen poor women, whose children were affected with 
itch, draw out, upon the point of a pin, from the smallest pustules, 
before they were ripe and purulent, a something, I know not what, 
which they crushed between their nails with a slight noise ; and he 
added, that at Leghorn, the galley slaves perform the same kind office 
for each other. He says, he does not know for certain, that these 
ciros are actually worms. We, therefore, resolved in common, to 
satisfy ourselves on the matter ; and having applied to a person la- 
bouring under the itch, we requested him to point out to us, the parts 
in which he experienced the most troublesome pruritus. He showed 
us a number of pustules not yet purulent. One of these I opened 
with the point of a fine needle, and after squeezing out a little of the 



fluid it contained, I drew forth a small white and almost impercep- 
tible globule. This globule we next examined under a microscope, 
and we found, with all possible certainty, that it was a worm ; the 
form of which, resembled that of a tortoise, of a whitish colour, the 
back rather of a duskier hue, and furnished with a few very fine 
hairs; the little animal moved with great vivacity ; it had six legs ; 
the head was pointed and armed with two small horns or antenna', at 
the extremity of the mouth. Not satisfied with this first observation, 
we extended our researches to a great many other individuals affected 
with itch, of different ages, sexes and temperaments, and at different 
seasons of the year, and always found animals of the same kind, and 
almost in every watery pustule, — I do not say all, for it occasionally 
happened that we could not find any. 

" It is at all times extremely difficult to distinguish these insects 
on the surface of the body, on account of their extreme minuteness, 
and of the similarity betwixt their colour and that of the skin. They 
first insinuate their pointed head, and then move about gnawing and 
pushing till they have buried themselves completely under the epider- 
mis, where we could easily perceive that they had a kind of covered 
way of communication between one point and another, so that the 
same insect occasionally produced several watery pustules ; now and 
then, also, we discovered two or three, either together or very near 
to each other. We were very curious to learn whether or not these 
little animals laid eggs, and after much research, we had at length the 
satisfaction of being assured of the affirmative ; for at the very time 
that M. Isaac Colonello had one of these ciros under the microscope 
to make a drawing of it, he saw a small white egg, scarcely visible, 
and almost quite transparent, extruded from the hinder part of the 
animal; it was of an oblong shape, like the egg of a pigeon. En- 
couraged by the occurrence, we again set about searching for eggs 
with the greatest attention, and we found many more at several differ- 
ent times ; but we never again observed them issue from the body of 
the animal under the microscope. These ciros pass readily from one 
person to another by mere contact ; for, being extremely active, and 
not always engaged in digging passages under the epidermis, these 
little animals are often upon the surface of the integuments, and are 
thus ever ready to attach themselves to whatever they touch, &C." 1 

Morgagni 2 informs us that he had himself made similar observa- 
tions. "I had occasion," says he "to give my advice to a lady 
of high rank in my native place. After experiencing several crises 
towards the end of a severe and long-protracted illness, one completely 
scabious in its nature was added to the rest, which, coming on sud- 
denly, spread over almost the whole body, but particularly to the palms 
of the hands, so that she could not sleep by reason of the pruritus. 
As the vesicles of which this eruption consisted, were filled with 
serum, and resembled those in which insects are discovered, I caused 
a servant to open one or two of them, and to take out any thing she 
might find, after pressing out the fluid, upon the point of a fine needle, 
and to deliver it to me for examination with some good glasses I had 
at hand. There was no necessity to look long; the animalcule was 
found alive, and of the very form which has been delineated by the 
more modern authors. I then took away another, and still another." 

Morgagni 3 also reminds us that Abenzour and several other writers 
make mention of this insect. Linnaeus speaks of it under the names 
of acarus humanus subcutaneus, and of acarus scabiei; but having 
subsequently thought that he perceived the most perfect resemblance 
between this insect and the cheese mite, he described them together 

' Obs. sur les cirons ou insectes de la peau des galeux, under the name of Dr. 
Giovan Cosimo Bonomo, in a letter addressed to the Academy of Paris, in 1687. 
Published in their Collect. Academ. Etrangere, 4to. t. 4, p. 574, liv. iv., Epist. 55. 

2 De Causis et sedibus morbor., lib. iv., Epist. 55. 

3 "Sunt enim syrones, inquit Abinzoar, pedecelli, Arabibus assoabat dicli, qui 
subter cutem et ad manus, et crura serpunt: pustulas quoque aqua plenas sub cute, 
ubi delitescunt, excitant: qua dissecta, prorepunt animalcula tarn parva, ut vix visu, 
quamvis perspicaci, segre deprehendi possint (J. Langius. Medicinalium Epistol. 
Miscell., lib. ii. Epist. 42.) Formam quoque ipsorum aliis antea fuisse microscopii 
auxilio non incognitam, cum Borelli observationes indicant a Velschio (Exercit. de 
vena medinensi), commemoratae secundum quas sirones testudinum effigies reprae- 
sentarunt, turn prajsertim Etmulleri ilia confirmat sironum observatio quae Lipsiae i 
Actor. Erudit. volumine (A. 1682. M. Sept.) proposita, prseterquam alios nominal qui 
prius viderint, animalcula ipsa sic descripta exhibet, et delineata, ut descriptio, et 
pictura perfectiores quidem paucis post annis reddi potuerint, sed tanquam nova; 
prorsus in medium proferri non potuerint." (Morgagni. De Sed. et Caus.morborum, 
lib. iv., Epist. 55, § 4.) 



SCABIES. 



137 



as mere varieties of one species. De Geer, 1 on the other hand, both 
in his descriptions and his figures, which are extremely accurate, left 
no doubt of their generic difference. The existence of the acarus 
scabiei, however, having been called in question, M. Gales, 2 after 
citing the older observations that had been made upon it, and quoting 
the more recent authorities of Wichmann 3 and Waltz 4 for its exist- 
ence, commenced a series of inquiries into the subject in 1812, and 
assured the world that he had seen more than three hundred speci- 
mens of the ciro or acarus of scabies, which always presented the 
same form, though not the same number of legs, there being some- 
times six, sometimes eight — a variety which he ascribed to variety of 
development. Many members of the Institute of France, and of the 
Ecole de Medecine were witnesses of these inquiries of M. Gales, 
so that the existence of the acarus scabiei was generally admitted as 
a fact. Subsequently, however, Galcotti and Chiarugi of Florence, 
Biett, Lugol, and Mouronval of Paris, sought in vain, with powerful 
magnifiers, and excellent microscopes, for this insect, in a great 
number of individuals affected with scabies. I was not myself more 
fortunate than they, in all my endeavours to discover the acarus; and 
the ascertained absence of that insect, in numerous instances, in 
vesicles in which, if it existed at all, I had been led to expect to find 
it, as well as the perfect resemblance of the figures given by Gales 
to the cheese mite, induced me, along with many others, to deny the 
existence of the acarus scabiei. A more careful study of the previous 
inquiries on this point would have prevented our adopting the erro- 
neous notion we did in regard to the seat of the acarus. Mouffet, 5 
long ago, remarked that the ciro was not found in the pustules, but 
by their sides. Casal, 6 too, had already described the little burrows 
made under the cuticle by the insects, which are mentioned in the 
letter of Bonomo. Adams 7 indicates, with the utmost precision, the 
seat of the acarus, and the mode of finding it. Finally, M. Renucci, 
student of medicine, who had often seen the common people of his 
native country (Corsica), extract the insect of scabies, and who had 
himself extracted it repeatedly, very recently (August, 1834), showed 
the medical practitioners of Paris the mode of discovering it, extract- 
ing it before them, and giving them information on the subject almost 
identical with that which is to be found in Adams. Since this 
time the existence of the acarus is placed beyond a doubt; Messrs. 
Lemery, Gras and Renucci, each showed me the mode of discovering 
it, and I have myself extracted several from the skin of individuals 
affected with scabies. For more ample details on this subject, I beg 
to refer to the published account of M. Renucci's observations, 8 to 
the work of M. Raspail, 9 who has given an excellent description and 
very good figures of the acarus, and to the researches of M. Gras, 10 
who has made many experiments with the view of determining the 
share which the acarus really has in the production of scabies, (a) 

(a) Mr. Wilson (op. cit.) records some of these experiments, which 
may appropriately enough be introduced in this place. 

" Exp. 1. — ' On the twenty-eighth of August,' writesM. Gras, 'in 
the presence of several physicians and students, I placed two living 
acari on the middle and anterior part of my forearm, and covered 

1 De Geer. Mem. pour servir a l'histoire des insectes. Stockholm, 1778, in-4to. 
t. vii. p. 92 et pi. 5. 

2 Gales. Essai sur Ie diagnostic de la gale, sur ses causes, etc. in-4to. Paris, 
1812. 

3 Wichmann (Johann Ernest). ^Etiologie der Kraetze. Hanover, 1786, in-8vo. — 
Ibid., 1721,in-8vo. 

* Walz (G. H.). De la gale de mouton, trad, de l'allemand. Paris, 1811. 
6 Mouffet. Theatrum insectorum. London, 1634, in-fol. 

6 Casal (Gaspard). Historia natural y medica del principado de Asturias. 
Madrid. 1762, in-4to. 

7 In looking for the insect of scabies, Adams informs us we must not examine the 
vesicle; but if a line, about a quarter of an inch in length.be seen going off from one 
of its sides, and at the extremity of this a reddish and in appearance dry and firm 
elevation be discovered, it is here that with the assistance of a good magnifying glass, 
the insect may occasionally be found ; it is at all events the only place in which it is 
ever to be expected. (On morbid poisons, p. 299, 4to. London, 1807.) Adams, in 
mentioning Bonomo, who says he took the insect from the moist vesicle, justly re- 
marks that this assertion renders all his observations suspicious. Adams has given 
two good figures of the acarus. 

s Gazette des hopitaux, Paris, 1834. — Gazette medicale, in-4to. Paris, 1834. 

9 Raspail. Mem. comparatif sur l'histoire naturelle de l'insecte de la gale. Fig. 
in-8vo. Paris, 1834. 

"° Gras (Albin.). Recherches sur l'acarus on sarcopte de la gale de l'homme, 
jn-8vo. Paris, 1B34. 

35 



If, therefore, there be no longer any doubt of the fact that in almost 
all who are affected with scabies, and who have as yet been subjected 
to no kind of treatment, a certain number of sub-epidermic furrows 
containing acari are to be discovered, it is also indubitable that the 
number of these furrows and of these insects bears no proportion to 
that of the vesicles. It is, farther, rare to discover these insects on 
the abdomen and on the groins, where the eruption of scabies is 
nevertheless very common and very apparent ; moreover, scabies is 
known to continue when no more acari are to be discovered. Lastly, 
the experiments instituted for the specific purpose of ascertaining 
whether the acarus is truly the artisan of the itch, do not appear to 
me altogether conclusive on the subject. 

The acarus will be described in the appendix along with the other 
parasitic animals infesting the human integuments. 

371. Diagnosis. — The diseases which are most apt to be confounded 
with itch are eczema, lichen, prurigo, ecthyma, and certain artificial 
vesicular and papular eruptions. 

When scabies occurs alone, and a sufficient number of its vesicles 
remain unbroken, it is easily distinguished from the papulce of lichen 
and prurigo, and from the pustules of ecthyma. 

Eczema simplex has a greater resemblance to scabies, inasmuch 
as the general elementary characters of both are the same ; but they 
differ in many essential particulars, and especially in the non-con- 
tagious qualities of the vesicles of eczema, which, moreover, are more 
highly inflamed, and flatter than those of scabies. The diagnosis of 
these diseases is not so easy, when the vesicles have been destroyed ; 
for if the small and slightly adherent scabs of the itch are very unlike 
the incrustations of ecthyma, intimately connected with the skin as 
they are, and the dry or humid excoriations of chronic eczema, they 

them with a watch-glass kept in its place by a bandage. On remov- 
ing the apparatus on the thirtieth, we found two superficial cuniculi 
(sillons) half a line in length, and at their extremity two little white 
points, indicating the presence of the acari. Substituting a fold of 
linen, retained in its place by a piece of adhesive plaster, for the 
watch-glass, the acari were left undisturbed for six days longer. At 
the end of this time the white points were no longer perceptible, and 
the cuniculi having become obliterated, had disappeared.' 

" Exp. 2. — ' On the first of September, I placed seven living acari 
on my forearm, and covered them with a fold of linen, and piece of 
diachylon plaster. Four days after, we found four or five well-marked 
cuniculi. On the sixth of September, two of the acari being extracted 
from their cuniculi, were found active ; they were then replaced. On 
the twelfth, another animalcule was removed and examined ; it was 
quite lively. On the fourteenth, there was considerable itching, with 
the development of a vesicle ; the cuniculi were two lines long. On 
the sixteenth, there were several new vesicles near to the cuniculi, but 
not on their line. On the seventeenth, the vesicles of the previous 
day had been rubbed off by the linen, but two or three new ones 
were visible. On the following day I put an end to the experiment, 
by rubbing some sulphuro-alkaline ointment into the part. During 
the course of the experiment, I suffered pruritus from time to time.' 

" Exp. 3. — ' On the ninth of the month, I imprisoned six acari on 
my ring finger, by means of the' finger of a glove. Next day there 
were two cuniculi half a line long. The acarus of one of these 
burrows was apparent for ten days, the other for three weeks, but 
after this period they both disappeared. During this interval, I cau- 
terized several suspicious vesicles developed on the same finger, and 
discovered two new cuniculi originating in acari that had fixed them- 
selves without having been observed. None of the vesicles showed 
themselves on the line of the cuniculi.' 

" Exp. 4. — ' I lately placed nine acari in the bend of my left arm, 
and retained them there by a compress and bandage. Four hours 
after, I felt considerable pruritus, and the next day perceived four 
cuniculi. Several days after, some vesicles showed themselves on 
my forearm.' 

" Exp. 5. — ' Having placed two acari in the flexure of the elbow of 
two persons, who expressed their willingness to submit to my experi- 
ments, on one, three or four vesicles were apparent on the fifty day, 
and were accompanied by severe itching. On the other there are 
two cuniculi, with pruritus, but no vesicles.'" 



i:W 



VESICULjE. 



differ but little from the smaller sized scabs of prurigo, and from those 
produced by pricking the integuments about the wrists and between 
the fingers, as is occasionally done by prisoners to simulate the disease 
of which we are now speaking. Lastly, when scabies has been treated 
by irritating lotions or unguents, which have produced adventitious 
eruptions, or when the disease is accompanied with large yellow pus- 
tules (scabies pundenta Batern), and when the vesicles which charac- 
terize it are altered in their nature, and the small scabs which succeed 
them are mingled with accidental pustules and papula?, it is only by 
a careful and minute study of the form and seat of the various altera- 
tions presented by the skin — vesicles, papula;, pustules, scabs, excoria- 
tion*, tfC, that we succeed in ascertaining the number, the nature, and 
the importance of the different lesions, which together, constitute these 
eomplicated cases. 

372. Prognosis. — If scabies be a much milder disease than is gene- 
rally imagined, still it very rarely happens, that its appearance exercises 
the salutary influence on certain acute and chronic complaints, which 
has been ascribed to it by certain writers. 1 It is still less positively 
ascertained that its cure, when this event has been followed by unto- 
ward symptoms, has actually proved their cause. It is, however, 
possible, that a severe and old standing scabies, in individuals of 
weakly constitution, and affected with diseased viscera, may in some 
sort modify or check the progress of this internal malady ; in such 
cases, it would only be advisable to seek the cure of the scabies in a 
very gradual manner, and after having established some other species 
of counter-irritant or drain, in a different district of the skin. On the 
other hand, I have often had no difficulty in perceiving that unpleasant 
consequences have been attributed to the discussion of itch, which 
have truly been due to the disappearance of eczematous and lichenous 
eruptions, improperly designated under the name of scabies. 

373. Treatment. — In old standing cases of scabies, when the vesi- 
cles appear crowded together in great numbers, and are attended with 
violent inflammation of the skin, or with adventitious eruptions, it is 
advantageous, if the constitution will admit of such practice, to begin 
the treatment by a bleeding from the arm, by soothing lotions, and 
occasionally by simple baths. But when the disease is uncomplicated 
and of recent date, its cure is easily obtained without any preparatory 
steps by local means, of which experience has proved the general 
efficacy. 

Frictions with the sulphur ointment (R. Adipis suil. lb. 1 ; Sulphur, 
sublim. lot. 3viii); or with this ointment, combined with sub-carbo- 
nate of Potash («. Adipis suil. li; Sulphur, sublim. drm. ii; Potassae 
subcarb. drm. i) ; or with the powdered sulphuret of lime, usually 
accomplish the cure of scabies within a fortnight. The sulphur 
ointment may be used in doses of two ounces daily, being rubbed 
morning and evening, over the whole of the parts affected with vesi- 
cles, so long as any remain visible. When the compound sulphur 
ointment is used, and it is the one I generally prefer, the patient's 
skin must be well cleansed with soap and water, after which, one 
ounce of the ointment is to be diligently rubbed during half an hour 
over the whole surface of the body, the rubbing is to be repeated 
at mid-day, and again before the patient lies down for the night, the 
treatment being continued on the following days in the same manner. 
In this way patients are often cured on the second or third day, and 
a very large proportion before the seventh. The course of friction is 
to be wound up with a warm bath, and an abundant use of soap to 
cleanse the skin. 

Helmerich was in the habit of prescribing four ounces of the com- 
pound sulphur ointment in eighteen hours, and repeating the same 
quantity next day. 

Such repeated inunctions have unquestionably the advantage of 
destroying the contagion rapidly, but they have the inconvenience of 
frequently causing artificial vesicular and papular eruptions, which 
compel us to suspend our treatment. Helmerich's plan is nevertheless 
the best when our object is the speedy recovery of a great number of 
individuals affected at the same time, and who, from their situation, 
are necessarily much in contact, such as soldiers, prisoners, the mem- 
bers of a large family, &c. I usually recommend the same plan to 

I Jerzemski. De scabieisalubritate in affections hydropicis. Halee, 1777.-Lepecq- 

dC "aL ° tU pK,K " bSei iv- SUr , les malad - epidemiques, 4to. Rouen, 1778,1. ii. 

p. 384 1 " Fnthisie guene par 1 inoculation de la gale." 



the work people and artisans who apply as out-patients at the Dis- 
pensary of the Hopital de la Charite. I occasionally employ sul- 
phureous baths in conjunction with the compound sulphur ointment, 
and find the plan extremely efficacious. 

In the plan of Pyhorel it is enough to add half a drachm of the sul- 
phuret of lime to a little olive oil, and with the mixture to rub the 
palms of the hands during a quarter of an hour night and morning. 
Obstinate cases of scabies are by this means generally cured at the 
twenty-fourth or twenty-fifth friction. I, however, greatly prefer to this 
partial method of inunction, the plan by which the specific is applied 
directly and at the same time to the whole of the affected surfaces. 

Artificial or natural sulphureous baths are particularly applicable in 
the cases of children, but the treatment carried on with these alone is 
expensive, twenty baths at least being required to accomplish the cure. 
Sulphureous washes, particularly one composed according to either of 
the following receipts: R. Potass, sulphuret. Ji ; Aqu. lbs. iij ; or B. 
Acid, hydrochloric, (muriatic) 3i ; Aqu. distil, lb. i ; an ounce of one 
of these mixtures added to four ounces of warm water and applied to 
the affected parts usually effects a speedy cure. These washes do not 
soil the linen and clothes of the patients like ointments ; but they 
prove irritating to the skin of many persons, causing vesicular and 
papular eruptions which occasionally require bleeding and the warm 
bath before they are subdued. 

Alcoholic saponaceous washes are less certain in their effects than 
sulphureous frictions and lotions, and may occasionally be recom- 
mended to the wealthy who are anxious to conceal the nature of their 
malady, or who show a repugnance to the use of sulphur in any of its 
forms or combinations : I make use of them but rarely. 

Sulphureous fumigations which are employed in some hospitals are 
not attended with expense, leave no unpleasant smell, and do not soil 
the linen ; but the long continuance of the treatment necessary to 
relieve the disease, more than counterbalances these generally insig- 
nificant recommendations. 

I cannot enter into any long details concerning the method of treat- 
ing complications of scabies with eczema, prurigo, lichen, ecthyma, 
&c. Each of these diseases of the skin requires appropriate remedies, 
which either have been or will be made known in the course of this 
work. When such complications appear at the beginning of the 
disease, it is a good plan to use the simple and the sulphureous bath 
alternately ; if taken every day, the latter might increase the concomi- 
tant affections, an effect which I have frequently observed when they 
were administered on account of varieties of scabies. When these 
diseases, or other artificial inflammatory affections of the skin, are set 
up towards the end of the treatment, we must be on our guard against 
taking such adventitious affections for modifications or degenerations 
of scabies : they would only be made worse by persevering in the use 
of sulphureous remedies. 

When the vesicles of scabies have been made completely to disap- 
pear, we must take measures against their return. With this view 
the clothes of the patient, especially those that are of wool, must be 
disinfected by exposing them to the fumes of the sulphureous acid 
gas ; the linen should be changed frequently, and the greatest atten- 
tion paid to general cleanliness. 

375. Having now made known the most successful and economi- 
cal methods of treating scabies, I shall only say further in connection 
with the curative plan, that the inunction of oil, as recommended by 
M. Delpech, is less efficacious than the preparations of sulphur ; and 
that the use of various acid ointments and washes, the bases of which 
are nitric acid and mercury, recommended for the cure of scabies, 
have occasionally produced salivation and disturbance of the diges- 
tive organs. A sulphuro-saponaceous liniment, (a) which has also 
been praised as effectual, I have seen followed by sweating, smarting, 
general uneasiness, and the development of artificial vesicular and 
papular eruptions. In fine, many other preparations such as the 



(a) R. Potassae sub carbonatis 3ij ; 
Aquae Si ; 

Oleae oli varum Iss ; 
Camphor, gum. £ij ; 
Sulphuris sublimati av ; 
M. 






MILIARIS SUDATORIA. 



139 



proto-ioduret and the deuto-ioduret of mercury, have appeared to me 
rather injurious than beneficial in this disease. I conclude by stating, 
that I have found the plan recommended by Helmerich, which I 
usually follow, to be the safest and most efficacious of all. (a) 

Historical Notices of the Disease. 

376. It has been said and repeated again and again, that the Greeks 
described the disease we call itch, under the name of 4k°- This 
assertion is incorrect. By this word they designated scaly diseases 
in a general way, and by no means a vesicular eruption, susceptible of 
transmission by contagion. I should also state, that if in works 
published in the Latin language since the revival of letters, the itch is 
designated under the name of scabies, and this denomination is even 
applied to the disease in this place, the word was not used originally 
in the sense now attached to it. The description in which Celsus 
makes use of the term scabies, is much more applicable to confluent 
and excoriated lichen than to itch. "Scabies vero est asperitudo 
rubicundior ex qua" pustulae oriuntur, quaedam humidiores, quaedam 
sicciores. Exit ex quibusdam sanies, fitque ex his continuata exul- 
ceratio pruriens, serpitque in quibusdam cito. Atque in aliis quidam 
ex toto desinit, in aliis vero certo tempore anni revertitur. Quo 
asperior est, quoque prurit magis, eo difficilius tollitur; itaque earn 
quae talis est ay^tav id est feram, Graeci appellant," etc. There is no 
mention whatever in this obscure passage of an essential character of 
itch, which could neither have been overlooked nor omitted, namely, 
its contagious nature; further, itch never terminates spontaneously. 
It does not recur at certain periods of the year, and so on. In no 
other way, therefore, but by interpreting this passage amiss, can it 
be maintained that Celsus knew and had described the itch. Galen, 
under the title 4u£a — translated into the Latin, scabies — describes 
several squamous alterations of the skin, especially of that of the eye- 
lids. There is nothing to authorize the assertion, that this writer was 
acquainted with the vesicular disease termed itch in England, gale in 
France ; for if, in the following passage from the treatise de pulsuum 
differentiis, lib. iv. cap. 1, " sed ut psora et lippitudine qui proprius 
accidunt, quidam corripiuntur inviti," it be said that psora may be 
transmitted by contagion, in connecting it with lippitudo, the author 
makes us suspect that he was discussing a disease of the eyelids, and 
not an eruption scattered over the fingers, wrists, bends of the arms, 
axilla?, &c. ; and in the passages particularly devoted to the history of 
the different species of psora — rendered scabies by the translators — 
not one of them is mentioned as contagious. 1 

In the Latin translations of Avicenna the word scabies where it 
occurs, does not seem applicable to the itch. Avicenna does not 
speak of contagion ; he says, however, " Et non acciddit plurimum 
nisi inter digitos, quia sunt debiliores." 

Guy de Chauliac is the first who points out the essential character 
of itch in an unequivocal manner : " Scabie," says he, " est une 
maladie contagieuse." 2 Fernelius and Pare, less accurate in their 
descriptions, have omitted this important feature of the disease, of 
which, however, Vesalius, Forestus and Van Helmont have taken 
notice. 

Among the numerous diseases of the skin, which Hafenreffer 3 com- 
prises under the title Scabies, he does not describe itch. 

Willis does not separate it with sufficient care from other prurigi- 
nous affections, but he was perfectly aware of its contagious nature, 
and of the value of sulphur in its cure. 4 Willan and Bateman 5 have 



(a) In general, it will be most prudent to administer sulphur inter- 
nally, in conjunction with bitartrate of potassa, or the sulphuret of 
potassa, with a neutral salt in solution — at the same time that sulphur 
is used externally. I have cured scabies by blue mass and laxa- 
tives without recourse to sulphur in any form. Camphor dissolved 
in oil, in the proportion of one drachm to an ounce, answers, as we 
learn from Mr. Wilson, every purpose of eradicating the disease. 

1 Novus index in omnia quae extant CI. Galeni opera, fol. Basillae, 1562 — Art. 
Psora, Scabies. 

2 Des signes de scabie, c'est-a-dire rogne, trad, du Guidon par J. Canappe, 8vo., p. 
358. Lyon, 1609. 

3 rTavWj^iTov iioXoJi{/u«, Tubing. 12mo., 1630. 
* Pharmac. rational, part i. § iii. cap. 6. 

8 A practical synopsis of cutaneous diseases, 8vo., 7 edit. 1829. 



very unnecessarily multiplied the species of this disease. M. Four- 
nier 6 has given a detailed history of the various methods of treatment, 
and Biett 7 has devoted himself to demonstrating its constantly vesicu- 
lar primary form. M. Mouronval has collected a great number ot 
particular cases, and has given the results of his experience on the 
majority of the curative plans which have been proposed, especially 
on the effects of fumigations and alcoholic lotions; as also an account 
of the researches of M. Lugol on the acarus scabiei.* 

M. Hurtel d'Arboval 9 has collected some observations on the itch 
of domestic animals ; but these are still very imperfect. 

Observations or cases of simulated itch have been published by M. 
Fabre, 10 and remarks on the repulsion of this disease 11 and on different 
methods of treating it, as by the liniment of the sulphuret of lime, 12 
the compound ointment of sulphur and subcarbonate of soda, 13 the 
use of oil alone, 14 or the chlorate of lime, 15 the root of the plumbago 
europ, 16 &c, maybe found considered in separate treatises, and vari- 
ous periodical publications. 



MILIARIS SUDATORIA, VEL SUDOR MILIARIS. 
Vocab. Miliaria, Sudor. [Sudatoria,] 

377. Sweating miliaria is an eruptive and contagious febrile dis- 
ease, which almost always appears as an epidemic, and is charac- 
terized on the exterior by a copious and continued sweat, and, 
generally, by the eruption of small, rounded vesicles the size of 
millet-seeds. 

The symptoms which precede or accompany the eruption may be 
complicated with those of other diseases ; hence arise diversities in 
the severity, and a host of individual peculiarities in the character 
of the malady, which may, however, be regarded as assuming two 
principal forms, mild or benign, and malignant sweating miliaria. 

378. When the disease appears in the milder form, the attack is 
often proclaimed by a feeling of lassitude, pain over the eyes, and loss 
of appetite ; frequently, however, the patient is seized at once with- 
out any premonitory symptoms. In the epidemic which raged in the 
department of the Oise, in 1821, many individuals who had gone to 
bed well awoke labouring under the disease, their bodies bathed in 
sweat which never disappeared till their death or convalescence. 
Occasionally an almost imperceptible degree of fever, a burning heat, 
or a feeling as if a vapour were passing over the whole of the limbs, 
and still more frequently, a sense of constriction about the epigastric 
region, precedes by some hours, or by some minutes or seconds only, 
the appearance of the sweat, or rather the hot vapour, which, steaming 
from a few districts of the body at first, is soon exhaled from the 
entire surface. The mouth is clammy and the tongue is covered with 
a foul white, or, more rarely, yellowish fur. The inclination for food 
is gone, or is at least exceedingly moderate. The urine frequently 
preserves its natural characters. The bowels are usually confined 
during the whole course of the disease. The pulse is good in many 
cases, and only becomes frequent at the period of the eruption. The 
respiration seems troubled or oppressed in the same manner as it is 
in an atmosphere the temperature of which is excessively high. The 
encephalon and its dependences, the organs of sense, and those of 
generation, do not seem to be affected. This state continues with 
slight variations through the second, third and fourth days of the dis- 
ease. It is on one of these days, usually the third, that after some 
slight sensation of tingling, a miliary eruption makes its appearance 

6 Dictionnaire des sciences medicales. Art. Gale. 
i Dictionnaire de medecine, en 21 vol. Art. Gale. 

8 Recherches et observations sur la gale. 8vo., Paris, 1821. 

9 Dictionnaire de med. veter. Art. Gale. 

io Fabre. Div. obs. de med. et de chirurgie, 4to. Paris, 1834. 

" Favarielle-Placial. Tableau des accidens funestes qui resultent du mauvais 
traitement de la gale et de sa repercussion. 8vo., Paris, 1807.— Wenzel. Des gales 
re*percutees (Bull, des sc. medic, de Ferussac, t. xii. p. 223). 

'* Journ. univ. des sc. medic, t. v. 

'» Methode du docteur Helmerich pour guerir la gale en deux jours, publiee par J. 
Burdin, 8vo. Paris, 1822. 

i* Delpech. Revue medic, t. xiv. p. 149. — Avril, 1829, p. 114. 

is Fantonetti. Arch. gen. medec, t. xxx. p. 407. 

'« Halle. Experiences pour determ. les propri^tes et les effets de la racine de 
dentelaire dans le traitement de la gale. (Mem. de la soc. royale de med., 4to. 1782.) 



140 



VESICULjE. 



upon the skm, spreading from about the sides and nape of the neck, 
where it usually shows itself first, to the ears, the mammae in the 
female, the back, the insides of the arms, the abdomen, and the inner 
aspects of the thighs and legs. It maybe evolved generally and 
rapidly, or partially and slowly, be circumscribed or progressive, come 
out suddenly or in succession, and be distinct or confluent. The 
vesicles which characterize this eruption are of the size of millet- 
seeds, pearl; and diaphanous, and more distinct when the skin is put 
upon the stretch, and they are seen obliquely ; they are also easily 
felt by the point of the finger. These vesicles are often intermixed 
with red and inflamed papulae, which make the skin look like sha- 
green; lastly, true bullffi may appear accidentally on different regions 
oi' the body. 

The duration of the vesicles individually, is from two to three days. 
They dry up and are followed by a desquamation of the cuticle greater 
or less in amount. 

More constant in its occurrence than the eruption, the sweating 
is always copious, and accompanied with a peculiar odour, 1 which 
I have compared to that of rotten straw. The sweating begins with 
the morbid symptoms, and continues profuse during the whole course 
of the disease. It is not attended with any considerable heat of 
surface. 

The whole of the symptoms decline by degrees, and disappear 
completely on the eighth, the ninth, or the tenth day. 

2d. The malignant form of this disease appears to be induced by 
various concomitant and accidental circumstances: in one case it is 
a severe inflammatory affection of the stomach and intestines; in a 
second, true inflammation of the lungs, or of the bladder, which is 
set up ; in a third, the nervous is the system which is implicated, and 
then we have delirium, coma, and convulsions, which speedily prove 
fatal. When the digestive organs are affected, the patient complains 
of an acute girding pain in the epigastric region ; the spasm extends 
to the organs of respiration, and occasions the most distressing 
anxiety ; the patients give vent to long-drawn sighs, complain of a 
sense of weight upon the chest, of a feeling of suffocation, of violent 
and unusual pulsations in the region of the stomach, synchronous 
with those of the heart, and of such general and indescribable uneasi- 
ness as makes them fear for the worst. These distressing symptoms 
occasionally appear in the very outset of the disease ; they recur 
frequently during its course, and make their attack with particular 
violence on the third or fourth day, immediately before the appearance 
of the eruption. From the commencement of their illness, some 
patients suffer from vertigo and violent headache, complain of nausea, 
and make repeated efforts to vomit ; or the countenance is flushed, 
the eyes are starting and injected, the temporal arteries throb, the 
pupil is contracted and immovable, and the patient sinks within a 
few hours, comatose, or convulsed. In other cases, a deep-seated 
pain in the chest, a diminution of its sonorousness, a crepitating 
rattle, or a blowing noise in one or several lobes of the lungs, oppres- 
sion of the breathing, which is short and quick, frequency and fulness 
of the pulse, and sanguinolent expectoration, proclaim a concomitant 
inflammation of the lungs. Lastly, some patients complain of diffi- 
culty in passing their urine, and of deep pains in the hypogastric 
region, symptoms which, together with the high colour and deficient 
quantity of the excreted fluid, give unequivocal evidence of an inflam- 
mation of the bladder. 

The malignant form of miliary sudor occasionally proves fatal within 
twenty-four or forty-eight hours; the disease occasionally runs its 
course within the week ; more commonly, however, it does not termi- 
nate till after the lapse of a fortnight, and it may even extend beyond 
the third week. 

1 This odour has been likened by M. Meniere to that of water slightly impregnated 
with chlorine, or to that of the evacuations of patients labouring under cholera. The 
.smell of rotten straw only struck him in those patients who were lying on indifferent 
bedding, of which an old palliasse formed the principal part (Archives Gener. de 
Medecine, t. nix. p. 100). I have, however, felt the peculiar odour in question very 
distinctly, from the persons of those patients who were laid on very comfortable beds, 
particularly from that of the Mayor of Girts les-Mello. Other writers as well as 
myself have also said that it was ascescent, and very similar to that of rotten straw 
(Schahl and Hessert). Lepecq-de-la-Cloture, says, that the sweat has a rotten sour 
.smell (atgre poum) : others have characterized" it as mephitic and insupportable 
(Pujol). It is certain, therefore, that the odour in these cases is always peculiar and 
very unpleasant. * r 



Epidemic miliary sudor much more frequently occurs without any 
eruption than epidemic measles, scarlatina, or small-pox; the absence 
of eruption is indeed a much more frequent phenomenon in this than 
in any of the other forms of eruptive fever. In the epidemic of 1821, 
the eruption was wanting in a great number of the individuals attacked 
(febris sudatoria). 

During convalescence from this affection, secondary diseases are 
more rarely observed than in recovery from any of the other eruptive 
diseases. When they do occur they are usually gastro-inteslinal 
affections, and they occasionally consist in eruptions of boils, or of 
pustules of ecthyma. 

379. Alterations of structure. — From the small number of post- 
mortem examinations that have been made of the bodies of individu- 
als who have died of this disease, it would appear that when the fatal 
event is preceded by anxiety, pain, and a sense of heat or burning 
in the epigastrium, the mucous membrane of the stomach is red, and 
its capillaries are injected. This state of increased redness is con- 
tinued into the duodenum and small intestines, where, however, it 
becomes less apparent. When the death had been sudden and was 
preceded by nervous symptoms, the vessels of the brain were found 
injected ; in those cases in which the catastrophe was less rapid, a 
quantity of serum, greater or smaller in amount, was invariably found 
in the ventricles of the brain. 

These inquiries, however, are still very incomplete. 

380. Causes. — In France this disease has principally been observed 
in Picardy, Languedoc, Normandy, Berry and Alsace. It commonly 
prevails as an epidemic. The epidemics denominated sweating sick- 
ness, which occurred in England in 1485, 1506, 1507, 1588, at Guise 
in 1759, at Beauvais, in 1750, at Hardevilliers, in 1773, &c, all 
differed essentially from the disease we are now investigating, in the 
important circumstances of duration and mortality, (a) The sweating 
disease with miliary eruption which prevailed in the department of 
the Oise in 1832, was much less extensively felt than that of 1821, 
and appeared to be modified by the reigning choleric constitution. 
In the epidemic of 1821, the theatre of its attacks was bounded 
almost on every side by extensive forests, and lay between north- 
west and south-west, the direction in which its ravages extended. 

Excessive heat, and an atmosphere surcharged with electricity, 
have in some districts been observed to precede the appearance of 
the disease. It is, however, evidently endemical in certain situations, 
and may occur sporadically in the places where it has prevailed as an 
epidemic. Several well-informed physicians have confounded the 
disease with inflammation of the gastric and intestinal mucous mem- 
brane, 2 or with the eruptions of sudamina, which are observed during 
several acute diseases. 

The miliary sudor only appears between the 43d and 59th degree 
of northern latitude. Moist and shady situations seem favourable to 
its development ; but it is contagious, and once engendered spreads 
in the same manner as measles and scarlet fever. It does not appear 
that it can be propagated in any other way : several practitioners have 
inoculated themselves with impunity with the fluid of its vesicles. 

No age gives immunity from the attack of this disease, but adults 
and females seem more especially obnoxious to it. During the epi- 
demic of 1821, the number of those affected was so much the more 
considerable in each district, as it lay nearer to that which was first 
attacked, as the situation was unhealthy, and its poor were numerous. 
Mr. Meniere ascertained that a great many of those who had been 
seized, during the epidemic of 1821, were again attacked and died 
during that of 1832. 

381. Diagnosis. To make the peculiar characters of the miliary 
sudor stand prominently forward, it is enough to contrast it with the 
other eruptive fevers, and the diseases which, like it, are proclaimed 
on the surface under the form of vesicular eruptions. 

In the sweating miliaria there is profuse and incessant perspiration, 
and generally an eruption of vesicles upon the skin, which appears 

(a) The author, in a subsequent paragraph (384), insists, however, 
on the unquestionable analogy that subsists between the two diseases. 

2 Se J e th ^ critical notices of my work, "sur l'epidemie qui a regne dans le departe- 
ment de 1 Oise, en 1821," inserted in the annates de la medecine physiologique. 
Janvier, 1823; and in the Journal general de medecine, t. lxxxii. p. 341. 



MILIARIS SUDATORIA. 



141 



like shagreen to the touch. In measles we have bronchial affections, 
and small red patches disposed in arcs of circles, separated by inter- 
vals in which the skin preserves its natural colour. In scarlet fever 
Ave have inflammation of the tonsils, and a bright, nearly uniform, 
raspberry red colour of the integuments. Neither of these diseases is 
accompanied by the excessive and continued perspiration which we 
remark in the miliary sudor. 

The vesicles of the different varieties of herpes are larger than those 
of the miliaria ; they also occur in clusters, and are confined to a 
single region of the body. Sudamina appear in several diseases, and 
do not form any morbid individuality, if the expression maybe allowed; 
they are observed accompanying the furuncular inflammation of the 
bowels, rheumatism, phthisis, the milk- fever of puerperal women, &c. 
Acute eczema is not attended with sweating, and in its progress has 
no character in common either with miliary sudor or any of the erup- 
tive fevers. The vesicles of eczema are far more minute, and those 
of chicken-pox more prominent and much larger than those of the 
sudor. As to those who would confound the miliary sudor with a 
gastro-enteritic affection, their hypothesis brings to mind that accord- 
ing to which measles and scarlatina are maintained to be, the one a 
bronchitis, and the other an angina reflected upon the skin. 

382. Prognosis. — The miliary sudor, in its simple state, is a per- 
fectly mild disease. The fever and the gastro-intestinal symptoms 
which precede and accompany the sweating and the eruption ; the 
affections of the brain, lungs and bladder which may intervene at dif- 
ferent periods of its course, combined with the general character of 
the prevailing epidemic, render our prognosis unfavourable in dif- 
ferent degrees, according to the severity of the symptoms. 

However alarming the first symptoms may have been, if they de- 
cline or yield after the eruption has appeared, the issue of the disease 
will generally be favourable. 

During the epidemic of 1821, the eruption was independent of any 
irritation of the stomach. I have seen it confluent without violent 
previous pain of the epigastric region, nausea, or redness of the 
tongue ; and I have several times met with all these symptoms in 
patients who suffered from profuse and incessant sweating, without 
any eruption whatever. It was also independent of the sweating, 
seeing that it did not invariably succeed even the most profuse ephi- 
drosis. 

Death often closely follows shriveling of the vesicles ; and occa- 
sionally occurs very suddenly, at times, — even in a more unexpected 
manner than in the other eruptive fevers. 

In the epidemic of 1821, the greatest mortality was observed 
among individuals of the ages of thirty-two, twenty-four and twenty- 
six. The mortality among males was one in thirteen and 3-llths ; 
among females it was not higher than one in twenty-eight and 
7-10fhs. Daily observations showed that the chances of death were 
greater at the beginning and decline of the epidemic than during the 
period of its greatest prevalence. Among certain trades or profes- 
sions, — the makers of matresses, bakers, postillions, smiths and far- 
riers, the mortality was greater than among individuals exercising 
other callings. The mortality was very various in different districts 
or townships : at La Chapelle the proportion of those who died to 
those who were attacked was as one to two, whilst at Neuilly-en- 
Thel, it was not more than in the ratio of one to one hundred and 
eighteen. 

383. Treatment. — Were isolation practicable it would unques- 
tionably be useful in the epidemic sudor ; the advantages of tem- 
porary emigration are undeniable ; any other preservative means are 
uncertain in their efficacy. 

Diluents, and the application of a few leeches to the epigastric 
region or to the feet, if there be pain in the stomach or head, answer 
in the milder cases of the disease, in the treatment of which, indeed, 
the purely expectant method may generally be recommended. 

General blood-letting, either alone or combined with powerful irri- 
tants, such as mustard-plasters, and blisters, has been occasionally 
used with success, when the brain appeared about to be seriously 
affected. I know not whether the temporal artery has ever been 
opened under these circumstances or not. These cases often prove 
rapidly fatal, and this termination has not seemed to be even delayed 
by the repeated abstraction of blood from the general system, during 
36 



the period when the cerebral symptoms were threatened. In the 
miliary sudor, as in variola and scarlatina, these nervous phenomena 
are occasionally independent of actual inflammation. 

After the eruption has appeared, blood-letting is always injurious. 
I have been witness to the fatal effects of repeated bleedings, prac- 
tised with the view of cutting short the disease, which, in these cases, 
when it did not end fatally, nevertheless went through the whole of 
its usual phases. 

When the eruption in this disease disappears suddenly, its return 
ought to be solicited by every means, — dry frictions, urtication, mus- 
tard cataplasms, &c. 

Sudorific drinks may be recommended in some particular cases to 
increase the determination to the skin, or to recall the eruption should 
it have disappeared ; it is not, however, in general, advisable to pur- 
sue any measures calculated to increase the sweating. 

Pujol not only recommends patients labouring under this complaint 
to be lightly covered, but would even have them rise and expose 
themselves to the open air. Messrs. Schahl and Hessert inform us, 
that they have observed good effects from cold bathing, and the as- 
persion of cold water. I did not try this measure in the epidemic of 
1821 ; but I have seen the spasm and pain of the epigastrium which 
precede the eruption, cease after the application of cloths dipped in 
cold water to this region. 

Emollient cataplasms and glysters allay the pains complained of in 
the abdomen, and lessen the dysuria. The general warm-bath, or 
the hip-bath, is often used with success in appeasing the irritable state 
of the intestinal canal which occasionally continues during the conva- 
lescence of the patients. 

In the epidemic of 1821 many practitioners tried the tartrate of 
antimony and the ipecacuanha, during the first stage of the disease, 
expecting, by these means, to render its subsequent progress milder 
and more regular. As a general and exclusive mode of treatment, 
this practice is really less efficacious than the simply expectant or 
moderately antiphlogistic system. 

Aperients at the period of convalescence have been recommended 
by several practitioners. They were little used in the epidemic of 
1821, and I do not recollect to have heard a single fact quoted which 
certainly proved their utility. 

Lastly, there was a practice prevalent in the earlier periods of the 
epidemic of 1821, which nothing tended to justify, and which was 
soon abandoned ; this was the keeping the whole of the patients, 
without distinction, constantly awake, in the intention of preventing 
seizures of the brain. 1 

Patients ought to be deprived of nourishment of every kind during 
the four or five first days of this disease, and confined exclusively to 
diluents. It may even be found necessary to continue this severe 
system of low diet so long as the seventh or eighth day. Patients 
may then be allowed a little veal or chicken broth, and the quantity 
and consistency of the food may be gradually increased afterwards. 
Almost all the relapses I observed, during the epidemic of 1821, 
were owing to indigestion, or the occurrence of gastro-intestinal in- 
flammation. 

It is almost needless to add, that due attention to cleanliness, to 
the renewal and purification of the air, to a regimen adapted to an 
acute disease, and a judicious employment of moral means ought 
in this, as in all other diseases, to be brought in aid of the medical 
treatment. 

Historical JYotices and particular Cases. 

384. Hippocrates, Galen and Avicenna make mention of miliary 
spots or elevations which occurred during the course of certain febrile 
diseases; but the characters of these eruptions are too indefinitely 
given to enable us, at the present day, to decide whether the ancients 
were acquainted with the miliaris sudatoria or not, or whether their 
observations refer to the papular eruptions of dothinenteritic affec- 
tions, or to the sudamina occasionally seen on the skin, in a number 
of acute and chronic diseases. 

' I remark, as a very singular circumstance, that Rush, in his account of the yellow 
fever, as it appeared in the city of Philadelphia in the year 1793, p. 35 , regards sleep 
as rendering the body more peculiarly susceptible of being influenced by the epidemic. 



142 



VESICUUE. 



I conceive thai I have, in another work, 1 demonstrated the un- 
ilogy ilr.H subsists between the sweating-miliaria of 
. . 1 1 r own davs, and the epidemic sudor, or sweating sickness, which 
i! England in 1485, 150G, 1517 and 1528. a The waiit of 
iniliar\ vesicles in the old English disease, does not necessarily make 
it different from the disease we are now discussing, a great number 
of the patients attacked in the epidemic of 1821 having had no 
eruption. 

Some choice and selection are necessary from among the cases and 

memoirs recently published on miliary sudor ; many of them refer to 

Una, others to the accidental vesicular eruptions occasionally 

observed in puerperal women; others to the spots which accompany 

dothinenteiitis, and so forth. 

I confine myself here to pointing out several works in wddch the 
epidemic miliaria is described with accuracy, 3 and for farther details, 
I beg to refer to the treatise I published in 1821, and to the observa- 
tions of Messrs. Meniere, Hourman, Pinel-Grandchamp and Moreau, 4 
on the epidemic which prevailed in the year 1832, in the department 
i| the Oise. 

Cask LVT. — Sweating-miliaria of a mild character. L. A. was seized 
on the 6th of August, 1821, with the sudor, shortly after the recovery 
of his wife. This patient presented a striking instance of the occa- 
sional mildness of the disease. When I asked him why he had sent 
tor me, he answered that he "was sweating profusely, but had no 
eomplaint to make." He had taken to his bed after a slight sensa- 
iion of uneasiness, and having several times felt chilly for an instant. 
Mis face was flushed, and when questioned closely, he complained 
of slight headache ; he was drenched in a profuse and fetid perspira- 
tion; the tongue was white and thickly furred; the epigastrium was 
not tender, even on pressure being made ; belly supple, urine natural, 
durst not very pressing, in spite of the copiousness of the perspira- 
tion; pulse soft, giving sixty-two pulsations per minute; breathing 
natural ; faculties of the mind untouched. ( Veal broth, infusion of 
borage sweetened with honey, for drink.) August 7th. The patient, 
whose fears I had dissipated on the presumed danger of yielding to 
sleep, had slept quietly for several hours during the night. The 
sweating was as profuse as ever, but the heat of surface was neither 
excessive nor troublesome; the tongue was still covered with the 
same whitish fur; its edges were neither red nor inflamed ; bowels 
confined, no pain of the abdomen, slight sense of oppression, pulse 
natural. 8th. Same state. 9lh. The patient has had a good night, 
but complains of oppression, and a feeling of weight at the pit of the 
stomach; he sighs deeply at intervals, as if he would cast off some 
load that weighed upon the chest. There is no complaint made of 
ihrobbing or sense of burning in the epigastrium. The pulse is full, 
beating seventy in a minute ; the skin is hotter, and the patient com- 
plains of itching over the loins and chest; a considerable number of 
red, conical, miliary vesicles are discovered on the neck, chest, and 
upper extremities, between which the skin preserves its natural 
colour and appearance. The pain of the epigastrium having in- 
creased, six leeches were applied to this region. The night of the 
10th was more restless than wont, but the pain of the epigastric 
region and the sense of oppression had greatly declined since the 
ippearance of the eruption and the application of the leeches. The 
bowels were still unrelieved; the urine was healthy; the patient was 

: Rayer. Histoire de 1'epidemie du suette-miliaire qui a regne en 1S21, dans les 
•lepartemens de I'Oise et de Seine-et-Oise, 8vo. Paris, 1822. 

J Joh. Caii Britanni de Ephemera Britannica, liber unus, summacura recognitus. 

Svo. Londini, 1721. — Forestus. Obs. et cur. medic, lib. xxviii. t. i. p. 198. Schenck 

Obs. med. rar. fol. I.ugd., 1644, p. 739. 

3 Bellot. An febri putrida? Picardis sueile dictre sudorifera ? 4to. Paris, 1733.— 
Description d'une fievre putride magligne vulgairement appelee la suette, qui a re>ne 
•n Guise en juin et juillet, 1759 (Journ.de med.de Vandermonde, 12mo. t xif p 
::.»).— Epidemie du suette a Freneuse, 1735 (Journ. de med. de Vandermonde t 
xxv. p. vi)\— Epidemie de suette a Beauvais en 1750 (Boyer. Methode 6. sun-re dans' 
le iraitemeni des diflerentes maladies epidemiques qui resneni le plus ordinairempnt 
dans la generaliie de Paris, l2mo. 1761).-L'Abbe Tessier. Memoire sur la suette 
qni a regoift Hudnrillien au mois de mai, 1773 (Mem. soc. rov. de medecine de 
Paris, 4.o t. u. P . 4G) Gastellier. Traite de la fievre miliaire epidemique, 12mo. 
Pans, 1784,-Pujol. Mem. sur la fievre miliaire qui a re*ne au Languedoc et dans 
les provinces hraurophes dorant le primemps de 1782. (Euvres. 1. ni. p. 261 Svo 

, 4 riv' mere - ,«;"? /""J e P ,domiede , ^-miliaire qui a regne dans le department 
de I Oi'-e en 1832 (Arch. sen. de med., l. xxix n 9So W„„r m .,„ r> >j- > 

i.„ „ »7i p-,ri« i«io Pin«.i r^„A L XX,X -P; »«)•— Hourman. Gaz. midirale, 
P- - 7I - p ar.s, 1882-Pinel-Grandchainps. Lane, iranc, I. vi. p. 161.-Moreau 
Journal hebdomad., Seplembre. . ' "" 



without fever, although feeling considerable thirst; the vesicles, 
rather numerous on the arms, were thinly scattered on the legs and 
thighs. (Beef tea.) 11th. Several hours' of tranquil sleep through 
the preceding night; sweating less; appetite beginning to revive; 
the vesicles gone. (Soup.) 12th. Patient well and able to rise. 
Though complaining at first of considerable weakness, he regained 
his strength very rapidly. 

Case LVII. — .Miliaris sudatoria; vomiting, delirium. A. II. 
eighteen years of age, of a hardy constitution, had complained for 
some days of a want of appetite and a disinclination to labour not 
usual with him. On the morning of the 1st of August he felt a 
violent headache, sense of constriction about the epigastrium and 
nausea. He was then seized with vomiting, and with profuse and 
incessant sweating. The patient was greatly alarmed, his master 
having died of the same disease with which he now felt himself 
attacked, a short time before. August 2d. — The sweating continues; 
the face flushed, eyes sparkling, tongue covered with a thick yellow 
fur, pulse full, hard and frequent, furious delirium during the nioht 
(fourteen leeches to the epigastric region). 3d. — Excessive restless- 
ness, the patient delirious and managed with difficulty (a large bleed- 
ing from t/ie arm, mustard poultices to the legs). The ensuing night 
pretty tranquil; the sweating continues; the anguish and depression 
of the patient are extreme. He thinks nothing can save him from 
death. (Sinapisms to the legs, and venesection in case the paroxysm 
returned.) 4th. — The patient was not bled ; the sweating continued 
as copious as ever; the eruption begins to be perceived on the fore- 
arms, hands and neck; throbbing and flushes of heat in the epigas- 
trium, which is tender to pressure ; other symptoms much the same. 
(Clysters, six leeches to the epigastric region.) 5th. — Sweating still 
continues ; the eruption now appeared successively on the neck, arms, 
and thighs, chest and face. It is so confluent that the whole of the 
vesicles might be. said to be in contact ; they are more particularly- 
crowded on the hands and wrists. Of all the patients I had seen, 
none presented so copious an eruption as A. H. 6th. — Apyrexia, 
skin rough to the touch, tongue less furred ; the urine deposits a 
copious white sediment. 8th. — Symptoms still declining, no fever, 
evident desquamation of the cuticle, tongue almost quite clean, urine 
depositing, appetite returning (veal and chicken broth, plain soup). 
9th. — Patient convalescent ; the pulse is remarkably slow, only beat- 
ing forty-five in a minute. The patient is able to rise, and feels com- 
fortable. His final recovery was slow. 

Case LVIII. — Sweating miliaria, haemoptysis, dysuria. M. B., 
jun., on the 25th of July, applied fifteen leeches to his legs in the 
hope of preserving himself from the sweating disease which prevailed 
around him. On the 6th of August he had the first symptoms of the 
disorder; supra-orbital headache, general lassitude, constriction of 
the epigastrium followed a few hours afterwards by the breaking out 
of a profuse and fetid sweat which drenched the whole surface of the 
body; mouth clammy and unpleasant, tongue white and furred, little 
thirst, slight pain of the epigastrium, which began after the sense of 
constriction went off, belly soft, bowels constipated, urine not much 
changed, pulse full, but not hard (seventy-five beats per minute); 
respiration natural, although the patient, complains of a load on the 
chest, which on percussion is found to be everywhere resonant. 
( Veal broth and lime-tree flower water sweetened with honey for drink.) 
August 7th.— The sweating continues; the tongue is still white and 
coated, but moist ; the thirst is by no means troublesome ; the other 
symptoms are much the same, except that the sense of oppression 
about the chest becomes so great that the patient is truly agonized. 
This state of suffering was undoubtedly increased by the fear the 
patient expressed of sinking under a disease which he had seen 
commit such havoc around him. 8th.— The patient had passed a 
restless night ; in addition to the symptoms already described he 
complained of a general tingling over the body, which was more 
especially troublesome in the region of the loins; in the course of the 
evening a great number of red miliary vesicles, scarcely rising above 
he level of the skin, made their appearance upon the loins, nape of 
the neck, and arms. The fingers passed over these parts received 
precisely the same impression as that conveyed by the surface of 
shagreen I he eruption came out rapidly; the patient was very 
restless during the three or four hours that preceded its appearance ; 






MILIARIS SUDATORIA. 



143 



violent pain in the head, anxiety about the praecordia, burning heat 
of the epigastrium, sense of oppression in the chest, and constriction 
of the stomach ; the pulse was full, the sweating profuse, accompanied 
by a marked increase in the temperature of the surface. {Antiphlo- 
gistic drinks; eight leeches to the epigastric region.) 9th. — The erup- 
tion had spread over the whole surface of the body; it consisted 
entirely of reddish, slightly transparent, miliary vesicles; the fever 
ran high, the heat of skin was considerable ; but the painful symp- 
toms about the chest and abdomen had sensibly abated, and the 
patient expressed less solicitude about the issue of his illness. Be- 
tween one and two o'clock in the morning, M. Pariset (who had 
attended the case along with me from the first), and I were summoned 
from our beds to see the patient who had been seized with a spitting 
of blood. We obeyed the call immediately, and found the patient 
much in the same state as we had left him at last visit, but extremely 
agitated, and declaring he should certainly be suffocated ; he had had 
several fits of coughing, and in the matter expectorated there appeared 
a small quantity of florid blood not amounting to a tablespoonful 
in all. The chest on percussion carefully practised, sounded well 
throughout the whole space occupied by the lungs. The patient 
could fetch a long breath without pain. We attributed the new 
symptoms to a determination of blood towards the mucous membrane 
of the bronchi, which probably commenced but a few hours back; a 
period at which the patient had felt what he called an accession, 
ascribable to no particular cause. I immediately bled him to the 
extent of eight ounces ; the pulse was scarcely weakened by this 
operation ; cataplasms of linseed meal and flour of mustard mixed, 
were applied to the feet, and the cooling drinks were continued. 
10th. — The blood withdrawn was buffy ; the serum scanty ; the patient 
had slept; the pulse was soft and less frequent, and a long breath 
could be drawn without causing cough or any uneasiness in the chest. 
The tongue was still white ; the constipation continued ; the vesicles 
were less numerous ; the sweating still profuse but without heat of 
surface. During the course of the day the patient began to com- 
plain of a deep-seated pain in the hypogastrium ; this was increased by 
pressure and accompanied by frequent calls to make water, with pain 
in the bladder on passing the urine, which was only excreted in very 
small quantity, high coloured, and loaded with salts, — if such an 
inference might be drawn from the amount of deposit let fall in the 
chamber utensil. These new symptoms were met by fomentations 
and emollient cataplasms to the hypogastric region, and by mucilagi- 
nous glysters. Next day almost the whole of the bodily functions 
appeared to be restored to their natural condition ; the sweating was 
transitory and not very copious; no desquamation of the cuticle had 
taken place, and the vesicles were disappearing. The patient took 
some beef-tea with bread in it, during the course of the day. By the 
12th there were no longer any traces of the disease, and on the 15th 
the patient was able to go out and attend to his business, (a) 

(a) Three cases of sudatoria, observed in the Hotel Dieu, during 
the summer, 1842. The following cases of a very rare affection were 
reported, by M. Marrotte, as having appeared in Paris, towards the 
close of the epidemic of typhus fever which had raged in that city. M. 
Honore, in whose wards the patients lay, had never before seen cases 
of this disease ; and M. Rayer, who is well acquainted with the dis- 
order, had never seen it in Paris. 

" Case 1. — A young man, twenty-three years of age, was received 
into the hospital, July 29, complaining of pain in his head, lassitude, 
great prostration, thirst, and drowsiness. His skin was hot, pulse 
frequent, tongue and teeth foul : had had no action of bowels, which 
could only be brought to move by medicine ; no rumbling in the iliac 
fossa. There were none of the lenticular spots which accompanied 
the prevailing epidemic. The skin, though very hot, was neither 
dry nor burning; on the contrary, it was moist. He complained, 
moreover, of an uneasy sensation and feeling of anxiety at the pit 
of the stomach, which led to the administration of an aperient emetic. 

" The present symptoms have lasted for three days. His first indi- 
cations of disease were, general uneasiness and loss of appetite, which 
were not sufficiently pressing to induce him to relinquish his duties. 
Suddenly, in the middle of the day, he was seized with pain in the 



head, and great prostration, which forced him to take to his bed, but 
he had no rigors, nor diarrhoea ; his skin was at the same time covered 
with a moderate, though constant perspiration. 

" For two or three days after admission, the patient continued in the 
state above described, without having been benefited by a bleeding 
from the arm, practised previously to his application at the hospital. 
After this period, the disease assumed all its severity; the prostration 
and drowsiness were more marked ; the perspirations and oppression 
became more intense. The perspirations streamed forth continually 
from the skin, the heat of skin increased, the pulse became stronger 
and more frequent, the oppression was accompanied by cough and 
mucous expectoration, and auscultation discovered mucous rales 
throughout the whole extent of the bronchi. 

" This combination of symptoms persisted in all their force for ten 
or twelve days: at the expiration of this period, the patient felt 
improved. His amendment seemed in some degree to have been 
effected by a change in the position of his bed to a better ventilated 
situation. Under the influence of this change of position, the per- 
spirations diminished, the tongue became soft, moist, and simply 
furred ; the teeth became clean, and the thirst was diminished. 

" On the 25th of August, the patient is progressing; the surface is 
still moist in situations where the skin is naturally perspirable. Vesi- 
cles are dispersed about the neck and trunk, some being filled with 
a milky serum and surrounded by slight areola ; others being transpa- 
rent. The return of appetite is more tardy. 

" Case 2. — A man, upwards of six feet in height, thirty years of age, 
had felt every evening a sensation of feverishness for about twelve 
days ; his appetite failed ; he suffered from thirst ; his skin felt burning 
hot, and he experienced considerable drowsiness. Since his admis- 
sion, the fever has become increased and continued ; his skin is 
covered by a constant perspiration ; he has headache, pain in the left 
side, anxiety, and oppression at the praecordia. 

" In the course of five or six days, the anxiety and oppression have 
assumed an excessive degree of intensity ; he has cough and expecto- 
ration, and mucous rales are very obvious throughout the whole of 
his chest. The perspirations have increased, together with the heat 
of skin, and the hardness and frequency of the pulse. The abdomen 
is distended, the tongue thickly furred ; there are great prostration, 
and perpetual drowsiness. An eruption of red pimples appeared 
upon the neck, and spread thence to the face and trunk ; in two or 
three days these pimples were surmounted by vesicles, containing a 
lactescent fluid, and were followed by successive eruptions of suda- 
mina, chiefly of the phlyctenoid kind, which occupied the vacant 
spaces between the papula?. 

" As the eruption increased and advanced in development, the 
oppression diminished, the pulse became softer, and the abdomen 
diminished in bulk. In this patient, as in the former, the bowels 
were inactive, and required the aid of medicine. His intellectual 
powers were unaffected, and the appetite returned gradually to its 
normal standard during recovery. On the 25th of August he was 
convalescent. 

" Case 3. — A young man, twenty-four years of age, for some time 
past suffering from uneasiness, loss of appetite, and lassitude, for 
which symptoms he was bled from the arm without benefit. He was 
next seized with headache, vomiting, diarrhoea, and perspirations, 
and was forced to take to his bed, where he remained for eight days, 
suffering with perspirations during the whole period. 

"On admission, August 16th, he was in a state of extreme prostra- 
tion ; heaviness was exhibited in his features, his tongue and teeth 
were covered with sordes, the perspirations were general and con- 
tinual, his abdomen was distended, and he suffered from thirst. For 
several days he remained in this state, answering with difficulty the 
questions that were put to him. He had retention of urine, and upon 
the passage of a catheter, a full basin of clear urine was withdrawn. 
In seven or eight days from this time, his state was improved ; the 
stupor has diminished, and the tongue is moist. The perspirations 
are mitigated, and this mitigation became strikingly apparent as soon 
as the patient was removed to a better ventilated situation. They 
have not yet, however, wholly ceased ; the hardness and frequency of 
the pulse have yielded. 

" From this period, amelioration was as speedy as in the former 



Ml 



VESICUL.E. 



.mina. (a) 

Voc&b. Hydroa, Sudamina, 

mina is a title given to minute prominent vesicles, the 
millet-seeds, of n round shape, transparent, and formed by a 
limpid watery fluid effused under various points of the epidermis. 
These small" vesicles occur, without accompanying redness of the 
skin, in the course of many acute and chronic diseases, independently 
of the severity of their general symptoms. 

386. Causes and symptoms. — This peculiar eruption is only ob- 
I in morbid states of the system. It appears most generally in 
dothinenteritis (typhoid fever), in scarlatina, measles, pleuro-pneu- 
monia, and peritonitis, especially in that form of the disease which 
occurs during the puerperal state. I have observed it occurring, 
although very rarely, in diseases of no severity, — such as slight in- 
termittent fevers and trifling affections of the mucous membrane of 
the bowels. 

3S7. Sudamina almost always appear along with, profuse sweating, 
but in the furuncular affection of the bowels (dothinenteritis) I have 
seen the eruption take place without any sensible increase of the cuta- 
neous perspiration. On the other hand, I have occasionally witnessed 
very profuse perspirations without the evolution of sudamina ; among 
the phthisical, and those affected with the sweating miliaria of 1821. 

Sudamina more commonly appear in the course of acute or chronic 
diseases, among females than males, among the youthful than those of 
riper years, and less frequently among the latter than the aged. The 
eruption is more commonly met with during the hotter months ; the 
colder seasons of the year, however, do not prevent its occurrence. 

388. Sudamina may appear on almost every part of the body, but 
occur more generally on those regions where the cuticle is the thinnest 
and most delicate, as on the front of the abdomen and thorax, on the 
neck, groins, and axillae. The eruption very seldom occurs on the skin 
of the back, limbs or face. 

Occasionally the eruption is almost general ; more frequently, how- 
ever, it appears on only one, or but a small number of districts at the 
same time. 

The eruption is never preceded by a sense of tingling in the parts 
it invades. The size of the vesicles is very variable ; some are so 
small as to be barely perceptible to the naked eye, whilst others equal 
a millet-seed in size. The vesicles, which at first sight, might be taken 
for small drops of perspiration, are rounded, globular and prominent, 
and so brilliant and transparent that they seem deposited on the surface 



cases, but the return of appetite was not so marked as is customary 
after typhus fever ; he was not so much emaciated as are patients 
convalescent from the latter disease, but he appears more debilitated. 

" M. Marotte remarks, with regard to these cases, on the exacer- 
bation which took place at the close of the fifth or sixth day ; the 
continuous perspirations which existed at that period both day and 
night ; the intensity of the prostration and drowsiness ; the cutaneous 
eruption which at this period made its appearance, but without being 
critical ; the oppression and anxiety at the pracordia appearing with 
the perspirations ; the protraction of amendment to the term of two 
weeks from invasion ; the continuance of perspirations to the close of 
the third week, and the marked benefit resulting from better air and 
ventilation ; all of which symptoms he looks upon as pathognomic. 

" Contrasting the disease with typhus fever, he recalls the negative 
characters of sudatoria. There was no diarrhoea in the commence- 
ment ; there were no headache, rigors, or vomitings ; the prostration 
of the physical powers is rarely so great ; it is rare that the tongue 
and teeth are so speedily covered with sordes, or that drowsiness is 
so strongly marked. The first week passed away without epistaxis, 
and without lenticular spots. The pulse of sudatoria, again, has 
never the smallness and frequency of the pulse of typhus." Wilson 
(op cit. ) 

(a) M. Rayer very properly separates miliaria, or miliary fever, 
which is often a severe constitutional disease, and sometimes prevails 
epidemically, from sudamina, which is symptomatic and the occasional 
accompaniment of so many different diseases. 



of the skin. Although most generally distinct, they are occasionally 
seen confluent, in which case they form small irregular bulla 1 , similar 
in their colour to that of the skin, around which no redness is per- 
ceived, except in a few extremely rare instances, and then it is only 
at the base of a very small number of the vesications. 

In some cases the vesicles within a few hours after their appearance 
be<rin to fade and grow milky, when they quickly disappear. In others, 
ao-ain, they preserve their perfect transparency and globular form for 
four and twenty hours and even longer ; they then lose their lustre, 
shrivel, and, before the end of the third or fourth day, are no longer 
to be seen. Lastly, it sometimes happens that this eruption runs its 
course more slowly, and does not totally vanish before the seventh or 
eighth day. The vesicles of sudamina rarely burst of themselves ; the 
fluid they contain is usually reabsorbed ; the epidermis is thrown off 
and no trace of their existence is left. Although ruptured by the 
rubbing of the clothes, as frequently happens, they never give rise to 
the formation of scabs. If they be opened a short time after they 
appear, a small smooth and reddish depression is perceived in their 
interior which is effaced in the course of a few minutes. When the 
vesicles have been very numerous or confluent, the cuticle is occa- 
sionally detached in pieces of some magnitude. It even happens 
occasionally that the slightest friction is sufficient to detach it from the 
intervals of skin between the vesicles, thus exposing the naked surface 
of the corion, which is at first of a pale rosy-red hue, but speedily 
acquires a brighter tint. 

When the eruption has disappeared spontaneously, small whitish 
spots are observed to remain, corresponding with the points occupied 
by the vesicles. These marks are speedily effaced. 

The eruption of sudamina usually occurs successively ; but it may 
show itself on several regions at the same time. 

As to the fluid contained in the vesicles of sudamina, it is thin, 
(vaporis instar, Becker,) colourless, inodorous, almost tasteless and 
without viscidity ; it does not redden turnsole paper, and appears 
therefore to differ from the perspiration, which has usually this pro- 
perty. 

389. Diagnosis. It is enough to have seen the eruption of sudamina 
once to recognize it ever afterwards. The touch distinguishes it in an 
instant from drops of sweat standing on the surface. It is never pre- 
ceded by redness of the skin, nor by pruritus, like eczema, hydrargyria, 
and the vesicles which follow exposure to the burning rays of the sun, 
(eczema solare,) with which it has been, by mistake, confounded. The 
eruption of sudamina is not preceded, and still less is it accompanied 
by the febrile symptoms which are observed along with the sweating 
miliaria, and the other eruptive fevers. Nevertheless, puerperal peri- 
tonitis attended with an eruption of sudamina (which was improperly 
designated under the title of miliary fever) was long and is still occa- 
sionally confounded with the epidemic miliaris sudatoria or sweating 
disease of Picardy. 

390. Prognosis. — Sudamina, and the sweating which accompanies 
the eruption, have appeared to be critical under certain circumstances. 
This eruption, however, in the great majority of instances, does not 
seem to have any influence on the progress of those diseases in the 
course of which it occurs ; it is a phenomenon the more and nothing 
beyond. 

Several writers have looked on the eruption of sudamina as an 
unfavourable symptom ; and it is undeniable, that it happens more 
commonly in severe diseases than in those that are unattended with 
danger. 

Historical JVotices of the Disease. 

391. Forestus 1 has specified the principal characters of sudamina ; 
the definition of Blancardus 2 appears applicable to lichen and eczema 
solare. Under the title of hydroa, Jos. Frank 3 has comprised and 
described the lichen tropicus, herpes labialis, and the peculiar erup- 
tion of typhoid fevers : this is more than mere confusion of nomen- 
clature. 

M. Barbie du Bocage 4 has detailed an excellent account of the 

i Forestus. Lib. ii. obs. 139. 

2 Blancardi Lexicon. Art. hydroa. 

3 Frank (Jos.). Praxeos univ. medic, praecepta, 8vo., t. iii. p. 9. 

* Barbie du Bocage (L.). De l'eruption des sudamina, 4to. Paris, 1828. 



ARTIFICIAL VESICUL^. 



145 



characters of sudamina. Andral 1 has given a case in which the vesi- 
cles were as large as bullae. M. Louis* has seen the eruption accom- 
panying phthisis and dothinenteritis ; I have, myself, met with it, I 
may say, in all the diseases during the course of which it is liable to 
occur; and if I give no particular instance of it here, it is because 
the eruption is, in fact, a symptom common to many maladies, and of 
no great importance in itself. 



ARTIFICIAL VESICULAR ERUPTIONS. 

392. The following cases seem to me calculated to convey some 
information upon those artificial vesicular eruptions, the speciality of 
whose several causes characterizes them individually, and the short 
duration and slightness of which, separate them no less distinctly 
from the whole of the other eruptions that appear under the same ele- 
mentary form. 

Case LIX. — Vesicular and papular eruption produced by exposure 
to the sun's rays (eczema solare, Willan). Mr. G. having, on the 20th 
of July, 1821, bathed in the Seine at mid-day, during excessively 
hot weather, got scorched with the sun. In the evening, the nape 
of the neck, the back, loins, shoulders, and inner parts of the arms, 
became of a scarlet-red, and continued extremely itchy during the 
whole of the night. Next morning an immense crop of vesicles 
could be distinguished by the naked eye, and still better by the mag- 
nifier, covering the red and inflamed surfaces of the skin. These 
vesicles were of the size of the head of the smallest pin that is made, 
and contained a small drop of transparent serum, the presence of 
which could be readily demonstrated by piercing them with a fine 
needle. Dispersed among these innumerable vesicles, there were a 
certain number of solid elevations similar to the papulae of lichen, 
which contained no fluid. The eruption was not accompanied with 
fever, nor with any other derangement of the functions generally ; 
{cold-bath, sherbet of tartaric acid, antiphlogistic regiment) During 
the next and following day, there was a gradual abatement of the red- 
ness of skin, and the vesicles and papulae were less distinct than they 
had been. The same plan of treatment was continued. Three days 
afterwards, a slight desquamation took place from the back, the pru- 
ritus ceased completely, .and the patient felt perfectly recovered. 4 

Case LX. — Vesicles produced by exposure to the sun. M * * *, thirty- 
two years of age, somewhat corpulent, and having a fine skin, after 
the excessive heat that was felt on the 10th and 11th of June, 1825, 
experienced a considerable degree of itching on the backs of the 
hands and between the fingers, occasioned by elevations, on the 
nature of which I was consulted. The skin in these places, which 
were rough to the touch, presented an immense quantity of mi- 
nute vesicles, the greater number of the size of a pin's head, and a 
few a little larger. These vesicles were very irregularly scattered 
over the parts mentioned. The skin did not appear inflamed, except 
in those situations where the patient had scratched himself; and in 
these the vesicles were succeeded by small yellow scabs. The hands 
were swelled and red, as they usually appear during the heat of 
summer. I recommended M. to endure the pruritus without scratch- 
ing, to bathe the hands frequently with cold water, and not to expose 
himself to the rays of the sun, but to wear light muslin gloves. The 
vesicles continued five or six days longer ; the itchiness then dimin- 
ished, and on the 23d of June, no traces remained of this slight 
inflammation. Small circular laminae of the epidermis were subse- 
quently detached from several points which had been the seat of 
vesicles. 3 

Case LXI. — Artificial vesicles from the application of a Burgundy 
pitch-plaster. Plasters of Burgundy pitch frequently excite a vesiculo- 
pustular inflammation, when they are kept applied for too long a time. 
M. D * * *, thirty-eight years of age, of a stout and plethoric habit, 
consulted me on account of a lumbago with which he had been 
affected several times. I recommended the use of purgative glysters, 

' Andral. Clinique medicale, t. i. obs. s. p. 54. 

2 Louis. Rech. anat. palh. sur la phlhisie, 870., p. 212. Paris, 1825.— Recherches 
sur la fievre typhoide, 8vo. t. ii. p. 244. Paris, 1829. 

s Consult. Ehrenberg, on the hydroarestivum JBgyptiacum (Bulletin des sc. med. 
de Ferussac, t. xiii. p. 232). 
37 



and the application of a Burgundy pitch-plaster to the loins. Three 
days afterwards, M. D * * * summoned me to his assistance in order- 
to free him from his plaster, which had caused so much itching that 
he had not closed his eyes during the preceding night. On removing 
the plaster, I perceived that the whole skin of the loins was covered 
with an infinity of small, transparent and but slightly prominent vesi- 
cles. The skin in this situation showed nothing of a general erythe- 
matous blush ; it was only here and there it appeared a little redder 
than in the natural state. The inflamed skin was cleansed with a 
little oil, and covered with compresses dipped in the mucilaginous 
decoction of althaea and poppy-heads. Eight days afterwards the 
lumbago and vesicles were both completely cured. 

Case LXII. — Eruption similar to the eczema rubrum from the in • 
ternal use of cubebs pepper. N * * *, thirty-eight years of age, con- 
tracted a clap in the month of March, 1829. After a due interval 
had elapsed, I commenced administering the cubebs pepper in the 
dose of a drachm every day. After four doses had been taken, the 
discharge was considerably diminished, and no longer accompanied 
with pain. After the sixth dose, N * * * felt the whole skin of hi-> 
body become excessively itchy. This sensation was speedily followed 
by an eruption, the size of pin's heads, and not very prominent, 
which appeared principally about the instep, and over the wrists 
and knees, situations where the pruritus had been more particularly 
troublesome. The skin was hot, red and swelled. The eruption 
seemed to differ in nothing from that which characterizes eczema 
rubrum: vesicles were very distinct under the magnifier, and when 
pricked with a fine needle, a small drop of transparent serum escaped 
from their interior. The affection of the skin was neither attended 
with fever, nor with any other evident functional disturbance. Com- 
presses wetted with soothing decoctions, applied to the affected parts, 
were found to increase the pruritus, and were consequently discon- 
tinued. Keeping the parts exposed, and sponging them repeatedly 
with cold water, gave speedy and great relief. The inflammation 
abated in the course of a day or two ; a few of the vesicles became 
covered with small yellow scabs; in general, however, they were 
only followed by desquamation of the cuticle, the fluid they contained 
being in all probability reabsorbed. Within eight days the patient 
was well. 

Case LXIII. — Vesicular and pustular eruption from the external ap ■ 
plication of the oil of the croton tiglium. I. M * * *, aged sixty-four, 
was admitted into the hopital de la Pitie, on the 29th of February, 
on account of a gastro-enteritis. With a view of relieving the con- 
stipation of the bowels, thirty-two drops of the croton oil were 
directed to be rubbed in upon the abdomen. This application was 
followed by alvine evacuations, and by a vesicular eruption of tha 
skin, the cause of which was at first overlooked. On the morning 
of the 8th, the face of the patient looked puffed, and the skin of the 
forehead and cheeks was of a pale red colour, which disappeared ou. 
pressure. Towards the alae of the nose and over the left cheek, a 
number of excessively minute whitish vesicles were discovered. 9th. 
Face swelled, and redder than ever; and the cheeks, lips, chin and 
nose, were now distinctly seen to be covered with small whitish 
vesicles, very much crowded together. These were prominent, and 
without areolae. The eyelids were slightly cedematous. The skin of 
the abdomen was covered with a vast number of vesicles of the same 
form, but larger and more elevated. These were white, filled with 
a limpid serous fluid. An eruption of the same kind was observed 
on the forearms. 11th. Desquamation had taken place around the 
mouth and upon the lips ; the redness and puffing of the face had 
disappeared. 12th. Desquamation going on over every part of the 
face and abdomen that had been affected. Termination of the erup- 
tion. The treatment of the affection of the digestive organs was 
continued. 



IW 



PUSTULE. 



II. PUSTULE. 

PUSTULAR INFLAMMATIONS. 
Toeab. rimple, Pustule, Psydracia, Phlyzuria. 

393. The pustular inflammations of the skin are characterized by 
the evolution of pustules; that is to say, by circumscribed pimples 
from half to three-quarters of a line in diameter, often surrounded at 
their base by an inflamed areola, and formed at their acme or height 
by a purulent, non-serous fluid, deposited within a follicle, or between 
the outer surface of the corion and the epidermic layers. Pustules 
terminate variously, by the reabsorption or the desiccation of their 
fluid contents, in the latter of which cases, scabs are formed by ulcera- 
tion, ami bj tuberculated induration. Their presence is subsequently 
indicated by marks, and frequently by cicatrices. 

394. Seven forms of pustular inflammation of the skin are reck- 
oned ; variola and its modifications {varicella); vaccinia and its 
modifications (vaccinellee) ; acne; rosacea; mentagra or sycosis ; im- 
petigo ; favus ; and ecthyma. To these must be added artificial 
pustules, and pustular syphilis, which I have, however, seen reason 
to associate with a different order. 

I have already observed, that in the arrangement of Bateman, 
scabies was erroneously placed among the pustular diseases, and I 
shall now give my motives for grouping together variola and the 
different varieties of k varicella, three of which are decidedly pustular 
in their nature ; vaccinia and the vaccinellae I have also felt obliged 
to class with pustules and not with vesicles. Pustules, in fact, differ 
from vesicles, not only in the circumstance of their containing pus or 
a non-serous fluid at the period of their height, but farther by the 
depth and intensity of the inflammation attending them. The latter 
character has appeared to me of so much the more importance as the 
serum of almost all vesicles becomes turbid, and occasionally even 
purulent at the time of their desiccation, whilst the fluid contained in 
several pustules is unquestionably serous at the outset. Willan and 
Bateman are both evidently mistaken when they maintain that rosacea 
and mentagra begin by tuberculations, for these diseases are undoubt- 
edly pustular at first. Of the tineas and porrigos I have only preserved 
favus (porrigo lupinosa, and porrigo scutulata), having for several 
years past, 1 perceived that the other eruptions of the hairy scalp were 
mere varieties, owing to peculiarities in the structure of the surfaces 
affected, of eczema, impetigo, psoriasis, &c. 

395. Viewing pustules in a general manner, Willan conceived that 
they might be reduced to two principal forms. And we do, indeed, 
observe that some are usually of a large size, seated on an indurated 
circular and inflamed base, and terminate in a hard thick scab, gene- 
rally of a brown or brownish colour: such are the pustules of variola, 
of ecthyma and of vaccinia. These are the phlyzacious pustules of 
Willan. Others, again, the psydracious pustules of the same author, 
are small in size, often irregularly circumscribed, scattered or arranged 
in clusters, and terminate in crusts of various forms (the pustules of 
impetigo), or by tuberculated indurations (the pustules of rosacea, 
acne and sycosis) ; but these various species of pustules present other 
differences in their modes of development, and in their appearances, 
which render this distinction of Willan altogether of secondary im- 
portance. 

396. Among the pustular inflammations some, as acne, rosacea and 
mentagra, are partial, that is to say, they never appear over the whole 
surface of the body ; others, such as variola, favus and ecthyma, either 
appear on or may extend to every region of the skin. 

Pustular diseases are occasionally accompanied by inflammatory 
affections of the mucous membranes. But the variolous eruptions 
are the only ones in which these membranes actually exhibit in those 
places where they are provided with an epithelium, true pustules 
analogous to those which are perceived on the skin. 

397. Each pustular inflammation possesses peculiar characters 
which are due to its seat, its form, its extent, the amount of inflam- 
mation accompanying the pustules, and the mode of their eruption, 

' Levain. Essai sur l'eczema, p. 19, 4to. Paris, 1830. 



as this is simultaneous or successive. Some pustules, as those of 
rosacea, are flattened ; others, as those of small-pox, are acuminated 
in their commencement and umbilicated or depressed in their centre 
at the acme of their development, and so forth. The fluid which 
pustules contain, usually opaque and white at their height, is trans- 
parent and viscid at first in vaccinia, and pasty in variola. This fluid 
is generally deposited in a single cavity ; in vaccinia, however, it is 
included in a multitude of cells. The matter of the pustules of variola, 
vaccinia and favus is contagious. 

398. The greater number of pustules dry off in the form of scabs 
(impetigo, variola, vaccinia, &c.) ; some of them decline at times 
into true ' ulcers, (ecthyma luridum and the pustules of syphilitic 
orio-in) ; and others frequently degenerate into tubercles (acne, rosacea, 
mentagra). 

The scabs produced by the drying up of pustules, present secondary 
characters, which demand attention. Those of favus are yellow and 
cup-shaped ; those of impetigo are prominent, yellowish, greenish or 
brownish in colour (impetigo figurata), and granular (impetigo of the 
scalp), or stalactitic in form. The characters supplied by the chemi- 
cal analysis of scabs are of but little interest; and as scabs and 
incrustations are only formed during the latter stages of pustular 
inflammations, it is easy to conceive that distinctions based upon 
such grounds must be extremely vague and imperfect. 

The state of the skin beneath scabs, ought to be so much the more 
carefully investigated in the diverse species of pustular inflamma- 
tions, as the incrustations may be accidentally altered, having been 
removed entirely, or in part, by washes, cataplasms, and other topical 
applications. The measure and amount of these hidden alterations 
of the skin, the number, the form and the appearance of the erythe- 
matous patches, of the sores, and of the tuberculations which follow 
pustular inflammations, ought to be studied and detailed with the 
most scrupulous precision. Even the cicatrices, when they occur, 
are occasionally found to be stamps characteristic of the disease which 
has produced them. 

399. The greater number of the pustular inflammations may, upon 
occasion, be observed occurring at the same time, and complicating 
one another, without their respective courses being in any way influ- 
enced by this circumstance. Others, on the contrary, such as small- 
pox and cow-pock, are never developed simultaneously without being 
modified ; they are even mutually exclusive of each other in the ma- 
jority of cases in which one of them has gone regularly through its 
several stages. Pustular inflammations are also occasionally compli- 
cated with cutaneous affections of a different order. Lastly, pustular 
eruptions are frequently preceded or attended by inflammation in a 
greater or less'degree of the mucous membranes; and those of variola 
especially, and at times even of varicella and vaccinia, are ushered 
in by other functional derangements of various degrees of severity. 

400. The duration of the pustular inflammation is extremely vari- 
ous ; some of them, as variola, varicella and vaccinia, are regularly 
acute and rapid in their course; favus, rosacea, mentagra, &c, areas 
constantly chronic in their nature. 

401. Of all the different forms of cutaneous inflammation, vesicles 
are the most nearly allied to pustules. The latter differ from the 
former by being evidently accompanied with a higher degree of in- 
flammation, and more frequently followed by cicatrices and tubercu- 
lated indurations. Pustules, at their height, are easily distinguishable 
from the exanthematous, papular, tubercular, squamous and other 
forms of inflammation ; but this is not the case at every period of 
their development ; and in some cases it would even be impossible 
to say, from a simple inspection of the eruption, and without taking 
into account preceding symptoms, the rapidity or tardiness of its 
evolution and so forth, whether the disease was to be pustular or not 
in its future stages. The spots or small red elevations by which the 
greater number of pustular diseases are announced are not character- 
istic ; pustules in themselves are in fact only completely proclaimed 
at the summum of their development; several, as those of vaccinia 
and of varicella, begin by small papular elevations of the skin, the 
summits of which are soon filled with a limpid fluid like that of vesi- 
cles, and only ultimately acquire the character of pustules. Lastly, 
the scabs, erythematous spots, ulcers, and indurations that succeed 
pustules, have not regularly and in every species, external characters 



VARIOLA. 



147 



sufficiently striking to admit of a diagnosis being established after 
their mere appearances, (a) 

(a) Mr. Wilson includes some of the pustulce of Willan. M. Rayer 
under the head of Suppurative inflammation of the Dermis. His 
introductory remarks on the occasion come in appropriately in this 
place. 

" Under the influence of a degree of inflammation of the dermis, 
for the most part greater, at least at its commencement, than that 
which exists in the effusive group of diseases, the inflamed dermis 
gives rise to the formation of pus ; the pus occupying the surface of 
the dermis, and producing an elevation of the epidermis to a limited 
extent. This irregularity of the surface of the skin — namely, an ele- 
vation of the epidermis consequent on the presence of pus, is termed 
a pustule, and this is the only accurate sense in which that term can 
be employed. There is a wide distinction between a vesicle and a 
pustule, when these two pathological forms present their typical 
characters; but it not unfrequently happens, that in consequence of a 
reparative action set up in the vesicle, pus is produced upon its 
dermic base, and mingling with the serum, constitutes a sero-purulent, 
and subsequently, a purulent or pustular vesicle. In such a case it 
is necessary to remember that a true pustule contains pus from the 
first moment of its formation, and by this circumstance is essentially 
distinguished from a vesicle. 

" It is requisite, at the outset of our study of cutaneous diseases, to 
be most precise in our definitions, and to draw as broad a line as 
possible between the various pathological forms which we are desirous 
of characterizing. Scarcely any word has been used more loosely 
than the term pustule in medical nomenclature. At one time it was 
employed to signify a papula, at another a vesicle, and it was not 
until the time of the Linnaeus of cutaneous pathology, that the proper 
application of the term was truly made. Willan employed it, with 
the characters above stated, as the type of his fifth order — pustulce; 
and in this sense it has been subsequently adopted by successive 
dermatologists. 

" The diseases which I propose to consider under the definition 
above given, are two in number — namely, 

Impetigo, 
Ecthyma. 

" The order pustulge of Willan embraces five diseases, two of 
which, had he lived at the present time, would, I am convinced, have 
been excluded by himself — namely, porrigo and scabies. The genus 
porrigo of Willan contains diseases of the most opposite kind, and 
has been the source of much confusion, so much, indeed, that it 
would be well that the term should, for the future, become obsolete 
and forgotten. What relates to true porrigo will be found in this 
classification under the designation, favus. Scabies, again, is a dis- 
ease possessing several elementary forms, of which both vesicles and 
pustules are accidental, and only occasionally present ; the pustules, 
when they exist, belonging to ecthyma. Variola, as placed by Willan 
in the order pustulse, is forcibly torn from all its natural affinities, and 
for this reason I have thought it correct to transfer the genus to the 
group of eruptive fevers. Rayer admits no less than ten genera of 
pustular inflammations, for four of which he is indebted to variola — 
namely, variola, varicella, vaccinia, and vaccinella. There could 
have been no objection to thus establishing a distinct group of vario- 
lous affections — indeed, some benefit might have flowed from such an 
arrangement — but the possible advantages are immediately destroyed 
by the companionship with which he has leagued them. Thus, from 
the highly inflammatory and contagious fever of variola, we pass on 
immediately to three diseases of the sebaceous glands — namely, 
rosacea, acne, and sycosis ; next in order follows impetigo, then favus, 
a peculiar disease of the hair follicles, and lastly, ecthyma. 

" The genera impetigo and ecthyma constitute the two essential 
forms of pustules indicated by Willan — namely, psydracia and phly- 
zacia, the former being a psydracious (^vxpa, vSpaxia, frigidae guttulae) 
pustule — that is, ' a small pustule, often irregularly circumscribed, 
producing but a slight elevation of the cuticle, and terminating in a 
laminated scab. Many of the psydracia usually appear together, and 
become confluent; and, after the discharge of pus, they pour out a 
thin, watery humour, which frequently forms an irregular incrusta- 



VARIOLiE. VARIOLOUS ERUPTIONS. 
Vocab. Variola, Varioloid, Varicella, Small-pox, Chicken-pox, $c. 

402. Under the name of variolous eruptions, I comprise several 
vesiculo-pustular, acute and contagious inflammations of the skin, 
which the strong resemblance they bear to each other in their mode 
of development, in their course, and especially in their constant asso- 
ciation, when small-pox appears as an epidemic, as well as their 
reproduction mutually, the one by the other, authorize us in consider- 
ing as effects of one and the same cause. 

These eruptions have, in truth, a greater number of points of re- 
semblance and of natural connection than many other diseases, the 
identity of whose origin has never been disputed, — than syphilitic 
affections for instance. 

403. The variolous eruptions may be arranged under two series : 
the one comprising the pure and legitimate variola which give the 
type to the genus ; the other including the varicella, which appear to 
be modifications of the former. This second series may be sub- 
divided into five principal forms, most usually met with mingled 
together; these are: — 

1st. The pustular umbilicated varicella or varioloid ; 

2d. The 'pustular conoidal varicella ; 

3d. The pustular globose varicella ; 

4th. The papular varicella ; and 

5th. The vesicula varicella or chicken-pox. 

404. The affinity of these affections, or their origin from the same 
source, is demonstrated by the following facts : 

1. During the prevalence of a variolous epidemic those individuals 
who have never had either small-pox or cow-pox, are almost inevita- 
bly attacked with the pure or legitimate variola, characterized by an 
eruption of umbilicated pustules and the occurrence of secondary fever; 
other individuals again, and these are such as have either had small- 
pox naturally or by inoculation, or such as have been vaccinated, show 
the umbilicated pustules of variola, but at the end of the seventh or 
eighth day there neither occurs any period of suppuration nor any 
secondary fever (varioloid); in some others, independently of this 
change in the current and duration of the disease, the form and struc- 
ture of the pustules are modified (pustular conoidal, and globose vari- 
cella) ; in others still, the appearance of the eruption is even farther 
changed, and instead of pustules we have papulae and true vesicles 
thrown out on the skin (papular and vesicular varicella or chicken- 
pox) ; lastly, in a very small number the disease is proclaimed by the 
same general symptoms, and advances without any eruption (variolous 
fever). This manifestation, or rather this association of variola and 
of the varioloid and other varicellar eruptions, during the prevalence 
of a variolous epidemic, was particularly observed in Scotland in 
1818; in England in 1822-23-24 and 25 ; at Philadelphia in 1824; 
at Montpellier in 1819 ; at Paris in 1825 ; at Marseilles in 1828, and 
in many other places. 

In the epidemic of Paris, in 1824, variola prevailed during July 
and August, and varioloid and varicella during September. In the 
attack of 1825, cases of varioloid and varicella were observed during 
the whole continuance of the epidemic, but were more particularly 
abundant in the month of October when its virulence had abated. 
One single cause, the epidemic influence, gave occasion to these vari- 
ous eruptions ; they were observed in the same districts, the same 
streets, the same houses ; if the disease broke out in a large family, 



tion.' The latter, a phlyzacious (^xv^iv, to be hot) pustule — that is, 
one, ' commonly of a large size, raised on a hard circular base, of a 
vivid red colour, and succeeded by a thick, hard, dark-coloured 
scab.' The achor and the favus of Willan are no longer considered 
as pustules. 

" The transition, which I have already had occasion to remark, 
from erythema to pemphigus, and from rupia to herpes, may also be 
extended to pustulous affections. Eczema, in certain of its forms — as 
in the impetiginous variety — is seen gradually merging into impetigo, 
while ecthyma is farthest removed, both in position and characters, 
from the vesicular group." 



148 



PUSTULE. 



one was attacked with variola, others with varioloid, and others with 
\ esicular varicella. 

2. A varicellar epidemic is never observed to occur without cases 
of variola and of varioloid; nor a variolous epidemic ever to prevail 
without cases of varioloid and varicella making their appearance; all 
arc effects of the same medical constitution. As to the relative pro- 
portion of the different species of eruption, it would be difficult to 
come to any precise conclusion at present. The French practitioners 
at first, only recognized two species of variolous eruption — variola 
and varicella ; whilst in England, two varieties of varicella — chicken- 
pox and swine-pox, and subsequently several others, as horn-pox, 
hives, &C., were described. Odier and other observers, without 
fixing the precise number, have admitted several kinds of varicella ; 
others, Lavit and Berard in particular, have regarded these diseases 
as anomalous variola ; lastly, it is only of late that another variety of 
varicella, more akin to legitimate variola, than any other eruption, — 
the varioloid, has been accurately described. Although, then, the 
proportions of these different species of eruption cannot be estimated 
in any even of the more recent variolous epidemics, their association, 
and their development under the influence of the same cause, are not 
the less incontestable. 

3. Variolous epidemics are occasionally varicellar at their begin- 
ning and termination, and truly variolous between these periods. 

4. In a single individual attacked with true variola, we occasion- 
ally perceive the whole of the varieties of form and appearance which 
are ever presented by the variolous eruption, to wit: umbilicated, 
globular, and conoidal pustules, papular rashes, and vesicles. 

5. The inoculation of variolous matter has occasionally given rise 
to the evolution of varicella, 1 that is to say, to an eruption, the natural 
cure of which took place on the eighth or ninth day, without second- 
ary fever. 

G. As to vesicular, varicella, or chicken-pox, the truly variolous 
nature of which has been most keenly contested, Dr.* Thomson 
has demonstrated from facts, on the one hand, that healthy persons 
brought into contact with individuals labouring under this form of 
disease, have caught the true small-pox; and, on the other, that ex- 
posure to the contagion of variola, has given occasion to the deve- 
lopment of chicken-pox. 

7. With regard to the symptoms in variola, varioloid and the other 
varicella?, the analogy is complete in every particular, during the 
periods of the incubation and of the development of the eruption. 
And we see, in fact, that if the pustules of a variolous eruption beo-in 
to dry up from the fifth to the sixth day, the greater number of practi- 
tioners will style the disease varicella; if they do not begin to decline 
before the seventh or eighth day, the disease will be pronounced a 
varioloid ; and if they continue in a suppurating state for some days 
longer the disease will be entitled variola; the principal difference 
evidently lies in the longer or shorter duration of the disease. But 
this is no essential difference ; for we see that confluent variola, dis- 
tinct variola, and inoculated variola, have not all the same course 
nor especially the same periods, and yet they are very certainly of 
the same nature, seeing that they readily spring the one from 'the 
other. 

8. To conclude, variola or true small-pox, the varioloid or modified 
small-pox, and the varicellar eruptions— chicken-pox, horn-pox, &c. 
are the varied effects of the same cause ; for under certain conditions 
they may all be seen arising the one from the other. 2 

405. Nevertheless, many writers insist on separating several of 
these eruptions from variola. They support their views by statements 
and facts, of which I shall give a summary. 

1. During the prevalence of a variolous epidemic, it is extremely 
difficult to ascertain precisely whether the development of this affec- 

I .rocuV;d M v;rv a sirh 1 , 1 .r aS , rep0r(ed u that , hy inoculatin S ™* the virus of variola, he 

av leann' °nn !l\, P ,lon i wlthoul fe ™r, which completely dried off on the eighth 

Journ vol r, C ' Ca ' nc "- Ex P- on variolous inoculation," Edin. Med. and Surg. 

cnnr e Vbt l he^ P h e L?: Z ° l - U \ and / ra,entin also describe an inoculated varioll, 

of he varicel ™ Tn&£n£ ,' dUrali ° n ° f Which is precisel - v ,he same as tha 
I SSTteanTwh.. lnocala t'on, p. 223, 8vo. Paris, an. viii. 

^J^JS^'JSj^^^^^'S^ fact ,„ support of this 

of Stoll, copies of which I have nof been abfe?n^ I0 S °f R " ' and ln . a work 

spunarum ex verarum pure onus Hal* S 9 V° s^nT 5 " V- DlSS - V.™ '™ 

Beobach.ungskuns. (vaViote spuria veram prod~u" :en L} ^ ^ medlclnlschen 



tion in an individual brought into contact with another labouring 
under varicella, be the effect of the communication, rather than Of 
the epidemic influence which then engenders the disease on every 
side. 

2. Vesicular varicella is not transmissible by inoculation, and is 
never observed giving rise to variola. 

3. Those who believe varicella to be contagious, have confounded 
this affection with the varioloid, or modified variola. 

4. Varicella occurs among those who have never been vaccinated 
and who have never had small-pox ; it cannot consequently be viewed 
as a variola modified by the previous existence either of this disease 
or of cow-pox. 

5. Vaccination practised a short time after the disappearance of 
varicella, runs its course in the most regular manner ; a circumstance 
which never happens when vaccination is performed after small-pox. 

6. Variola often prevails epidemically, without being accompanied 
by varicella ; and, on the contrary, this last affection may reign as an 
epidemic without being attended with small-pox. Thus, between 1810 
and 1823, no cases of small-pox were observed at Copenhagen, and 
yet Dr. MoehP informs us, that varicella appeared there almost every 
season. 

7. Lastly, the characters of the eruption, and the symptoms of vari- 
cella differ essentially from those of variola. 

406. I shall discuss these objections one by one. 

1. It is not only during the epidemic prevalence of a variolous dis- 
ease, that varicella or chicken-pox has been observed to give rise to 
variola ; but under other circumstances which render the fact more 
conclusive and altogether without reply : " no case of small-pox had 
occurred in this town (Kirriemuir) for nine years, till last winter; 
when an idle boy, who was in the habit of wandering about the 
country, happened to be at a house where some of the inmates were 
said to be ill of the small-pox. He himself had been vaccinated some 
few years before. On his return home he was seized with febrile 
symptoms, and confined two or three days to his bed, when an erup- 
tion similar to chicken-pox, made its appearance. Immediately the 
fever abated, and in a few days more he left his bed and attended a 
cattle market, half a mile distant from the town, without any bad 
consequences. About a week afterwards one of his master's children 
was taken ill, and went through the regular stages of small-pox in a 
mild manner; then a second, similarly; a third suffered in a very 
alarming degree from the confluent kind ; a fourth worse than the two 
first, and the youngest, of eight months old, had what, if the other 
cases had not occurred, I should without hesitation have called 
chicken-pox, for there was little or no fever, the pustules were filled 
with a watery fluid, which was not converted into the purulent 
appearance of small-pox. None of these children had undergone 
vaccination." 4 

2. The second objection is not better founded : several experiments 
prove incontestably that chicken-pox may be transmitted by inocu- 
lation. 5 It is true, indeed, that the inoculation of the matter of the 

» pe varioloidibus et varicellis, 8vo. Hafn., 1827.— Bullet, des sc. med. de Feruss. 
t. xin. p. 47. 

* Letter of Mr. John Malloch, Surgeon, to Dr. John Thomson, in his account of the 
varioloid epidemic, 8vo. Lond. 1820. 

5 The results of the experiments made up to the present time, upon the inoculation 
ol the varicellas may be arranged under three heads:— 

1. The first includes those cases in which the inoculation was without effect, and 
these are the most numerous. Brasdor in reference to two children (Anc. Journ. de 
medecine, t. xhx p. 308). Freteau, also in reference to two children (Journ. de med. 
et dechir. par Corvisart, &c, t. ii. 1801). Thouret experiments on five children 
(Journ. gen. de medecine, t. xi. p. 132). Valentin (Journ. de midec. t. xiii.) The 
vaccine committee of France, in its report for the years 1806 and 1807; Bremer 

SmiftPP^fP ' "V ed - £ r £ ah £» Ung ' 1801 ' P- 307 ) S Cosier, in report of vaccine 
committee of France for 1813; Fontainelles in his descrip. do lk vaccinequi a regne 




IKriS wh ,°m these results are borrowed, thirteen fruitless experiments 
(in Allgem. med. annalen des xix. Jahrhunderts, June, 1828, p. 721). 
eruJl e - Se cTJ^ Ti T ,h ° Se ca l es in Which inoc " la li°n ™ followed by a local 
L P ion'd a 8n^ k M de t Cnptl0n havebeen recorded by Willan (on vaccination, 
Thomson's TcV^I i Fo "| anei11 ^ (op. cit.) in two children; by M'Inlosh (in 
HessT(Toc cT) ' ' P> 3) ' ° n ,W ° Children: and lhree cas ^ s are reported by 



VARIOLA. 



149 



chicken-pox never communicates variola ; but this circumstance does 
not annul the preceding fact, in which the inoculation is performed 
in another way ; besides, the serous fluid of the pustules of variola 
not yet arrived at their height, when inoculated, does not always 
communicate small-pox, and this fact does not destroy their truly 
variolous nature, which even at this period is incontestable. More- 
over, is it demonstrated that the fluids of the conoidal and globular 
pustules, or of the vesicles which are observed on some parts of the 
surface of almost every individual labouring under small-pox, com- 
municate or transmit this disease with the same energy as the matter 
of the umbilicated pustules ? 

3. To say that those who consider vesicular varicella or chicken- 
pox to be contagious, have mistaken this disease for the varioloid, is to 
dispute the contagious nature of the chicken-pox, a fact experiment- 
ally proved, and gratuitously to suppose a serious error in diagnosis. 

4. If varicella appear in persons who have never been vaccinated, 
this fact is not more extraordinary than that of the well-attested 
development of the varioloid, the variolous nature of which is not 
disputed, among individuals who have neither been vaccinated nor 
inoculated, nor had the natural small-pox. 

5. Vaccination performed after chicken-pox, is undoubtedly most 
generally followed by regular cow-pox ; but is it well ascertained that 
those who have had chicken-pox contract cow-pox and small-pox as 
readily as those who have never had this disease? During a vario- 
lous epidemic, individuals attacked with varicella rarely catch the 
small-pox ; what is the reason of this ? 

On the other hand, it is incorrect to say that vaccination can never 
be developed in an individual who has had small-pox or varioloid. 

6. What inference can be drawn from the fact of the course of 
varicella being always the same, whether the disease happen before 
or after the small-pox ? Is not the course of the inoculated varioloid, 
or of the varioloid contracted by an individual during a variolous 
epidemic who has neither had small-pox nor cow-pox, the same as 
that of the varioloids observed among the vaccinated ? 

7. I deny, for my part, positively, that variola often prevails epide- 
mically without being accompanied by varicella. As to those vari- 
cellar epidemics, independent of the cause of variola or of varioloid, 
which are admitted by Eichhorn 1 and several other authors, I do not 
remember to have met with a single well-attested instance of such an 
occurrence ; the whole that are upon record have been observed 
during the prevalance of variolous medical constitutions. 2 

During the varicellar epidemic which prevailed in the Norwegian 
bailiwick of Smaalennen, in 1819, Dr. Hoist 3 observed that the dis- 
ease occurred both among those who had had small-pox and who 
had been vaccinated ; about the same period a variolous epidemic 
broke out in the country around Christiana; in the epidemic of 
Milhau, 4 variola prevailed conjointly with varicella, and this con- 
nection has been ascertained to subsist in a very great number of 
variolous epidemics. 

8. To say that the symptoms of varicella are essentially different 
from those of variola is absurd, inasmuch as the same eruption in a 
multitude of cases 5 has been considered as varicellar by some, and 
as variolous by others. 

3. The inoculation of varicella lymph, has produced a general eruption in those 
cases related by Dimsdale (on inoculation, Samml. auserles. Abhand. Bd. vii.) by 
Mumsen (Acta Hafniensia, vol. iii. p. 33); by Heim (loc. cit., and in Horn's archiv., 
Jan. and Feb., 1825); by Salmon and Willan, in the work of the latter on vaccination ; 
by Fontaneilles (descript. de la varicelle qui a regne epidemiquement a Milhau, 
8vo. Montpel., 1818, p. 81); by Dr. Thomson (an acct., &c, p. 113); by Carmichael 
(loc. cit.) and by Hesse, in a case which he details in the publication already men- 
tioned. 

' Eichhorn (H.). Ueber die Behand. und verhfitung der contagioes fieberhaften 
Exantheme, 8vo. 'Berl. 1831, p. 437. 

2 Thus in the varicellar epidemic of Copenhagen, described by Moehl, if no cases 
of variola were seen, many of varioloid were encountered. The varicellar epidemic, 
whose history is related by Mr. Barnes, was preceded several months by legitimate 
variola ; and it is not shown that cases of varioloid were not observed at the same 
time with chicken-pox (see vesicular varicella). 

3 Bulletin des Sciences Medicales de Ferussac, t. xiii. p. 46. 

* Fontaneilles. Description de la varicelle qui a regne epidemiquement et con- 
jointment avec la variole a. Milhau (Aveyron) en 1817, 8vo. Monlpellier, 1818. Vide 
also Valentin. Epid. varioleuse et pseudo-varioleuse (Arch, gener. de medec., t. vii. 
p. 602). — Black (James). Obs. on small-pox, natural and modified, as they appeared 
at Newton-Stewart. (Edinb. Medic, and Surg. Journ., vol. xv. p. 37.) 

6 M. Bousquet has given several instances in his Traite de la vaccine et des erupt, 
varioleuses et varioliformes, 8vo. Paris, 1833. 

38 



To sum up, then, none of the objections to the theory according 
to which variola and varicella depend on the same cause, appear to 
me of any weight ; none of them cast a doubt upon the fact of the 
common origin of variola and varicella under the same epidemic influ- 
ence, and especially that of the mutual and reciprocal development, 
in certain circumstances, of the one by the contagion of the other. 



Vocab. Small-pox, Variola. 

407. Variola is an acute contagious inflammatory disease, pro- 
claimed on the external surface of the body, in the course of the 
third or fourth day from the invasion, by an acuminated eruption, 
which arrives at its height between the seventh and eighth day, 
having in the mean time become pustular and umbilicated or de- 
pressed in the centre ; the pustules after this still continue in a state 
of suppuration during a secondary fever of several days' duration ; 
they then dry up and become covered with scabs, which finally, 
falling off towards the end of the third, and occasionally of the fourth 
week, leave small, irregular, and generally permanent cicatrices on 
the skin. 

There are two very distinct varieties or kinds of small-pox : the 
one is known under the name of the natural small-pox, the other is 
the inoculated small-pox. 

408. The natural small-pox presents four well-marked periods : 
that of incubation, that of invasion, that of the eruption, and that of 
the desiccation. In one instance the pustules are exceedingly nume- 
rous, agglomerated as it were, and united by their corresponding 
edges {confluent small-pox) ; at another the pustules are fewer in num- 
ber, and are distinct or scattered singly over the whole surface of the 
body (distinct or discreet small-pox). 

409. Symptoms. — First period. — Incubation. During the course of 
this period, which usually lasts from ten to twenty days, no morbid 
symptoms, either of a general or local nature, are commonly observed. 

Second period. — Invasion. The attack of small-pox is always 
accompanied by symptoms of a more or less serious character. It is 
frequently marked by shivering fits which recur irregularly, by a sub- 
sequent rise of temperature, with dryness of the skin, or a disposi- 
tion to sweating ; there are acceleration of pulse, lassitude, pains in 
the limbs, back, loins and epigastrium ; nausea and vomiting are 
common ; the patient complains of violent pain in the head ; he feels 
sunk to the earth, and is drowsy and restless. Among children, a 
state of somnolence is very common, and then they awake frequently 
with a start; or they are restless and toss about without shutting an 
eye, moaning pitifully. In some cases the face is flushed, and the 
patient might be believed on the eve of some cerebral affection, 
especially when the vomiting is troublesome, and the epigastric 
region continues free from pain on pressure, a suspicion which seems 
at times to gain in likelihood by the agitation of the patient and the 
convulsive twitches which often take place in the lips, the muscles 
of the face, or those of the body at large. To form a true estimate 
of these preliminary symptoms, it is necessary to keep in mind the 
prevalent constitution and reigning epidemic. 

At other times, but less commonly, the patient yawns continually, 
complains of an indescribable sense of uneasiness, of dyspnoea, and 
anxiety; the beat of the heart is tumultuous and rapid; shooting 
pains are felt in the chest, which occasionally become fixed in a par- 
ticular point, and symptoms of pleurisy appear to be present; or the 
patient is attacked with cough ; or this symptom, in case it exist 
already, becomes more troublesome and incessant. 

In some cases the nausea is incessant, the vomiting frequent, the 
thirst great, the tongue red upon its tip and edges; the abdomen, 
painful in different parts, most usually at the epigastrium, may be 
tumid and generally sensible to pressure, in which case we have 
often cerebral symptoms, a state of stupor, great prostration of 
strength, &c. 

These various symptoms most usually occur independently of any 
local and primary lesion; they often appear simultaneously," as if all 
the systems of the economy were affected together. 



150 



PUSTULE. 



In some bad cases die skin and origins of the mucous membranes 
Hi diffused ecchymoses or circumscribed livid spots before the 
appearance of the eruption {variola nigra). Passive hemorrhages 
then frequently occur by the different natural passages, and are occa- 
sionally so general that the blood transudes by almost every abraded 
point of the body,— from the surface of blisters, for example, and 
from the bites of leeches, when any happen to have been applied. 

These various phenomena, in sum, which appear before the erup- 
tion, may be combined in so many different ways, and run so com- 
pletely into each other, that it is often difficult to distinguish upon 
which of the organs or systems the variolous virus has acted with 
the greatest intensity. 

These properly precursory symptoms may cease with the appear- 
ance of the eruption, or continue during the whole course of the 
disease to its decline. It may even happen that a severe febrile 
paroxysm, accompanied with continual delirum and extreme restless- 
ness, may cut oil" a patient in the course of a few days, whether the 
eruption have made its appearance or not. These initiatory symp- 
toms most generally cease or abate when the eruption appears and is 
regularly developed ; if they continue, they indicate the danger, 
already imminent, to be still greater. 

Third period. — The eruption is speedily accomplished, especially 
whin it appears after the occurrence of hemorrhage. From the second 
to the third day of the invasion, small and papular-looking spots which 
rise above the level of the skin, make their appearance. On the face 
they are commonly very numerous, and either greatly crowded to- 
gether, or united by their bases and arranged in clusters (variolce 
co/terentes ; variolce corymbosce). These have all a slightly livid tinge. 

The eruption is occasionally preceded by a very extensive erythe- 
matous efflorescence of the face or trunk; in this case it is always 
corifluent. The pustules show themselves on every part of the body, 
— in the mouth, pharynx, larynx, &c, as well as over the integuments. 
The face and neck swell in the same manner as in erysipelas ; the 
patient complains of violent pain in the throat, and deglutition is 
performed with difficulty. Many white points, isolated or crowded 
together, appear on the membrane of the mouth, which is red and 
injected. The cough, which was hoarse at first, becomes dry, hard, 
painful and tearing; the voice, which was also hoarse at first, grows 
weaker and weaker, and is at length entirely lost. The restlessness 
and sense of anxiety continue, but there are not such marked symp- 
toms of dyspnoea as in croup, which is further distinguished by a 
laryngotracheal whistling sound, not heard in small-pox. 

At other times the eruption, having been preceded by symptoms 
of little severity, is evolved without any untoward accident; and it 
is in the passage from the second to the third period, that gastro- 
intestinal affections, and especially a true dysentery {variola dysen- 
terica, Sydenham), or, otherwise, variolous bronchitis, pleurisy, 
pneumonia, &c., are apt to intervene and cloud the prospect of a 
happy termination to the disease. Pneumonia occurring under such 
circumstances is, in one case, proclaimed by characteristic and 
decided symptoms ; in another, and more dangerous instance, it is 
completely masked, and then it has often disorganized the lung by 
its progress, before even its existence is suspected. In the greater 
number of cases pneumonia interferes with the due development of 
the cutaneous eruption, and this complication is one of the most 
frequent causes of those irregular variolas which usually prove fatal, 
and which, by the older writers, were characterized as cases of malig- 
nant small-pox, — cases in which the evolution of the pustules was 
suspended, in which they became flaccid, and were mingled with 
sanguinolent bulla*, and in which the suppurating stage was slow of 
setting in. 

Fourth period. — Suppuration. (Seventh or eighth day of the erup- 
tion.) An interval of four or five days divides the period of eruption 
Jrom that of suppuration. During this time the small red papular 
spots ol small-pox increase in size, and soon present a sort of flattening 
of their summits, followed by a central depression, by which each 
pustule assumes an umbiUcated appearance. If the structure of the 
pustules be studied at this period, they are found to contain a little 
serum and a small disc of a whitish substance, which is very soft at 
iirst, but soon increases in consistency. On the third day of the erup- 
tion the central depression is very conspicuous in the greater number 



of the pustules; their umbilicated aspect becomes more and more 
marked as they increase in size, and as the period of suppuration 
approaches; they are whitish in colour, and are surrounded by an 
areola of a red, or purplish red colour. When the pustules are con- 
fluent, or are clustered together in patches, these middle depressions 
are rarely perceived ; from the second or third day the face then 
appears covered with a continuous sub-epidermic whitish pellicle, — 
a kind of membranous exudation, similar to that which is observed 
at the bottom of isolated pustules. 

It is at this stage that the fever runs highest, and the most serious 
complications are observed to occur. The integuments generally 
appear swollen ; those of the face, where the puffing is always con- 
siderable, are more especially affected. Delirium, or a drowsiness 
more or less oppressive, is occasionally observed. The vomiting may 
be obstinate, and attended with severe pain of the epigastrium ; diar- 
rhoea makes its appearance or increases. The character of the cough 
shows that the eruption has implicated the mucous membrane of the 
air-passages. A ptyalism, whether there have been pustules on the 
mucous membrane of the mouth or not, now sets in and commonly 
becomes profuse. This symptom, indeed, often appears before this 
period, most usually showing itself between the third and seventh 
day of the eruption, at the same time as the swelling of the face, 
along with which it also declines. The ptyalism may be accompanied 
by some difficulty of swallowing ; it is a symptom which does not 
occur among children. 

The number of pustules frequently bears no proportion to the 
excessive swelling of the face. The tumefaction often extends to 
the subcutaneous cellular substance to the neck and cranium. At 
this period the pustules look turgid with pus and centrally depressed 
on the trunk and limbs, where they are less numerous than on the 
face, except in those cases in which they become confluent on the 
inner sides of the thighs and on the buttocks, an event that is more 
particularly apt to befall young children, in whom these parts are 
habitually wet and irritable from the contact of the urine. Upon the 
parts just mentioned the pustules usually run their course more rapidly 
than elsewhere. 

The presence of pustules upon the eyelids causes great irritation 
and very violent pain ; those that are evolved on the mucous mem- 
brane of the mouth advance rapidly; in the larynx they are more tardy 
in their progress. In proportion as the pus is secreted, the pustules 
lose their flattened appearance and central depressions, and become 
more rounded and globular. When they are at no great distance 
from each other, the intervening spaces are red and swollen, and the 
patient complains of an extremely painful feeling of tension in the skin. 

When the disagreeable symptoms which are often observed during 
the first stage, occur in this, the pustules rarely suppurate freely ; the 
pustules are flaccid, and their areolae look pale ; or otherwise they 
become filled with a bloody serum and assume a livid hue; petechia; 
appear in the spaces between them, large flaccid and bluish phlyc- 
tenaa are evolved (variolce conftuentes crystalline, Burserius), and 
passive hemorrhages takes place. 

Fifth period. — Desiccation. This process almost always begins in 
the face; this part, indeed, is often completely covered with scabs, 
before the pustules on the lower extremities have attained their full 
maturity. The swelling now subsides, the pustules dry up, and the 
scabs that follow seem but to form one continuous incrustation over 
the face. The features are then hidden beneath a thick, brown- 
coloured mask, which falls off on the fifth or sixth day from the date 
of its formation, and is succeeded by a furfuraceous' desquamation, 
the scales of which are several times renewed. The scabs in very 
confluent cases remain soft and moist. The patients exhale a pecu- 
liar faint and sickly smell; they complain of pain and tension in the 
integuments till the crusts are detached, an event that happens be- 
tween the fifteenth and twentieth day from the attack of the disease. 
The pustules frequently ulcerate ; their surface bleeds and becomes 
covered with black scabs. When these sores spread superficially 
and extend to the whole thickness of the corion, they are always 
followed by unseemly cicatrices in the event of the patient's recovery. 
At the same time the linen of the patient and the furniture of the bed 
are more or less soiled by the exudation of purulent matter from 
different parts of his body. 



VARIOLA. 



151 



A pruritus of some intensity accompanies the formation of the 
scabs, and often induces patients to tear themselves with their nails. 
In children especially, black, bleeding, and excoriated points which 
are due to this cause, may often be observed on the face. 

In some rare cases, there is neither any desquamation nor forma- 
tion of scabs ; the pustules sink in the course of eight and forty hours ; 
there is then probably absorption of pus into the system; for a sudden 
prostration of the powers coincides with the shrinking of the pustules, 
and the phenomena observed, are in other respects analogous to those 
that occur in the animals into whose veins purulent matter has been 
injected. 

Fever of great severity and violent cerebral symptoms may occur 
at this period ; convulsions and profound coma, when they supervene, 
are speedily followed by death. 

When the scabs are completely thrown off, the surfaces are covered, 
have a vinous-red tint, which only disappears with extreme slowness. 
In proportion as this red tint fades, the pits or scars left by the dis- 
ease, become continually more apparent. These are always more 
numerous on the face than on other regions of the body, and there 
occasionally form a succession of seamed and puckered cicatrices 
which disfigure the countenance dreadfully, (a) 

(a) The following brief description of small-pox, being the result 
of very ample opportunities of observation enjoyed by me in the 
epidemic, as it presented itself in Philadelphia in 1823-4, may not be 
without interest to the readers of these pages. 

" In the premonitory symptoms, constituting the characters of the 
fever precursory to the eruption, there was considerable uniformity: 
the complaint of nearly all those attacked being at first chills and 
rigors ; pains in the loins, head and limbs, with thirst and want of 
appetite ; with which were soon associated gastric uneasiness, and in 
many, soreness of throat, rendering deglutition painful, hoarseness 
and weeping eyes. The duration of these symptoms, aggravated by 
febrile exacerbations, varied from one to three days, more usually the 
latter, after which the eruption begins to appear. It is first seen round 
the forehead and temples, near the hairy-scalp ; then on the cheeks 
and breast and back ; on the arms near the shoulders ; the abdomen 
and thighs ; and subsequently on the forearms and hands, and finally 
on the legs and feet. The appearance of the eruption is that of red 
or scarlet papula?, presenting to the touch a sensible resistance, but 
not much raised, and without roughness or hardness. These papulae, 
becoming more and more defined and elevated, are after a day or two 
converted into vesicles, with small elevated centres or bodies of a 
yellowish-white, and more diffused red and somewhat hard bases or 
margins. The redness extending as the eruption becomes copious, 
converts the skin, especially of the face, neck, and hands, into a red 
ground, from which project, in relief, the whitish vesicles. Similar 
appearances, but of a less marked nature, owing to the eruption being 
more scattered, are found on the trunk. The vesicles containing at 
first a thin, semi-transparent fluid, become gradually larger, fuller and 
yellower, and filled with a thick tenacious matter. This change is 
completed, and the pustules are entirely formed, after a lapse of time 
from the first eruptive effort, which varies from the fifth to the ninth 
day, and is occasionally longer. The mean for the beginning of 
maturation, or the finishing of the secretion of matter in the pustule, 
may be received as five days for the face, and eight or nine days for 
the body generally. The stages of the eruption, as regards its appear- 
ance, may be very properly called papular, vesicular, and pustular. 
This last having attained its height, completes what is termed the 
period of maturation, during which the pustules retain their fulness 
and spheroid figure, and exhibit the greatest proportion of whitish- 
yellow shining surface of their body, and diminished extent of redness 
at their base. A yellow dry point on the summit of the pustule, 
which loses thereby somewhat of its former spheroidal shape, by 
becoming flatter, or slightly indented, indicates beginning desiccation, 
at which time the body exhales that peculiar odour so unpleasant and 
so readily recognizable after it has once been perceived. There is 
no uniformity in the size of the pustules on the body generally, nor 
any equality among them on a particular part ; more usually one larger 
and fuller is surrounded by others less so. Nor is it to be supposed 
that the changes above mentioned are gone through in regular suc- 



The diarrhoea, when it has been present from the beginning of the 
disease, as often happens in children, continues, or becomes more 
profuse during this stage; occasionally the evacuations are even 
sanguinolent ; or otherwise the cough becomes more troublesome, and 
a pneumonia, more or less decidedly characterized is set up. These 
different affections always correspond in severity with the nature of 
the variola, and the constitution of the individual. After the detach- 
ment of the crusts, especially among children, it is less common to 
witness subsultus of the tendons, convulsions, drowsiness, coma, or 
any approach to the apoplectic state. 

It is at a generally somewhat advanced period of this stage that 
what are styled nervous symptoms commonly appear. These have 
been referred to cerebral irritation ; but they occur more regularly 
than in true meningo-cephalitis, and they bear no relation to the 
swelling of the face, which by this time has disappeared. This 
is also the stage of the disease at which ophthalmia so frequently 
supervenes. It is often difficult to learn whether this affection be 
pustular or not ; because, whilst the eyelids are swelled, the presence 
of pustules upon the conjunctiva cannot be ascertained, and at the 
period when the tumefaction of the eyelids subsides, the pustules are 
resolved. The course of ophthalmia occurring under such circum- 
stances, is insidious: within an interval of twenty-four hours the 
cornea has been found softened and opaque, in cases where previ- 
ously no trace of injection had been perceived. In other cases this 

cession on all parts of the surface, uniformly. It was no uncommon 
thing to see the eruption papular on the legs, vesicular on the trunk 
and arms, and pustular on the face, at the same epoch. One part 
even, as the arm for instance, has exhibited to us the three forms at 
the same time. 

" Maturation complete and desiccation going on, the pustules break, 
and have their thin coverings converted into a yellow hard coat or 
crust, to which adheres the pus that was not removed by absorption, 
and the residue by evaporation of its watery part, is now converted 
into a scab of varying thickness, firm and prominent in its centre, and 
made up outwardly of concentric circles. The margins of the pustules, 
before of a distinct red, now assume a bluish-red or purplish-colour, 
and the skin begins to desquamate. 

" The constitutional sympathies, or the symptoms in the milder and 
regular variety of the disease, are not of any great violence or intensity. 
The premonitory pains, diminishing or disappearing, after the coming 
out of the eruption, leave in their place a regular fever. The action 
of the heart and capillaries is hurried during the papular and vesicu- 
lar stages; but becomes more equable while maturation is going on. 
During the former period, the loaded and not unfrequently furred 
tongue evidences disordered stomach, the cravings of which are for 
cold drinks. The somewhat laborious respiration may, in some cases, 
depend on the swelling and soreness of the fauces and pharynx ; in 
others, on the eruption extending along the lining membrane of the 
larynx ; whilst in others, it may be caused by bronchial engorgement." 

" The febrile symptoms which abate during the process of matura- 
tion, are apt to return during desiccation ; and when the skin begins 
to desquamate, then they constitute what is called secondary fever. 
The skin which had suffered so much, occasionally exhibits at this 
time an erysipelatous blush, accompanied by an inflammation of the 
subjacent cellular tissue, and the formation of troublesome boils, or 
infiltration of serum, especially where there is much laxity of struc- 
ture, as in the eyelids, cheeks, lips, &c. The cutaneous system, during 
and immediately after the removal of its cuticle, and much of its rete 
mucosum, is of course very sensible, as well to the impression of 
clothes as to atmospherical extremes, and particularly cold. This is 
with many a critical time. It not unfrequently happened that persons, 
who had passed through the different stages of the disease and were 
advancing rapidly to convalescence, were suddenly seized with an 
affection of the chest, — pleurisy, bronchitis or pneumonia, and speedily 
carried off by the violence of the inflammation. The skin, exquisitely 
sensible in its denuded state to atmospherical vicissitudes, transmits 
with great promptness the morbid impression to the lungs, already 
prone to take on disease, in consequence of the active part they are 
compelled to play during the eruptive fever." — North Am. Med. # 
Surg. Journ., July, 1826-7. 



152 



PUSTULE. 



ane u perforated by ulceration, and a staphyloma shoots forth ; 
small phlegmonous abscesses are now also frequently developed on 
the head, neck, or extremities, as are pustules of ecthyma, furuncles, 
and the bolls of rupin, which are succeeded by excoriations and 
i various depths and decrees of intractability, causing sleep- 
ss, and wearing out the strength of the patient. Lastly, chronic 
inflammations of the mucous membranes of the bronchi and intestines, 
are the severest of all the secondary affections of small-pox, and those 
which most frequently protract the convalescence. Phthisis pulmo- 
nalis has in general been observed to be accelerated in its progress 
by the influence of variola ; in a few rare cases, however, the progress 
of pulmonary tubercles has appeared to be favourably modified by 
this disease. 

It occasionally happens, however, that no serious symptom is ob- 
served in the first, second, and third periods of small-pox. Although 
confluent, the disease seems at times to be running its course with 
perfect regularity, when the patient suddenly sinks and dies, without 
our being able to detect, from a post-mortem examination of the body, 
any morbid appearances sufficient to account for this rapid and disas- 
trous termination, which is then probably owing to the fatal action of 
the variolous poison upon the economy at large. 

410. Distinct and benign small-pox (variolce discretes benignce, Bur- 
serius), is usually preceded by general symptoms of less severity, but 
of equally long continuance as those of the confluent variola. 

On the first day of the invasion, we have shivering fits, alternating 
with flushes of heat, general uneasiness, and loss of appetite ; on 
the second day, distaste for food of every description, nausea, hot 
skin, occasionally pain of the epigastrium, especially on pressure, a 
sense of heat in the stomach and pharynx, great thirst, redness of the 
point of the tongue, the middle and base of which are covered with a 
white or yellowish fur ; next headache, drowsiness among children, 
disposition to perspire among adults, frequency of the pulse and re- 
spiration, restlessness, yawning, and pain in the back and loins, joints 
and limbs universally. 

On the fourth day, the eruption is proclaimed by a number of small 
red, isolated spots, similar to flea-bites, upon the lips, then on the 
face, chin, neck, breast, abdomen and extremities. Next day, the 
rash is thicker, the spots are more prominent, and apparently papula?-. 
Their apex then becomes vesicular and transparent. On the third 
and fourth days of the eruption, the spots appear distinctly pustular, 
are well defined upon the skin, and, occasionally, on the mucous 
membrane of the mouth, pharynx, eyelids, prepuce and female 
labia. The pustules of these parts differ from those of the skin ; for 
when the epithelium covering the whitish circular spots which cha- 
racterize the pustules in these situations is removed, neither serum 
nor pus is found underneath it. 

The integuments in the spaces between the pustules are frequently 
red and swollen. The pustules appear hard to the touch; the fluid 
they contain grows thick, becomes yellow in colour, and is not long 
before it acquires a perfectly purulent appearance. The pustules 
have a well-marked umbilicated form. The swelling is greatest in 
the face, although the pustules are commonly less numerous there 
than elsewhere; this part also becomes the peculiar seat of a tensive 
pain and burning heat. A secondary fever now (fifth day of the erup- 
tion) arises, and continues during the course of the suppuration of the 
pustules. The swelling of the face appears at first about the upper 
lip and alse of the nose ; it extends in succession to the lower lip, the 
cheeks, eyelids, and temples. At the same time, a slight ptyalism 
occurs, even when no pustules have been thrown out upon the mouth. 
This state of things continues till towards the eleventh or twelfth day 
(eighth of the eruption); the desiccation of the pustules then takes 
place. The swelling of the face begins to subside, and the pustules 
to shrink, and subsequently to dry. The scabs are thrown off on the 
fourteenth or fifteenth day. Those of the hands are formed and de- 
tached three or four days later. There is a particular circumstance, 
and it is a remarkable one, which may accelerate the progress of the 
pustules ; this is the existence of inflammation in the parts where they 
are evolved. Thus when individuals labouring under psoriasis, lichen, 
or chronic eczema, are attacked with small-pox, those pustules which 
appear on the parts already inflamed, very commonly run through the 
whole of their stages within eight days. 



After the fall of the crusts, circular red marks of a brownish-red 
colour, and small irregular cicatrices, which are more especially con- 
spicuous on the face, remain. These marks are occasionally after- 
wards affected with a furfuraceous desquamation. 

411. The distinct small-pox may be attended with very severe 
symptoms, so as frequently even to prove fatal (variola discretes ma- 
ligna, Burserius). 1 In these bad cases nervous symptoms are often 
observed, as also passive hemorrhages, petechia?, dysentery, pneu- 
monia, &c, complications which arc more frequently seen in the con- 
fluent variola, (a) 

412. The inoculated small-pox differs in several particulars from the 
natural disease. This variety is produced by introducing the variolous 
poison into the system, by applying it to an abraded surface by rubbing 
it upon the skin or mucous membranes, by inserting it, in fine, by 
means of the puncture of a lancet under the epidermis. 

During the first, and occasionally even the second day of the inocu- 
lation, no change is perceived in the punctures ; on the second or third 
day a slight itchiness is felt, which precedes the appearance of small 
spots of an orange or tawny-red colour. On the third day these spots 
enlarge. On the fourth, the redness of the spots increases, and a sense 
of tingling or pricking takes the place of the pruritus ; the punctures 
become prominent and lenticular. On the fifth, the pricking sensation 
is more acute ; local inflammatory symptoms are more strongly marked. 
On the sixth, the spots contain a transparent fluid in their apices. On 
the seventh, they grow white and purulent, and show a depression in 
their centre ; the pain extends along the inner side of the arm, when 
the punctures have been made on this member, as is usual ; the spots 
become phlegmonous, and are surrounded by a livid areola. On the 
eighth, slight shivering fits take place, the skin feels hot, there is head- 
ache of varying intensity, listlessness and want of spririts, nausea, now 
and then actual vomiting at intervals during four and twenty hours, 
and drowsiness. On the ninth, the inflammation of the inner part of 
the arm and axilla abates, the livid colour of the areola fades ; the pus 
is dried up ; occasionally the neighbouring pustules, when more than 
one puncture has been made, unite and form one thick and large crust, 
which is detached between the twentieth and twenty-fifth day from 
that of the inoculation. In this case, a broad and deep cicatrice is 
left upon the point inoculated, very similar to that which results from 
an issue. 

Besides the local variola, wdiose history has thus been traced, another 
and general eruption appears upon the twelfth day of the inoculation, 
having been preceded by many symptoms of general functional de- 
rangement, analogous to those which go before the development of 
the natural small-pox. A crop of pustules appears on the face, neck, 
trunk, and limbs ; this is usually but scanty : the pustules of inocu- 
lated small-pox are rarely numerous, and still more rarely confluent. 
The general eruption is commonly finished on the thirteenth or four- 
teenth day from that of the inoculation. The pustules arise, become 
depressed in their centres and semi-globular, like those of the natural 
small-pox. A purple areola surrounds their base ; they become turgid 
with pus ; the red circle which surrounds them fades at the same time 
that their centres whiten ; the pus assumes a yellow colour, a small 
black point forms in the middle of each pustule, the areola of which 
has now disappeared. Their surfaces shrivel at length, and the pus 
they contain dries up and forms scabs of a grayish-brown colour, 
which, falling off in due season, leave behind them spots of a deep 
red hue, and occasionally superficial cicatrices. 

413. Inoculated small-pox is not without its varieties : — 

1. The secondary eruption may not happen, and the inoculation 
does not then prove effectually preservative. 

(a) The varieties of small-pox, deduced from its external charac- 
ters, which I described in the paper already quoted, were, the conflu- 
ent, the roseolar, the tuberculous, and the erysipelatous. The tuber- 
culous variety was most common in negroes, and was distinguished 
by hard, rough and knotted prominences, flattened in the centre, and 
containing little or no pus. 

Ponticelli (Silv. Ant.). Inforlunii del vajuolo e metodo di andarne al riparo, 8vo. 
Parma, 1761, cap. iii.— Morten. Exercit. iii. cap. vi.vii. viii.— The anomalous variola? 
observed by Sydenham in 1670, 1671, and 1672 (variola; nigra), must be referred to 
the malignant distinct small-pox. 



VARIOLA. 



153 



2. More rarely, there are no pustules developed in the situations of 
the punctures, and the secondary eruption does not the less take place. 

3. The secondary eruption may appear in several successive crops. 

4. The course of the eruption may be so accelerated, that within 
the space of eight or nine days, the disease passes through the whole 
of its periods, like varicella or modified small-pox ; and, on the con- 
trary, the pustules may be more tardy in their progress than in the 
natural small-pox. 

5. And lastly, inoculation may be followed by a variolous fever 
without eruption. 

Inoculated small-pox, as has been said, is generally distinct. The 
period of suppuration is not characterized by any violent symptoms. 
This variety of small-pox is occasionally complicated with an inflam- 
mation of the exanthematous kind (roseola variolosa, 268). It is 
much less frequently associated than natural small-pox with serious 
inflammatory affections of the mucous membranes, or other accidental 
complications of importance. 

414. Variolous fever, (variola sine variolis). This variety of the 
variolous contagion has been pointed out by several observers. 1 The 
resemblance which the symptoms of this fever bore to those of small- 
pox, induced me, says Sydenham, to give it the title of variolous fever, 
which indeed seemed so much the more appropriate, as the fever raged 
at the same time with small-pox, and got well under the same treat- 
ment ; the two diseases belonged evidently to one family ; and there 
was no difference between them, saving that in small-pox the morbific 
matter was directed towards the skin in the shape of an eruption, 
whilst in the variolous fever this matter was expelled from the system 
by the salivary glands. 2 Several inoculators assure us, that they also 
have seen these variolous fevers; 3 and some have added, that they 
gave subsequent immunity from small-pox. 

I have not myself observed any fever of this description; perhaps 
it has escaped my notice, and I have not looked for it with sufficient 
attention. 

415. Anomalies of small-pox, and of tlte variolous pustule. — The 
pustules of small-pox have not all the same course ; some of them 
advance and terminate at the usual period; others having got half or 
a certain way, to the tenth, eighth, sixth, or even only the fourth day, 
the period at which true pus begins to be formed in their interior, 
stop short in their progress, shrink, suppurate no farther, and instead 
of pus, contain but a small quantity of coagulable lymph. This 
variety of pustule seems to me to correspond to papular varicella. 

In other cases, a kind of double suppuration seems to take place, 
or rather the period of suppuration is prolonged beyond its usual term. 

The secondary fever has been said to be wanting in some cases of 
small-pox; these, however, ought to be regarded as cases of the 
varioloid or modified disease. 

416. Independently of the inflammation of the mucous membranes, 
which ought to be held one of the elements of variola, the disease 
may be complicated with other affections — with measles and scarla- 
tina, purpura, croup, and pneumonia, more rarely with haemoptysis, 
meningitis, &c, which may occur before and during the eruption, or 
the desiccation, and after the detachment of the scabs. These com- 
plications are particularly to be dreaded during very hot or very cold 
seasons. The fear of death, and other violent moral affections, fre- 
quently give rise to such a state as is promptly fatal. 

During convalescence, erysipelas, furuncles, and phlegmons of the 
legs, thighs and arms, are very commonly observed ; ecthyma ap- 
pears upon the extremities ; chronic inflammation of the intestines, in 
fine, often protracts the cure, and even leads to an unfavourable ter- 
mination. I shall by and by point out the best remarks that have 
been made in regard to these complications and secondary affections. 

417. Alterations of structure. — The pustules of small-pox are com- 
monly more confluent and farther advanced on the face than on other 
parts ; they are also flatter there than elsewhere, and occasionally 

•Sydenham. Opera. Sect. iii. cap. iii. p. 181, edit. Patav. 1700. — Ludwig. Instit. 
medicin. clinic. Pars. i. cap. i. subsect. vii. §. 167. — Azzoguidi (Germ.). Leltera 
soprai raali effetti dell' inoculazione. Venez. 12mo. 1782. 

2 De Haen also says that this species of fever is attended with ptyalism, like con- 
fluent smallpox. Divis. Febr. p. 97. 

3 Fouquet. Traitement de la petite-veriole des enfans, p. 123, 12mo. Paris, 1772. 
— Gatti. Nouvelles reflexions sur la pratique de I'inoculation, 12mo. Bruxelle.*, 
1797.— Dezoteux el Valentin. Traite de I'inoculation, p. 297. 

39 



form a sort of whitish layer spread over the whole face and forehead. 
If death occurs at a later period of the disease, the pustules are 
already dry upon the face, where they form a kind of bluish scab, 
whilst, over the rest of the body, they are still at their height. The 
surrounding skin continues white or very slightly tinged with violet. 
On other parts of the body the pustules are for the major part umbili- 
cated; their centre, slightly depressed, is in general of a little less 
dead white colour than the rest of their superficies ; at other times, 
and especially upon the legs, they are of a vinous red or dusky 
brown colour. 

The pustules, at the period of their height, feel hard and solid 
under the finger. Those of the palms of the hands are usually of 
considerable size, slightly rounded, and without any depression in 
the centre ; their colour is not of quite so dull a white as the pustules 
in general. The pustules of the soles of the feet are either not raised 
at all, or but very slightly so ; they appear through the thick cuticle 
of this region, under the form of circular obscure violet-coloured 
spots, surrounded by a border of a deader white colour than the rest 
of the skin. The pustules of the penus and scrotum are usually 
small, and feel very firm to the touch. 

Some pustules have a follicular orifice about their middle, from 
which sprouts a hair ; the greater number, however, present nothing 
of the kind. On cutting them across, the following appearances 
present themselves : the subcutaneous vascular rete seems very much 
developed in places ; but this is far from being invariably the case. 
The deep layer of the corion, in which the middle of each pustule is 
situated, is always very much injected, and looks as if it were suf- 
fused with blood ; occasionally, indeed, it presents a red, streaked and 
punctuated appearance. The outer surface of the corion, in which 
the general surface of the pustule has its seat, is swelled, slightly 
transparent, and yellowish in colour. Above the corion we meet 
with a pseudo-membranous layer, which forms the substance of the 
pustule. It appears in the shape of a truncated cone, about half a 
line in thickness, more or less, according to the size of the pustule. 
It is a substance of a dull white colour, of some consistency, but 
rather friable, and intimately connected with the inner surface of the 
cuticle, with which it appears to be confounded ; it is less adherent 
to the surface of the corion. In pustules that are farther advanced, 
a few small vacuities are perceived, or a waving line, or small wind- 
ing cavity is seen between the outer surface of the dermis and the 
adventitious white layer of which mention has just been made. 
These intervals, or this cavity, is found full of a serous fluid. In 
the pustules of the face, farther advanced than those of the other 
regions, this fluid becomes opalescent, and is more abundant, occur- 
ring not only in the cavities of the pustules, but effused below the 
cuticle of their circumference. The cuticle thus raised may then be 
detached in shreds of considerable size. Beneath it, in situations 
corresponding to the pustules, a great number of irregularly rounded 
prominences are observed, separated from each other by sinuous 
furrows of the skin. 

This eroded appearance of the dermis only occurs in those places 
that are beset with pustules in a state of suppuration. The cuticle 
appears thickened in some degree, but maceration shows that this is 
not the case. 

In the situation of the beard, the cuticular canals of the hairs ap- 
pear under the form of opaque white lines, traversing the substance 
of the skin, and ending at a species of white bulbs, bearing a prettv 
strong resemblance to the figure given of them by Cotugno. 

418. After macerating portions of the skin of individuals who had 
died under small-pox, in water for several days, Mr. Young and I 
observed the following appearances : the cuticle was detached with 
the slightest touch, and always presented on its surface the elevations 
and opaque white-coloured spots of the pustules. This dull white was 
visible over the whole surface of a certain number of the pustular 
impressions ; but in the majority it either diminished considerably or 
ceased entirely towards their centres, thus preserving the umbilicated 
character. The inner surface of the cuticle presented nearly the 
same appearances as depressions, which on the outer surface were 
conspicuous as elevations ; the pseudo-membranous layer to which 
the pustule at its height owes its umbilicated form and dull white 
colour, was here found in a manner isolated and distinct. In the 






PUSTULE. 



hollows, indeed, a kind of disc or ring of a whitish, pseudo-membra- 
nous matter was found, winch could easily be removed by scraping; 
the cuticle always remained a little depressed, but it preserved nearly 
its natural appearance. The piliferous ducts which passed through 
of these discs, were whiter, larger, and more conspicuous than 
those that were visible upon the surrounding cuticle. 

The annular disposition of this white substance was particularly 
remarkable in the pustules of the soles of the feet. Here too the false 
membrane, stopping abruptly at the circumference of the pustule, pro- 
duced the white border which we had remarked during life. The 
outer edge of this pseudo-membranous ring was more prominent than 
the inner margin, so that a kind of cupped appearance was produced, 
and a piece of the cuticle of the sole of the foot, pretty numerously 
beset with pustules viewed from the inside, bore a strong resemblance 
to the surface of a laden honey-comb. When this false membrane 
was removed, the inner surface of the epidermis looked of a very 
taint whitish colour; an appearance which might perhaps be ascribed 
to the presence of the deep epidermic membrane. 

The skin of the palms of the hands presented the same appearances, 
but these were here less strongly marked. 

The outer surface of the dermis or corion, in those places corre- 
sponding to the centres of pustules, exhibited rounded eminences 
which contrasted strongly, by their yellowish colour and semi-trans- 
parent appearance, with the tint and character of the rest of the skin. 
These elevations were always of smaller dimensions than the alveolae 
of the epidermis w-ith which they were in relation. Around several 
of them a linear depression could be perceived, produced by the im- 
pression of the outer and prominent edge of the pseudo-membranous 
substance ; it was observed more especially on the soles of the feet, 
where the outer rims of the discs, here slightly llocculent, were nearly 
half a line in thickness. These eminences, examined with the mag- 
nifier, presented the slight superficial grooves which separate the 
papilke of the corion. This feature was especially remarkable in the 
palms of the hands and soles of the feet, situations in which the papillae 
appeared to be increased in size. 

This appearance was the same as that which was evident in the 
interior of the greater number of the pustules when arrived at their 
height ; but in several pustules, farther advanced, the surface of the 
corion, instead of presenting these papillary risings, was on the con- 
trary, more or less depressed ; nevertheless, a slight elevation could 
still be discovered in the centre of a great many of the depressions. 
To conclude, the skin was in some places manifestly eroded. 

The elevations observed in the pustules of the outer surface of the 
corion were softer, and much more affected by prolonged maceration 
(during a month) than the other parts of the skin. In the situations 
where they had existed, a brownish and soft depression was dis- 
covered, contrasting strongly with the dull white of the rest of the 
dermal tissue. 

On examining those variolous pustules which had been touched 
with caustic very shortly after their development, during life, we found 
the crusts and squamae of a deep brown colour, somewhat depressed, 
and dry on the exterior; their inner surface was yellowish. Under 
these squamae the corion appeared to be more eroded than in other 
parte of the body. 

To conclude, the size, the colour, and the umbilicated depression 
of the pustules of variola depend evidently on the pseudo-membranous 
disc, secreted by the papillary body, inllamed and elevated in the 
form of a zone, in the places occupied by the pustules. 

When two or three pustules happen to have become united by their 
corresponding edges, the anatomical characters of each of the several 
pustules are often perceptible in the group. Scattered among the 
true variolous pustules we also frequently perceive conoidal or globu- 
lar pustules precisely similar to those which characterize two of the 
varieties of pustular varicella. In fine, the skin of the face and poste- 
rior parts of the trunk is usually very much injected, (a) 

(a) " The form of the pustule of small-pox is strikingly modified 
in reference to the seat of its development. Thus, on the face, where 
the pustules advance very rapidly to maturity, they are flat, and non- 
u .abdicated. On the palms of the hands, and on the palmar surface 
of the fingers, they rise gradually from the surface, are but little raised 



419. The mucous membranes present alterations which are not less 
remarkable than those of the skin. The conjunctiva, the raucous 
membranes of the nasal fossae, mouth, pharynx, larynx, trachea, and 
bronchia, of the prepuce in the male and labia in the female, &c, are 
usually injected, and exhibit traces or rudiments of pustules. The 
nasal fossae, of a bright red colour, are covered with thick mucus ; 
the arch of the palate and upper surface of the tongue present gray 
pseudo-membranous exudations, or small flocculi of the epithelium. 
The mucous membrane of the mouth is of a livid red, and shreds of 
the epithelium and a gray pseudo-membranous deposit are observed 
as far as the eye can penetrate, hanging from the velum palati to the 
aryteno-epiglottidean ligaments. In cases of confluent variola, the 
interior of the larynx and trachea also presents unequivocal signs of 
inflammation: the mucous membrane is of a violet hue, with whitish 
or grayish points scattered over it, circular in shape, and varying from 
half a line to two lines in diameter, having a red, central point, with- 
out any epithelium, and several other spots, irregular in their shapes 
and of various sizes, probably consecutive to groups of coherent pus- 
tules. Whilst examining the body of a woman who had died on the 
fourth day of the eruption of a confluent small-pox, Chaussier 1 found 
a great number of pustules in the larynx and trachea similar in size 
and shape to those which existed on the skin. These pustules were not 
confined to the larynx and trachea ; several were even found in the 
principal ramifications of the bronchia, on the inside of the mouth, on 
the pharynx and upper part of the oesophagus. I must, however, add 
to this statement, that ia my own experience I have always found the 
variolous pustules of the mucous membranes differing in many respects 
from those of the skin. Thus I have never seen pustules in the larynx, 
trachea, and bronchia, precisely similar to those of the skin ; that is 
to say, formed of a pseudo-membranous disc, with purulent matter 
deposited between the corion and cuticle ; farther, the variolous 
pustules of the mucous membranes never become incrusted, and in 
several, the pseudo-membranous deposit is not even covered with an 
epithelium ; lastly, they are not generally succeeded by visible cica- 
trices. 

I have never seen variolous pustules in the oesophagus, stomach, 
or intestines ; but I have observed that these parts were always in- 
flamed in a greater or less degree. Cotugno informs us that he saw 
well-characterized variolous pustules on the mucous membrane of the 
rectum, in a case of prolapsus of this part; 2 in such cases, however, 



above the level of the surrounding skin, and are also non-umbilicated. 
On the soles of the feet, again, they are large in extent, and still 
more flat than the preceding, appearing like purplish disks with a 
distinct white margin, and non-umbilicated. Usually, the umbilicated 
centre presents a reddish or brownish tint, and sometimes, though 
rarely, it is perforated by the shaft of a hair. 

" When a well-formed and mature pustule is examined by dissec- 
tion, it is found to be divided in its interior by a transverse septum 
into two chambers, both containing pus. The upper chamber is the 
larger of the two, and they communicate with each other, to a greater 
or less extent, by the rupture of the transverse septum around its 
marginal border. The epidermis, forming the superficial boundary 
of the pustule, is the segment of a sphere, and continuous by its 
circumference with the cuticle covering the adjoining skin. The 
transverse septum is a layer of false membrane, of a whitish colour, 
which was deposited on the dermis at an early stage of the pustule. 
Subsequently this layer becomes separated from the dermis, and raised 
by the formation of pus beneath it, and at the same time it is broken 
around its edges, and permits the pus of the deeper cavity to com- 
municate with that already contained in the superficial chamber. In 
consequence of the peculiarity in the mode of its production, this layer 
of false membrane generally retains permanently the umbilicated form 
of the primitive pustule, and is thinner at the centre than towards its 
circumference. When this septum is removed, the deep chamber is 
brought into view, and the depressed and sometimes ulcerated base 
of the pock exposed. The surface of the base is of a bright or 
purplish red colour, and highly vascular." Wilson (op. cit.). 

' Bullet, de la faculte de med. de Paris, 8vo. t. iv. p. 14. 
2 De Sedib. Variolar, p. 152, l£mo. Vienna. 



VARIOLA. 



155 



it is well known that the mucous membrane approaches the skin in 
its structure. 

The mucous membrane of the stomach and bowels frequently pre- 
sents spots of extravasated blood, and its follicles are enlarged and 
more than usually prominent; ecchymoses are also seen in many cases 
in the substance of the intestinal parietes, especially in variola nigra. 
The follicles of the mucous membrane of the great intestines are 
remarkably enlarged, of a violet colour, and flattened or projecting, 
when symptoms of a dysenteric nature have accompanied the disease. 

420. In some subjects the blood has been found fluid, serous, and 
apt to penetrate the tissues ; bloody effusions have also been observed 
in the subcutaneous and sub-serous cellular membrane, and in the 
substance of the corion ; as also petechia? and ecchymoses of the sto- 
mach ; a sanguinolent loading of the lungs {variola nigra) ; and a 
remarkable pale and flaccid state of the heart, on the inner surface of 
which, small circumscribed violet or red-coloured spots have occa- 
sionally been discovered. 

Gendrin 1 relates that having injected the blood of individuals 
labouring under confluent small-pox into the veins of animals, very 
violent and rapidly fatal symptoms were induced, and that on opening 
the bodies after death several organs were found very much inflamed. 

It is more rarely that we meet with alterations of other viscera. In 
some small-pox patients who exhibited symptoms of meningitis, the 
membranes of the brain have been found to be injected, and effusions 
of a limpid or sanguinolent serum to have taken place between the 
convolutions, and into the ventricles of the brain, as well as the arach- 
noid membrane of the spinal cord. M. Berard found the arteries very 
commonly stained of a red colour in an epidemic variola which pre- 
vailed at Angers among a detachment of recruits. Messrs. Rigot and 
Trousseau 2 tell us, that having been present at the dissection of a great 
number of subjects wdio had sunk under small-pox, they almost uni- 
formly observed a red colour of the blood-vessels, but in no instance 
did they find the parietes of the arteries thickened so far as sensibly 
to diminish the capacity of their canals. M. Tanchou 3 had before this 
period called the attention of pathologists to this red state of the arte- 
ries, which he attributed to inflammation. Upon one occasion, in 1826, 
when discharging for a time the duties of M. Bailly, at the Hopital de 
la Pitie, I had several opportunities of observing this redness of the 
vascular parietes, which in the greater number of cases appeared to 
me to have taken place after death, and to be due to a particular state 
of the blood. I have, however, occasionally seen a redness of the arte- 
ries occurring in long patches, without there being any blood present 
to account for the phenomenon, in the bodies of subjects who, during 
their lives, had exhibited symptoms of ataxic or nervous variola. To 
conclude this subject, M. Costallat has observed gangrene of the lungs 
along with severe small-pox, and M. Fred. Cuvier, jun., has found 
small abscesses in the pulmonary tissue of those who had died during 
the suppurative stage of the disease, very similar to the purulent depo- 
sits encountered in these organs after unfortunate surgical operations on 
the limbs. 

In all the varieties of small-pox which end fatally, the lungs are fre- 
quently found gorged with blood. 

421. Causes. — Small-pox is a highly contagious disease ; it is trans- 
mitted by mediate as well as by immediate contact ; the contagion 
extends to some distance in the atmosphere and follows the direction 
of the wind. The contagious character is developed during the sup- 
puration of the pustules, and remains till the period of their desiccation. 
It does not appear to undergo any change from the individuals it affects 
or the varieties it presents ; the pus and miasm of a confluent variola 
may communicate one which shall be distinct, and vice versa. 

Small-pox spares no sex nor age, not even excepting the foetus, 
which maybe attacked through the medium of the mother, though she 
should not feel the effects of the poison, either from having been pre- 
viously vaccinated, or had the small-pox naturally or by inoculation. 4 
Such was the case of the mother of Mauriceau, according to Desor- 
meaux : s she had been tending the eldest of her children, who died of 

1 Hist, des Inflammations, t. ii. p. 460. 

* Archives gen. de med , t. ii. p. 460. 

3 Journ. Complem. Nov. If25, t. xxxiii. p. 90. 

* M. Marc cites three cases of the kind. Diet, des sc. med., t. xvi.p. 71. 

* Diet, de med. en 21 vol., t. xv. p. 397. 



small-pox, and the day after this event she was delivered of Mauriceau, 
who, according to the testimony of his parents, came into the world 
with five or six distinct pustules of small-pox upon his body. 

I am indebted to the kindness of M. Costallat for an opportunity of 
seeing a somewhat similar case : Rosalie L * * *, aged twenty-four, 
presented a cicatrice on each arm nearly the size, of a crown-piece, 
which appeared to have been produced by the fusion of several vaccine 
pustules into one. When about four months gone in her pregnancy 
she contracted small-pox along with three other individuals of her 
family, on the 6th of April, 1833. The eruption was characterized 
by large, distinct, flat pustules ; Rosalie was so little incommoded that 
she went about her usual avocations, and it was only upon particular 
recommendation that she consented to keep her room for two or three 
days. After the 20th of April she mounted to a sixth flat, many times 
a day, to wait upon her father and husband. On the 28th she no 
longer felt the motions of her child, and on the 13th of May she mis- 
carried. The whole surface of the foetus was covered with variolous 
pustules perfectly well characterized. 

Some privileged persons resist repeated inoculation, and even escape 
amidst variolous epidemics; but these individuals very commonly end 
by contracting small-pox at a later period of life. 

The disease appears at all seasons and in every climate ; it does not 
generally attack the same individual oftener than once ; but we have 
well-authenticated instances to the contrary; 6 and some individuals 
even show a kind of predisposition to catch the disease a second and 
a third time. 7 (a) 

Small-pox is occasionally sporadic; it, however, most usually 
occurs epidemically. It commonly commences its ravages in the 
spring, prevails during the summer, and disappears in winter. I 
have mentioned many small-pox epidemics which have occurred ; in 
almost all of these have the divers forms of variola and its modifica- 
tions, the varicellae, been observed. Some of these epidemics were 
remarkable for their mildness, others as much distinguished for their 
malignancy, whilst several of them have appeared benign at one 
epoch of their continuance, and malignant at another. 

422. Diagnosis. — Before the appearance of the eruption, the diag- 
nosis of small-pox always presents much uncertainty, even when 
every attention is given to the character of the prevailing constitu- 
tion or epidemic : the precursory symptoms of variola are common to 
many diseases ; they acquire peculiar importance only when it is 
known that the patient has been immediately exposed to the influ- 
ence of the variolous contagion. 

The spots and papular rash which precede the formation of the 
umbilicated pustules may be distinguished from the spots of measles, 
as they feel granular, like small hard bodies under the finger ; they 
are also evidently deeper, as well as firmer, than those of measles. 

The umbilicated pustules of small-pox can only be confounded 
with those of pustular varicella, which present the same flattened 
appearance; these, however, are much less uniformly depressed in 
the centre, suppurate during a shorter period, and are of a duller 
white colour ; farther, this species of varicella is not accompanied 
with any secondary fever. As to the other varieties of varicella, 
the points of difference are so many and so striking, that no mistake 
seems possible. 

The pustules of small-pox are very unlike those of any of the 
other pustular diseases, particularly ecthyma, and do not differ less 
from the artificial pustules which are produced by mechanical irrita- 
tion of the skin, and which have been very improperly entitled false 
inoculated small-pox. These eruptions, moreover, do not run any 
thing like the regular course of those of the eruptive fevers. 

423. Prognosis. — Distinct small-pox, unattended with nervous 
symptoms, passive hemorrhage, dysentery, &c, almost always ends 
favourably from the fourteenth to the twentieth day. The duration 
of confluent small-pox is incomparably longer when the disease does 
not terminate fatally in either of its two first stages. 

In the epidemic of Marseilles of 1828, the distinct variola did not 

(a) We met with examples of a second attack of small-pox in the 
epidemic in Philadelphia in 1823-4. 

6 Thomson's Hist. Sketch, &c, 8vo. Lond. 1822. 

7 Gregory, Lond. Med. Gaz., vol. viii. 



156 



PUSTULE. 



last beyond the fifteenth day, whilst the confluent species went on to 
the thirty-first day, and even longer. 

Even from the very commencement of the attack the course of the 
disease may he in some measure calculated, from the intensity of the 
initiatory symptoms: " Quo febris variolosa mitior, e6 eruptio parcior, 
t'6 lenior status inflammationis, suppurationis." 1 As a general rule, 
however, it is advisable to be extremely cautious in the prognosis of 
small-pox. 

The favourable or unfavourable chances of small-pox, in truth, 
cannot be calculated without a just appreciation of each particular 
circumstance after it has occurred. 

If the eruption be successive in confluent small-pox, the danger is 
in general less imminent; if, on the contrary, the pustules appear at 
once on the face, neck, trunk and extremities, the disease proves one 
of the most formidable to which the human body is subject, and death 
is very frequently its consequence. 

Cerebral symptoms (nervous variola) at the invasion and height of 
the disease are very alarming. 

Ecchymoses and petechia? frequently announce a fatal alteration of 
the blood, and approaching dissolution. 

Variolous inflammation of the larynx and trachea, croup and 
pseudo-membranous bronchitis make the prognosis more and more 
unfavourable. 

Obstinate ophthalmia, otitis, cceco-colitis, abscesses and other acci- 
dental affections, are the causes of additional symptoms which protract 
and increase the risks of the convalescence. 

The precocious development of the eruption, the smallness of the 
pustules, a flatness in their form, irregularity in their periods, &c, 
have all been signalized as unfavourable symptoms. The danger 
has been held to be extreme, when the elevations were filled with 
transparent serum instead of pus ; the occurrence of hemorrhage 
during the period of suppuration, has also been regarded as a very 
disastrous symptom. These notions are fortunately but too well 
founded, when such outward signs occur along with the deeper 
lesions of the mucous membranes or of the viscera, or along with 
nervous symptoms and altered conditions of the blood. Under other 
circumstances, however, it would be rash to draw such serious infe- 
rences from any irregularity in the progress of the disease, (a) 

424. Treatment. — The variolous fever, and inflammatory actions 
of small-pox having necessarily to pass through certain stages before 
they can be resolved, we must be content with endeavouring to 
moderate the severity of the principal symptoms, and not attempt by 
any perturbating measures to prevent their evolution or cut short 
their progress. 

Intervening diseases, not variolous in their nature, may be met by 
more active and more varied modes of treatment. 

425. In benign small-pox the inflammation of the skin is always 
slight, and that of the mucous membranes of the air and alimentary 
passages is seldom of any severity ; still, as there is no necessary and 
invariable ratio between these affections of the two orders of surfaces, 
it may chance that a small-pox, distinct externally, may be accom- 
panied by internal lesions of such importance as to require the strictest 
watching. 

If the fever be trifling, if the inflammation of the skin and that of 
the mucous surfaces which accompany it, be slight, we shall have 
little else to do than to see the patient placed in a large room, and in 
good air of a moderate temperature. If the appearance of the erup- 
tion be preceded by vomiting and pain of the epigastric region of 
considerable severity, it is advisable tofapply leeches to this part, to 
cover the abdomen with emollient cataplasms, prescribing at the same 
time complete abstinence from food, acidulated drinks to quench 



(a) The character of the prevailing epidemic, when small-pox 
appears in this way, the circumstance of the patient being in a hospital 
or crowded room, or in his own apartment, and the previous habits 
of those attacked are all to be considered in forming a prognosis. 
\\ ithio my own experience I found that the proportional mortality was 
greater among my patients in the hospital, than in dispensary practice. 
Drunkards among men and prostitutes among women rarely escape 



Sioll. 



Aphor. de cognos. et curand. febrib. Aphor. 338, 8vo. Vien., 1788. 



the thirst, and mucilaginous glysters to empty the bowels. If the 
inflammatory symptoms do not yield, if they become associated with 
a variolous laryngo-tracheitis, and if their severity seems to prevent 
the free evolution of the pustules upon the skin, general blood-letting 
ought to be practised, unless the application of a larger number of 
leeches to the scrobiculus cordis and fore part of the throat be pre- 
ferred. When the eruption is complete, and the progress of the 
internal inflammatory affections is arrested, we have only to watch 
the further progress of these diseases, the symptoms of which soon 
begin to decline, and finally disappear under the influence of low diet 
and diluents, and by the natural progress of the disease. 

426. The treatment of the severer cases of variola is attended with 
more difficulties. 

1. The whole surface of the body is occasionally covered with 
pustules; the subcutaneous cellular tissue is greatly swollen; the 
parotid and sub-maxillary glands are enlarged, and variolous inflam- 
mations are set up in the mouth and nasal fossae, on the conjunctiva?, 
pharynx, larynx, trachea and bronchia, and occasionally even in the 
stomach and intestinal canal (inflammatory variola). In this case, 
especially if the patient be young, the inflammatory condition must 
be modified by the abstraction of blood generally and locally, by oily 
and emollient embrocations, such as soft cerate or cream applied 
either cool or cold, and by the use of the temperate bath; the latter 
means has often appeared to me extremely beneficial in these varie- 
ties of small-pox. When the disease has attained its suppurating 
stage, the pustules should be punctured with the point of a needle, 
and the matter they contain suffered to escape and afterwards absorbed 
by a sponge dipped in some emollient decoction. 

2. This purely antiphlogistic plan also appears to me preferable to 
any other in those cases where the disease wears a formidable aspect, 
from the intensity of the variolous inflammation of the air-passages, 
evinced by the dyspnoea which then accompanies the development of 
the eruption, and the livid tint of the pustules themselves (laryngeal 
variolce). 

3. As to nervous variola? I feel truly at a loss to lay down any 
rules for their treatment. Patients sink when they are bled, and 
almost always die when treated upon other systems, such as the 
exhibition of camphor, assafcetida, valerian, oxide of zinc, &c, 
medicines, the whole of which have been very generally recom- 
mended. In these untoward cases I have frequently had recourse to 
the application of ice to the head, combined with diluents, and the 
administration of calomel in laxative doses. But this method, like 
all the rest, is but too frequently unsuccessful. 

4. When confluent small-pox is accompanied with petechia?, ecchy- 
moses, epistaxis, and other hemorrhages analogous to those which 
are observed in purpura hemorrhagica, and which are very commonly 
attributed to an alteration of the blood, the use of purgatives, and of 
the acidulated decoction of bark, seem preferable to the antiphlo- 
gistic plan alone. Under all circumstances this variety of small-pox 
is almost uniformly fatal. 

427. Other general plans and particular means have been recom- 
mended; but the circumstances which especially or exclusively re- 
quire their employment have not been determined in a very precise 
manner. Thus, with a view to diminish the violence of the eruption 
and the symptoms which attend it, some have proposed to expose 
patients to the cold air, to plunge them into a cold bath, and to 
sprinkle or sponge the surface with cold water. The last-named 
measure never makes the pustules disappear, as some pathologists 
have expressed their fears it would ; but I have known it aggravate the 
symptoms of the laryngo-bronchitis, which, in a greater or less degree, 
always accompanies confluent variola. I have not, however, seen it 
tried sufficiently often to have made up my mind as to its advantages 
and inconveniences. Some physicians,— De Moneta, Ploucquet, and 
Hoffmann, have advised the use of cold applications to be restricted 
to the face. 

428. Several practitioners have supposed that they could cut short 
the course of the pustules by the free use of venesection. M. Janson 
states that a number of leeches, having been applied to the throat of 
a little girl labouring under confluent small-pox, gave occasion to a 
violent hemorrhage by which the patient was brought into great jeo- 
pardy, but which had the effect at the same time of causing the greater 



VARIOLA. 



157 



number of the variolous pustules to die off. This fact, however, and 
several others, analogous in their nature, by no means authorize in- 
discriminate attempts to cut short every case of confluent small-pox 
by copious and repeated bleedings ; the method, first recommended 
by De la Metrie, pursued as a general rule, would certainly be hurt- 
ful ; but such cases should embolden us to deplete freely at the 
commencement and during the eruption of coherent small-pox of a 
decidedly inflammatory character, accompanied by erysipelatous puf- 
fing of the face, congestion of the brain and laryngo-tracheitis. 

Pediluvia have been recommended in the hope of diverting the 
eruption to the lower extremities especially ; I have never seen this 
expectation realized. Dr. Delaroche, of the Maison Royale de Sante, 
directed the application of blisters to the legs with better success. 

When the eruption of small-pox appears slowly or with difficulty, 
and especially when this delay appears due to the impression of 
cold, as occasionally happens in winter among the poorer classes, 
some practitioners advise recourse to be had to the warm and vapour 
bath ; others recommend emetics, and others sudorifics, such as the 
acetate of ammonia : I have seen too few of these tardy eruptions to 
feel myself in a position to recommend in particular any one of the 
plans mentioned. 

Mercurial preparations internally and externally have been much 
lauded, as preventing or lessening the violence of the variolous erup- 
tion ; I have not myself tried them to a sufficient extent to enable me 
to venture an opinion upon their efficacy. 

Purgative medicines have been recommended in confluent small- 
pox to diminish the violence of the eruption, and even to make it 
abort entirely ; further experiments on the value of this idea require 
to be made. Purgatives are frequently of use at the period of suppu- 
ration, to lessen the ptyalism and inflammatory affections of internal 
organs so apt to show themselves at this stage ; they have also been 
particularly prescribed with a view to prevent verminous complaints, 
which are extremely rare at the present time. 

Tonics — wine, the bark, the mineral acids, and camphor internally 
and externally, may all become useful at the period of suppuration 
and desiccation, especially to the aged, and to cachectic children, or 
when the disease assumes a putrid or hemorrhagic character (Syden- 
ham, Foucquet). 

Opiates, especially by way of injection, are useful when dysenteric 
symptoms complicate small-pox ; and they have been recommended 
during the state of insomnia and delirium that accompanies the con- 
fluent disease (Sydenham, Stoerck). In these alarming cases, how- 
ever, their advantages have often appeared to me questionable. 

429. Symptoms of small-pox having once been declared, is there 
any mode of diminishing the virulence of its poison ? Some physi- 
cians have maintained the affirmative of this proposition. Moublet 1 
asserts that we may cut short the disease, or at least produce at our 
pleasure, variola sine variolis, by evacuating the virus with emetics 
and purgatives. De la Metrie believed that he could attain the 
same end by copious venesection, and this notion has been again 
brought forward in these latter times. Eichhorn is of opinion that 
the disease maybe made to abort by the free use of the mineral acids, 
and of calomel and antimonial preparations exhibited from the inva- 
sion of the primary fever. He also sets forth another piece of prac- 
tice, which, according to him, has great influence in rendering small- 
pox more benign. This consists in making from forty to fifty 
incisions on the person of the patient, as soon as the symptoms of the 
primary fever are discovered, or even when the eruption begins to 
appear on the face in the form of small hard papulae, into which as 
great a quantity of the vaccine virus as possible is to be introduced ; 
and he assures us that if the medical attendant have been called in 
time to do this, it will be his own fault if he ever lose a patient from 
small-pox. I have tried this practice on two occasions ; but both of 
the patients died, the one of the confluent, the other the nervous form 
of the disease. The stigmata of the eruption, however, were con- 
spicuous over the whole body at the time the vaccine inoculation was 
performed, and it was perhaps too late to give the operation a fair 
chance of succeeding ; it was also done with vaccine matter preserved 



Journal de Med. t. xvii. 1762. 



40 



between two plates of glass, and Eichhorn recommends the virus to 
be transferred directly from the vaccine pustule to the punctures. 

I must add that the experiments of Woodville, Willan, and M. 
Herpin upon the reciprocal influence of the variolous and vaccine 
virus, appear to favour the idea of Eichhorn, and I should, for my 
own part, certainly put the plan in practice as often as the opportu- 
nity for doing so occurred. 

430. The local treatment of variolous pustules has been the subject 
of numerous experiments. 

During the suppurating stage in adults, and especially in children, 
it is proper to wash the eyes frequently, with some emollient decoc- 
tion, and to cleanse and unplug the nostrils by instilling fluids of the 
same description from time to time. The heat which is complained 
of in the inside of the mouth maybe lessened by washing or garbling 
repeatedly, and by making patients sip a little cool drink at frequent 
intervals. It is also proper to prevent children from scratching them- 
selves, and should the skin appear in anyplace excoriated or ulcerated, 
it must then be dusted over with fine starch or the powder or lycopo- 
dium. Cotugno further recommends the pustules to be frequently 
bathed in order to accelerate their progress, and to render the pits 
less apparent afterwards. It was the practice formerly to follow the 
advice of the Arabian physicians, and open the pustules arrived at the 
period of suppuration, to squeeze out the pus they contained, and 
then gently to bathe and cleanse the surface with tepid milk and water, 
decoction of mallows or of poppy-heads. This system has always 
appeared to me to be beneficial: a patient who was under my care in 
the Hopital St. Antoine, on account of a very severe confluent small- 
pox, evidently owed his recovery to the zeal and attention of Dr. 
Bonnet, of Poitiers, who expressed and wiped away the matter from 
the whole of his pustules. 

Hufeland and Tournay recommended the pustules to be laid open, 
and Mr. Stewart, in 1829, proposed to plunge the point of a needle 
into the variolous elevations on the first or second day of their appear- 
ance, and by compression to force out the serum or blood which they 
contained. This measure does not seem so good as the system of 
cauterization to be mentioned immediately. 

With a view to check or modify the eruption, some practitioners 
have advised the skin to be briskly rubbed with a coarse towel, a 
short time after the appearance of the pustules. This recommenda- 
tion is now never acted on. 

431. Messrs. Bretonneau and Serres have proposed cauterization 
with the nitrate of silver as a means of cutting short the progress of 
the pustules of small-pox. M. Bretonneau recommends the apices of 
the pustules, shortly after their appearance, to be transfixed and re- 
moved with a needle of gold or silver charged with nitrate of silver. 
M. Velpeau advises the summits to be first removed, and the exposed 
points to be then touched with a sharp pencil of nitrate of silver, or a 
fine probe charged with a solution of this substance, which is to be 
plunged into the centre of the pustule, the surface being subsequently 
farther cauterized by the application of the caustic in substance. 
Others again have held that it was better to cauterize the pustules en 
masse, with a camel's hair pencil dipped in a solution of nitrate of 
silver, containing about a scruple of the salt to an ounce of distilled 
water, and to repeat this application if the first did not seem effectual. 

432. If, during the course of the first and second day of the erup- 
tion, the variolous papulae be deeply cauterized individually after 
opening their apices with the point of a lancet, they are often com- 
pletely arrested in their progress. About the seventh day the cuticle 
which has been exposed to the action of the caustic, falls off in plates, 
generally without leaving any apparent cicatrice. If the pustules are 
not treated with the caustic sooner than the third day, they frequently 
do not miscarry completely, and if the measure is not attempted earlier 
than on the fourth and fifth day, the operation then fails to check the 
progress of the inflammation, and the pustules are followed by cica- 
trices. 

The plan of cauterizing en masse is less painful and much more 
expeditious than the preceding one, which requires long hours to 
touch the whole of the pustules even of the face, in a confluent case. 
The general application of the caustic, however, scarcely ever puts a 
complete stop to the progress of the pustules when it is done even so 
early as the first or second day of the eruption. It suspends, indeed, 



158 



PUSTULE. 



to outward appearance, the march of the eruption, but when the crust 
produced by the caustic, comes to be detached, traces of variolous 
pustules which have- continued to advance unmodified through their 
regular stages, arc discovered beneath it. 

To sum up, on this head, then, it appears: 1. That the general 
cauterization of the pustules can only be advantageously instituted on 
... second day of the eruption. 2. That the application of 
the caustic solution should be restricted to those places which we are 
sted in preserving free from cicatrices; for the pain that attends 
the operation, and the reaction which follows it, induce me to believe 
that the cauterization of a large extent of surface would be more likely 
to cause than to prevent affections of the brain. 3. Lastly, the sole 
incontestable advantage of the individual cauterization of the pustules, 
performed in time, being to preserve the skin from cicatrices, the 
ectrotic method appears to me applicable rather to those pustules 
evolved upon the face in distinct or semi-confluent small pox, than to 
the coherent pustules of the most serious varieties of the disease, (a) 

(a) Among the means of abating the eruption and preventing the 
quent pits from small-pox, are the exclusion of light from the 
sick room, and covering the skin, as that of the face, with gold leaf, 
directly upon the invasion of the disease, and continuing the applica- 
tion, by renewal every morning and evening, until the end of matura- 
tion and the suppurative fever. The same good effects are represented 
to have been obtained by anointing the face of those who had small- 
pox with sweet oil. Another means of carrying out the ectrotic 
method, is by the application of sulphur ointment, slightly rubbed 
over the entire cutaneous surface, as recommended by Dr. Medivaine, 
of Ghent. The ointment is composed of two drachms of sulphur to 
one ounce of lard ; and it is to be used three times a day, at as early 
a stage of the disease as possible. 

A still more important ectrotic remedy is found in the external 
jtpplication of mercury by plaster or even ointment. M. Briquet 
;. IrcMves Cfhiirales de Medecine, Oetob., 1838), points out the details 
and advantages of this practice in the treatment of all the varieties of 
small-pox, whether simple, confluent or modified. " The effect of 
these plasters is, in general, either to prevent the development of the 
pustules, or so to modify them that they become mere abortions, and 
very slightly affect the skin. M. Briquet details several cases which 
support him in his opinion that mercury, locally applied, exercises 
great influence on the course and nature of the eruption. By the 
application of the plasters the exanthema either undergoes complete 
resolution, or it is converted into vesicles or tubercles. The resolu- 
tion is either primitive or secondary. The former takes place when 
the plaster has been applied whilst the eruption is still papular, and 
its effect is the complete disappearance of a number of papulae, which, 
without the application of the plaster, would have passed into pustules. 
This diminution of number, as ascertained by counting the number of 
papulae before and after the application of the plaster, varies from a 
third to a tenth of the whole number. Secondary resolution ensues, 
when the papula;, after being covered by the plaster, increase in size 
for two days, and then pass into resolution. But the most general 
effect of the plasters is to produce conversion of the eruption into a 
vesicular or tubercular form. The vesicular is the more common, 
and in such cases the eruption bears considerable resemblance to 
herpes, or to vesicles which have been developed under a cataplasm. 
The vesicles, when they have reached their maximum development, 
contain a milky fluid ; theirwalls are formed by an epidermis extremely 
thin, and not at all tense, and their base is sometimes surrounded by 
a slight areola of a pale rose colour. They vary in size ; the smallest 
are not larger than the point of a pin, the largest equal a millet-seed. 
The skin between the individual vesicles is pale and white, and never 
red and swollen as in pustular small-pox. 

" The slightest friction destroys the epidermis of the vesicles, and 
their base then appears as a moist, slightly red surface, which, on the 
day after the removal of the plaster, has already become dry and 
covered by a debcate epidermis. No scales are ever formed on this 
surface. In no case has M. Briquet ever seen a prominent cicatrix 
formed, except in one whmh was treated by M. Nonat, and in which 
there were a number of very minute cicatrices, but still widely differ- 



433. Certain complications and several phenomena which occur in 
the course of small-pox, require particular attention. 

The inflammatory affections of the mucous membranes which ac- 
company the eruption of small-pox — the ophthalmia, coryza, laryngo 
tracheitis, stomatitis, &c, all require the antiphlogistic plan of treat- 
ment. "Ubi vistituerctur si variola non adessen''' is a rule which I 
used at one time to take as my guide, but which now appears to me 
to require modification. In fact, it is found that variolous inflamma- 
tory affections do not give way to blood-letting like the inflammations 
that are independent of the agency of miasmata, or the inoculation 
of a poisonous virus; in the latter description of cases the antiphlo- 
gistic treatment ought certainly to be much less energetic than in the 
former. 

If inflammation of the encephalon be an extremely rare complica- 
tion in confluent small-pox, it is still worthy of remark that the noc- 
turnal exacerbations are almost always accompanied by delirium and 
agitation. After the abstraction of a moderate quantity of blood, and 
the application of a number of leeches behind the ears, or to the 
openings of the nostrils, I have several times succeeded in allaying 

ent from the deep marks of common small-pox. In this case M. 
Briquet doubts whether the plaster had been rightly applied. 

"In order that the plasters may have the effect of modifying the 
eruption, they must be applied before it has become pustular; when 
applied later than the fifth day, they do not appear to exert any bene- 
ficial influence. 

" The conversion into tubercles is more rare, and generally takes 
place in cases of confluent small-pox. They harden and desquamate, 
soon after removal of the plaster, without leaving any permanent 
cicatrix. 

" The plaster is best applied spread upon some coarse stuff, stiff 
enough to support itself, and thus remain in exact contact with the 
skin. A little mercurial ointment is applied to the eyelids and nostrils, 
as the plaster cannot readily be kept upon these parts. The plaster 
is allowed to remain for three days in simple small-pox, and a day 
longer in confluent cases. No benefit is derived from a longer appli- 
cation, but rather the reverse, as softening of the base of the vesicles 
may ensue in consequence, and cicatrices be formed. 

" When the plasters are allowed to remain too long, a slight ery- 
sipelas may be the consequence, but this is extremely rare. In two 
cases an eruption resembling measles followed the application of the 
plasters, but it did not appear certain that it was in consequence of 
them. A slight eczema is sometimes produced by the plasters, but 
its extent is always very limited, and it is of little consequence. In 
no case was any deleterious effect produced by thus modifying the 
eruption, but the advantages appear to be many. The inflammation 
that would otherwise have ensued in confluent cases was obviated, 
and the brain thus in all probability prevented from being affected. 

" The mercury seems to be the chief agent in effecting the modifi- 
cation. Pressure did not produce the same effects, for the pustules 
were developed as fully below the adhesive plaster as upon the free 
surface of the skin. Neither have the plasters of lead any effect in 
changing the nature of the eruption; but the modification is produced 
by mercurial ointment spread upon the surface, equally well, if not 
better than by the mercurial plaster." 

M. Olliffe, President of the Parisian Medical Society, read a paper 
before that body, recommending the mercurial topical practice. It 
would seem from his experience, that, although it failed as an ectrotic, 
when used in the pustular stage of small-pox, it still greatly modifies 
and ameliorates the local inflammation. 

The plaster employed by these gentlemen is the emplastre de vigo, 
or the emplastrum vigo cum mercurio of which the following is the 
formula. 

R- Mercury 95 parts: 
Balsam of Storax 48: 
Common plaster 312: 
Wax, resin, and turpentine, of each 16: 
Gum ammonia, bdellium, olibanum and myrrh, each 5 : 
Saffron 3 : 

Spirit of lavender 2 : 
M. 



VARIOLA. 



159 



these cerebral symptoms by the prolonged and repeated application 
of ice, or of cloths wrung out of cold water, to the head, at the same 
time that the feet were enveloped in warm emollient cataplasms, or 
that blisters were applied to the legs. 

434. During convalescence from small-pox, the occurrence of 
furuncles, of ecthyma, and of various other forms of cutaneous in- 
flammation, besides attention to regimen, almost always require the 
use of the simple emollient warm bath ; this is also the period when 
it is frequently useful to exhibit mild purgatives, unless the state of 
the intestinal canal contra-indicates the practice. 

The diarrhoea and cceco-colitis of convalescence are successfully 
met by means of milk diet. 

Abscesses ought to be opened at as early a period as possible, and 
sloughs and excoriations of the sacrum, when they occur, require to 
be dressed with the greatest care. 

435. From time immemorial, it has been the practice in Georgia, 
Circassia, Egypt, and Hindostan, to inoculate small-pox, in order to 
make it less fatal in its effects. This operation, long unknown in 
Europe, was performed, for the first time, in 1673, by Timoni and 
Pilarino, 1 during the prevalence of an epidemic small-pox which 
desolated Constantinople. The fame of the method, introduced into 
England by Lady Mary Wortley Montague, spread rapidly, and was 
generally practised all over Europe, until Jenner showed that the 
inoculation of the cow-pox possessed immense advantages over that 
of the small-pox. (a) (Vide Vaccinia.) 

Historical Notices and particular Cases of the Disease. 

436. Aharoun or Aaron is the first writer who mentions small-pox 
(622 B. C.) under the name of djidri, which the Latin translators 
have rendered by the word variolce. The description of Rhazes 2 is 
so accurate as to leave no doubt in regard to the nature of the disease 
he witnessed, although it is very singular that he should have made 
no mention of the contagiousness of the affection. As to the thera- 
peutical views of the Arabian writer, M. Eusebe de Salle 3 has shown 
that these formed the prominent feature in his work, and that Syden- 
ham, whatever may have been said to the contrary, had, in fact, 
added little to their excellence. 



(a) " In inoculated small-pox the proportionate mortality is very 
small ; but although the individuals who were submitted to the process 
of inoculation were safe, with comparatively little risk from present 
disease, and protected with considerable certainty from future attacks 
of small-pox, yet the mortality from this disease among the people 
generally was greatly increased. A large class of unprotected persons, 
who either could not or would not avail themselves of the benefit of 
inoculation, continued to exist in every country; and they became 
greater sufferers by the multiplied foci of contagion, caused by the 
separate cases of inoculation. Dr. Lettsom, by documents delivered 
to the committee of the House of Commons, and founded on deduc- 
tions from the bills of mortality, distinctly proved that in the fifty-five 
years preceding the introduction of inoculation, or between 1667 and 
1772, the average number of deaths occasioned by small-pox was, to 
the number of persons that had died of all diseases, only as seventy- 
two to 1,000; while in the forty-two years succeeding the practice of 
inoculation, the proportion had increased to eighty-five in the 1,000; 
and subsequently, Sir Gilbert Blane had calculated, that in the last 
thirty years of the past century it had increased to ninety-five in 
1,000; adding, that in the year 1800 the small-pox had broken out 
twenty times in the Channel fleet alone." Bell and Stokes' Lectures, 
3d edit., p. 722, vol. ii. 

1 Timoni (Em.). Historia variolarum quae per incisionem excitantur. Constan- 
tino, 1715. — Pilarino (J.). Nova et tuta variolas excitandi per transplantationem 
methodus, 12mo. Venetiis, 1715. 

* Rhazes. De variolis et morbillis,interprete Joanne Channing,4to. Oxon., 12mo. 
Goettingae, 1781. (6) 

3 De Salle (Euseb.). De la yariole chez les medecins Arabes [Journ. complem., 
U xxxii. p. 193]. 

(6) See also an English translation from the Latin version, pre- 
pared by Dr. Mead and published with the works of the latter. 



Many inquirers have maintained that small-pox had been seen by 
the Greek physicians; Willan 4 has strengthened this opinion by much 
deep and very learned research, which, however, has not satisfied 
my mind of its accuracy. 

It is generally believed that the first eruption of small-pox occurred 
in Arabia. According to an Arabic manuscript in the library of Ley- 
den, it seems to have appeared there about the 572d year of the 
Hegiera. Transported into Egypt in 640, at the period of the con- 
quest of this country by the Caliph Omar/ it afterwards spread in all 
the directions in which the Saracens carried their arms. In this way 
it reached Spain, Sicily, Naples, and France, from whence it was 
communicated to the rest of Europe and to America. There is a 
passage, however, in the chronicle of Marius, Bishop of Avenches, 6 
which might lead to the belief that small-pox had appeared in Europe 
long before the date usually assigned to its introduction. 

437. Interesting observations on congenital small-pox ; 7 on second 
attacks of the disease; 8 on variola sine variolis ; 9 on the laws of the 
etiology of small-pox ; 10 on epidemics of benign, 11 and of malignant 
small-pox ; 12 and of small-pox possessed of various characters; 13 on the 
complication of this disease with peripneumonia ; u with (edematous 
angina; 15 with pseudomembranous angina; 16 with croup ; 17 with pseudo- 
membranous bronchitis, 18 with the granular eruption of the intestinal 
canal, 19 with purpura, 20 &c. Various remarks have also been made 
on the secondary fever , 21 and on diseases consecutive to small-pox. 22 

For information on the structure of the pustules, the work of 
Cotugno 23 may be consulted (he has given a good account of the 
small white filaments which traverse small-pox pustules), and the 
lectures of M. Chevalier, 24 who has demonstrated the existence of 
a pseudo-membranous substance in the umbilicated pustules. M. 
Deslandes has erroneously ascribed the pits in the centres to the 
pores of the skin ; another writer, 25 upon no better grounds, indicated 
the sebaceous follicles as the seat of the disease. Even the crusts"'- 6 
of small-pox have repeatedly been made the subject of chemical 
analysis. Remarks have been published on the treatment of small- 
pox, by excluding the light, 27 by puncturing, 2S and by compressing 29 the 
pustules, and on the ectrotic, or method of treatment by cauteriza- 

* Willan. Miscellaneous Works. — An inquiry into the antiquity of the small-pox, 
etc., edited by Ashby Smith, 8vo. London, 1821. 

5 Paulet. Histoire de la petite-verole, 12mo., 2 vol. Paris, 1768. 

6 "Hoc anno (570) morbus validus, cum profluvio veniris et variolis, Italian 1 ., 
Galliamque afflixit." (Histor. francor. scriptor. t. ii. — Marii Episcopi chronicon.) 

i Jenner. Med. chir. transact., v. i. p. 269. — Deneux. Cas de variole chez un 
nouveau-ne, la mere ayant ete vaccinee (Journ. hebdom., t. viii. 2e serie, p. 5G) — 
Husson. Revue medicale, t. xi. p. 151. — Noblet. Archiv.gener.de med., t. xvii. p. 
126. — Jermyn. Diss, de variolis a graviditate foetui traditis. Leidse, 1792. 

6 Oppert. Journ. complent., t. xxxvi. p. 189. — Bull, des sc. med. de Ferussac, :. 
xx. p. 182. — Th. Barnes. Cases of five indiv. having the small-pox twice. Edin. 
Med. and Surg. Journ., v. xix. p. 182). — Gregory, med. gaz. 

' Pautier de Libreville an variolarum morbus absque eruptione? Paris, 1747. — 
Du Boury. Diss, an variolarum morbus absque eruptione 7 Paris, 1772. 

"° Herpin. (Gaz. medic. 1832, 4to. p. 563.) 

11 Von Hoven. Geschichte eines epidemischen Fiebers, etc., 8vo. Jena, 1795. 

12 Plinta (Jo. Max.). Histor. epid. variolos. Erlangensis, anni 1790. — Erlangap. 
1792. 

13 Otto. Note sur les epid. de variole qui ont regne en Danemark et en Suede. 
(Revue med., t. viii. p. 115.) 

14 Robert. Epidem.de Marseille (Rev. med., Jan. 1829, p. 90). — Couture. Des 
varioles compliquees, 4to. Paris, 1829. 

15 Nole. Journ. Hebdomad., 1832, t. ix. p. 434. 
'6 Louis. Gazette medic, 1831, p. 224. 

17 Gazette medic, 1833, p. 141. 

18 Lancette francaise, t. vi. p. 21. 

'9 Bouilland. Journ. hebd., 1832, p. 327. 
2" Journ. Hebd., 1832, p. 327. 

21 Halle. Sur la fievre secondaire et l'enflure dans la petite-verole. (Mcm.de la 
Soc. Royal de Med., t. vii. p. 423.) 

22 Arch, gener. de medec, t. xxvii. p. 542 (abces nombreux).— Weller. Traite 
theor. et pratiq. des mal. des yeux, t. ii. p. 154. 

23 Cotugno. De sedibus variolarum syntagma, 12mo. Vienna?, 1771. 

24 Chevalier. Lectures on the general structure of the human body, p. 168, 8vo. 
London, 1823. 

26 Deslandes. Memoire sur les boutons de la variole, precede de quelques con- 
siderations sur les pores cutanes. (Revue medicale, t. vii. 1825, p. 329.) 

2i Oakley Heming (G). Lond. Med. Gaz., vol. v. p. 140. 

27 Lassaigne. Analyse des croutes varioliques (Journ. de chimie medicale, t. viii. 
p. 734). — Lamorliere. Journ. de chim. med., t. iv. p. 488. 

28 Picton. Archiv. gener.de medec, t. xxx.p. 406. — Nouvelle rev. med. 1832, t. iii. 
p. 293. 

29 Stewart. Lond. Med. Gazette, t. iii. p. 525 : Treatment of small-pox, by punctur- 
ing the pustules. 



160 



PUSTULE. 



lion. 1 Calamine' and chlorate of lime 3 have been recommended 
to prevent the occurrence of cicatrices; lastly, copious venesection 
baa been recommended to cause the miscarriage of the pustules. 4 
The Bubiecl of inoculation of small-pox has given occasion to many 
This operation by means of punctures has been performed 
on animals in the hope of producing the small-pox pustules, but in 
v.iin." Dr. Sunderland 7 having lately announced that he had suc- 
ceeded in engendering vaccinia in kine, by clothing them with a 
id taken from the bed of a small-pox patient, the experiment 
was repeated by Dr. Numan of Utrecht, 8 who informs us that no 
eruption occurred either on the teats or udder, but that a few vario- 
lous pustules were developed on the bodies of the animals. These 
experiments require to be repeated. 

To conclude, Dr. Gregory has proposed to divide legitimate variola 
into five varieties. 9 

Case LXIV. — Confluent small-pox of the face ; cerebral congestion 
treated by means of ice ; gastro-intestinal irritation ; boils. Et. Tron- 
chet entered La Pitie on the 24th of February, 1826. Eight days 
previously he had been attacked with sickness and vomiting, head- 
ache and fever, which for the last three days had kept him confined 
to his bed. Last night, after several attempts to vomit, and a noise 
of ringing in the ears, an eruption was remarked upon the skin. A 
considerable number of red raised spots, which under the finger feel 
like small rounded grains, are scattered over the face, and also, but 
more sparingly, over the trunk and limbs. These spots become pale 
on pressure, but still continue elevated above the surface; some of 
those of the face show a transparent point at the summit ; the skin 
is hot and perspiring; the tongue white, moist and very red on the 
edges; the patient is thirsty, complains of epigastric pain, and the 
belly seems tumid ; he has a dry cough, which increases the pain of 
the abdomen ; the pulse is full and frequent {fifteen leeches to the epi- 
gastrium; mucilaginous drink ; low diet). 26th. — No sleep through the 
night ; singing in the ears ; chills succeeded by copious perspirations ; 
the leech bites continue to bleed; the spots of the face are larger and 
more numerous ; the tops of the majority of them look white ; the 
skin preserves its natural colour in the intervals between several of 
them, but it is red in those places where the eruption is clustered and 
confluent. The eruption is greatly increased since yesterday on the 
forearms, wrists, and eyelids. Tongue of a yellowish white ; pain 
and heat of the pharynx ; constipation ; cough without alteration of 
voice ; heaviness of head, and tardy answers to questions {mucilagi- 
nous drinks). 27th. — Sweating; delirium during the preceding night. 
The pustules are larger, less prominent, and full of a sero-purulent 
fluid ; several show a small depressed point in the centre. The con- 
junctiva is injected and moist, the nose swelled and painful; the 
nostrils seem obstructed. The patient complains of shooting pains in 
the head, of inability to fix his eye steadily on any thing, and of 
weakness in the senses of sight and hearing {thirty-two leeches to the 
forepart oftlie neck, mucilaginous drinks). 28th. — The patient had 

' Serres. Methode ectrotique appliquee au traitement de la variole confluente. 
(Arch. gen. de med., 8vo. Paris, Juin 1825.)— Velpeau.— Note sur l'emploi des 
caustiques comme moyen d'arreter I'eruption varioleuse (Arch. gen. de med., t. viii. 
p. 437).— Meyraux. Methode ectrotique de la variole (Annales de la med. physiog. 
t. viii. p. 267). — Discussions academiques sur la methode ectrotique (Revue medic, 
t. viii. pp. 166-174.— Ibid. t. ix. pp. 153-157).— Serres. Considerat. nouvelles sur la 
variole. (Gaz. medic. 1832, pp. 58-77.) 

2 George. Lancette franc., t. v. p. 252. 

3 Gubian. Lancette franc., t. v. p. 7. — Lond. med. Gazette, v. viii. p. 240. 

4 De la Mettrie CEuvres de medecine. Berlin, 4to., 1775. — Janson. Arch, gener. 
de med., t. yi. p. 75. 

6 Dezoteux et Valentin. Traite theorique et pratique de I'inoculation, 8vo. Paris, 
1799. — Woodville. The history of the inoculation of the small-pox in Great Britain. 
London, 1796. Dimsdale. Present method of inoculating for the small-pox, 8vo 
Lond. 

« Fiard. Gaz. medic. Paris, 4to., 1833, p. 693. 

" Sunderland. Bull, des sc. medic, de Ferussac, t. xxv. p. 158. 

s Numan. Inoculation de la variole et de la vaccine aux brebis. (Bull, des sc. 
medic, de Ferussac, t. xii. pp. 45-142.) 

» London medic, gazette, vol. v. p. 221 j 

1. Superficial variola in which the eruption only attacks the skin. 

2. Cellular variola in which the variolous action extends to the subcutaneous cel- 
lular membrane, and is followed by abscesses. 

3. Laryngeal variola in which the inflammation attacks the larynx and trachea. 

4. Nervous variola. J 

5. The fifth variety is owing to an altered state of the blood, and is characterized 
by petechia; and passive hemorrhage. 



passed the night in a delirious state, and had sprung several times out 
of his bed. The face is red and swollen, and the pustules are almost all 
coherent. Other symptoms continue much the same ; pulse frequent 
{ice to the head). The confusion of head went off while the ice 
remained applied ; but as it subsequently returned, the ice was re- 
newed and the patient passed a quiet night. March 1st. — The face 
more swelled than ever ; several pustules discovered on the sides of 
the tongue, which is white and moist. General symptoms continue 
as before, but the pulse is no longer quick, and there is some head- 
ache {demulcent drink with honey ; ice to the head, emollient glyster). 
The whole of the cerebral symptoms are much improved since the 
ice was applied, and the patient has not again been delirious. 2d. — 
The pustules of the face are nearly in the same state as yesterday ; 
the features are swelled, but the colour of the skin is not so deep as 
it is usually in confluent small-pox. A series of small pustules beset 
the free edges of the eyelids. The tongue is dry in the centre, moist 
on the edges ; the patient is thirsty ; he swallows with greater ease, 
and has had a natural evacuation from the bowels ; the pulse is 
quick ; the voice, clear and sonorous {demulcent drink ; lavement). 
In the evening, some degree of deafness, singing in the ears, and 
headache ; a fresh application of ice was followed by sleep. 3d. — 
The eyelids are closed and bathed in a serous and puriform fluid ; 
several pustules have begun to dry up. The tongue is painful and 
swelled ; thirst ; abdomen tumid ; expulsion of flatus by the mouth ; 
colic ; pain in the pharynx, voice natural ; pulse frequent. The ice 
was not applied during the day ; the headache returned, and was 
followed by a sort of stupefaction. 4th. — The desiccation of the 
pustules is very far advanced on the lips, chin, and ake of the nose ; 
on the limbs and chest the eruption is still suppurating, the pustules 
being large, slightly flattened, and opalescent in colour ; a very few 
of them only are punctuated and depressed in the centre. Ecchy- 
moses have taken place spontaneously over the clavicles. Continued 
perspiration, tongue dry and brown, considerable thirst {demulcent 
drink ; ten leeches to the front part of the neck ; ice to the head). The 
patient slept during the night. 5th. — Swelling of the face subsided ; 
the whole of the skin is hot, and painful to the slightest touch. 
Tongue moist ; deglutition still more easy ; thirst ; constipation ; 
voice sonorous ; pulse by no means quick ; slight headache {honey 
drink ; ice to the head for half an hour). The patient passed a quiet 
night. 6th. — Large brown incrustations on the chin, yellow or 
brownish scabs on the cheeks, separated by several pustules, the 
development and suppuration of which occurred at a late period. 
The pustules of the forehead and temples are not yet desiccated. 
The patient complains of intense pruritus and painful shootings in the 
face ; on the breast the greater number of the pustules are still full of 
pus ; on the limbs they are generally umbilicated, and have a silvery 
appearance ; on the forearms the centres of a few of them begin to 
grow yellow ; many clusters are shrunk and wrinkled. Tongue 
moist and white ; considerable thirst ; some sensations of hunger ; 
natural evacuations from the bowels. Headache in the evening 
relieved by the application of ice for three-quarters of an hour ; sleep 
during the night. 7th. — The pustules of the back part of the neck 
flattened and brown in their centres. On the wrists they look silvery. 
Proceeding from the circumference towards the centre, the greater 
number are surrounded successively with a pale rosy and linear 
areola, a white circle, a second slightly brown circle, lastly a circle 
of yellowish-white, the centre of which is depressed. The whole 
face seems covered with one large incrustation, forming a kind of 
party-coloured mask, of various shades of brown, yellow, and green. 
Several purulent bullae are observed on the wrists and left forefinger. 
Tongue and digestive apparatus are in the same state as before. 8th. 
Several pieces of incrustation are detached over the right cheek, and 
the skin they covered appears ulcerated in different places. On the 
left cheek the incrustations seem ready to fall ; on the forehead they 
are more adherent. The pustules of the chest shrink and dry up 
apace, as do those of the forearms also. The greater number of those 
situated on the knees and legs are still full of pus ; all the others are 
flaccid {mucilaginous lemonade; soup). 10th of March. — The desqua- 
mation continue in the face ; the skin, where freed from the incrus- 
tation, presents several chaps from which a few drops of blood have 
distilled. The pustules are drying on the fingers {panada ; broth ; 



VARIOLA. 



161 



■mucilaginous lemonade). 11th. — Desquamation continues. A boil has 
been evolved on the right side of the chest. Tongue clean ; appetite ; 
sleep ; pulse weak and slow (lemonade as before, the eighth hospital 
allowance, without any wine ; lavement). A second boil has appeared 
on the sacral region ; the patient was up for four hours during the 
day. 13th. — Itching and tingling over the whole of the integuments ; 
mouth clammy, belly somewhat tense. 14th. — Same state (the half 
portion without wine). 15th. — Mouth dry, thirst, pains in the bowels 
(mucilaginous lemonade, beef-lea). The irritable state of the aliment- 
ary canal which had formed one of the features in the case during the 
whole of its course, and was attended with the disengagement of 
large quantities of flatus, still continued for some time longer, requir- 
ing particular attention to diet and regimen ; but the patient finally 
left the hospital perfectly well on the 20th of March. 

Case LXV. — Congenital ichthyosis ; confluent small-pox, the pustules 
of which seemed to be impeded in their development by the unusual thick- 
ness of the epidermis ; laryngo-tracheitis . — J. Porte, aged twenty-three, 
the subject of a congenital ichthyosis, entered La Piti6 on the 10th 
of March, 1826. He had complained of headache, and great pain 
in the loins on getting up in the morning of the 11th ; next day, he 
vomited two or three times. On Monday, the 13th, an eruption of 
small-pox appeared ; a great number of red prominent elevations were 
scattered over the whole surface of the body. The skin of the face 
looked mealy, that of the thorax was uneven, rough to the touch, and 
traversed by slight furrows and prominent lines which crossed each 
other irregularly. On the sides of the chest and upper parts of the 
abdomen the cuticle was coming off in scaly layers. On the other 
parts of the belly it was of a mixed gray, and light greenish colour, 
disposed in perpendicular bands about three lines in breadth, sepa- 
rated from each other by slight furrows, the delicate cuticle of which 
formed a strong contrast with the thickness of that of the bands. On 
the back, arms, and shoulders, the cuticle was hard and thick, and 
was detached in scales. The forearms and thighs were affected with 
a slight furfuraceous desquamation. The patient informed us that 
his mother, his maternal uncle, and one of his brothers were affected 
in the same way. On the 15th, the furfuraceous skin of the face was 
covered with pustules so closely crowded together, that there was 
scarcely a point unoccupied ; they were also confluent on the fore part 
of the neck, and were extremely numerous on the chest and limbs. 
The tongue is white, covered with nascent pustules ; there is head- 
ache ; answers to questions are delivered slowly ; noises are complained 
of in the ears ; the pulse is frequent and unequal ; deglutition is difficult; 
pain is felt in the throat and pharynx ; and fits of sneezing occur at 
intervals. 16th. — Sleeplessness, and raving during the night (the 
patient confined with the strait waistcoat) ; great dryness of the skin ; 
pustules of a dull white colour, tongue yellowish, pain and very evi- 
dent heat in the pharynx ; swallowing performed with great difficulty ; 
hard and distressing cough ; pulse strong and frequent. 17th. — The 
delirium last night was again violent and attended with extreme rest- 
lessness. 

The pustules on the face are confluent and umbilicated, but they 
scarcely rise above the level of the skin. On this region as well as upon 
several others, they seemed to be impeded in their evolution by the 
morbid and thickened state of the epidermis. The redness and swell- 
ing of the face are less remarkable than in small-pox developed in 
healthy integuments. On the abdomen and lower extremities, the 
eruption is less marked. The conjunctivae are injected and the seat 
of an unpleasant sensation of smarting ; the bowels have been locked 
up for a week, but the abdomen is nowise painful ; cough very dis- 
tressing. (Diluents, sixty leeches to the lower part of the neck.) 
18th. — Rather better ; the pustules of the face are stationary ; the fea- 
tures are not swelled ; cough guttural and frequent ; nostrils dry and 
plugged with mucus ; conjunctiva? injected ; bowels opened ; degluti- 
tion easier (gum-water). 19th. — The pustules of the face are generally 
shrunk and shriveled ; those of the legs are small, white and but 
slightly raised above the surface ; some of them are even shrunk and 
of a brownish colour ; the restlessness and delirium were less in degree 
last night ; slight headache ; frequent cough ; pain in the windpipe ; 
voice altered and hissing ; guttural rattle during expiration ; tongue 
brown ; deglutition followed by cough ; pulse excessively quick. 20th. 
— Several brown scabs have formed on the forehead and at the root of 
41 



the nose. On its alae and bridge, the cuticle is detached over a space 
of an inch in diameter, leaving the dermis exposed, the surface ol 
which appears uniform and of a brownish-red colour. No farther 
traces of pustules are discoverable on the cheeks ; on the other parts 
of the face they are coherent, flattened, and form large white and 
slightly prominent patches. On the trunk the pustules are flattened, 
white, very slightly raised above the surface ; several of them are dry 
upon their summits. On the lower parts of the legs, large epidermic 
scales appear ready to fall off; the skin is of a pale red in the greater 
number of the intervals between the pustules, and white in the rest. 
The eyelids are flaccid, lips half open, tongue brown, covered with 
yellowish pustules upon the edges ; abdomen soft, epigastrium painful : 
deglutition followed by cough ; sonorous rattle at the inferior lateral 
part of the left lung, respiration noisy, cough troublesome, voice 
hoarse and weak, pulse small and contracted, death at noon. 

Examination of the body. — The skin of the face is but little in- 
jected ; that of the neck, legs, posterior parts of the thighs and buttocks 
is of a deeper red than usual ; and the morbid coloration has not the 
livid tint observed in dead bodies generally. All the pustules which 
have not been injured are umbilicated, even in those situations where 
the ichthyosis is most remarkable ; but they are generally smaller than 
the pustules at this period of small-pox. Head, abdomen, thorax. — The 
subserous cellular tissue of the arachnoid membrane covering the right 
lobe of the brain is injected ; the same structure of the left side also 
exhibits several red patches ; the base of the brain does not appear 
more vascular than usual ; the white substance of the interior is slightly 
sandy (sabUe) and there is a little serum in the ventricles ; the other 
parts as well as the cerebrum are natural. The conjunctiva of the eye 
is not inflamed ; but the membrane of the nasal fossae is of a vivid red, 
and overlaid with thick yellow mucus. This membrane can be de- 
tached with the greatest facility from the bone beneath ; the arch of 
the palate is covered with a great quantity of gray matter, the remains 
of the pustules with which it has been beset. The pendulous veil of 
the palate and its pillars are of a livid red. The tongue is covered 
with a thick, white matter ; its papillae are extremely prominent ; its 
centre is livid and its muscles are injected. The whole of the pharynx 
is covered with a yellowish exudation ; the natural colour of the 
oesophagus forms a strong contrast with the inflammatory tint of the 
pharynx. The stomach is distended by matters tinged with bile. 
The inferior curve presents a punctuated red appearance over an 
extent of about three inches every way. The termination of the small 
intestines, and the ccecum in particular, are not inflamed, and show no 
traces of pustules. A large quantity of bilious-looking stuff is con- 
tained in the different portions of the intestinal canal. The liver is 
large, and the spleen looks gorged with blood. The lining membrane 
of the larynx, trachea and bronchia is beset with small white spots 
crowded together in different degrees. These were not pustules, in 
the proper sense of the word, for small spots of a white colour, cir- 
cular in shape, flattened on their surface and from one to two lines in 
diameter, were all that were detected. Some of them were no larger 
than a millet-seed, others in their form and dimensions resembled the 
clusters of confluent small-pox as they appear in children ; others again 
were of the most irregular and dissimilar shapes, and evidently re- 
sulted from the agglomeration of several of the patches. The mem- 
brane over which these spots were dispersed, was in several regions 
of a livid red colour, and the various changes of which it formed the 
subject, gave it altogether a marbled or variegated appearance. The 
redness declined gradually from above downwards, and became less 
and less appreciable as the minuter subdivisions of the bronchi were 
attained. There was no trace of pustules beyond the bifurcation of 
the trachea, although the mucous membrane of the air-tubes generally 
was highly inflamed. The lungs were gorged in their posterior parts ; 
the bronchial glands, situated near the first division of the bronchi, 
were black ; the heart was sound, the right auricle alone presenting a 
livid tint, probably communicated by the great quantity of blood dis- 
tending its cavity. The aorta and crural arteries contained little blood, 
but presented a great number of red stains of various shades of colour, 
which did not extend beyond their inner membrane. 

The muscles were of a brownish-red hue ; the sheaths of the ex- 
terior tendons of the left foot were full of yellowish pus ; the articula- 
tions were healthy. 



162 



PUSTULE. 



The red colour of the inner membrane of the arteries which I was 

formerly, 1826, inclined to attribute to inflammation, appears to me 

now tube owinc rather to the lutltbition of blood, which would seem 

i iToured in some patients who die of small-pox by a peculiar 

state of this fluid, (a) 



(a) I introduce here the three following cases which occurred in 

mi hospital practice, and which are detailed in the passages already 

referred to in JV. . lm. .\hd. Sown. They will serve to show the 

appearance of the gastro-pulmonary mucous membranes in the several 

s of the disease. 

" I. — Ann Collins, white, aged 18 years, unprotected, became sick on 
Tuesday evening March 23, 1824, and was taken to the Almshouse, 
as one having the measles on Wednesday. On Thursday evening, 
some eruption was visible ; on Saturday evening, March 27th, ad- 
mitted. 

" 28th. — Visited. Face covered with a red, flat, dry eruption, par- 
ticularly on the cheeks; small and vesicular on the chin and around 
the mouth. On the arms, it has the appearance of measles ; on the 
hands, it is of a deep scarlet, with central vesicular elevations ; on 
the legs is slight; tongue loaded and yellow, except at the borders, 
which are clean ; pulse natural ; complains much of pain in the back 
and sickness of stomach. 

"30th. — Eruption covering the face, vesicular on a deep red ground 
with some tumefaction ; rising vesicular on the limbs with scarlet 
bases. Tongue smooth and shining anteriorly, and with vesicles on 
it. Throat sore. Salivation. Pulse small and feeble. Has had 
menorrhagia since her admission into the hospital. 

"31st. — The menorrhagia continues. Had last night epistaxis. 
Pulse small and slow. Tongue furred and red. Eruption confluent 
with indented and dark centres. Surface white and dry. Skin 
between red and inflamed. Very slight eruption on legs, and none 
on feet. 

"April 1st. — Menorrhagia continues. Pulse small and labouring. 
Respiration laborious and hurried. Face swelled. Surface smooth, 
with white spots to represent the pustules. On breast and arms the 
eruption is in confluent patches which are nearly continuous — some 
pustules flat and indented, others smooth, with appearance of radii, 
and some more elevated forming blebs. Skin of the feet cold, and 
blue in spots; no elevated eruption on lower extremities. Tongue 
furred and yellowish. Throat sore. Eruption very copious on body, 
generally with blebs. 

" Vespere; pulse hardly perceptible. Anxiety and distress £reat. 
Dead at 10 P. M. 

"Examination April 2d, in the afternoon. — On opening the thorax, 
the lungs and heart were found of the natural appearance and size. 
The larynx and trachea being divided, exhibited all the way down 
to the lungs an injected surface with whitish irregular spots, having 
nearly the same appearance as the flat smooth eruption on the face : 
in parts it was more evidently pointed, and showed by the aid of the 
microscope, a pustular appearance. In the lungs, the inner surface 
was still darker. The root of the tongue was covered with large and 
rather hard papillae, with open summits. The oesophagus was smooth 
and white. The stomach near the cardia injected, and of a brownish- 
red in spots : the remaining portion white, presenting no diseased 
appearance. The spleen was very large and covered with copious 
miliary points. The omentum, to appearance gangrened, was dark, 
and altered in texture. The peritoneum, especially in the pelvis' 
was injected and inflamed, being of a semi-opaque dark colour! 
Che uterus, small and firm, contained some bloody mucus in its 
cavity. 

" 1 1.— Joseph Foster, white, aged 22 years, unprotected, became sick 
on Monday evening Sth of March. The eruption began to show itself 
on \\ ednesday morning, 10th. 

" 12th.— Admitted and visited. Face covered with a red, dry, 
tubercular eruption, with some few yellow pustules. Same on arms 
but no pustular appearance; partly tuberculous, partly vesicular. 
sparse and scattered on breast and legs : none on feet. Slight 
cough. I ongue white, clammy, and loaded in middle-red at borders. 
I'ulse rather frequent. 

"14th.— Face covered with a pustulo-vesicular eruption with 



whitish summits, red and inflamed bases. Skin between of same 
colour. Eruption dry and hard ; very red, copious on limbs; less so 
on trunk. Tongue moist and less loaded. Pulse regular. 

" 15th. — No fever. Face of a deep red colour; eruption rising from 
it rather flat, irregular in figure and white at summits. Eyes inflamed. 
On limbs the eruption is red at base, vesicular in body and summit: 
on trunk in clusters. Tongue yellowish and rather furred. No com- 
plaint made; rests easy; sleeps well. 

"16th. — No fever; tongue moist and a little loaded. Pustules 
nearly white. Some yellow, and beginning to dry on summits. Skin 
between still of a deep red. Eruption filling on limbs and trunk. 

"17th. — Pulse strong and frequent; skin hot; tongue moist and 
loaded. Pustules scabbing on face. Not yet entirely filled on limbs, 
where they are in clusters with inflamed bases. 

" 18th. — Pustules full and matured on limbs. Running into each 
other in places. Tongue dry, brown, and furred in centre, yellow 
and loaded at sides. Pulse quick and frequent. Lies easy. 

" 19th. — Blebs formed on arms; pustules running into each other, 
beginning to shrink; matter oozing out. Tongue covered with a 
dark crust. Pulse quick and frequent. Erysipelas of eyelids and 
ophthalmia. Throat sore. 

"20th. — Blebs larger and more numerous on hands and arms; 
purulent matter oozing out from some of the pustules. Face nearly 
scabbed over. Some small white pustules formed on the eyelids. 
Pulse frequent and vibrating. Tongue as yesterday. Gums tender. 

"21st. — Pulse weaker. Desquamation going on; pustules shrunk 
and drying on limbs. Tongue as yesterday. 

"22d. — Matter much absorbed on limbs, leaving a shrunk cuticle. 
Face covered with a brown and yellow scab and scurf. Tongue 
black and furred ; clear at apex. 

"23d. — Some erysipelatous inflammation of the skin ; pustules all 
nearly disappeared from arms, trunk and thighs ; some few, white and 
soft remain scattered over breast. Pulse frequent. Tongue black 
and incrusted. 

"24th. — Was brought into town from Bush Hill. 

"30th. — Desquamation nearly complete. Low frequent pulse. 
Respiration slow and laboured. Tongue incrusted. 

" April 2d.— Dead at 10 A. M. 

" Calomel had been freely given to this man in the earlier stage of 
his disease : and during the last week, spts. terebinth, and nutritive 
farinaceous food. 

"Examination. — The pericardium, of a greenish colour, and its 
capillaries finely injected, was full of yellow serum. The lining 
membrane of the larynx and trachea was of a greenish-yellow colour 
throughout, and in the spaces between the cartilages, ulcerated and 
disorganized in several spots. Beneath the membrane was a venous 
injection. About the bifurcation it was injected ; and in the ramifi- 
cations of the trachea were seen several inflamed, and in places 
abraded and disorganized spots. A chocolate-coloured liquor with 
a sediment filled the bronchia? and the larger tracheal subdivisions. 

"The oesophagus was sound. The stomach showed clusters of 
bright red and brownish-red spots, in stellated and other irregular 
figures extending along the smaller curvature. The duodenum, at 
its commencement and in its course, presented similar clusters. The 
rest of the intestine was healthy. The brain was to appearance in a 
natural state. 

"HI. — Peter Johnson, black man, aged 38 years, unprotected, was 
taken sick on Monday, 29th March, in Sandy Hook. Eruption of 
small-pox appeared. April 3d, Saturday morning. Admitted same day. 

"4th. — Eruption copious on face; papular and of irregular figure. 
Eyes suffused and red. On arras, same appearance as on face, but 
less tuberculous. On breast and body, eruption small and pointed ; 
beginning to show on legs. Throat sore. Tongue yellow and 
loaded at sides ; red in centre. Pulse full, equal, and rather frequent. 
Cough. 

" 5th. — Much anxiety and moaning. Eruption rough and tubercu- 
lous on face. On arms, it is in parts papillary and pointed, and in 
parts flat with indented centres. Pulse slow and equal. 

"6th. — Eruption hard and tuberculous on face and arms; small 
and pointed on breast. Pulse slow ; throat less sore ; mind wandering. 
Is sitting up in bed, dressed. Tongue moist and yellow. 



VARICELLA. 



163 



"7th. — Delirious through the preceding night; is now dozing. 
Eruption same as yesterday. Not so thick on legs, but hard and 
tuberculous. 

"8th. — Tongue black and incrusted. Throat very sore. Eruption 
hard and flat. Pulse active. 

"9th. — In a comatose state. Pulse slow. Skin cool. 

" 10th. — In the same condition. Drawn down in the bed, the 
thighs flexed on the abdomen, and lies on his side. 

"11th.— Dead at six A.M. 

" Examination. — The upper surface of the tongue of a brownish- 
yellow, full of holes and rough. At the posterior part, in place of the 
larger papillae, were ulcers and cavities. The posterior nares and 
pharynx were covered with holes, formed by ulceration, and of a 
brownish hue, adjoining injected and apparent pustular parts. Tonsils 
ulcerated, and their investing membrane mostly destroyed. The 
oesophagus immediately below the glottis, smooth and sound. Yel- 
lowish matter flowing from the glottis. On opening the larynx, it 
was found half filled with a viscid light olive-coloured fluid ; on 
removing which, the whole lining membrane, down to the bifurca- 
tion of the trachea, was found covered with clusters of ulcerated 
pustules of a yellow colour, with the intervening spaces of a brownish- 
red, highly injected, and destitute of its natural smooth, shining 
appearance. The internal surface of the glottis and epiglottis was in 
a similar but less marked state as the larynx and trachea. The pustular 
surface extends to the minute ramifications of the bronchiae, and their 
cells beyond were highly injected. 

" On opening the abdomen, the omentum was found dark and 
shrunk. Stomach contracted. Intestines distended, shining, and 
very vascular, with capillary injection when viewed externally. The 
peritoneal covering of the stomach showed a similarly injected appear- 
ance. 

" The stomach being opened, displayed at its upper curvature, 
spaces studded with spots of a deep red or purple ; apparently effusions 
surrounded by a vascular net-work. Same appearance towards the 
pyloric orifice, and in places on the duodenum, which together with 
the jejunum, particularly the latter, is of a dark leaden colour, and 
injected. 

" The diaphragm on its upper surface, highly injected, as was also 
the pleura lining the thorax. The pericardium healthy. 

" The brain was not, unfortunately, examined." 

The following observations and tables by Dr. Gregory, (Lectures on 
the Eruptive Fevers,) as noticed in the Medico- Chirurgical Review, 
January, 1844, will form an appropriate conclusion of the subject: 

" Upon an average of years, 350,000 persons die annually through- 
out England and Wales,' and 46,000 in the metropolis. The mor- 
tality by the four great epidemic maladies (small-pox, measles, scar- 
latina, and whooping-cough), is very nearly 40,000 in England and 
Wales, and about 5000 in the metropolis, averaging one in nine of 
the total mortality, or eleven per cent. This is a very large propor- 
tion. That four diseases only should absorb one-ninth of the total 
mortality of this, and probably of all other countries, may well excite 
our surprise. 

•' Table, exhibiting the Amount of Epidemic Mortality in England and Wales, during the 
years 1838, 1839, 1840. 



Small-pox ...... 

Total Mortality by the Exanthemata 
Whooping-cough - 

Total of Epidemic Mortality ... 

Total Mortality throughout England and 


Year 
1838. 


Year 
1839. 


Year 

1840. 


16,268 
6,514 
5,802 


9,131 
10,937 
10,325 


10,434 

9,326 

19,816 


28,584 
9,107 


30,393 
8,165 


39,576 
6,132 


37,691 


38,558 


45,708 


342,529 


338,979 


359,561 



" This table shows that every year is distinguished by some master 
epidemic. In 1838, small-pox was the ruling epidemic throughout 
England. In 1839, measles and scarlatina struggled for the mastery. 



VARICELLJE (VARIOLJE SPURIA). 
Vocab. Varicella. 

438. I designate under the collective title varicella or modified 
small-pox, several contagious inflammations, pustular, vesicular or 
papular in their nature, unaccompanied with secondary fever, arising 
from, and having the power of transmitting the variolous contagion, 
and running their course within the space of one or two weeks. 

The word varicella has long been familiarby employed in the lan- 
guage of medicine to signify a modified or spurious kind of small-pox ; 
this consideration has determined me to make use of the term here, 
in the same general and comprehensive acceptation. 

The number of varieties composing this group is not yet precisely 
ascertained. I have restricted myself to a description of the following : 
1st. Pustular varicella (the varioloid of some recent writers), distin- 
guished according to the form of its pustules into the umbilicated, the 
globose and the conoidal. 2d. Papular varicella. 3d. Vesicular vari- 
cella or chicken-pox, and 4th. Varicellar fever. 

439. A smaller number of species than those now enumerated were 
recognized in earlier times. Rhazes 1 speaks of a false variola which 
does not give immunity from small-pox at a subsequent period. Guido 
or Vidius 2 describes this false variola under the title of crystalli. 
Sennertus 3 admits three varieties of spurious variola ; Sydenham, 4 
whilst giving an account of a variolous epidemic, mentions a false 
variola which does not protect from a second attack; Morton 5 bor- 
rowed from the vulgar the denomination of chicken-pox to designate 
a disease of the same description. In a word, all the writers anterior 
to the period when inoculation was generally practised, speak of the 
occurrence of spurious variola which does not secure the individual 
affected against a future attack of the legitimate small-pox ; and whilst 
some of them regard it as a very slight and benign variola, others 
treat of it as a distinct and specific disease. From the year 1772, the 
period at which small-pox inoculation was first practised in England, 
till the introduction of vaccine inoculation, the same opinions were 
constantly entertained. Hoffmann, 6 again, associated the whole of 
these eruptions under the single head of variola spuria. Van Swieten 7 
recognized three species (steen-pocken, water-pocken, wind-pocken) ; 
Heberden 8 and Cullen 9 held chicken-pox to be the product of a pecu- 

In 1840, scarlet fever was so general and so fatal that the mortality 
by it exceeded by one-fifth the ravages of small-pox during an epi- 
demic season (1838), and more than doubled the mortality by that 
disease in 1839. 

" The following table, exhibiting the amount of epidemic mortality 
in the metropolis during a period of five years, shows that the same 
general principle applies to town and country, but is less manifest in 
the smaller population : — 

" Table, showing the Amount of Epidemic Mortality in London, during Five Years — 
1838 to 1842. 



Small-pox .... 
Measles .... 
Scarlet Fever ... 

Total Mortality by the Ex- 
anthemata ... 
Whooping-cough 

Total of Epidemic Mortality 

Total Mortality throughout 
London - - - - 


Year 
1838. 


Year 
1839. 


Year 
1840. 


Year 
1841. 


Year 
1842. 


3,817 

588 

1,524 


634 
2,036 
2,499 


1,235 
1,132 
1,954 


1,053 
973 
663 


360 
1,292 
1,224 


5,929 

2,083 


5,169 
1,161 


4,321 
1,069 


2,689 
2,278 


2,876 
1,603 


8,012 


6,330 


5,390 


4,967 


4,479 


52,698 


45,441 


46,281 


45,284 


45,272" 



1 Rhazes. De variolis et morbillis, cap. v. 

2 Vidius Vidius. Ars univ. medicinas, torn. ii. cap. vi. De variol. et morbill. 

3 Sennert. Oper. omn. in-fol. Lugduni, 1676. 

4 Sydenham. Opera, p. 132. 

5 Morton. Opera, t. iii. p. 58. 

6 Hoffmann. Medicina rationalis systematica, in-4., t. iii. p. 33. 

7 Van Swieten. Comment, in Boerhaave. Aphorismos, t. v. p. 10. 

8 Transact, of the Rl. Colleg. of Physic, of London, v. i. p. 427. 

9 Cullen. Synopsis nosol. method., t. ii. p. 134. 



164 



PUSTULE. 



liar specific cause, whilst Sauvagcs 1 and Burserius- describe the 
disease as B variety of small-pox. Lastly, since the practice of vac- 
cination became general, a remarkable modification of small-pox has 
often been observed, which Dr. Cross, 3 of Norwich, has regarded as 
B species of varicella, (varicella ccllulosa,) and I have treated of here 
under the title of umbilicated pustular varicella, but which has been 
Separated from this class of complaints by Dr. Eichhorn 1 and others 
under the name of varioloid. 

However different these opinions may appear, it is still an assured 
fact, that ever since the small-pox was observed as a peculiar disease, 
.1 certain number of spurious cases, as they have been entitled, have 
occurred, which did not confer security against an ulterior attack of 
the more formidable malady. It is also established that many of these 
eruptions are characterized, like legitimate small-pox, by pustules or 
pseudo-membranous vesicles, whilst others show themselves under 
the form of transparent vesicles or of papula 1 . Now if they be all of 
.the same essential nature, and produced by the same contagious 
influence, as I conceive it is satisfactorily demonstrated that they are, 
the different elementary forms of these varieties will be found adequate 
to distinguish them from each other, without there being any necessity- 
felt to resort to a new denomination for this purpose. Several modern 
pathologists, however, have especially designated the pustular vari- 
cella, — that variety of the disease in which the pustules are umbili- 
cated like those of small-pox, under the name of varioloid. But other 
observers, with Dr. John Thomson at their head, who first made use 
of the title, have employed the term varioloid diseases as designating 
all the forms of eruption to which the contagion of small-pox could 
give rise, chicken-pox included among the number. Lastly, others, 
among whom we have to reckon Dr. Eichhorn, have detached legiti- 
mate small-pox and chicken-pox from this group, and have restricted 
the application of the name varioloid to those variolous eruptions which 
presented umbilicated pustules in larger or smaller numbers, but were 
in every case unaccompanied by secondary fever. 

With so many different meanings attached to the word varioloid, 
therefore, and with a feeling of disinclination arbitrarily to detach the 
pustular varicella from those that show themselves with other and 
different features, I find myself obliged to reject the term entirely, 
which, indeed, is nowise necessary to me, inasmuch as I believe 
that even the purely vesicular form of varicella is produced by the 
contagion of small-pox. 

The treatment of the varicellse is in general the same as that of 
the distinct and benign form of small-pox. § 425. 

Pustular Varicella (the Varioloid of modern authors). 

440. The red raised spots by which pustular varicella makes its 
appearance, are often pretty large and firm under the finger. They 
are surrounded by an irregular pale red areola, which is not uniform 
in its depth of colour, but is, as it were, sprinkled over with redder 
points or patches, usually of small dimensions, but occasionally very 
extensive, particularly in those situations where the eruption is to be 
confluent, or in their immediate vicinity. 

On the second day of the eruption the summits of the spots are 
detached from the corion, the interspace being occupied by a minute 
globule of transparent fluid. These vesicles increase slowly in size, 
becoming gradually more and more opalescent, and at last appearing 
quite white. The pustules are now firm under the finger and scarcely 
discharge any thing if punctured. The opacity and white colour of 
some of the pustules appear to depend almost entirely on the presence 
of a sero-purulent matter which they contain ; they thus form a kind 
of link of transition from the vesicular to the pustular form of cutane- 
ous inflammation. More generally, however, the opacity in question 
is owing to another cause, namely, the presence of a disc of pseudo- 
membranous exudation in their interior {umbilicated pustular varicella) 
closely applied and adherent to the inner surface of the epidermis ; 
although it must not be forgotten that a thick, yellowish and semi- 
transparent matter like jelly can be squeezed out of the interiors of 

i Sauvages. Nosol. method., t. li. p. 369. 

» Burserius. Institut. medicin. practic, t. ii p 288 

! £ r °uu A h |f ° r - V ° f th f VarioK e P' de mic, 8vo. Lond. 1820, p. 207. 
4 bichhorn. Op. cit., vide varioloid. ' 



the very large or confluent pustules, especially when they are some- 
what far advanced. The same circumstance is also very well seen 
in some globular pustules (globose pustular varicella), which, after 
the very lirst days of their existence, become opalescent, and at 
length opaque and white. A transparent vesicular circle is perceived 
to be formed around the pseudo-membranous disc, evidently by the 
detachment and serous elevation of the neighbouring cuticle. At a 
later period this circle disappears, the fluid it contains becoming 
milky. The false membrane is occasionally very thick ; but in gene- 
ral it is less so than in small-pox ; it always adheres to the cuticle, 
with which it might be confounded without due attention. It has a 
cellular aspect, but does not present the cupped appearance observed 
in small-pox except in the umbilicated pustules, which approach 
those of true small-pox more than the generality. The false mem- 
brane of the interior of the pustules also adheres to the surface of the 
corion; if they be laid open, a soft and whitish matter is found 
covering the surface of the papilke. The epidermic conduits of the 
hairs which happen to pass through the pustules, look larger and 
whiter than usual. It appears consequently that the form and colour 
of the pustules of varicella depend on the extent and thickness of 
the false membrane deposited, and on the quantity of serum effused 
within them. 

441. The red elevated spots of the corion continue, and even 
occasionally increase after the formation of the pustules. In those of 
a large size, and especially in such as are confluent, (in which, after 
having removed the cuticle, a better view can be obtained of the 
surface of the corion, of the false membrane and of the gelatinous- 
like matter contained in the pustules,) we observe in the point corre- 
sponding to the centre of each primary pustule, a small eminence or 
nipple-like projection, white on the top, red in the circumference, 
and surrounded by an intense degree of redness and some slight 
sanguineous effusion. At a subsequent period this little swelling of 
the corion subsides, but it is at times still visible, after the fall of the 
incrustations that are subsequently produced under the form of a 
lenticular eminence of a pink colour, surrounded by a white border 
which is due to the torn edge of the epidermis. 

442. The areola, or red ring, which surrounds varicellar spots, 
broad at first, faint and irregular afterwards, becomes at length more 
circumscribed and of a deeper hue ; when these spots are clustered 
together, or arranged in bands, they occasionally bear some resem- 
blance to herpes. The intense red colour of the areola continues rill 
the beginning of the period of desiccation, when it decreases con- 
siderably, and assumes a brownish hue which disappears in the 
course of time. 

It is rare that true suppuration is set up in the pustules of varicella ; 
they consequently almost never leave cicatrices. 



1. UMBILICATED PUSTULAR VARICELLA. 
Vocab. Varioloid, Modified Small-pox, Cellular Varicella. 

443. This variety, which in fact differs from distinct small-pox in 
nothing but in the non- occurrence of the secondary fever, has been 
studied with particular attention in these latter days. It is most 
frequently observed under rather remarkable circumstances: 1st, in 
individuals who have had small-pox naturally or by inoculation, or 
who have been vaccinated and have been accidentally again ex- 
posed to the contagion of variola; it occurs, also, in those who have 
been a second time inoculated with the variolous virus; lastly, in 
some rare cases, it appears in individuals who have never been vac- 
cinated, and have never had small-pox; it would seem farther to 
have been occasionally communicated by inoculation. 

444. Symptoms. — The eruption maybe slight or confluent; it is 
occasionally preceded by roseolous blotches disseminated over the 
surface of the body. In other respects the precursory symptoms of 
the umbilicated pustular varicella are extremely similar to those of 
the distinct small-pox. Generally of extreme mildness, these are, 
however, occasionally very alarming, and are attended with pain of 
the epigastrium, vomiting, delirium, &c. Their progress and inten- 
sity are by no means in relation to the extent of the cutaneous 



VARICELLA. 



165 



inflammation which is to succeed them : to a very smart attack of 
fever, extreme restlessness, and much delirium, we often see a very 
slight eruption succeed, the appearance of which is followed by the 
complete cessation of every serious and alarming smyptom. 

On the third or fourth day, dating from the invasion, the eruption 
shows itself upon the trunk, face and extremities, under the form of 
small red spots similar to large flea bites, which soon become hard, 
elevated, and, as it were, papular, though all do not follow the same 
course. Some disappear without becoming pustular, and others 
become vesicular or pustular in the course of eight and forty hours. 
On the morrow after the appearance of the eruption, the red spots 
are more prominent and acuminated, and contain a serous fluid in 
their apices. On the third or fourth day of the eruption the larger 
number are found to have acquired the flattened form, which the pus- 
tules of legitimate variola only present at a considerably later period. 
Thus arrived at their height, the pustules of this variety of varicella, 
flattened and oval-shaped, generally present a depressed point in the 
centre, and are surrounded by a narrow pale red circle. They are 
mostly from one to two lines in diameter. When compressed they 
resist under the fingers like bees-wax, and when they are punctured 
in one or two places with the point of a lancet, the plastic and nearly 
solid matter they contain does not escape. Their colour, at first of a 
pale pink, becomes of a dull white on the fifth and sixth day. On 
the seventh day of the eruption the greater number of the pustules 
have not yet changed their shapes ; others, and especially such as are 
the most remarkable, are by this time occupied in the centre by a 
small brown or yellowish point of incrustation, which makes them 
appear still more umbilicated. Whatever may have been the degree 
of intensity of the eruption, no secondary, or as it is entitled, sup- 
purative fever , which, in legitimate small-pox, is set up at this stage, 
ever appears. On the eighth day of the eruption, (thirteenth or four- 
teenth of the disease,) the pustules have shrunk, and are replaced by 
scabs of a yellowish- brown colour, laminated in their texture, sub- 
epidermic and lenticular; on the face, indeed, the greater number of 
the crusts are often detached before this time. 

After the removal of the crusts, a few circular and depressed cica- 
trices, and a great many small or red livid spots are discovered upon 
the skin ; these may continue very conspicuous, even two months 
after the invasion of the disease. 

Inflammatory affections of the larynx and trachea, so frequent in 
confluent small-pox, are seldom observed in the umbilicated pustular 
varicella ; but the skin, and especially that of the face, may be very 
much injected, erysipelatous in appearance, and the seat of severe 
tensive pain. Pustules are now and then observed thrown out on the 
mucous membrane of the mouth and on that of the genital organs. 

The flattened and frequently umbilicated pustules of this form of 
the disease, are almost always mingled with conoidal and globular 
pustules. They also occasionally assume very various shapes when 
several of them happen to be congregated in the same spot and fused 
together. 

445. The course of the eruption is occasionally irregular, so that 
papular elevations, pustules, and incrustations are found at the same 
time in the same individual. This circumstance is remarkable when 
the pustules appear in successive crops ; very frequently, however, 
the course of the umbilicated pustular varicella, during the first week, 
is as regular as that of small-pox itself. 

When the eruption of this species of varicella is confluent, the 
face may become entirely covered with thin yellowish and lamellar 
incrustations similar to those of small-pox ; but in the variety of vari- 
cella we are now discussing we observe no secondary fever, and this 
character distinguishes it certainly from legitimate small-pox. 

The umbilicated pustular varicella runs its course in from twelve 
to fourteen days; it almost always ends happily; patients on their 
recovery carry about with them, for a long time, traces of their disease, 
and are sometimes marked with true cicatrices similar to those of 
small-pox. (a) 

(a) The uniform absence of secondary fever in varioloid, as assumed 

by the author, is not entirely accurate. The fever occurs but seldom ; 

still it does occur. On the subject of the appearance and general 

course of varioloid and of its sameness with the variola, Dr. Mitchell's 

42 



experience and my own were recorded in the paper before cited. 
As the narrative and argument are not long, the reader may not 
perhaps be displeased at their introduction here. 

" That in an epidemic season, in which the tendency to cutaneous 
disease was very great, as in the years 1823 and 1824, the poison of 
small-pox should affect the then three privileged classes, viz., those 
who had had the disease naturally in early life, those who had had 
it by inoculation, and those who had been vaccinated, was not an 
anomaly. 

" The operation of the variolous poison, when it took effect on the 
vaccinated, was often similar for the first few days to that on the 
unprotected, that is, on those who had never been subjected to inocu- 
lation or vaccination, or who had not been in any former period 
attacked with the small-pox. The fever, the gastric distress, and 
pains in the back and head, were occasionally as distinctly defined, 
as in the first period of the unmitigated disease. In some cases, the 
activity of the circulation, and the determination to the brain, seemed 
to be greater in the modified, than in the unprotected subject. The 
eruption on such occasions, was at first of maculae, in abundant crops, 
of a crimson colour, with scarlet borders, especially copious about the 
back, shoulders and hips. But it is worthy of observation, that these 
macula?, smooth and without elevation, would for the most part dis- 
appear, without leaving corresponding papulae. Where the eruption 
was constant, and proceeded on to maturation, the pustules were 
usually fewer, the constitutional disturbance at the time less, and the 
subsequent process of desiccation, more rapid than in the genuine 
small-pox. Nor was there in general, secondary fever in the former, 
as in the latter. In these particulars, there were, however, some 
notable varieties; so that some who had been previously vaccinated, 
were attacked with such violence by the varioloid disease, or modified 
small-pox, as to have their lives endangered, and the face subse- 
quently marked with the scars in the pustules. But, in general, the 
disease in this form was milder, more obedient to remedies, and very 
rarely of fatal termination. 

" It will be observed that we speak of the disease occurring in the 
vaccinated, and possessing the characters already described as neces- 
sarily the product of variolous poison, or that same contagion, which, 
in the unprotected, produced the natural small-pox. The identity of 
cause of the two forms of eruptive fever, variolous and varioloid, has 
been, we know, denied by some ; but, for ourselves, we see no ground 
to doubt the sameness, if Ave are to be swayed by the customary 
laws of evidence. We are led to this conclusion by the follow T in»- 
reasons. 

" 1. Some of the vaccinated have at all times, since the introduc- 
tion of the cow-pox, had, on exposure to the poison of the small-pox, 
an eruptive fever similar, in appearance and symptoms, to the latter 
disease, except on the score of its mildness. 

" 2. Some of the vaccinated have, on the introduction of small-pox 
matter by inoculation, had a pustule with an extensive areola, ac- 
companied by fever, and a partial eruption on the other parts of the 
body. 

" 3. In the same family, persons previously vaccinated have had 
this modified eruptive fever, while living with, or nursing, those 
labouring under the natural small-pox ; and e converso persons have 
had the natural disease without having been exposed to any other 
known cause than living with others who were then suffering under, 
or had just recovered from, the modified or varioloid disease. 

" ' The fact that small-pox, by effluvia, or in the casual way, can 
take place within a limited time after the cow-pock, was first observed 
in Mr. Malim's case, see Med. and Chir. Review, No. 58 ; and I 
think Mr. Bevan's case (Med. and Phys. Journal, p. 455, vol. v.) is 
an instance of the same kind." ' Hence,' continues this writer, 
' it appears there are two different sets of eruptive instances, to wit, 
1. Those of the casual small-pox cotemporary with the vaccina. 2. 
Those of the casual small-pox supervening a few days after the con- 
stitutional affection in the vaccina.' Dr. Pearson was one of the 
earliest and most zealous advocates for the practice of vaccination, 
and his opinion, as just given, comes in most opportunely in the 

1 An examination of the report of the committee of the House of Commons, on 
the claims of remuneration for the vaccine-pocit inoculation, containing a statement 
of the principal historical facts of the vaccina. By George Pearson, M. D., F. R. S. 



166 



PUSTULE. 



446. Structure of the pustules.— The flattened pustules of the 
imbilic liar varicelh are extremely analogous, in point of 
structure, to those of small-pox. As in these the duller while colour 
md depressed centre of the pustules are owing to the presence of a 
small pseudo-membranous disc deposited between the corion and 
epidermis, and adherent to the latter. Perhaps the sole anatomical 

lifference between the two eruptions lies in the minor degree of 
levelopment of this false membrane, and of the papular eminence 
ipon which it is situated, in the modified small-pox. These emi- 
nences, which in legitimate small-pox almost invariably sink down 
.md become ulcerated, are very seldom so affected in the pustular 
varicella, true suppuration occurring but very rarely indeed in the 
interior of the pustules of modified small-pox. 

447. Causes. — Umbilicated pustular varicella prevails at the same 
lines as small-pox and the other varieties of varicella, and is engen- 
dered under the same influences; it appears more especially in the 
beginning as also at the end of variolous epidemics, attacking particu- 
larly those subjects who have had small-pox or been vaccinated. 

huring the epidemic small-pox of Marseilles, in 1828, of 30,000 
persons vaccinated, nearly 2000 were attacked with spurious, and 
some few with apparently true variola; of this number, twenty fell 
victims to the disease ; of nearly 2000 individuals who had had 
natural small-pox, about twenty were affected with the prevailing 
epidemic, of which number four died. Of 8000 not vaccinated, 
nearly 4000 were attacked with small-pox and of these 1000 perished. 

Pustular varicella has been said to have been observed especially 
among the vaccinated who have had few pustules, or among those 
in whom the vaccine pustules had been pale and without activity, 
or, further, among those in whom the pustules had been opened before 
their perfect evolution; these statements all require confirmation. 

During the Marseilles epidemic it was thought that the pustular 
varicella could be traced as attacking in preference those individuals 
whose vaccination had been performed at the remotest periods, and 
I have been assured that this form of the disease was actually most 
.severe in those who had been longest vaccinated, two statements the 
accuracy of which M. Gendrin has disputed, so that the question is 
still undetermined. 

The contagious principle of small-pox, operating upon individuals 
little susceptible of its influence, and who have neither had small-pox 
nor cow-pox, may engender the umbilicated pustular varicella. 

The same individual may be several times affected with this species 
of eruption by renewed exposure at different times to the variolous 
contagion. 

Pustular varicella has been seen in individuals who have never 
had small-pox, and who have been vaccinated fruitlessly. 

The inoculation of the fluid of the umbilicated varicellar pustule is 
not commonly followed by any symptom of general infection, and only 
produces a local eruption analogous to that of cow-pox. (Dugat.) 
The inoculation, however, may be succeeded by a general eruption 
with or without initiatory, certainly without secondary, fever. Lastly, 
the inoculation of this matter performed upon individuals who have 
never had such an eruption, and who have never been vaccinated 
nor been affected with small-pox, may cause the development of 
legitimate variola of various degrees of severity, as has been demon- 
strated by the experiments of Messrs. Dugat and Lafont-Gouzi, in 
opposition to the opinion of M. Gendrin, who had maintained that 
varioloid was transmitted by inoculation without ever approaching 
variola in its characters. Further, small-pox has been seen rising 
from the contagion of pustular varicella, and pustular varicella 
springing from the contagion of small-pox. In the Marseilles epide- 



present argument. In his time, we see that the liability of small- 
pox coming on after vaccination, was thought to depend on the 
recency of this latter operation, merely, we presume, by a process of 
negative reasoning, for there were no opportunities to ascertain the 
liability of those vaccinated for a length of time, as the practice was 
then but of few years' adoption. In our day, we have seen an oppo- 
site opinion held, viz., the greater susceptibility to small-pox in those 
vaccinated for a term of years. Experience has shown long ago the 
fallacy of the first belief; the second must, we think, be abandoned 
on the same showing." 



mic a young man who had neglected vaccination was attacked with 
small-pox and died; his cousin, bearing handsome points of cow- 
pox pustules upon his person, went to visit this young man, and 
caught a pustular varicella; at the same time a brother, who had not 
been vaccinated, was infected with the most characteristic small-pox 
imaginable by others of the family who had been vaccinated and 
were now labouring under pustular varicella. 

448. Diagnosis. — During the first week the resemblance between 
variola and umbilicated pustular varicella is such, that there is no 
means of distinguishing between them. 

The pustular varicella differs from confluent small-pox in the more 
rapid progress of its pustules when they have attained their height, 
and in the non-occurrence of secondary fever ; the areolae are also 
inflamed in a less degree, and the pustules are more rarely followed 
by cicatrices. 

This species of varicella differs from distinct small-pox, not, as has 
been stated, in the extreme irregularity and rapidity of its course, 
which is often as regular as that of small-pox, but by the entire 
absence of secondary fever. 

449. According to Dr. Luders, of Copenhagen, the pustular vari- 
cella (varioloid) differs from small-pox in the irregularity of its course, 
the uncertainty of its symptoms, the mode in which its pustules ap- 
pear, which is in successive masses, occupying first the extremities, 
then the trunk, and lastly, the face ; in the imperfection of the sup- 
purative stage, the promptitude with which the desiccation is com- 
pleted, and the failure of the secondary fever. In my opinion, it is 
to this last circumstance that we are especially to cling ; for, in the 
majority of cases, pustular varicella advances with the greatest regu- 
larity, and variola itself is not without a considerable number of 
individual anomalies. 

Others imagine that pustular varicella differs from variola in this, 
that the inflammation extends to the substance of the corion in variola, 
whilst in the varicella, it stops at the surface of the papillary body, 
which is the reason of its seldom leaving cicatrices after the fall of 
the scabs. 

It has also been said that the pustules of modified small-pox con- 
sisted of no more than a single cavity ; but this peculiarly belongs to 
the varicellas with globular and conoidal pustules alone. 

M. Gendrin maintained that umbilicated pustular varicella (vario- 
loid) differed from small-pox in the structure of the pustules, which, 
in the varioloid, contained no fluid, did not appear multilocular, and 
always ended in resolution. M. Guersent has, with justice, dis- 
puted the accuracy of this proposition ; after a careful examination of 
the pustules of variola, and of varioloid, during the course of the 
first week, he was frequently unable to perceive any difference 
between the one and the other. My own researches agree with 
those of M. Guersent, § 440 ; and M. Gendrin's statements respect- 
ing the structure of the varioloid pustule, are, in truth, only applica- 
ble to a very rare variety of varicella, namely, the papular. 

Ptyalism is a symptom in small-pox which only happens among 
adults, and cannot be assumed as a feature distinguishing true small- 
pox from pustular varicella. 

The odour of small-pox has been said to be different from that of 
pustular varicella ; if such be the fact, it requires such delicacy of 
organ to appreciate the circumstance, that it can never be made 
available in practice. 

450. Messrs. Favart and Robert, of Marseilles, 1 perceived full well 
that umbilicated pustular varicella (varioloid), followed the same 
course as the confluent small-pox, during the periods of incubation 
and eruption, and that the two diseases first assumed different cha- 
racters after these periods : small-pox continues to pursue its course ; 
to the swelling of the face succeeds that of the hands ; the pustules 
go on increasing, and acquire a whitish colour ; the inflammation 
of the face and hands is then at its height ; the spaces between the 
pustules become of a bright red ; the fever, which has been almost 
insensible since the appearance of the eruption, is lighted up afresh, 
constituting the secondary or suppurative fever; the pustules of the 
face, followed immediately afterwards by those of the hands and 
other parts of the body, pass from white to yellow ; lastly, the tume- 

1 Robert. Precis historiquede l'epidcmic qui a regne h Marseille, et vues nouvelles 
sur la vaccine. Marseille, 1828. 



VARICELLA. 



167 



faction of the face subsides, the eyelids become of their natural size, 
and the patient regains the use of his sight (this happens on the tenth 
or eleventh day) ; from this period the pustules grow brown, shrink, 
become hard and dry, and the friable crust is detached from the 
twentieth to the twenty-fifth or thirtieth day from the invasion, 
leaving exposed the deep cicatrices that ever afterwards proclaim 
the attack of the disease, at first of a deep red colour, and only in 
the progress of time acquiring something of the tone of the skin. In 
the umbilicated pustular varicella (varioloid), on the contrary, the 
suppurating stage is stationary, and there is no secondary fever; 
arrived at the eighth, ninth, or tenth day, the disease stops of itself, 
the pustules dry up, and the crusts fall off from the skin towards the 
twelfth, thirteenth, or fourteenth day. 

To resume, if there be pretty evident differences between confluent 
variola and the umbilicated pustular varicella, this disease is assimi- 
lated in numerous particulars, with distinct variola, from which, how- 
ever, it still differs, by the constantly progressive state of its pustules 
during what should be the stationary and suppurating periods, and 
the absence of the secondary fever. 

The flattened and frequently umbilicated form of the pustules suffi- 
ciently distinguishes this from the other varieties of pustular varicella. 

451. Prognosis. — The eruption of the umbilicated pustular vari- 
cella is usually distinct; and, as has already repeatedly been said, is 
unaccompanied by secondary fever. Neither does it present the 
formidable symptoms of nervous variola, of laryngeal variola, nor of 
hemorrhagic variola. It is therefore usually a disease of little severity. 
During the epidemic of Marseilles, nevertheless, twenty persons who 
had been vaccinated died, and in several others the attack possessed 
a character of great severity. 

This modified small-pox may even occasionally present more for- 
midable symptoms than legitimate distinct variola. 

Pustular umbilicated varicella (varioloid) preserves occasionally at 
least, if it does not uniformly give security from small-pox. In an 
epidemic small-pox which appeared at St. Paul-de-Leon, in 1826, M. 
Guillon having inoculated six hundred and sixty children with the 
matter from the pustules of a vaccinated subject labouring under the 
prevailing disease, the greater number had nothing more than a local 
eruption analogous to that of cow-pox or inoculated variola, and not 
one of them contracted small-pox. Messrs. Gendrin and Cullerier 
have also seen varioloid taking the place of variola ; M. Bourgeois 
saw two children, who, after having had the varioloid, tended with 
impunity two brothers attacked with variola ; lastly, M. Cullerier 
inoculated children who had never had more than the varioloid with 
the matter of small-pox, without the operation being followed by any 
eruption. However this may be, my own opinion is that the umbili- 
cated pustular varicella does not give immunity against small-pox to 
the same degree as cow-pox and legitimate variola. 

The time which has elapsed between the vaccination, or a pre- 
vious attack of variola, and the evolution of umbilicated pustular 
varicella, does not appear to cause any modification in the progress 
and severity of this eruption. Thus, this species of varicella has been 
seen of considerable severity in individuals vaccinated but a few 
weeks previously, and, on the contrary, with a character of extreme 
mildness in persons who had been vaccinated, or who had had the 
small-pox twenty years before, (a) 

452. The treatment of umbilicated pustular varicella is the same as 
that of distinct small-pox. 

453. Although individuals have been subjected to the influence of 
natural or inoculated small-pox, or to that of cow-pox, it has been 
proposed to re-vaccinate them from time to time, with a view to 
render them unsusceptible of the attacks of the pustular varicella (vide 
Vaccinia). 

Historical Notices and Particular Cases. 

454. The umbilicated pustular varicella is probably as old a dis- 
ease as small-pox itself, for it is indisputable that eruptions of a 

(a) This assertion, of the entire accuracy of which I have had abun- 
dant evidence, merits serious attention ; and is a sufficient reply to 
those who would persuade us that vaccinia wears itself out after a 
certain period. 



similar nature were observed among those who had had the small-pox 
naturally, or by inoculation, 1 long before the development of this 
modification of variola was made the subject of particular study in the 
vaccinated, among whom it occurs most frequently. A very con- 
siderable number of the vaccinated have been attacked in each of the 
small-pox epidemics that have recently prevailed ; and the vaccina- 
tors have spoken of it as a spurious small-pox, due to a faultily per- 
formed or imperfectly developed cow-pox inoculation, or as a variety 
of varicella produced by a peculiar and specific contagion. The 
opponents of vaccination again, and those who believed that cow- 
pox did not always afford security against variola, have triumphantly 
pointed to this eruption as a legitimate small-pox, and assumed its 
occurrence as proof positive of the inefficacy of vaccinia as a preserv- 
ative from this formidable disease. 2 Lastly, Dr. Eichhorn has pub- 
lished a new division of the variolous eruptions observed among the 
vaccinated. 3 

455. Some writers, having given the title of varioloid to all the 
varioliform eruptions observed among individuals who have been 
vaccinated, have described these eruptions with such generic charac- 
ters as are rather to be met with in the conoidal and pustular varieties 
of varicella, than in the umbilicated pustular form of the disease. 
Thus it has been said, that elevation, and basilar induration of the 
pustules were scarcely to be detected ; that their areola was irregular 
and badly defined ; that after the fourth day the apices of the spots 
were of a pale watery white; on the fifth, that they became serous 
and rounded; on the sixth, that the fever and areola disappeared; 
that the serum occasionally became opaque or red without assuming 
the purulent character; that it escaped from the greater number of 
the pustules, and was absorbed from the remainder ; lastly, that the 
seventh day was marked by the desiccation of the pustules and the 
convalescence of the patient. 

1 Thomson. Hist, sketch of small-pox, 8vo. Lond., 1822. 

2 Pougens. Petite-verole chez plus de deux cents individns vaccinas, observee a 
Milhau, en 1817, 8vo. Milhau, 1817. — Gastellier. Expose fidele de petites-veroles 
survenues apres la vaccination, 8vo. Paris, 1819. 

3 Dr. Eichhorn divides the variolous eruptions observed among the vaccinated 
into : 1. True variola. — 2. Purulent varioloid, differing from the former only in the 
speedy desiccation of the pustules, and the absence of secondary fever, although the 
ocdematous swelling of the slcin proper to the legitimate small-pox occurs here also, 
during the suppurative stage. — 3. Lymphatic varioloid, the eruption being full of 
transparent fluid. 4. Verrucous or warty varioloid, the spots remaining solid to the 
end and never becoming filled with fluid. S. Papular varioloid ; a disease which 
occasionally appears to be attended with danger.and not merely a modifiedbal a true 
small-pox under a papular form. 6. Varioloid fever. 

Dr. Eichhorn attaches the greatest importance to the umbilicated depression ; if but 
one spot of an eruption present this character, he holds it warrant enough of the 
varioloid nature of the disease. This author also designates as pustular a spot, that is 
umbilicated, whether it contain pus or lymph; he reserves the title of vesicles to spots 
filled with lymph and not umbilicated; the variolous spot, whether filled with pus or 
lymph, or solid, is depressed in the centre, or umbilicated; the varicellar spot may be 
purulent, may be a true pustule, but it is not umbilicated. 

Eichhorn maintains that varicellas only excite varicellas, and never variola or vario- 
loid, and concludes that varicella is the effect of a peculiar contagion. He distin- 
guishes this disease into: 1. Vesicular, bullous or globular, and, 2. Cellular or pustular 
varicella. The former has occasionally been mistaken for pemphigus; the latter is 
not completely emptied by a puncture. The pustular varicella presents a considerable 
number of varieties : 

(a) Lenticular or lymphatic varicella, the eruption of which appears eitherflatiened 
or pointed, and is afterwards filled with purulent serum. (6) Verrucous varicella 
(horn-pock, stone-pock) shaped like the former, but solid and warty; its point is also 
distended with a lymphatic or purulent fluid, (c) Conoidal or acuminated varicella; 
the eruption of which is pointed, (d) Spongy varicella which seems to be intermedi- 
ate between a and b; the eruption in either of them swelling and becoming spongy. 
The whole of these forms arise from one cause, — the varicellar contagion. 

The diagnosis of varioloid from varicella, according to the same author, is as 
follows: 1. During the period of eruption, variola and varioloid present stigmata of a 
dusky red, ill defined, without hard nuclei, and are succeeded by soft pustules or 
vesicles, most commonly after an interval of no more than six hours, in consequence 
of which papula? are not usually observed. 2. At the height of the disease, the pus- 
tules of varioloid are umbilicated. Several among those of varioloid have the de- 
pressed centre also. The pustules, vesicles, or whatever they be, of varicella never 
show this characteristic feature. 3. During the period of desiccation, variola and 
varioloid are followed by scabs in the form of sections of a cone; varicella never 
leaves crusts of this shape. 4. The cicatrices left by variola and varioloid are nigged 
or uneven. Varicellas only give rise to cicatrices, when they have been excoriated, 
or a purulent fluid has been long confined within their interiors. These cicatrices 
also when they do occur, are smooth on the edges and even, antl not always of a 
round, but frequently of an oval form. 

Although I do not agree with Dr. Eichhorn in all his opinions, I have thought it 
fair to give a statement of them from the great pains he has been at to develop them 
fully. (Vide Eichhorn. Neue Entdeckungen uber die Verhutung der Menschenblat- 
tern bei Vaccinirten, 8vo. Leips., 1829.) 



168 



PUSTULE. 



.horn considers the varioloid disease as a modification of small- 
pox, from which it differs in being unaccompanied by secondary fever. 
He thinks, too, that the varicellar eruptions are produced under the 
influence of B specific contagion, distinct from that of small-pox and 
\ arioloid. 

In these latter times many observations and inquiries have heen 
into the characters 1 , and the inoculation 2 of the pustular vari- 
cella' (the varioloid of many modern authors). Some remarks of a 
comparative nature have also been published on the modified pustular 
diseases of sheep denominated Clavelee in France, 3 which is trans- 
missible by inoculation. 

Case LXVI. — Umbilicated pustular varicella occurring during the 
ic prevail.' nee of small-pox in an individual previously vaccinated. 
M. FL, twenty-three years of age, began to complain on the 18th of 
September, 1825, of a feeling of fatigue, uneasiness, and disrelish for 
food : an epidemic small-pox prevailed at this time in Paris. M. Fl. 
had been vaccinated in his youth, and his arm bore marks of the 
cicatrices left by regular cow r -pox. The state of uneasiness described 
continued through the 19th; on the 20th, he felt greatly depressed, 
yet went abroad ; on returning home in the evening he had a violent 
shivering lit, accompanied with distracting headache. He passed the 
night without sleep, feverish and restless. On the 21st, epigastric 
heat and pain ; nausea ; tongue foul, and red at the point ; headache ; 
shivering fit, to find relief from which, M. Fl. took a hot bath at a 
high temperature, but the symptoms did not continue with the less 
violence. On coming out of the bath he went to bed ; he was sick, 
and repeatedly vomited a quantity of bilious stuff during the day, and 
course of the succeeding night ; the head was excessively hot, the 
legs extremely cold. On the 22d, I was summoned. I found the 
patient vomiting, and he informed me that the slightest movement was 
enough to induce the act, which was accompanied by violent con- 
vulsive motions of the stomach, and painful eructations (twenty-Jive 
leeches to the epigastric region ; mucilaginous drink). The leeches con- 
tinued attached for two hours ; after their fall the bites were covered 
with an emollient cataplasm. In the evening the patient was delirious, 
and this state continued far into the night (weakened mustard cataplasms 
to thetnsteps; drink as before). At midnight, (fourth or fifth day of 
the disease,) an eruption was discovered, especially upon the breast, 
very much resembling flea bites in its appearance. 23d.— Several 
small distinct red pustules were scattered over the trunk and extremi- 
ties; a few were also situated on the face ; the patient had perspired 
profusely ; the headache and vomiting had diminished. 24th.— Second 
day of the eruption, which is now very abundant on the face; the 
headache had ceased; the vomiting returned again at nio-ht • the 
perspiration was incessant and copious (barley water for drink). 'The 
night was pretty tranquil. 25th.— Third day of the eruption, which 
is making marked progress ; the pustules are also becoming more 
numerous. Ihe sweating has now ceased: the patient complains of 
a tense, stiff, and burning sensation in his face, as if it was covered 
with a mask of fire. In the afternoon, the patient rambled in his talk 
for about a quarter of an hour; in the evening he was quieter (bar- 
ley water with one-fourth part of milk). 26th.— Fourth day of the 
eruption ; no sleep last night ; the pain of the face very distressing • 
restlessness; the patient rambles from time to time, and complains 
repeatedly of heaviness of his head. The foot bath three times a day 
relieved this symptom. The urine, which was high-coloured for the 
hrst few days, has been transparent and yellow during the last three. 
the pustules of the thighs are now well evolved. 27th.— Fifth day 

rinlnTK "'! A" accoun, ,. f the varioloid epidemic which has lately prevailed in 
Ed.nbnrgh and other parts of Scotland, etc. 8vo. Lond., 1820—Gregoryf Cons dera 
SL"Li SETT**? « developpe ch« des s'ujets prfaA&^TSfiS 

p. I. .89;— x. p. 443).— Lflders. Essai historique sur ces 



(Arch. gen. med., t. 



A a ho°na S 1824 * E^/J.T Ch f Z de \ su J e,s , Prealablement vaccines "(in" Da^shT 8* 
r^nr^corS ' ^ l ^J&*'&*-™ P- ^Gendrin. & la 



Ji?p 3tl^r de ,li VB 5. 0,e ' de 1^ vaccine et de la'varioiolde (Journ. Z " 

sc medic' I ri;- P ' 154 :'- Kus1 "- Notice sur la varioloide f Journ. ,ZJ±l ' 
sc. medic., I. xxxm. p . 105.)— Copretta. 5 
vanoo.de (Journ. complem., t. xxxiv. p 20) 



la varioloide (Journ. complement. 

la variole des sujets vaccines dite 
-Robert (M. C. S. M). Obs. sur la 
e med., 2e serie, t. ix. p. 77). 

M»l ,. xxv. p. 33)^^r r ^^ Ul,,d " SC - m ' d - deF " USSaC ' 
(Revue med., Pans, 1830, t. xxv. p. 253)._R ber V 
-use des vanoles modifiers (Revue medic t vii ioo* 
■ PisanietLibba.d. A«Ar. t JHr^^*»»)- 



des SC. medic, 1. xxxiii n 1 -uuiLNciueiii 

varioloide (Journ compkn ,°7x X ?H 4fl ^vV" 1 ?^ d A* J UJe * S VaCC ^ s dite 
variole, la varioloide eTFa Taccin "rwJ - 20 >T Rohe f (* C. S. M). Ob 

^^7xv7253? qUe R\ NO v Vel,e ,, inocu,alion de )a varioloide 
ease des varioles modifies (Revue 3k . ™ ^ bles l,?F la Propnete contagi- 



of the eruption ; the conjunctiva) are injected ; every part of the surface 
of the body from the crown of the head to the soles of the feet, as well 
as the lining of the mouth, and the mucous membrane of the glans is 
covered with pustules. These are in greatest numbers on the breast 
thighs and face ; eight were counted on the forehead, and one hundred 
and nineteen on one of the cheeks. 

Some, indeed the greater number, of the pustules are voluminous 
regularly circular, flattened, depressed in the centre and without areola' 
or surrounded at most by a very pale pink circle. The matter of the 
pustules is neither watery nor sero-purulent. They are firm and rather 
unyielding to the touch ; and are evidently distended by a concrete 
substance which does not flow out when the cuticle which covers 
them is punctured or is removed. Several pustules are observed of 
a larger size, of an irregular shape, and evidently formed by the fusion 
of two or three of the ordinary pustules into one. Others of a smaller 
size and globular are about a line in diameter filled with an opaque 
and whitish fluid, and surrounded by a red and pretty regularly circular 
areola, interrupted, however, in those situations where the pustules 
are confluent, or where pustules of a larger size are approached. The 
part of the skin upon which pustules of the latter description are 
developed is erythematous. Lastly, not more than from fifteen to 
twenty small conical pustules can be counted over the whole surface 
of the body ; the generality are flattened and umbilicated. The patient 
has no cough, and no affection of the bowels; the pulse is natural ■ 
the tongue is covered with a thick white fur, and there is little thirst 
(pediluvium ; barley-water). The heat of the face was now greatly 
lessened ; all the stormy symptoms had subsided and the patient slept. 
28th. — Sixth day of the eruption. The whole of the pustules of the 
face were in full suppuration ; three or four on the nose and several 
on the chest presented a black, dry, central point. Several, on differ- 
ent parts of the body, seemed to have stopped short and were no larger 
than those of impetigo. The pustules of the face were not so flat, and 
were whiter and more purulent than those of the hands ; the rest were 
pink-coloured ; the tongue was getting gradually cleaner. 29th. — 
Seventh day of the eruption. Tranquil and uninterrupted sleep through 
the preceding night. The progress of the pustules presents some va- 
riety : those of the hands that are flattened and umbilicated have not 
yet changed either their form or their colour. Several of the same 
description situated on the forearm are purulent and have a yellowish- 
white tint ; others on the nose and trunk are yellow and almost dry, 
with a crust in their centre (barley water with milk; chicken-broth.) 
30th.— Eighth day of the eruption. An excellent night ; the detach- 
ment of the crusts going on ; from the face, the greater number have 
already fallen, leaving small red marks behind them, each of which 
presents a central, more highly-coloured and depressed point. None 
of these spots has the livid colour of those that follow legitimate small- 
pox. The pustules on different parts of the body are shrinking apace ; 
the tongue is moist and white in the middle. (Broth, semolina.) 

31st.— Ninth day of the eruption, thirteenth of the disease. The 
night has not been so quiet; quantities of small lamellar scabs are 
found in the bed, having the form and dimensions of lentils. The 
pustules dry up without rupture of the epidermis ; the appetite has 
returned, and the convalescence is complete. 

A few small cicatrices were left on the face bearing a striking resem- 
blance to those of small-pox. Two months after the invasion the 
marks of the disease had not entirely disappeared. 

Few cases of varicella occur with so many points of resemblance 
to small-pox as the one just detailed. The eruption, in fact, look 
place on the fourth day from the attack, after severe precursory 
symptoms, such as delirium and repeated attacks of vomiting, and 
during the prevalence of an epidemic variola. The eruption con- 
sisted of numerous flattened and umbilicated pustules, and the face 
was puffed and inflamed ; but the eruption differed from that of 
small-pox in the rapidity of its progress, which was such that the 
whole of the pustules were dry by the thirteenth day of the dis- 
ease, and in the complete absence of ptyalism and non-occurrence 
oi secondary fever. 



VARICELLA. 



169 



2. CONOIDAL PUSTULAR VARICELLA. 
Vocab. Vuricella conifurmis (Willan),- Varicella (Pknck); Swine-pox. 

456. In this variety the eruption is preceded by febrile symptoms, 
occasionally of great severity, which last for two or three days. Fre- 
quently also at the end of twenty-four hours a crop of small red spots, 
similar to flea-bites, appears upon different regions of the body, and 
change for the most part into pointed elevations like those of small- 
pox in their first stage. The day after their appearance these risings 
preserve their original form, and exhibit an opaque white speck on their 
summits; they are never completely transparent like the vesicles of 
chicken-pox. Their bases are not so hard, nor so much inflamed as 
those of the pustules of small-pox, but more so than those of the 
vesicles of chicken-pox. The fever usually ceases after the erup- 
tion appears. On the third day the bases of the spots are more 
inflamed ; on the fourth and fifth days they continue nearly in the 
same state ; on the sixth they begin to shrivel and to dry upon their 
summits. On the seventh those of the face are transformed into 
prominent crusts of a yellow or yellowish-brown colour. On the 
eighth and ninth these crusts are detached, many of them leaving 
small cicatrices. On the following days the scabs fall from the other 
parts of the body. 

The pustules of this variety of varicella may be developed succes- 
sively so as to protract the eruption to the twelfth or thirteenth day. 

The pustular conoidal varicella is observed during the epidemic 
prevalence of small-pox, most commonly attacking those who have 
been vaccinated, and occasionally those who have already had small- 
pox. This form is always well marked on the face ; a number of 
umbilicated pustules, however, are often observed on the thighs. 

M. Fontaneilles has shown that this form of varicella could be 
transmitted by inoculation. 1 

Historical Notices and particular Cases. 

457. The pustular conoidal varicella was described by Willan, 
who classed it among the vesicular diseases. It is indisputable, 
however, that an opaque white point is almost uniformly developed 
on the apices of the eruption, in consequence of the formation of a 
false membrane, and that the greater number of the spots become 
purulent before their termination. I have collected several cases of 
this variety myself; the one which follows I have borrowed from 
Messieurs Berard and Delavit. 

Case LXVII. — Conoidal pustular varicella. 2 Louis, aged fifteen, 
and having been vaccinated, was seized in the evening with alternate 
chills and flushes, supra-orbirary headache, lassitude, and pain of the 
limbs. Second day, the same symptoms continued ; an eruption of a 
number of spots (boutons) appeared on the hands ; these were at first 
of a red colour, but became white within a few hours. Their centre, 
uniformly raised, ended in a point. They are but little elevated 
above the level of the skin, and surrounded by a broadish pale red 
circle; they disappear on pressure, which is not painful. Second 
day of the eruption: additional spots developed on the face, exactly 
similar to those that have been already described. Third day: head- 
ache over the eyes, intolerance of light, tongue yellow, with red 
spots on its edges, mouth clammy, pain of epigastrium increased on 
pressure ; the pustules of the hands are dry, and present in their 
centres a pale, gray and slightly adherent scab ; they are surrounded 
by an areola of greater breadth than on the preceding days ; those of 
the face are small and white ; some of them present a gray point in 
the centre, which is not depressed, and are surrounded by a rosy 
circle, which melts into the natural colour of the skin. New pus- 
tules have appeared on the arms ; these are red and of small size ; 
their colour disappears on pressure, and they are surrounded by a 
broad areola (tartrate of antimony). The medicine caused vomiting 
of yellow matters; the bowels were relaxed; the belly felt hard 
and painful; perspiration; pulse natural; heat of surface not raised. 
Fourth day: no sleep, slight perspiration, headache, tongue as it ap- 
pears in the best state of health; the pustules of the face are larger, 



43 



1 Epidemie de Milhau, pp. 47 — 51. 
* Berard et Delavit. Op. cit. p. 129. 



more prominent and whiter; the areolae still broader; the pustules of 
the arms are white and silvery in their centre ; no pustules are observed 
on the breast or lower extremities. Fifth day: the pustules of the 
face are shrunk, dry, and covered with a gray scab, which is flat and 
slightly raised above the surface of the skin; several of those of the 
arms have also dried, and formed red scabs, raised above the surface, 
rounded, and with the appearance of the pustules (boutons) of verru- 
cous small-pox. Sixth day: general and profuse perspiration during 
the night; disappearance of all the morbid symptoms; the patient 
feeling perfectly well ; the crusts of the face began to be detached, 
leaving in their place a slight red mark level with the skin. Seventh : 
recovery. 

3. GLOBOSE PUSTULAR VARICELLA. 
Vocab. Hives, Varicella. 

458. In this variety the precursory symptoms are commonly more 
severe than in chicken-pox, and now and then approach those of 
small-pox in their long continuance and intensity. 

The eruption appears in the form of red spots, larger than those of 
the preceding variety, occasionally wearing the aspect of a large 
papula, or bite of a gnat, and which, in the course of twenty-four or 
forty-eight hours, change into globular elevations, whose bases are 
not precisely circular, and whose centres are of a dull milky white 
colour. On the third and fourth days the eruption is propagated to 
different regions of the body; on the fifth, and often even on the 
fourth day the pustules become rounded, and the areola which sur- 
rounds them grows brighter; the pustules have then attained their 
greatest size, which occasionally equals that of the crystalline lens ; 
they are of a dull white colour on their centres, upon which a kind 
of little disc, iridescent in its circumference, is observed ; but they 
are transparent in their parts nearest their base. When they are 
opened with a lancet, and the epidermis is removed through the 
whole extent in which it is loosened, the opacity and central white- 
ness are found to be produced by a small pseudo-membranous disc, 
which differs from that of true small-pox in not extending over the 
entire surface of the pustule. On the sixth day, the circumference 
of the pustules passes or overhangs their bases, which are inflamed; 
next day many of them" are soft and flaccid to the touch; the day 
following they are shrunk and wrinkled in their circumference ; the 
eighth and ninth days, the desiccation advances, and laminated 
brownish crusts are taking the places of the pustules ; on the tenth 
and eleventh, these scabs are detached from the skin, upon which 
marks of a deep red colour, and occasionally even cicatrices remain. 

A few pustules are very frequently to be found, presenting the 
characters of the preceding varicellar eruptions, scattered among 
those which characterize the variety now under consideration. 

As there is always some degree of pruritus of the skin, children are 
apt to tear the pustules with their nails; and the crusts which suc- 
ceed them, now and then continue adherent for a long time, and 
leave small cicatrices when they are at length detached. 

The eruption taking place successively during two and three 
days, pustules in different stages of their progress may always be 
found at the same time in patients labouring under the disease. 

It may be transmitted by contagion, although the inoculation of its 
virus often remains without ulterior consequences. 

Historical Notices and particular Cases. 

459. Willan describes this variety of varicella as vesicular; but the 
spots have a purulent appearance in their centre, from the second day, 
in consequence of containing, like those of small-pox, a pseudo-mem- 
branous disc attached to the inner surface of the epidermis. I here 
republish the case of President d'Hericourt as an instance of this 
variety exhibiting general symptoms of some severity ; the evolution 
and appearances of the eruption have not been described with suffi- 
cient care. 

Case LXVIII. — Globose pustular varicella. 3 — M. d'Hericourt, on 

3 Darcet. Hist, de l'eruption du President d'Hericourt. Joum. de med., t. 49. p. 
303. 1798. * 



170 



PUSTULE. 



I h Norember, passed a bad and restless night. 25ih. — Second 
dav of the disease, the head was heavy and confused; there was pain 
of the Stomach, and particularly of the fronts of the thighs and under 
the knees ; the body was bent ;' the use of the foot-bath was followed 
l'v a fainting lit. 26th. — Same state; the night had been worse ; no 
sleep; burning heat with passing chills. 27th. — Third day of the 
several stains or small spots (boutons) were discovered on 
the face and neck ; soon afterwards the patient felt himself worse than 
be had yet been, and was compelled to return to his bed. 28th. — 
Fourth day of the disease (second of the eruption.) The patient was 
still very ill, complaining of headache, and very distressing pain in 
the stomach, loins, and thighs ; the eruption was more conspicuous, 
and in the evening sore throat was added to the list of sufferings (the 
foot bath). The patient prespired freely, and the eruption continued 
to be evolved ; at one time the face appeared very full. The night 
was no better. 29th. — Fifth day of the disease. M. d'Hericourt 
was now told that he had small-pox, his medical attendant informing 
him that be would have communicated the matter before, but feared 
that he might be deceived, and his patient distressed by supposing 
himself attacked anew with this disease after having had it by way of 
inoculation. This day was more tranquil, and the. night that followed, 
better than the five which had preceded it. 30th. — The eruption 
seemed to be completed ; yet the patient again suffered severely from 
fever, and lost a few drops of blood by the nose. The night was 
stormy till about two o'clock in the morning of the 1st December, 
when the patient fell asleep. This day (fifth of the eruption) M. 
d'Hericourt was much better. Suppuration was established in the 
tace, where there were no more than from a dozen to fifteen pustules 
(boutons), and extended gradually to the other parts of the body 
where the eruption was much fuller, especially on the back, on the 
arms, thighs, ears and hairy scalp. The pustules (boutons) rose and 
became well rounded; the matter with which they were filled was 
already opaque and white, and they were surrounded by a red circle 
or areola perfectly characterized. 2d.— Sixth day of the eruption; 

nation of the face completed, and well advanced over the rest 
ot the body. Several pustules, and these the smallest, already begin to 
dry off at their summits. The patient, who had hitherto been kept 
extremely low, was allowed to take food for which he felt very much 
inclined. On the 3d December, seventh day of the eruption, the 
desiccation was well advanced, and the patient felt able to rise in the 
afternoon. 4th. — The strength returned with the appetite, and the 
patient who had had no passage in the bowels for three days, obtained 
to-day a copious and healthy evacuation. 5th— (ninth of the erup- 
tion). The pustules of the face were completely dry,— it was for- 
gotten to be stated sooner, that no salivation has occurred. From 
this time the pustules dried up, the scabs fell off, and the patient 
made a rapid recovery. A single pustule only left a mark on the 
face which will probably never wear out, and which is easily distin- 
guishable from those that remain after the inoculated small-pox. The 
red marks of the pustules continued longer visible on the body than 
on the face. 



4. PAPULAR VARICELLA. 

Vocab. Horn-Pox. 

460. This variety does not differ from the others save in the cir- 
cumstance that the greater number of the spots seem to miscarry, or 
to stop short at their first stage. In fact, after the precursory symp- 
toms of a varicellar eruption, a crop of smaller or larger red-coloured 
papula; is discovered upon the skin, which dry up or shrink away 
without being followed by crusts, never seeming to contain either 
pustular or pseudo-membranous matter in their interior. These 
papule are very generally mixed with a few of the lenticular vesicles 
ot chicken-pox, or of the conical pustules which distinguish another 
variety of varicella ; a circumstance which, added to the character 
of the prevailing epidemic, contributes to enlighten us in regard to 
the diagnosis. It is also common enough to meet with these vari- 
cellar papula scattered among the vesicular or pustular spots of the 
other varieties. r 



Papular varicella has been produced by inoculating with small- 
pox virus, individuals who had been previously inoculated or attacked 
with variola. 



Historical J\"otices and particular Cases. 

461. Cases and observations on this disease have been published 
by Black. 1 Peter Frank mentions this variety in his Epitome, under 
the title of varicella solidescens. It must be a very rare disease • I 
have never met with it myself, though I have repeatedly seen papular 
elevations scattered among the pustules of the conical varicella, and 
the vesicles of chicken-pox. Sims 2 has given an account of an 
epidemic modified small-pox, under the objectionable title of chicken- 
pox, in which papular and globular varicellas were observed. 



5. VESICULAR VARICELLA. CHICKEN-POX. 

Vocab. Chicken-pox, Varicella Lymphalica. 

462. Symptoms. — The attack of vesicular varicella is preceded by 
slight febrile symptoms, which continue for twelve, or at longest 
forty-eight hours. The febrile state, indeed, is often so slight as to 
escape notice, — a little depression and headache do not prevent 
children from engaging in their usual play. Such extreme mildness 
in the precursory symptoms of chicken-pox is not, however, an inva- 
riable circumstance ; in some rare cases the invasion of the disease 
is proclaimed by violent pains of the epigastrium, nausea, vomit- 
ing, &c. 3 

The eruption of chicken-pox, although usually distinct, is occasion- 
ally confluent. 4 On the first day of its appearance it is characterized 
by small red superficial and oblong or nearly circular spots, of larger 
size, and more irregular in their outline when they are formed by 
two or more fused together. In the course of the next day a promi- 
nent vesicle filled with a perfectly transparent and colourless or pale 
citrine tinted fluid, which flows out readily when the cuticle is pricked, 
is developed in the centre of the greater number of these prominent 
spots. On the second day this vesicle is nearly a line and a half in 
diameter ; it becomes pointed, or it increases a little more slowly over 
a larger surface, assuming a rounded form. New spots appear suc- 
cessively, in the centres of the majority of which, a vesicle soon arises, 
their bases being occasionally a good deal inflamed. On the third 
day the colour of the lymph becomes yellowish, and this is the only 
change the vesicles are found to have undergone. On the fourth day, 
such vesicles as have not been accidentally ruptured, shrink in size, 
and grow wrinkled in their circumference. On the fifth, a small scab, 
which is adherent to the skin, forms on the centres of the vesicles, 
and a small quantity of turbid lymph is included in their circum- 
ference, a change which occasionally gives them an umbilicated 
appearance. On the sixth, small yellowish or brown scabs replace 
the vesicles. On the seventh and eighth, the scabs fall off and 
expose red and undepressed marks upon the surface of the skin, 
which continue visible for a few days longer. 

During the course of this eruption, many of the elevations seem to 
abort : some remain in the state of simple stains, or papular elevations, 
and gradually disappear; others are surmounted by a very small 
vesicle only, which either bursts or shrinks away in a very short 
space of time. 

Distinct vesicular varicella is commonly accompanied by only a 
very slight derangement of the functions of digestion and circulation. 
When the eruption is confluent, the general symptoms are usually 
more severe. 

When the eruption proves successive, and is preceded or followed 
by other affections, such as erysipelas and ophthalmia, which are 
usually ascribed to its influence, or when such affections happen to 
occur at the same time as the vesicular varicella, the disease may be 
protracted through a period of two or three weeks. 

1 Black, in Edinb. Med. and Surg. Journ., vol. xv. p. 41. 

2 Sims. Obs. on epidem. diseases, 8vo. Lond., 1773. 

3 Sims, ut supra, p. 115. 

* Ring. A case of confluent chicken-pox. Med. and Phys. Journ., v. 14, p. 141. 



VARICELLA. 



171 



463. Causes. — Chicken-pox may be transmitted by the inoculation 
of the serous fluid of its vesicles, or of that of the pustules of the 
umbilicated, conical, and globular varieties of varicella, or by the air 
charged with the contagious miasm of either of these. " I remember 
on two different occasions," says Vieusseux, of Geneva, " to have 
seen a transient small-pox, the pustules of which continued five or 
six days ; they were full of opaque white pus, and were surrounded 
by such an inflamed circle as made me suspect them to be no true 
cases of small-pox, the more as I knew that one of the children 
affected had had this disease, and that the other infected his brother 
and sister with an eruption which was merely the common transient 
small-pox (la petite verole volante ordinaire). 1 '' 

Vesicular varicella or chicken-pox may produce legitimate small- 
pox, and true small-pox may engender chicken-pox. (§ 406.) 

Chicken-pox is a disease which occurs almost exclusively among 
children ; I have, however, seen it in adults and persons of riper 
years; Messrs. Hesse and Stieglitz were consequently mistaken when 
they stated that it only attacked the young. It is contagious, but in 
a less degree than small-pox and pustular varicella, and is trans- 
missible by inoculation. This fact has been lately disputed very mal- 
a-propos;* for Willan and others succeeded long ago in propagating 
the disease in this way. 

464. A certain number of cases of chicken-pox are almost invari- 
ably observed during the epidemic prevalence of small-pox, and of pus- 
tular varicella ; or otherwise, chicken-pox very frequently follows these. 

465. I have already said that chicken-pox appeared to me one of 
the varieties of the variolous eruption. Dr. Eichhorn, 1 however, 
assures us that he has observed vesicular variola prevailing epide- 
mically when no cases of variola were encountered ; and Mr. Barnes 2 
has given a notice of an epidemic chicken-pox which prevailed at 
Carlisle in 1826, at a time when no case of small-pox had been seen 
for several months. 

The epidemic occurrence of chicken-pox, independently of the 
other variolous eruptions, is extremely rare. 3 At Carlisle, small-pox 
had prevailed some months previously ; and the chicken-pox was 
perhaps a last effort or effect of a variolous medical constitution. 
But in whatever manner this fact be interpreted, there is another much 
more satisfactorily demonstrated circumstance, namely, the almost con- 
stant occurrence of chicken-pox during the epidemic prevalence of 
small-pox. Other facts, moreover, prove that these two diseases are 
the effects of one and the same common contagion. (§ 406.) 

466. Diagnosis. — When the vesicles of chicken-pox are fully deve- 
loped, it cannot be mistaken for any other of the variolous eruptions, 
as it alone appears at the period of its height under the form of com- 
pletely transparent vesicles. 

The eruption in chicken-pox is general and scattered over the whole 
surface of the body, very differently therefore from the manner in which 
the vesicles of herpes phlyctenodes appear clustered together, and 
occupying a limited number of regions. 

Acute pemphigus is characterized by bulla?, and not by vesicles ; 
it is not contagious, and occurs independently of the prevalence of 
variolous medical constitutions. 

When P. Frank, described chicken-pox under the title of pemphi- 
gus varioloides, thus uniting two most dissimilar diseases in the same 
group, he evidently suffered himself to be led into error by a mistaken 
analogy. 4 

1 Eichhorn. Handbuch ilber die Behandlung und Verhiltung der contagiosfieber- 
haften exantheme, p. 437. 

« Barnes (Thorn.). Sketch of an epidemic varicella, which prevailed at Carlisle 
in the summer and autumn of ItJ26. (Edinb. Med. and Surg. Journ., vol. xxvii. 
p. 61.) 

s I have looked through the indices of a great number of periodicals, such as the 
Journ. gener. de medecine, the Archives gen. de med., the Journ. der Heilkunde of 
Hufeland, the Edinb. Med. and Surg. Journ., the Bibliothecse of Ploucquet and the 
Repertorium of Reuss without meeting with any other instance of the occurrence of 
epidemic vesicular varicella, independently of prevalent variolous medical constitu- 
tions. 

^ It is even with more surprise that we find this author expressing himself as fol- 
lows in another passage: 

" Quas spurias dixere variolas, hns, licet veras interdum praecedant ac annuntiare 
futuras videantur; licet ex insitione, cum pure varioloso ac optimo instituta, spurias 
provenisse referant variolas, ac licet obsimilitudinem in multiscum variola legitima, 
tam communi, qnam anomala sen abnormi, cum hac ipsa confundi facillime queant ; 
ad alind tamen morborum genus, utpote a variolis natura diversas, relegamus." De 
curand. horn. Morb. Epit., lib. iii. p. 97, 8vo. Vien., 1811. 



467. The treatment of vesicular varicella is the same as that of 
distinct and benign small-pox 

Vesicular varicella does not give immunity from small-pox. 

Historical JYotices and particular Cases. 

468. If at the present day there still prevails some obscurity in re- 
gard to various points in the history of vesicular varicella or chicken- 
pox, it is undoubtedly owing to several different kinds of eruption 
having been described under this title. 5 Besides the observations I 
have already mentioned, there are those of Willan, 6 who described 
three varieties of varicella according to the form of the vesicles, those 
of Heberden, 7 who was the first that imagined chicken-pox to be 
produced by a contagion different from that of small-pox, and those 
of Dr. Thomson, 8 who maintains, and in my opinion, has proved, 
that chicken-pox is a mere variety of variolous eruption, which all 
deserve to be particularly consulted. 

Case LXIX.— Inoculated vesicular varicella (Willan). M. P., aged 
seven years, was inoculated with the fluid of chicken-pox, October 
23d, 1798, by two punctures in her right arm. October 24th. — A 
slight redness surrounded the punctures. 25th, 26th, and 27th. — 
The redness gradually increased, and was attended with a sensible 
hardness and elevation. 28th. — The appearances on the arm became 
much fainter. 30th. — Thinking the inoculation had failed, I did not 
inspect the arm again till the 3d of November, when she complained 
of an itching about one of the punctures. On examining the place, 
I found it red, elevated, and somewhat hard, with a small vesicle in 
its centre. November 4th. — The redness and hardness were much 
increased, and she complained of a sensation of tingling about the 
vesicle. Its size was equal to that of a variolous pustule on the 
seventh day after inoculation. In the evening, two small red erup- 
tions appeared on her shoulder, and soon became vesicular. 5th. — 
The appearance on the arm continued the same, but no fresh vesicles 
were observed. 6th. — The redness on the arm was very faint ; the 
hardness and elevations were abated. No further eruption appeared. 

Case LXX. — John Coles, aged ten months, took the chicken-pox 
by contagion, in July, 1799. On the third day of the eruption, he 
was inoculated from a pustule of the confluent small-pox. On the 
9th and 10th he was feverish ; pustule on the arm proceeding as usual. 
On the 11th, there were several small pustules round the place inocu- 
lated. On the 12th, an efflorescence appeared on the arm. On the 
13th, there was an eruption of about 200 pustules. 18th. — The pus- 
tules had all suppurated. 20th. — Inoculated parts covered with a scab ; 
pustules drying. Some of the vesicles of chicken-pox contained 
yellowish lymph, till the third day of variolous inoculation. 

Case LXXI. — Edmund Wilson, aged six months, was inoculated 
with chicken-pox, May 28th, by two punctures in the left arm. On 
the third day, May 30th, slight elevation and redness round the punc- 
tures. On the fifth day, more inflammation ; in the middle of it, 
shining vesicles, flatfish at the top, with an irregular margin. The 
child had been feverish the preceding night. He was inoculated 
this day with variolous matter, by two punctures on the right arm. 
Seventh day ; the vesicles larger. Two other vesicles appeared on 
the left arm near the puncture. Ninth day, the primary vesicles 
broken ; they appear bluish at the centre ; there are many small vesi- 
cles around them. On the morning of the eighth day, the child was 
sick ; through the succeeding night he was feverish and restless. 
Besides those round the punctures, there are twelve vesicles on differ- 
ent parts of the body, some of them rather indurated, others containing 
lymph. The pustules, on the variolated arm are advancing. Tenth 
day: the child had a convulsive fit yesterday afternoon. He was 
feverish through the night, and had an efflorescence or rash over the 
whole body : vesicles broken and drying. Eleventh day, rash con- 

s A sketch of the history of varicella, in a history of the variolous epidemic which 
occurred in Norwich. By John Cross, 8vo. Lond., 1820. 

e Willan. On vaccination, 4to. Lond. 180G, chap. vii. On the chicken-pox and 
swine-pox. 

i Heberden. Med. transact, of the College of Physicians of London, vol. i. p. 427. 
— This opinion of Heberden is adopted by Bryce (Edinb. Med. and Surg. Journ., vol. 
xiv. p. 467), by M. Eichhorn (op. cit.), and by Doctor Abercrombie. 

8 On the identity of chicken-pox and modified small-pox (Edinb. Med. Surg. Journ. 
v. xiv. pp. 518-657). 



17-2 



PUSTULjE. 



limi. s ; about fifty pustules appeared this morning. Vesicles on the 

left arm perfectly dry and scabbing. Pustules at the inoculated places 

on the rigfal arm, much enlarged and surrounded by an efflorescence, 

t variolous inoculation. On the fourteenth, the secon- 

ariolous pustules are maturating, but they remain indented at 

litre, — tenth day of variolous inoculation. Eighteenth day of 

the first inoculation,—- fourteenth day of variolous inoculation — scabs 

over the places inoculated, the other pustules drying. Twenty-second 

<la\ of variolous inoculation ; pustules have been succeeded by scabs; 

Bome of them are separating. 

6. VARICELLAR FEVER (\ARICELLJE SINE VARICELLIS). 

469. Certain fevers without eruption, arising from contagion of 
small-pox in individuals who have been vaccinated or inoculated, and 
from that of pustular or vesicular varicella, in subjects obnoxious to the 
influence of variolous contagion in all its shapes, have been described 
under the titles offebris varicellosa, nndfebris varioloidosa. 

I have never myself seen a case of this kind of fever, for informa- 
tion on the nature and character of which, the works of Dr. Eichhorn 
particularly may be consulted. 1 



VACCINIA. COW-POX. 
Vocab. Cow-pox, Grease, and Vaccinc-pox. 

470. On the teats of the cow, there occasionally occurs a particular 
hind of pustule, known in England under the name of cow-pox. The 
fluid of this pustule inoculated upon the skin of the human subject, 
gives rise to an eruption of similar pustules, to which the name of 
vaccine-pox, cow-pox, or vaccinia has been given. The disease thus 
communicated has the remarkable property of almost constantly pre- 
serving the constitution from the contagion of the small-pox, and 
always of notably diminishing the virulence of the variolous action, 
when it fails to give complete immunity from its influence. 

471. The vaccine pustule appears three or four days after the inocu- 
lation of the virus ; on the seventh and eighth days, it contains a viscid 
and transparent fluid, which is collected within a reticulated pseudo- 
membranous deposit. On the eighth, the pustule is surrounded by an 
elevated border, and an inflamed areola, and appears depressed in the 
centre. The contained fluid is at length changed into a brownish 
crust, which is detached towards the twenty-fifth day, leaving a puck- 
ered and characteristic cicatrice on the skin. 

472. Inoculation of the vaccine pox. — Vaccinia cannot in general be 
excited oftener than once in the same individual ; it has, however, been 
communicated a second time. 2 It may also be produced in some rare 
cases in those who have had small-pox naturally, or by inoculation. 
In these individuals, however, a modified cow-pox or vaccinella is 
more commonly engendered. Cow-pox may be communicated to 
persons of all ages ; but it seems to be more readily excited in chil- 
dren than in adults. Infants have been vaccinated a few hours after 
their birth ; the operation, however, except under pressure of the 
epidemic prevalence of small-pox, may be deferred till the second or 
third month. It is seen, in fact, from the statistical tables of small- 
pox given by M. Mathieu, that this disease is infinitely rare from the 
period of birth to the age of six months, (a) 

Certain seasons exercise an indubitable influence on the evolution 
of cow-pox; the heat of summer accelerates; intense cold retards its 
progress. Menstruation and pregnancy do not contra-indicate vacci- 
nation. (6) 



(a) The proper time is about the third month after birth. 

(b) Common ailments do not interpose an obstacle to vaccination, 

Kichhorn, op. ciu p. 407. 
« Boffinet Journ. compl. des sc med., t. xxxi. p. 79.-M. Moreau, Professor of 
Midwifery, has given a case-M.M. Bricheteau and Boucher of Versailles, have seen 
several cases of these double vacciniw.-M. Trannoy assures us that he knew a 
lady who took cow-pox as often as she was vaccinated. On the other hand M. 
Barrey informs us, that he re-vaccinated above 300 individuals without producing a 



Healthy individuals do not require any preparation before being 
vaccinated. Occasionally, however, it is well, in the case of adults 
and the aged to diminish the rigidity of the skin by the use of the 
warm bath and the application of a soft poultice to the part selected 
for the punctures, the night before inserting the vaccine virus. In 
weakly children, of a lax fibre, the skin should previously be rubbed 
briskly with a coarse towel. By using these and similar means, indi- 
viduals have at length been successfully vaccinated on whom the 
operation had been fruitlessly attempted several times before. 

474. Certain circumstances, such as the existence of an acute 
inflammation of any of the viscera, too great a flow of blood from 
punctures carried too deeply, and peculiar medical constitutions, may 
prevent the success of the operation. 

In a small number of subjects, some inscrutable condition or idio- 
syncrasy occasionally prevents the development of cow-pox. Vac- 
cination performed on infants of three or four days old, fails on an 
average two in three times; it succeeds, on the contrary, ninety- 
eio-ht times in a hundred, after six weeks. 

475. Methods of performing vaccination. — The fluid of the pock of 
the cow's teat, or of the vaccine pustule of the human subject, may 
be inoculated by means of a blister, an incision, and a puncture. 

1. Blisters have the twofold inconvenience of exciting an irrita- 
tion, which tends much rather to prevent the action than to favour 
the absorption of the virus, and of causing an inflammation which, 
in young infants, occasionally terminates in ulceration. 

2. Incisions are frequently followed by cutaneous inflammation, 
not vaccinial in its nature. This, however, is the only mode availa- 
ble, when all the virus at our disposal is contained in threads which 
have been soaked in the fluid. A superficial cut is made in the skin, 
a line and a half or two lines in length, in such a way as to cause 
little or no bleeding, into Avhich a piece of the thread charged with 
the virus, a line in length, is introduced. The wound is covered 
with a bit of sticking plaster, and the whole secured by a turn or two 
of a roller. After an interval of two or three days, the dressing may 
be removed, and if the process of infection appears to have begun, 
the bit of thread may be drawn out of the wound. 

The method by puncture is less painful, and also more certain in 
its results than that by incision. Two or three punctures are usually 
made in each arm with the point of a common lancet, or better, of a 
lancet constructed for the purpose, charged with the vaccine virus. 
Jenner was in the habit of making only one puncture in each arm ; 
Dr. Eichhorn makes from sixteen to twenty altogether. If the vac- 
cination be performed from arm to arm, which is the preferable plan, 
the lymph ought to be taken from the pustules on the fourth day of 
their evolution. 

476. The usual method of performing this trifling operation is as 
follows : after having taken up on the point of a lancet or needle, a 
little of the fluid, the vaccinator, with the left hand, grasps the pos- 
terior part of the arm of the subject about to be vaccinated. He 
then makes the portion of skin that intervenes between his thumb 
and fore-finger tense, and with the right hand pushes the point of 
his instrument in a horizontal or slanting position a short way into 
the substance of the integuments. The thumb of the left hand being 
now applied over the puncture, he allows the instrument to remain 
for an instant, and when withdrawing it, presses gently upon the 
blade, as if to wipe it within the wound. 

477. Dr. Eichhorn' s method. — He advises from sixteen to twenty 
punctures to be made — a number which he esteems adequate in 
almost every case to secure individuals against the contagion of 
small-pox. Twenty-four or forty-eight hours after the appearance of 
the red circle, which is developed around the pustules, Dr. Eich- 
horn, with the matter of the nascent vaccine-pustule, vaccinates the 
same individual a second time; performing what he entitles the 
proof vaccination, in which he makes from four to six punctures. 
Three events may now occur. 1. The proof vaccination does not 

if there be any urgency for having the operation performed. But in 
no case, unless small-pox be in the house, or the child be unavoida- 
bly threatened with its contagion, should vaccination be practiced 
on a subject whose skin is affected with any eruption or running 
sores. 






VACCINIA. 



173 



fake; the punctures do not rise; and the individual is then com- 
pletely safe from small-pox. 2. The proof vaccination takes; but 
very small pustules only are developed, although possessing the form 
and structure of the true ones ; the red circle is formed at the same 
time as that of the pustules already existing, and the whole dry off' 
together ; the individuals in whom this occurs are not secure. 3. The 
proof vaccination succeeds, and fresh pustules are evolved with so 
much regularity, and with the same slowness as the first; in the 
majority of these cases, the individuals are not protected. 

These statements and experiments of Dr. Eichhorn deserve to be 
further inquired into and repeated. 

478. If no other vaccine virus can be procured but that which is 
preserved between two plates of glass, or upon a piece of linen-rag, 
it must be softened or mixed with the smallest possible quantity of 
cold water, and then employed in the ordinary way by puncture. 

To use the vaccine virus preserved in glass tubes, 1 the two ex- 
tremities must be broken off', when by blowing gently into the tube, 
the matter it contains can be collected on- a plate of glass and inserted 
by a puncture, as is done from arm to arm. 

479. The vaccine pustule possesses its full energy on the fourth 
day of its appearance, and its contents present the following charac- 
ters: 1. When several small punctures are made with the point of a 
lancet in the surface of a vaccine pustule, the contained fluid exudes 
slowly under the form of globules of a silvery colour. 2. When 
copiously shed over the surface of the areola this fluid resembles the 
slime left by a snail in its track. 3. It is viscid and mixed with diffi- 
culty with blood ; it may be drawn out into threads between the 
thumb and finger ; it sticks readily to the surface of a lancet or plate 
of glass applied to it ; it dries quickly in the air, forming on the point 
of an instrument a gummy-looking crust. Threads imbibed with it 
become stiff' when dry, and if they are then bent, it flics off" in scales 
of a vitreous aspect and considerable hardness. 

4S0. The whole of the fluid of a vaccine pustule does not appear to 
possess the same activity. Thus when a very large number of children 
are vaccinated from one or two pustules only, the first operated on 
have a better chance of infection than the last. 

The vaccine virus possesses its full activity from the moment of its 
deposition within a pustule, and its power continues, although not in 
the same degree, till the eighth or ninth day of the vaccination. In 
general it is so much the more energetic as it is taken nearer to the 
period of its formation ; the smaller the quantity of virus a properly 
developed pustule contains, also, the more energetic does it appear 
to be. 

The virus of the vaccine pustules of young children is more certain 
in its effects than that taken from those of adults. 

M. Bousquet assures us that the vaccine virus becomes rapidly dete- 
riorated when preserved in tubes. It suffers less change when kept 
dry, between two plates of glass. 

The scab of a vaccine pustule will occasionally transmit the disease ; 
it is very uncertain however, (a) 

Chemical analysis has showed the vaccine fluid to be composed of 
water and albumen ; it has taught us nothing in regard to its peculiar 
contagion, (b) 

481. Symptoms. — At the time each puncture is made, there is 
almost always formed around the point a superficial slight red circle 



(a) In the United States, the scab or dried crust is almost the sole 
material used for propagating vaccine disease by vaccination. Al- 
though we might prefer, on the score of greater certainty of success, the 
fresh lymph, yet this cannot be procured in common, or more than 
once from one person, without injustice to the latter, owing to the 
irritation and inflammation which may follow and modify injuriously 
the progress of the vaccine pustule to entire maturation. 

(6) M. Donne assures us that the microscope has not, as yet, 
revealed any distinctive character of vaccine vesicles or scabs. 

' These tubes are six lines in length and capillary at their ends. To charge them 
with vaccine virus, nothing more is necessary than to touch the little globules of fluid, 
which flows from a puncture of the vaccine pustule, with the smaller extremity of 
the tubes. When sufficiently charged they are hermetically sealed in the flame o!' a 
candle. The virus thus collected is said to preserve its properties unimpaired for 
several years, if it is not exposed to too great a degree either of heat or cold. The 
tubes can be packed in the barrel of a quill, with a little bran, and sent anywhere. 
44 



from six to twelve lines in diameter, which disappears within a few 
minutes. This primary phenomenon is by no means a criterion of the 
future success of the operation as has been imagined ; it follows punc- 
tures of every description. When the blush has disappeared, the 
puncture rises in the form of a small half lentil, looks slightly red, and 
continues longer than the first efflorescence ; but it also subsides and 
vanishes in the course of a few minutes. Till the third and fourth 
days the vaccinated part presents no appearance of change (the period 
of incubation). At the end of the third day, or during the course ot 
the fourth day, the evolution of the vaccine pustule commences: the 
finger readily detects a slight degree of hardness in the points where 
the punctures were made ; upon these a small red elevation is not long 
of showing itself. On the fifth day this elevation becomes circular, am 
assumes an umbilicated appearance. The part is somewhat itchy. On 
the 6th day the red tint of each elevation becomes brighter, the circum- 
ference, which is surrounded by a red circle half a line in breadth, 
enlarges, and the centre of the pustule is more depressed. On the 7th 
day the size of the pustule increases ; it spreads in its circumference 
and acquires a silvery aspect ; the red colour which tinged it is lost in 
the central depression, and continues to occupy a very small part onh 
of the outer margin. The red and very narrow circle, which up to 
this time has circumscribed the pustule, fades somewhat from the 
intensity of its colour; the inflammation extends to the subcutaneous 
cellular substance. On the ninth day the circumference of the pus- 
tule is still larger, its surface is more raised, and appears more turgid 
with the matter than ever; the red circle, the irradiations of which 
extended in streaks before, now acquires a more uniform rosy hue. 
and a perfect areola is formed. On the tenth day the turgid circum- 
ference of the pustule continues to spread, the areola acquires a 
diameter of from one to two lines, and the part of the skin upon 
which it is developed occasionally becomes indurated and very mucl 
swelled (the vaccine tumour). Its surface appears granular and 
slightly (lotted, and by means of the magnifier a great number of 
minute vesicles filled with transparent fluid may be distinguished 
upon it. The person vaccinated experiences a biting heat and vio- 
lent pruritus in the part affected, and a sense of weight and pain, 
which occasionally extends to the axillary glands, in the whole of the 
arm. This inflammatory period is often accompanied by some degree 
of fever and restlessness, with acceleration of pulse, &c, &c. On 
the eleventh day every thing continues in the same state as on the 
tenth. The vaccine pustule at this period is elevated from one ft 
two lines above the level of the skin, and resembles a large lentil, the 
edges of which are raised in a pique. It is of a pearly hue, and 
its diameter varies from two to five lines ; it feels hard to the touch, 
and resists pressure like a body intimately connected with the skin. 
During the whole of this period the vaccine fluid is contained within 
a reticulated pseudo-membrane, very nearly in the same manner as 
the vitreous humour of the eye is entangled in the cellular web. On 
the twelfth day the pustule begins to dry; the central depression 
assumes the appearance of a scab ; the fluid, contained within the 
circular puffed circumference, limpid hitherto, now grows turbid and 
opalescent. The areola becomes pale, the general swelling subsides, 
and the cuticle covering it begins to scale. On the thirteenth day the 
desiccation advances in the centre ; the pustule which has been cel- 
lular hitherto, now consists of but a single cavity. If it be punctured 
its whole contents, consisting of a turbid yellow purulent matter, an 
evacuated. The areola changes into a circle of a pale purplish hue. 
On the fourteenth day the scab acquires the hardness of horn, and a 
tawny yellow colour something like that of barley-sugar. The circle 
which surrounds it decreases in breadth at the same pace as the 
vaccine tumour or general swelling subsides. From the fourteenth 
to the twenty-fifth day, the solid yellow crust becomes of a deepe 
colour, approaching mahogany in its appearance, and almost always 
preserves its umbilicated form. In proportion as the general swelling 
subsides, the scab seems to rise more and more above the level of the 
skin ; it finally falls off between the twenty-fourth and twenty-sevent] 
day, leaving exposed a deep cicatrix, studded with minute depressed 
points, similar to those which are often seen on the thin biscuits called 
wafers, (a) 

(a) The vaccine pustule runs a given course of varus and of 



174 



PUSTULE. 



, una is not always deTeJopftd thus completely and thus 
regularly. 1. Occasionally but one or two pustules follow a much 
punctures. In the opinion of the majority of vacci- 
le protects the constitution as effectually as six or a 
Messrs. Eichhorn ami Robert, however, are of a different 
pinion). 2. The period of incuhation may be prolonged to the 
wenty-aecond or twenty-fifth day, and even much longer, 1 or it may 
nid 10 more than two or three days. 3. Irregular pustules 
mally arise from the accidental conjunction of two pustules 
evolved in the immediate vicinity of each other. 4. The vaccine 
virus occasionally produces in the same individual the true, and the 
w-pox or vacrimlk. 5. Vaccine pustules may appear on 
parts of the body where no inoculation was performed. It is almost 
tlways on inflamed surfaces which have lost their epidermis that these 
secondary pustules are developed, such as parts affected with chronic 
and impetiginous eczema, excoriated lichen, &c. These pustules, 
indeed, are occasionally produced by the accidental inoculation of the 
vaccine matter carried on the fingers in scratching from the original 
pustule to the abraded surfaces, when the constitution happens to 
have been but imperfectly modified by the first eruption. More com- 
monly, however, t lie supernumerary pustules are the result of a secon- 
dary eruption analogous to that which even so uniformly occurs after 
the inoculation of the virus of small-pox. 6. In the negro and mulatto 
the inflammatory areola of the vaccine pustule is not very apparent, 
the skin, in its usual situation in the white, presenting in them merely 
a coppery appearance. In them, too, the cicatrix is red. Lastly, 
there occur vaccinia sine vacciniis. A well-constituted child, on the 
eighth day after vaccination complained of general uneasiness, and 
exhibited febrile symptoms which continued for a week. The erup- 
tion was looked for in vain. M. Pistono re-vaccinated the child, but 
without effect. 2 M. Petiet having vaccinated an individual who had 
had the operation fruitlessly performed the year before, this person, 
after an interval of eight days, was seized with fever which continued 
for thirty-six hours ; vaccination performed at three different times 

vesicle, which at length terminates in a concretion, and forms a crust. 
The stage of varus, or the papular, lasts but one day; the vesicular 
consists of four days umbi Heated, and three acuminated and pustular: 
the process of incrustation is also three days more; so that allowing 
three days for incubation, the whole duration of the disease, from the 
time of puncture until the formation of the crust, is from fourteen to 
seventeen days; but some days elapse after this before the crust or 
scab falls off. The eighth day is the period of the first blush of the 
areola; this enlarges on the three following days, or those of pustula- 
tion, which is also the period of slight fever. 

Anatomically considered, the vaccine pustule has its seat in the 
muciform tissue of the cutis, and is a little more superficial than the 
small-pox pustule, which has its seat in the thickness of the dermis. 
At its origin, it is only a small tubercle, more or less hard, but when 
most perfectly organized, bisect, either horizontally or perpendicu- 
larly, a pustule, and it will be seen divided into a number of cells, 
separated from each other by a thin cellular tissue, each filled with a 
clear diaphanous liquid, which is the vaccine virus. The cells do 
not communicate together, but radiate from the circumference to the 
centre, where they unite in a common bride, which depresses the 
cuticle and gives the umbilicated character to the pustule. This is 
the state of the parts from the sixth to the ninth day — but it does not 
last, the lymph becoming altered and turbid, and pus mingles with 
the virus, the bride is broken, and the pustule ruptures. There are 
many anomalies in the form and character of the pustule. This latter 
we should regard as an external sign of a constitutional disease, but 
not necessary to it. 

The vaccine cicatrix is round, deep, puckered, radiated, and 
studded with points, which answer, without doubt, to the cells into 
which the interior of the pustule is divided. It is more marked in 
proportion as it is more recent ; but it is never entirely effaced by- 
time. The cicatrix is not to be received as an infallible criterion of 
the actual amount of constitutional protection, although, in the exist- 
ing state of our knowledge, it is the best. 

' Baker.-Obs s Ur un bouton vaccin deveU.ppe six mois apres insertion du Virus. 
Arch, gen de med., i. I. p. 27/. 
* Rapport du comite de vaccine, 1612. 



subsequently produced neither eruption nor fever ; inoculation of small- 
pox was also performed in vain. M. Bousquel gives several analogous 
facts, which must be distinguished from the simple febrile paroxysms 
produced by the punctures/ In cow-pox as in small-pox, the general 
infection is the essential matter; the eruption is merely secondary. 

483. Cow-pox is a very mild disease ; but it may accidentally be 
complicated with other affections. When the pustules are extremely 
numerous, inflammation of the axillary glands, eczema, accidental 
pustules, roseola, erysipelas, phlegmon, and inilaramation of the lining 
membrane of the bowels, are the diseases that most frequently com- 
plicate cow-pox in children. 

The direct inoculation of cow-pox has also been known to occasion 
the same complications in adults. 

Of all possible complications, however, that of small-pox with cow- 
pox is the one which is fraught with the highest interest. 4 These 
eruptions most commonly modify each other when the two contagions 
exert their influence at the same time. 5 Yet it would appear that, 
under certain circumstances, the variolous contagion is not modified 
in its effects. (§ 500.) Thus at Marseilles, during the month of June, 
1828, nine persons died of small-pox during the development of cow- 
pox, and three others had, previously to the above date, died under 
the same circumstances; in the month of August two more died, and 
in September two more, in all sixteen individuals, who became the 
victims of small-pox, in spite of cow-pox, which accompanied it. 

When a mixture of the variolous and vaccine virus is inoculated, 
two different eruptions are occasionally developed perfectly in accord- 
ance with the twofold and dissimilar nature of their exciting cause. 
Woodville was the first who made this experiment, wdrich has been 
repeated by Messrs. Salmade and Bousquet. 6 In opposition to the 
opinion of the latter, I conceive that the action of the variolous virus 
was modified in his experiment, and that the eruption which left no 
cicatrices w r as rather the umbilicated pustular varicella than legitimate 
variola. 

484. Professor Monteggia, 7 in a paper read on the 17th of Febru- 
ary, 1814, before the Institute of Milan, maintained that if a syphilitic 
child were vaccinated, a pustule was developed which contained the 
two poisons. In 1821, M. G. Cerioli again advanced the same opin- 
ion: " Catterina Sclibino, two months and a half old, healthy to all 
appearance, was vaccinated. The vaccine pustule became perfectly 
well developed; on the 16th of June, 1814, ten children were vac- 
cinated with the lymph from her arm, and with the virus from these 
ten, thirty other children were inoculated. Within a few months 
Catterina Sclibino and five of the first vaccinated children died. Of 
the thirty vaccinated in the second instance, only seven could be 
traced. Of these, one was seized with a peculiar disease which he 
communicated to his brothers, and another also exhibited morbid 
symptoms. The parents of Catterina had long laboured under a 
syphilitic complaint which they neglected. A few days after the 
vaccination, the child became covered with pustules, which appeared 
upon the external parts of generation, about the anus, on the neck, 
forehead, and around the mouth. The other children vaccinated 
were attacked with similar pustules, ulcerations of the mouth, and 
morbid growths about the arms ; the disease was also communicated 
to several nurses, who suckled these infants, and to different other 
children who were nursed along with them." 

485. Diagnosis. — Cow-pox is not liable to be confounded with the 
accidental pustules which have very improperly been designated/ate 
coio-pox, and which are produced every time that pus or another stimu- 
lating fluid is inoculated. Such pustules are evolved on the morrow, 
or the day after that, on which the operation was performed; they 
are circular in their shape, and rise into a point from the period of 
their evolution ; their summits are yellowish, and they are so fragile 

3 Fauchier. Obs. sur la vaccine sans erupiion. (Rec. period, de la soc. de mtd. 
de Paris, t. xxxi. p. 281.) 

4 Sedillot (J.). Observat. de petUes-verotes malignes survenues pendant le de- 
veloppement de la vaccine (Rec. period, de la soc. de med. de Paris, t. xxviii. p. 3). 
— Duplan. Observat. sur la petite-veYole snrvenue pendant le cours de la vaccine, et 
sur la marche simultanee de ces deux Eruptions (Ibid., torn, xxviii. p. 126). — Bouteille 
(C. M.). Tableau de vaccine et de la petite-verole, en concurrence sur le meme 
individu. (Ibid., I. xxiv. p. 393.) 

6 Petit. Journ. hebd. Ire serie, t. viii. p. 302. 

e Bousquet. Op. cit. Rapport entre la variole et la vaccine, p. 328. 

' Marcolini (F. M.). Sulle complicazioni della vaccina, 8vo. Milano, 1823. 



VACCINIA. 



175 



that they give way under even the slightest pressure ; the pus they 
contain escapes and dries up from the third to the fifth day. The 
scabs that succeed are yellow, soft, and often bathed in an ichorous 
fluid. In a word, these pustules have neither the course nor the 
umbilicated appearance characteristic of those of cow-pox. 

Vaccinella or spurious cow-pox bears a greater resemblance to 
cow-pox, the disease being characterized by the presence of one or 
of several pustules, accurately circumscribed" and umbilicated, which, 
like those of the true cow-pox, appear on the fourth day, advance 
like them, although with an inferior degree of attendant inflammation, 
to the eighth or ninth day, and usually dry up about the fourteenth 
or fifteenth day. The fluid they contain, if inoculated, is capable of 
producing the legitimate cow-pox (Eichhorn), as well as a pustule, 
which differs from true vaccinia, either in the greater rapidity of its 
progress, after it has attained the period of suppuration, by being 
accompanied with a less degree of inflammation either of its circum- 
ference or of its areola, and by being followed by a mere mark or 
very slight scar instead of the pinked and puckered cicatrice charac- 
teristic of true vaccinia; lastly, the pustules of vaccinella do not so 
certainly preserve from variola as those of cow-pox. 

In the various particulars of their form and progress the pustules nf 
cow-pox have the greatest similarity to those of inoculated small-pox. 
Like these they are evolved several days after the insertion of a pecu- 
liar virus ; like them they are of a circular shape, pitted in the centre, 
and pass through their periods in the course of about three weeks ; 
but they differ in the circumstance of their contagion not being trans- 
mitted like that of small-pox by the medium of the atmosphere. The 
eruption of variola is also essentially of a general nature, whilst that 
of vaccinia, with the exception of a very small number of cases, is 
purely local. Despite their common features, however, these two 
diseases seem to be even mutually opposed ; their simultaneous 
inoculation very commonly induces modifications in their outward 
appearances and in their progress. It has been said, indeed, that the 
virus of small-pox inoculated upon the common heifer produces cow- 
pox ; but the experiment has been repeated without such a result. 1 
Dr. Sunderland 2 has also been said to have succeeded not only in 
giving small-pox to a heifer by clothing it with the coverlid of a 
variolous patient's bed, but in successfully using the matter of the 
eruption thus produced for engendering cow-pox in the human sub- 
ject ; Dr. Numan, however, on repeating this experiment, did not 
obtain the same results. 

The researches of M. Guillon have demonstrated the analogy of the 
umbilicated pustular varicella when produced by inoculations, to cow- 
pox. 

Vaccinia being the product of the virus of cow-pox transplanted 
upon the human subject, it can be no matter of astonishment that the 
two eruptions in man and the animal should resemble each other, nor 
that the virus of the vaccinia of man inoculated upon the teat of the 
cow, should there occasionally produce cow-pox. 

The matter of the small pustules of the grease of the horse, inocu- 
lated upon man, or the cow, has been said to cause the development 
of vaccinia or cow-pox, 3 but the experiment was repeated by Wood- 
ville, Simmons, and Buniva without any such consequences. Several 
of the cases of grease which have been shown to me by well-informed 
veterinary practitioners, belonged evidently to eczema impetiginodes, 
or to impetigo, (a) 

(a) I cannot better present the subject of the probable origin of 
cow-pox and of its connection with small-pox, than by repeating the 
brief summary which I have recently made in another work. 

" The original source of vaccine virus was believed by Jenner to 
be in the heel of the horse when this animal is affected with the dis- 
order called grease. Experiment and analogy are, however, opposed 
to this view. Another hypothesis of Jenner has been revised of late 
years, and apparently its reality confirmed by experiment. He ex- 
pressed ' his unalterable conviction that how different soever they 
might be in some particulars, the cow-pox and the small-pox were in 
reality identical ;' that the cow-pox was not ' an antidote but the 

1 Voisin. Mem. sur la vaccine, 8vo. 18. 

2 Arch. gen. de med., Nov. 1.-31. 

a Loy. Acct. of some experiments on the origin of cow-pox, 8vo. London, 1820. 



486. Prognosis. — Vaccinia attains the height of its preservative 
power on the second day of its appearance. 

M. Bousquet has shown that the integrity of the pustules was not 
required to give vaccinia its preservative virtues ; he opened and 
cauterized the pustules from the moment of their appearance, and 
vaccination performed anew was without effect. 

Not only is cow-pox generally a complaint of extreme mildness, 
but in certain circumstances it may even prove a kind of salutary dis~ 
ease. Like several other forms of external inflammation, it has occa- 
sionally brought about or hastened the cure of ophthalmia, otitis, 
chronic bronchitis, and hooping-cough ; further, its virus inserted 
into various chronic inflammatory affections of the skin, may accele- 
rate the progress of these affections. 

substitution of a mild species of small-pox instead of a malignant sort, 
or of cow small-pox for human small-pox.' Trials were made to 
test this hypothesis ; but although many cows have been clothed with 
blankets taken from the bed on which small-pox patients had just 
died, and have been inoculated in every possible way, yet, not only 
has this small-pox not been satisfactorily produced, but this failure of 
such experiments rendered it probable that the cow was unsuscepti- 
ble of the disease. 

" Of late years the question has assumed a new aspect since the 
success of Mr. Ceely's trials, by inoculating the cow with variolous 
virus, and procuring from the pustules matter which, introduced into 
the skin of the hitherto unprotected human subject, gave rise to dis- 
tinct vaccinia and allowed of successive transfers to other subjects, 
with the preservation of all the regular features and other phenomena 
of the cow-pox. Mr. Fare, in his letter to the Registrar-General of 
England, in the annua] report for 1842, adopts, as a received truth, 
these, results, when he says, varioline, or the specific matter of small- 
pox, is converted into vaccine. It had been asserted in 1828 by Dr. 
McMichael, in an essay read before the College of Physicians, that 
' vaccine matters having failed in Egypt, medical gentlemen were 
led to institute certain experiments by which it has been discovered 
that, by inoculating the cow with small-pox from the human body, 
fine active vaccine virus is produced.' Connected with this ques- 
tion are the interesting facts on record, of the prevalence, at the 
same period, of the cow-pox among cattle and the small-pox among 
men, and the transmission by contagion of the small-pox to cattle, and 
the consequent development of cow-pox in these animals. 

" If we are to speak of the habits of the vaccinine or vaccine poison 
as seen in the cow, we learn that the disease is occasionally epizootic 
or prevalent, at the same time, at several farms at no great distance 
from each other, but that more commonly it is sporadic, or nearly 
solitary. So irregular is its appearance, that Mr. Ceely ( On Variolce 
Vaccina), states that he has known it to occur twice in five years, in 
two contiguous farms in Buckinghamshire ; while at a third adjoininc 
dairy it had not been known to exist for forty years. It is said to 
appear most commonly about the beginning or end of spring, rarely 
during the height of summer, but has been seen at any period from 
August till May, or the beginning of June. One other remarkable 
circumstance, however, connected with the disease in the case, is 
that it is peculiar to some countries, and to certain districts of the 
same country. On the first publication of Dr. Jenner's discovery it 
was much sought for in England, but found to exist only in eighteen 
counties. It has been found, also, among the cattle of Lombardy, 
Holstein, Persia, the southern parts of America, and in India. It is 
singular, however, continues Dr. Williams, whose narrative I am 
now following, that it was altogether unknown in France till 1836, 
when, by an inexplicable biazarrerie, it was discovered in three 
separate districts, at a short distance from each other, or at Passy, 
near Paris, Amiens, and at Rambouillet. This latter fact is strong 
argument against the disease being small-pox, and of the cow beino- 
affected by the human subject, for on such an hypothesis it is im- 
possible to assign any reason why the disease should be so often 
communicated in England and so seldom in France. The poison is 
capable, also, of producing the cow-pox in many animals, not natu- 
rally liable to it by vaccination, as the dog, the goat, the she-ass, the 
sheep, and, perhaps, the horse." Bell and Stokes's Lectures on the 
Practice of Physic, 3d edit., p. 735, vol. ii. 



176 



PUSTULE. 



The detractors from the merits of vaccine inoculation on the other 

hand, have said, but without proving their assertions, that phthisis, 

fula, nervous lever, &C., have hecome much more i're- 

in Europe since this eruption has been made to replace that of 
small-pox. 

tment. — Cow-pox, uncomplicated with any other co- 

nt affection, requires no treatment ; it ought to be left to itself, 
in order that it may run through its natural periods unimpeded. The 
pustules should be preserved from all rubbing and compression which 

injure them before the period at which the virus they contain 
1 for other vaccinations. The custom of giving an 
aperient after the fall of the scabs, so generally insisted on by mothers 
and nurses, is seldom necessary. 

. Should roseola, (§ 269, )a large phlegmon, extensive erysipelas, 
acute inflammation of the axillary glands, &.c, complicate vaccination, 

various affections must be subdued by blood-letting, low diet, 
and the other measures usually adopted in their treatment. Should 
the development of too large a number of pustules appear to occasion 
unpleasant symptoms, one or more of the points may be touched with 
caustic, and their progress thus arrested without the protecting in- 
fluence of the others being injured by the practice. 

t89. It has been said that the vaccine virus has degenerated, and 
that of late years the eruption has not been so vigorous as it was of 
old ; that the vaccine fever is less marked, and the cicatrices not so 
definite ; that the disease can no longer be transmitted back to the cow ; 
that small-pox occurs more frequent after vaccination now than for- 
merly, and that we also succeed more readily in giving cow-pox twice 
to the same individual. In the expectation of finding a remedy for 
this presumed degeneracy of the vaccine virus, it has been proposed 
:o recur to the matter of cow-pox developed spontaneously in the 
animal, or to the virus tempered anew in its source by being transferred 
from man to the cow. 1 (a) 

490. These fears, however, appear exaggerated at least. It is certain 
that we every day meet with vaccine pustules which resemble in every 
particular those, the description ot' which have been transmitted to us 
by the earliest vaccinators, several of whom, and Marshall in particu- 
lar, inform us that persons vaccinated, may go about their ordinary 
business. The assertion in regard to the cicatrices is entirely gra- 
tuitous. It has at all times been found a difficult matter to inoculate 
the cow with the vaccine virus. The occurrence of small-pox after 
vaccination appears more frequent at the present day only because 

(a) Means of comparison in this respect, within the last four or 
five years, have been furnished to the profession in England, and 
measurably to some physicians in the United Slates, chiefly through 
the labours of Mr. Estlin, of Bristol; but as yet the question is not 
clearly settled. The few trials made by myself do not incline me to 
give a preference to the vaccine virus recently procured from the 
cow; or to retro-vaccination, as it is called. We have no evidence 
of its greater protecting power, although generally the inflammation 
is greater and the areola larger than in vaccinia induced by the older 
transmitted matter. Upon the whole, however, we are justified, — and, 
considering the possible causes of deterioration of the vaccine matter 
in its transmission through a great succession of persons, perhaps we 
should add, authorized — to recur to the primary lymph from the cow. 

The following curious fact, if it be a fact, is worth mentioning in 
this place. I find it in a note at p. 116 of Mr. Wilson's book. — 
Am. edition. 

"Dr. Lichtenstein, in a paper, entitled ' on the sources from which 
matter preservative against the small-pox has been derived,' inHufe- 
land's Journal for 1841, remarks, that limpid lymph taken from the 
pustules produced by tartarized antimony, and inoculated in a person 
who has not been vaccinated, produces vesicles, which cannot be 
distinguished from those of vaccinia. These vesicles appear to be 
equally protective against small-pox with the cow-pox, and the matter 
may be transmitted from person to person in the same manner. The 
author has inoculated and re-inoculated thirty-one persons with the 
matter procured from this source ; and these persons were protected 
during an epidemic of small-pox, although placed in association with 
patients affected with that disease." 

1 FiarJ. Necessite de rcgenerer la vaccine (Rev. Med., 2de serie, t. ii. p. 338.) 



the fact is no longer disputed, and perhaps because variolous medical 
constitutions have been more than usually prevalent of late. Lastly, 
the possibility of communicating cow-pox a second time, twenty years 
after its first inoculation, so far from proving that the vaccine virus at 
our disposal in the present day is less energetic than it used to be, 
tends rather to demonstrate the reverse of the proposition. Nothing, 
then, shows that cow-pox has degenerated. 

491. In the event of a variolous epidemic, it is well to vaccinate 
anew all who may have had the operation already performed, but who 
possess no certificate or assurance of their having previously passed 
regularly through the different stages of cow-pox. 

Several practitioners having thought they perceived that those 
among the vaccinated who had had the operation performed most 
remotely, were more subject to attacks of variolous eruption than the 
rest, have proposed to re- vaccinate the same individual at intervals 
of a year, tw r o years, seven years, &c. For my own part, I conceive 
that vaccination ought to be attempted as often as a variolous epidemic 
prevails, or at least on occasion of the first epidemic of this kind that 
follows the vaccination, when the operation has not been performed 
in the way proposed by Eichhorn. (a) 

(a) Overweening confidence, as I have elsewhere remarked, in the 
all-protecting power of vaccination against small-pox was followed by 
undue mistrust of its efficacy. Physicians had too generally forgotten, 
that Jenner himself, and some of his zealous cotemporaries engaged 
in the same philanthropic task with him, had clearly pointed out the 
fact of small-pox supervening after vaccination had been duly per- 
formed. The reason assigned then was the shortness of time that 
had elapsed between the vaccination and the exposure to variolous 
contagion. Since, and now, the reason set forth is the length of 
time, by which the vaccine impression on the system is worn out. 
Both of these two opposite and contradictory reasons cannot be true 
— the probability is, that neither rests on a stable foundation. 

" In the two papers which I wrote exhibiting the joint experience 
of Dr. J. K. Mitchell and myself, we concluded with the following 
inferences, the accuracy of which has been tested by succeeding 
observations in different parts of Europe, and of this country. The 
first inference was, that the disease wdiich prevailed in Philadelphia, 
in 1823-4, and which we had been called upon to treat in so large a 
number of cases, was the real small-pox. 

" 2. That this disease, distressing to the persons labouring under it, 
and disgusting to those in attendance, is usually violent, never with- 
out danger, and always in large proportion, under any known treat- 
ment, is of fatal termination. 

"3. That the unsusceptibility of persons who have once had the 
small-pox to a second attack, though of general notoriety and truth, 
is not universal, and that with us, as elsewhere, persons, thus appa- 
rently protected, were seized with the disease, of which some of them 
died. 

" 4. That inoculation of small-pox, though in general conferring 
on the person subjected to this process immunity from the effects of 
variolous contagion in after life, does not necessarily or infallibly 
guarantee him against the disease, nor prevent death when it has 
made its invasion. 

" 5. That vaccination cannot now, any more than on its first intro- 
duction, be received as a certain preventive against the effects of the 
variolous poison, though now, as formerly, it must be considered as 
the best and safest with wdiich we are acquainted. 

"6. That occasionally under all circumstances of exposure, but 
more especially during the epidemic prevalence of small-pox, its con- 
tagion will effect both the inoculated and the vaccinated, and pro- 
duce in them a fever and eruption, differing in no essential feature 
from the primary variolous disease, except in the general mildness 
and speedier subsidence of the cutaneous disorder, and the more 
common exemption from secondary fever. 

" 7. That, of the inoculated and the vaccinated exposed to the 
variolous poison, the former will more probably escape its influence 
than the latter; but if both be affected by this contagion, the chances 
of recovery are in favour of the vaccinated. 

" 8. That the protecting power of the vaccine virus on persons 
who have been duly subject to its influence, is not diminished nor 



VACCINIA. 



177 



492. Since Jenncr made his discovery, variolous epidemics have 
desolated various quarters of Europe, and the vaccinated themselves 
have not escaped their ravages. Dr. Eichhorn has made a particular 
study of these epidemics, and has deduced the following conclusions 
from their different histories : 1. The vaccinated may have legitimate 
as well as modified small-pox, and they generally suffer more severely 
in proportion as the number of vaccine pustules has heen smaller. 2. 
Among all who have been vaccinated up to the present time, not more 
than the half have been protected from all attack, slight or severe, of 
small-pox. 3. The ratio of modified (varioloid) to true small-pox after 
vaccination, is very various ; it is milder or more serious in propor- 
tion as a greater or a smaller number of vaccine punctures have been 
made. 

The vast importance here attached to the number of vaccine pus- 
tules engendered, is a point that has been disputed; I have seen 
individuals labouring under modified small-pox whose arms were 
marked with four or five vaccine cicatrices, but my observations are 
not sufficiently extensive to warrant me in drawing any general con- 
clusions in opposition to those of Dr. Eichhorn. 

destroyed by the length of time from its first introduction into the 
bodies of such persons ; and that no proportion whatever exists be- 
tween its efficacy and the recency or remoteness of the epoch, when 
the constitution was placed under the influence of the virus. 

" 9. That there is no reason for believing in the deterioration or 
alteration of the vaccine virus, which is used at this time, from that 
which was in use during the first years of the practice of vaccination. 

" The data on which we based the above conclusions were obser- 
vations of 248 cases of natural and modified small-pox, of which 176 
were visited at the hospital. Of these there were — 

Unprotected. Vaccinated. Inoculated. Prev. Small-Pox. Unk. 
155 04 9 7 13 



Id. unprotect. 
91 

54 



Deaths 85 1 3 3 

In regard to colour the proportion was — 
Whites, total. Whites unprotected. Col. persons total 
111 60 122 

Deaths 31 

" It is pleasant to find, after a period of enlarged experience of 
fifteen years, these opinions of ours so fully sustained by the conclu- 
sions of the French Commission of Vaccine, made in 1839. 

" 1. That the simultaneous vaccination of the mass instantly arrests 
the progress of the variolous epidemic. 

" 2. That if vaccinia be not an absolute and infallible preserva- 
tive ap-ainst variola, it is at least the most certain, and the most 
exempt from danger. 

" 3. That varioloid, in the majority of cases, is the only incon- 
venience to which the vaccinated are exposed. 

" 4. That there seems no reason for the belief that the long vac- 
cinated are not as surely preserved at the present day as they have 
hitherto been ; or that' the recently vaccinated have received less 
security than those who preceded them. 

" 5. That the complete success of re-vaccination affords no proof 
that the individual had ceased to be protected by vaccination, and 
that he had again become susceptible of variola. 

" 6. That a second vaccination does not appear to possess the 
power, any more than the first, of protecting all persons indiscrimi- 
nately from the risk of a future attack of variola. 

" 7. That government ought not to command a general re-vacci- 
nation. 

" 8. That the total extinction of variola is to be effected by the 
universal adoption of vaccination. 

"lam well aware, that of late years re-vaccination has been 
practiced on a large scale on the soldiers in the armies of Prussia 
and Wirtemberg, as well as on the people, and with such results as 
would seem to weaken a belief in the continuedly protecting power 
through life of the first vaccination — but other and different testimony 
leave us nearly free to retain our first belief, with the explanations 
already offered." — Bell and Stokes'' s Lectures on the Practice of Physic, 
3d edit., p. 737, vol. ii. 
45 



Historical jYotices and particular Cases. 

493. Jenner published his " Inquiry into the causes and effects of 
variola vaccinae.," in 1798, 1 and his admirable discovery spread rapidly 
over the whole of Europe. Mr. W. Bruce, 2 Consul at Bushire, in a 
letter dated March, 1813, tells us that the preservative powers of the 
vaccine pustule were perfectly well known among the nomadic tribe 
of the Eliaats. 

Cow-pox has been the subject of very numerous inquiries (vide 
Appendix, art. cow-pox). Jenner himself imagined that it arose from 
the grease of the horse ; an opinion which has been successfully com- 
bated by Pearson, Simmons, 3 and Buniva. 

Besides the excellent treatises of Messrs. Husson, 4 Sacco, 5 and 
Bousquet, 6 the reader ought to consult the several essays and obser- 
vations which have appeared on the identity of small-pox and cow- 
pox, 7 on the period at which cow-pox becomes preservative? on the 
multiplicity of the pustules of cow-pox, 9 on the fever of incubation 
of cow-pox, 10 on the influence of cow-pox appearing to extend from the 
mother to the foetus during pregnancy, 11 on the anomalies presented 
by cow-pox, 12 on its complications, 13 on the attempts to inoculate with 
small-pox, individuals already vaccinated, 1 - 1 and on the reciprocal influ- 
ence of small-pox and of cow-pox. 15 

The remarks which have been published on modified small-pox, 
(§ 503,) on the salutary influence of vaccine-pox in whooping-cough, 10 
on quartan ague, 17 on "ophthalmia, 18 on gout, &c., 19 all deserve to be 
consulted as well as those that have been made, on its influence 
on the ratio of mortality, 20 on repeated vaccination, 2 ' on the develop- 
ment of legitimate vaccine-pox in individuals who have had small- 
pox, &c. 22 

Lastly, several interesting experiments have shown that the vac- 
cine infection could not be prevented by applying cupping glasses, 25 
aqua ammoniae, 24 or lotions containing solutions of the chlorates to 
the punctures immediately after the insertion of the virus. Differ- 
ent plans of collecting the vaccine virus have been proposed, 25 and 
various attempts have been made to infect the cow and other animals 
with the disease, by inoculating them with the virus of vaccinia 26 and 
of small-pox. 27 

Case LXXII. — Vaccinia in an individual already vaccinated, and 
bearing on his arms several characteristic cicatrices. On the 30th of 

1 London, in 4to. 

2 Extract of a letter to W. Erskine, Esq., Bombay, from the Trans, of the society of 
Bombay, translated into the Ann. de Chimie et de Physique, 1819, t. x. p. 330. See 
also the inquiries of Moreau de Jonnes, on the state of knowledge among the Indian > 
and Chinese, relative to cow-pox. (Arch. gen. de med., t. xiii. p. 126.) 

3 Simmons (W.). Reflections on the propriety of performing the Cesarian opera- 
tion, &c, to which are added experiments on the supposed origin of the cow-pox. 
8vo. London, 1799. 

4 Husson. Recherches historiques et medicates sur la vaccine, 8vo., premiere 
edition. Paris, 1803. 

6 Sacco. Trattato di vaccinazione, con osservazioni sul giavardo e vajuolo pec- 
corino, 4to., Fig. Milano, 1809. 

6 Bousquet. Traite de la vaccine, 8vo. Paris, 1832. 

7 Desportes. Journ. hebdomad., 2d serie, t. viii. p. 217. — Eusebe Desalle. Revue 
medic, t. viii. p. 252. — Elliotson. Lond. Med. Gazette, t. xi. p. 305. 

8 Bousquet. Bullet, des sc. medic, de Ferussac, t. xxiii. p. 150. — Revue medic. 
Septembre, 1830, p. 463. 

9 Frischler. Gazette medic, 4to. 1832, p. 142. 

•o Eichhorn. Bull, des sc. medic de Ferussac, t. x. p. 337. 

■' Gillard. Revue medic, t. i. p. 153. 1824. 

12 Genouville. Recueil period, de la soc de med., 2de serie, t. iii. p. 332. 

13 Morcolini (F. M.). Sulle complicazioni della vaccina. Milano, 8vo. 1823. 

u Consultez les premiers rapports du comite de vaccine. — Legallois. Revue 
medic, t. viii. p. 252. 

is Gazette Medic. Paris, 4to., 1832, p. 847.— Lisfranc Note sur plusieurs cas de 
coincidence de variole et de vaccine. Diss, inaug. Paris, 1813. 

'« Lond. Med. Gazette, t. viii. p. 40. 

w Ermisch. Revue medic, t. i. p. 715. 1824. 

"• Coxe. Archiv. gene>. de med., t. xvii. p. 443. 

19 Casper. Revue medic, t. iv. 1824, p. 288. 

2 ° Woll'ers. Revue medic, t. x. p. 158. 1826. — Dornblut. Bull, des sc. med., de 
Ferussac, t, xi. p. 2.61. 

21 Cavin. Revue medic, t. viii. 1825, p. 171. 

22 Molas. Journ. compl. des sc medic, t. vi. p. 377. 

23 Bousquet. Arch, gener. de med., t. xvi. p. 641. 

24 Meuche. Lane, franc., t. v. p. 397. 

25 Pouzelot. Journ. hebdomad., t. i. p. 311. 

26 Valentin (L.). Vaccinations pratiqnees avec succes sur des animanx (anesse, 
chevre, chien, mouton), et transmission de la matiere-vaccine de ces animaux a 
l'homme. (Rec per. de soc. de med., t. xii. p, 177.) 

*i Experiences de Sunderland etde Numan. Bull, des sc. med., t. xxv. p. 158. 



173 



PUSTULE. 



:, M. Hun. 1 vaccinated a lady, thirty-four years of age, who 
had never had the operation done before, and who did not remember 
having ever had the small-pox. Towards the end of the fourth day 
following, he found two red spots in the situation of his punctures, 
about a line in diameter, and depressed in their centre, which, con- 
tinuing to advance, presented in regular succession the whole of the 
.haiacters of regular vaccinia. A sister of this lady, twenty-two 
vean of age, who had been vaccinated when two years old, was 
present at the vaccination, and although she bore two very distinct 
cicatrices upon the upper part of each arm in the situation where 
vaccination is usually performed, she desired that the operation might 
be done again. M. Hamel consequently made six punctures in either 
arm, from which he anticipated no effect. On the fourth day, how r - 
ever, he was surprised to find a single point (all the others had faded) 
on the right arm inflamed, and forming a spot about a line in diameter, 
depressed in the centre, and similar to those by which the success of 
vaccine inoculation is usually proclaimed. By the end of the seventh 
day the pustule was perfectly characteristic of vaccinia ; its centre 
was depressed, its margin was raised and transparent, and it was sur- 
rounded by an inflamed areola of small extent. At the end of the 
eighth day the pustule was still more fully developed, and the in- 
flamed areola broader. The parts in the neighbourhood of the pus- 
tule were itchy ; the young lady complained of being indisposed ; 
the glands of the axilla were slightly inflamed. On the ninth day 
M. Hamel related the case to me, and on the tenth day I had an 
opportunity of seeing it along with him, when I found a perfectly 
regular vaccine pustule ; the fluid it contained had by this time lost 
its transparency, and presented the peculiar appearance which an- 
nounces approaching desiccation. 

One of the cicatrices of the former vaccination was circular, de- 
pressed, and pinked (gauffree) like the cicatrices which result from 
the most regular vaccine pustules. It was three lines in diameter. 
A second cicatrix on the right shoulder had also the same characters, 
but was different in shape, apparently from the fusion of two pustules 
into one. The young lady left Paris on the 19th day, the vaccine 
incrustation still adhering. 

Case LXXIII. — Vaccinia in an individual sticcessfully inoculated 
for small-pox thirty years before, and bearing on his person several 
characteristic cicatrices. The Prince de * * * * had been inoculated 
in England in his infancy; the operation succeeded, and the erup- 
tion was held protective. Happening, in 1833, to be present when 
I was re-vaccinating another individual, the Prince proposed that I 
should make a few punctures on his arm with a lancet charged with 
vaccine virus. The operation was succeeded by the most regular 
cow-pox, a fact which was attested by several competent witnesses. 



VACCINELLA OR MODIFICATIONS OF VACCINIA. 
Vocab. Vaccinellae, Vaccina; spurise, Spurious Cow-pox. 

494. Under this title I include several pustular inflammations of 
the skin, contagious in their nature, and similar to cow-pox in their 
appearance, which the inoculation of the vaccine virus or of the 
virus of grease, according to some accounts, occasionally produces 
in individuals who have previously had small-pox or vaccinia, or 
who only contract the latter malady imperfectly, either from want of 
sufficient energy in the vaccine virus, or from a kind of inaptitude to 
feel its effects; I also employ the same word to designate those modi- 
fied vaccine eruptions which are thrown out after vaccination during 
the period of incubation or of the primary fever of small-pox, and to 
those which often proceed from the simultaneous inoculation of cow- 
pox and small-pox. These eruptions in fact are to vaccinia precisely 
what the varicella? are to variola. 

It is necessary to distinguish those eruptions, the matter of which 
possesses the power of reproducing vaccinia (Eichhorn), from certain 
accidental and non-contagious pustules which have also been de- 
scribed under the name of spurious cow-pox, and which seem to result 
either from the matter of cow-pox altered and deprived of its peculiar 
virulence, or from the inoculation of good vaccine matter upon con- 
stitutions which have become callous to its proper influence, in con- 



sequence of a previous preservative variolous or vaccine infection. 
Several eruptions, transmitted to the human subject from the eow 
attacked with spurious cow-pox, or from the heel of the horse labour- 
ing under grease, might, perhaps, without impropriety, be also classed 
in this group. 

495. 1st. Vaccinella from tlie inoculation of individuals with vac- 
cine vims who have already had vaccinia. 1 — This variety has been 
observed by several practitioners who have re-vaccinated a large 
number of subjects. M. Bousquet says, that in one case which he 
met with, this second cow-pox advanced at a more rapid pace than 
the first, and that there was the same difference between the two 
eruptions that is observed between small-pox and varicella. 

496. 2d. Vaccinella from the inoculation of vaccinia upon individu- 
als who had previously had natural or inoculated small-pox. 2 — When 
persons who have formerly had small small-pox are vaccinated, the 
operation is usually without effect. Occasionally, however, a vaccine 
eruption, modified in its external appearances, and in its progress, 
is excited. This result cannot be more aptly compared than to the 
varicella which the variolous poison produces in some vaccinated 
individuals, or to the eruptions observed among the inoculated or 
small-poxed, who are submitted to a fresh inoculation of the vario- 
lous virus. However this may be, the progress of this modified 
vaccinia or cow-pox is as follows : 

From the first, occasionally on the second, and at latest on the 
third day, the punctures inflame, and pustules, most commonly of a 
circular shape like those of cow-pox, are formed. Their margins 
are flat, irregular, and not distended with fluid, which is always 
scanty, and of a pale-yellowish colour. The areola, occasionally as 
bright, is rarely so broad as that of vaccinia, although it appears 
at any earlier period. During the whole time this process is going 
forward the punctures and then the pustules are affected with an 
insupportable pruritus ; the axillae are occasionally painful, and the 
axillary glands become enlarged ; headache is also felt at times, or 
irregular febrile paroxysms intervene. The inflammatory period is 
very rapid ; there is no tumour nor circumscribed induration as in 
regular vaccinia, and if some degree of puffing be felt around the 
puncture it is irregular and superficial. The scabs, well formed from 
the seventh or eighth day, are detached nearly at the same period as 
those of vaccinia, and occasionally sooner. They often present the 
same appearances, with this single difference, that they are not so 
large nor so thick, and that they do not leave cicatrices, but merely 
marks on the skin. The fluid of the pustules is contagious, and in- 
serted under the skin by a puncture ; the disease can be propagated 
like legitimate vaccinia, but without proving preservative in the same 
degree against small-pox. 

497. 3d. Vaccinella from the accidental inoculation with cow-pox 
of an individual who had had small-pox. Jenner relates 3 that he saw 
five persons on the farm of Mr. Andrews, who after having had small- 
pox, contracted cow-pox from milking kine affected with this disease. 
But he adds, that the eruption was incomparably milder than it com- 
monly proves. 

498. 4th. Vaccinella from the simultaneous inoculation of variola 
and vaccinia. 4 When the variolous and vaccine virus are inoculated 
as nearly as possible at the same time, they reciprocally modify each 
other's action. The vaccine pustule produced under these circum- 
stances appears like, but somewhat smaller in size than that of the 
natural vaccinia upon the fourth day after the inoculation ; on the 
seventh and eighth days the areola is scarcely perceptible, and on the 
ninth and tenth no true vaccine tumour is formed. On the other hand 
the inoculated variola is itself modified in its characters, and appears 
with the features of the umbilicated pustular varicella. 

499. 5th. Vaccinella from the insertion of vaccinia during the 
incubation of the variolous contagion or the period of the precursory va- 
riolous fever. Many cases have been related of vaccinia modified by 
small-pox, either in its external characters or in its duration. In a 
case which I have just seen at La Charite, cow-pox is developed in 

' Moreau. Rapport de la commiss. de vaccine (Rev. medic. 1825, t. riii. p. 170). 

2 Rapport de la commission m£dico-chirurgicale instituiee a Milan, 8vo. Paris, 
an. x. 

3 Op. cit. 

* Willan on vaccine inocul., 4io. Lond. 1806. 



VACCINELLA. 



179 



an individual who has already felt the influence of small-pox con- 
tagion. (The elevations of small-pox appeared at the beginning of the 
seventh day from that of the vaccination, after four days of initiatory 
variolous fever, and at least eight if not ten days after exposure to 
small-pox infection.) The vaccine pustules had their usual duration ; 
they were only not accompanied on the seventh and eighth days with 
that degree of inflammation which produces the hardness, known 
under the name of the vaccine tumour. 

Case LXXIV. — Vesicular varicella (chicken-pox) ; vaccination and 
development of vaccinia ; appearance of small-pox on the seventh day of 
the vaccination. P. M. Dufeu, 33 years of age, presented himself for 
admission into La Charite, on the 9th October, 1833. He was in the 
third day of an eruption of vesicular varicella, the precursory pheno- 
mena of which had been extremely slight and had only lasted six and 
thirty hours. The patient was without fever; the eruption was scanty 
and looked shrunk in many places, in which small red spots irregu- 
larly rounded, were perceived, covered in the centre with a slight 
scab, or incrustation of dried blood. Under the clavicles, and in the 
axillary spaces the eruption preserved its primary character. It con- 
sisted of vesicles a little larger than hemp seeds, of a rounded figure, 
very prominent, widely scattered and filled either with a transparent 
or an opaline fluid. Each of these vesicles was surrounded by a red 
areola of a diameter the double of itself. October 12th. — The shri- 
veled vesicles had lost their transparency, and several of them which 
had been ruptured by the friction of the clothes were covered with a 
small brownish scab. On the 17th the recovery was complete. 

Small-pox, at this period, was rife in Paris, and several of the 
patients in La Charite were attacked. This patient not appearing to 
have been vaccinated, or at least having no variolous or vaccine cica- 
trices about him, I had the operation done at the Royal Academy of 
Medicine on the 19th of October ; three deepish punctures were made 
on the inner aspect of both arms. 

October 20th and 21st, a small bloody point showed the spot where 
each of the punctures had been made. 22d. — Third day of vaccina- 
tion ; the patient, towards evening, felt feverish ; the appearance 
of the pustules had not changed. 23d. — Headache, nausea, higher 
fever ; the punctures are slightly prominent and surrounded by a red 
circle. {Low diet, lemonade, foot-bath.) 24th. — Headache worse ; 
nausea incessant. The vaccine elevation, which is readily distin- 
guishable, has not enlarged ; in its centre a point of a pale rosy hue is 
perceived, veiled by the epidermis. 25th. — Same general phenomena. 
The vaccine pustule larger this day than yesterday, is of a bluish- white 
colour; its centre is slightly depressed. The areola is not more than 
a line in breadth. Same treatment continued. The patient revacci- 
nated. 26th. — Seventh day of the vaccination ; the patient is freer 
from headache and fever. The vaccine pustules are small, not being 
more than two lines in breadth, and are but slightly prominent. 

This almost entire cessation of the febrile symptoms coincided with 
the appearance of a new eruption which I remarked at the morning 
visit. A considerable number of .small, red, and slightly prominent 
spots, the size of flea bites, several of which were in contact at their 
edges, had appeared upon the face, and in smaller numbers on the 
breast and arms : small-pox, as I have said, was prevalent; four days 
of febrile symptoms had preceded the appearance of the eruption : I 
had no hesitation in deciding on the variolous nature of this eruption. 
28th. — The eruption is confluent on different parts of the face ; some 
of the pustules have already assumed the umbilicated form ; several 
are evolved on the very circumference of the vaccine pustules with 
which they cohere. The areola of the latter is not more extensive 
than before ; it is of a bright enough colour, but of little breadth. 

30th. — The small-pox pustules in the neighbourhood of those of the 
cow-pox, resemble them so closely that it would be impossible to 
distinguish the one from the other, had not the points upon which the 
vaccination was performed been particularly noted. The desiccation 
is commencing in their centre ; there is no longer any areola properly 
speaking. The variolous pustules of the face have an opalescent look; 
the whole countenance is slightly puffed. 31st. — Slight epistaxis; 
some confusion of head, and wandering of ideas. November 1st. — 
Unequivocal symptoms of secondary fever ; ptyalism ; rambling talk ; 
heat of surface, &c. ; the swelling of face continues ; the pustules are 
flat and umbilicated on the arms, globular on the face. 2d.— The 



vaccine pustules are covered with yellow crusts ; several of the vari- 
olous pustules of the face begin to dry; the pulse is pretty full with- 
out hardness or frequency. 3d. — The pustules of the trunk and limbs 
are in full suppuration. 5th. — Both vaccine and variolous pustules 
are drying apace. 6th. — The face is fully incrusted, and from the 7th 
to the 11th, the drying and fall of the scabs proceeded on the other 
parts of the body. The crusts of the vaccine pustules were not de- 
tached till the 9th of November (22d day of the vaccination). They 
left red marks behind them without distinct depressions. 

500. It would appear, that a kind of spurious cow-pox may be 
developed on the teat of the cow, and be transmitted to man by con- 
tagion. The degree of analogy which these false cow-pox bear to the 
true account of which is blended by Willan and Bateman with that of 
rosa disease, and which these false cow-pox transmitted to the human 
subject bear to vaccinia, is as yet ill ascertained. The eruption 
observed by Loy, 1 has no apparent resemblance to vaccinia. In the 
beginning of 1801, this writer saw an eruption on the hands of a far- 
rier, which appeared shortly after having dressed the heels of a horse 
affected with grease. The eruption consisted of separate round pus- 
tules, like blisters produced by a scald, containing a limpid fluid, 
having a slight black speck in the centre, and being surrounded by an 
inflamed areola. During the whole course of this disease the man 
did not suffer from fever. 

Historical Notices. 

501. I have already signalized the principal characters which 
distinguish legitimate vaccinia from vaccinella (§ 485). These differ 
in the contagious nature and specific properties of the fluid they con- 
tain, and in the progress and form of the pustules, from those accidental 
pustules which have been improperly denominated spurious cow-pox 
or spurious small-pox, according as they have followed the inoculation 
of matter taken from the pustules of subjects who had previously been 
vaccinated or had had small-pox, in which the contagious and specific 
properties were extinct. 

None of the varieties of vaccinella protect completely from small- 
pox ; they however seem to render individuals less apt to contract 
the disease. They are always very mild complaints, and require no 
treatment. 

502. Of all these eruptions, one only has been studied with par- 
ticular attention; that, namely, which is produced by inoculating with 
vaccinia individuals affected with small-pox or already vaccinated. 
The other varieties of vaccinella have been rather hinted at than 
particularly described, and their history requires elucidation by addi- 
tional experiments and researches. 

M. Bousquet admits no more than a single species of spurious cow- 
pox. Nissen 2 recognizes two, proceeding from two different species 
of cow-pox (the one with black and the other with amber coloured 
pustules). Hellwag has described a third variety, characterized by 
vesicles filled with a yellowish and non-contagious serum ; Viborg 
admits as many as nine species of cow-pox. By making the varie- 
ties of spurious cow-pox or varicella a particular subject of study, the 
counterparts of the different varicellas may perhaps be detected. 
(Vide sub. cow-pox in vocab.) 

According to Eichhorn, 3 re-vaccination occasionally produces legi- 
timate and unmodified, but much more frequently modified vaccinia. 
The latter includes four varieties : 1. Purulent modified vaccinia ; 2. 
Lymphatic modified vaccinia; 3. Tuberculo-pustular modified vaccinia; 
4. Tubercular modified vaccinia. To each of these varieties he assigns 

t o 

particular characters. 

1 Loy. An account of some experiments on the origin of cow-pox, 1 vo. 1802. 

2 Kiihn (C. G.). Op. cit. p. 13. 

3 Eichhorn admits four species of modified vaccinia, a title which he restricts to 
the eruption developed on the vaccinated by the inoculation of the true vaccine virus. 
He distinguishes carefully between modified vaccinia and spurious vaccinia, which, 
according to him, arises from the false cow-pox of the animal. He has re-vaccinated 
an immense number of individuals ; 288 of the whole number remained unaffected, 
hut among the rest, the four varieties of modified vaccinia specified in the text, were 
produced in various proportions. The three first of these, Dr. Eichhorn informs us, 
are capable of producing true vaccinia inoculated upon the unvaccinated. He was 
unable to prove that the fourth variety had the same property. Op. cit. p. 486. 



180 



PUSTULE. 



ACNE. 



Vocab. Acne, lontltot, Vurus, Whelk. 

603. -l'tius in ancient, and Sauvages in modern limes, employed 
the word acne to designate the red tubercles of the disease which we 
shall describe under the title of Rosacea. More lately, Drs. Willan 
and Bateman have included under this denomination, the couperose, the 
dartre pustuleuse miliaire, and the dartre pustuleuse disstmince, of 
Alibert. The term couperose (the rosacea or gutta rosea of English 
writers), being generally adopted in France to signify a chronic and 
pustular inflammation affecting the follicles of the skin of the face, I 
have felt myself compelled to use the word acne in a more restricted 
sense than that in which it was employed by the English pathologists, 
and to take it as indicative of the affection particularly described by 
M. Alibert under the title of dartre pustuleuse disshninie, and which 
was blended with couperose by Willan and Bateman, under the 
head of acne punctata. Whilst I thus separately describe these two 
affections, I begin, nevertheless, by acknowledging that acne (the 
disseminated pustular tetter of Alibert) occurs under the same form, 
and affects the same elements of the skin as rosacea. I have, in 
fact, only consented to separate these two varieties, because the term 
couperose (rosacea) is applied in France to a very rebellious disease 
of the face, while acne is frequently an eruption attending adoles- 
cence, much less serious in its symptoms, and confined exclusively 
to the skin of the trunk. 

In an anatomical point of view, sycosis, along with acne and rosacea, 
constitutes a third variety of one and the same form of pustular in- 
flammation. The principal features which severally distinguish these 
three affections from each other, may be explained by the diversities 
of structure observed in the skin of the face generally, of the chin in 
particular, and of the trunk, especially as regards the number, dispo- 
sition, dimensions, and depth of the sebaceous follicles of these different 
regions, (a) 

Acne. — Under the title of acne, then, I shall describe a chronic in- 
flammation of the sebaceous follicles common in youth and manhood, 
characterized by isolated acuminated pustules, most usually developed 
on the shoulders, sternal and scapular regions, the skin of which looks 
dense and unctuous, and more rarely on the face ; these pustules are 
succeeded by livid or violet-coloured spots, by tuberculated indura- 
lions of the same, or of a milky- white hue, almost always intermingled 
with the accumulations of sebaceous matter with black points, vulgarly 
styled worms, and with follicular enlargements, (b) 

(a) Acne, regarded as a genus by Willan and Bateman, is by them 
divided into four species, viz., 1. A. simplex; 2. A. punctata; 3. A. 
indurata; 4. A. rosacea — to which was subsequently added A. syphili- 
tica. The first is simple pimple, the second maggot pimple, the third 
stone-pock; and the fourth rosy drop or gutta rosea. 

(b) Acne by Willan and Bateman is placed among the tubercula, 
but l>y Alibert, Biett and M. Rayer it is arranged with the pustular 
diseases of ihe skin. The latter is the correct view ; the tubercles or 
lurcumscribed indurations, so constantly observed in this affection, 
being, as Dr. T. J. Todd (Cyclop. Pract. Med.) justly observes, the 
consequences of pustules, but not constituting the elementary forms 
of the eruption. 

The peculiar seat of acne is stated by the author in the text, to be 
the sebaceous follicles ; a location for the disease asserted by Plumbe 
to be its uniform one, and never, as some allege, the cellular texture 
of the corion. Willan had indeed made the follicular the character of 
his second species, or acne punctata; and by Dr. Todd it is called 
follicularis. Plumbe describes acne, sycosis, the scrofulous form of 
disease of the follicles, and lupus, or noli me tangere as four varieties 
ot disease, depending on, or connected with obstructed and diseased 
follicles; while the pustules of the more obstinate forms of porrigo 
may be, he thinks, with propriety considered as the result of the local 
irritation of the hair. 

" In its most simple and trifling; form, the disease consists merely 
of obstruction of the sebaceous follicles, in consequence of their con- 
tents becoming too hard to pass readily to the surface. Inflammation 
of the follicle and the production of what is called a pimple result, 



504. Symptoms. — The pustules of acne always appear in succession, 
one after the other. Usually scattered over the trunk, and occasion- 
ally over the face, the disease may be confined to the sternum and 
shoulders, or it may appear over the whole of these regions, and even 
extend to the posterior parls of the arms, to the cheeks and to the 
forehead. It is commonly evolved without heat or local pain, and 
very generally without pruritus. I have seen several young people 
seeking advice for a few spots of acne developed on the sternal region, 
whose backs were covered with the pustules of the disease, without 
their being aware of the circumstance. 

Some of the pustules of acne are very small, others are a little larger. 
The first, at their origin, appear under the form of small inflamed 
and slightly conical elevations, the bases of which are hard and sur- 
rounded by a red blush or areola. These elevations suppurate slowly, 
and each pursues its course independently of the others around it; in 
the same individual, consequently, it is usual to find, at one and the 
same time, elevations not yet purulent, pustules in a state of suppura- 
tion, and others transformed into tubercles, or replaced by indurations 
of a milky-white colour, or by small cicatrices. The more volumi- 
nous pustules begin as follicular elevations or tumours full of sebaceous 
matter : either from over-distension or some other cause, the follicles 
themselves have become inflamed. By compressing the portion of 
skin surmounted by these pustules between the fingers, it is easy to 
ascertain that the stuff which can be squeezed from their summits is 
veritable pus ; whilst the matter that remains within them, and which 
may also be forced out by continuing the pressure, is of a sebaceous 
nature, similar to that which is contained within the follicular eleva- 
tions disseminated in the neighbourhood of the pustules. When the 
pustules begin to fade, their tops become covered with a small scab 
of variable thickness, which is soon detached, either spontaneously 
or by the friction of the clothes. Small spots of a livid-red, slightly 
elevated, and which disappear very gradually, proclaim at a later 
period the particular points which had been the seat of pustules. 
These are sometimes followed by small indurations of a milky-white 
colour, the size of a small pea, somewhat similar to the cicatrices that 
follow leech bites, although differing in shape. Lastly, the pustules 
of acne are often partially transformed into violet indurations, the 
resolution of which is generally looked for very long in vain. These 
tubercles are frequently of a violet-red colour, very analogous to that 
presented by such as are of a syphilitic nature. The tubercles of acne 
may, however, be distinguished from those of syphilis, by characters 
more positive than any that belong to colour, a class of signs, the value of 
which in diagnosis has been very much overrated by some pathologists. 

In acne, the sebaceous follicles, besides being affected with sup- 
puration, very commonly present three remarkable morbid pheno- 
mena ; the orifices of the follicles of the skin of the back, shoulders, 
anterior part of the chest, and occasionally of the face are extremely 
apparent; the skin of the same districts is unctuous and shining; 
the pustules of acne are mixed with the concretions called worms 
indicated by more or less conspicuous black points, and formed by 
the accumulation of sebaceous matter within the follicles, from the 
cavities and ducts of which it may be extracted upon the point of a 
pin, or by pressure between the fingers. Further, the follicles of the 
sternal regions are occasionally hypertrophied in acne, and appear 
under the form of globular, or rounded and somewhat flattened bodies, 
not prominent, and of a duller white than the linear spaces of the skin 
which separate them. Lastly, small whitish and rounded granula- 

and are soon followed by the formation of matter ; the follicle is de- 
stroyed by this process, the matter is discharged, a little redness 
remains for a day or two, and the part returns to the healthy state." 
" The situations in which the eruptions designated as above, make 
their appearance, will generally be sufficient to enable us to determine 
their character. It has been observed in a preceding page that the 
sebaceous follicles are chiefly distributed to the face, more particularly 
on the forehead, tip and ate of the nose and the adjoining parts, anil 
less copiously on the chin. Next to these the chest, below the 
clavicle, to about the fifth or sixth rib and the back to an equal extent, 
are most liberally furnished with them ; and as the disease consists in 
the derangement and inflammation of these structures, it is these parts 
solely in which it makes its appearance." (Plumbe, op. cit. pp. 47-8.) 



ACNE. 



181 



tions, the size of a pin's head and formed by follicles, the orifices 
of which are either very little or not at all apparent, are frequently 
observed among the pustules and sebaceous concretions, especially 
on the fore-part of the breast. In some individuals, these follicular 
elevations are more numerous than the pustules ; in others the con- 
trary disposition is observed to obtain. Thus several cases of acne 
compared together always show great variety in the disposal of the 
pustules or of the indurations left behind these, as also in the number 
of the sebaceous concretions and follicular elevations that occur. 

Such is commonly the progress, and such are the appearances 
presented by acne. It is by no means rare to meet with this erup- 
tion associated with rosacea or sycosis, affections which occasionally 
replace it in maturer years. Several other inflammatory affections of 
the skin may accidentally occur in the course of acne without their 
appearing to exert any influence on its progress or termination. I 
have seen an adult affected at the same moment with acne, with 
herpes phlyctenodes of the face, trunk, and scrotum, and with pulmo- 
nary catarrh. I attended another young girl labouring under acne, 
herpes of the nose, and pulmonary tubercles; and an adult who pre- 
sented a remarkable example of acne and chloasmata or liver spots 
of the skin. 

The follicles of the scrotum, which are commonly very large, are 
occasionally affected with acne, precisely in the same manner as those 
of the upper part of the trunk. I have seen these follicles, distended 
with sebaceous matter, become transformed into pustules, from which 
the contents, — pus and sebaceous concretions, could be forced by 
squeezing them between the fingers. This change of the follicles of 
the scrotum is altogether independent of a venereal cause. 

505. Alterations of structure. — The mode in which the pustules of 
acne are formed, the different morbid features that almost invariably 
accompany the disease, (greasy state of the skin, sebaceous concretions, 
large size of the follicular orifices, &c.,) the enlargement of the follicles 
on those regions of the skin where the acne appears, the immunity 
from this disease enjoyed by those districts unprovided with seba- 
ceous follicles, such as the palms of the hands and soles of the feet, are 
so many circumstances that authorize us in assigning the follicles as 
the element of the skin, which is particularly attacked in acne. This 
presumption, indeed, becomes matter of certainty, when the nascent 
and untouched pustules of the disease (or those which are older), 
after being laid open with the point of a lancet, are ex&mined through 
a magnifying glass. Mr. Plumbe first satisfactorily demonstrated 
this anatomical fact ; but he fell into an error, when he maintained 
that the inflammation of the follicles was always excited and kept up 
by the accumulation of sebaceous matter within their cavities. The 
whole of the pustules of acne certainly do not appear as sebaceous 
concretions, or follicular elevations at their outset; a certain number 
only commence in this way ; the rest from their origin exhibit inflam- 
matory characters (sanguineous injection, followed by the formation 
of pus), and blood or pus may frequently be extracted from their 
cavities unmixed with indurated sebaceous matter. Further, the 
greasy exudation upon the skin, the follicular elevations with or with- 
out inflammation, and the pustules of acne are consequences of differ- 
ent pre-existing morbid conditions of the sebaceous follicles. The 
accuracy of these remarks in regard to the seat of acne has recently 
been called in question ; but their truth is demonstrated by the minute 
study of the mode in which the pustules of the disease are formed, 
and by a comparative examination of the elements composing the 
skin in different regions of the body. 

506. Causes. — Billard, in his work onjthe diseases of infants, 1 in- 
forms us that he never saw acne in children at the breast. Children 
further advanced seem also almost completely exempt from the 
disease; the great majority of the cases I have met with, indeed, 
have occurred among individuals from about fourteen to thirfy-six 
years of age. In these, the acne was almost always associated with 
rosacea, more rarely with sycosis, diseases which, to individuals of 
maturer years, are analogous to acne attacking earlier in life. As to 
the causes of acne, they are for the most part extremely obscure. In 
young females, the disease seems occasionally to coincide with the 
occurrence of dysmenorrhoea. I have frequently seen it prove ex- 

' Traits des Maladies des Enfans Nouveau-nes et a la mamelle, 9vo. Paris, 1828. 
46 



tremely troublesome in individuals possessed of the best constitutions ; 
and on the other hand, I have known it attack young persons addicted 
to certain secret vices, and those subject to abdominal irritations, or 
given to the use of spirituous liquors, (a) 

507. Diagnosis. — Acne is a disease easily distinguished from all 
others. If rosacea, sycosis, and acne are chronic inflammations essen- 
tially of the same nature, if they affect the same element of the skin, 
the three eruptions are still easily distinguished from each other by 
the regions upon which they commonly make their attacks, and by 
several other peculiarities which result from the unequal development 
of the vascular rete, and of the follicles in these different districts of 
the integuments. Those fiery spots which accompany the tubercles 
or pustules of one form of rosacea, developed on the[nose and cheeks, 
are never observed on the shoulders or sternal region, however thickly 
they may be beset with the pustules or tubercles of acne. The pus- 
tules and tubercles of sycosis are not seen intermingled with sebaceous 
concretions and follicular elevations like the pustules of acne. Psy- 
dracious pustular syphilis, and some forms of artificial inflammation 
developed on the skin of the trunk, alone present an apparent analogy 
with the dartre pustuleuse disseminee (Alibert) or acne. Thus psydra- 
cious syphilitic pustules, like those of acne, present a small purulent 
deposit at their apex, and are occasionally scattered over the trunk, 
but they are not confined to this, and several are seen at the same 
time on the extremities. Further, the pustules of acne are more pro- 
minent than those of the syphilitic affection, which are of a violet hue 
in the middle, with a copper-coloured base. The skin which sepa- 
rates the pustules of acne is shining, oily, and studded with sebaceous 
concretions or follicular swellings. In psydracious syphilis, these 
products of augmented follicular secretion are not observed ; the skin 
between the pustules has its natural colour and appearance. It is 
occasionally earthy and sallow, indeed, a character which, as being 
common to many chronic diseases, has been specified very mal-a- 
propos as characteristic of syphilitic eruptions. The small cicatrices 
consecutive to psydracious syphilitic pustules differ from those of 
acne, in being livid and depressed, whilst those of acne are very 
commonly raised. At first sight, the purple or livid and circum- 
scribed indurations consequent on the pustules of acne might be taken 
for syphilitic tubercles ; but the latter are not preceded by pustules ; 
left to themselves they usually end by becoming ulcerated, and 
covered by thick incrustations under which there are formed, not 
ivhite and rounded indurations like those of acne, but small depressed 
cicatrices, or a kind of irregular zigzags, and spiral puckerings of the 
skin. Lastly, syphilitic pustules and tubercles are often mixed with 
spots or papula? of an unequivocal nature, to say nothing of the other 
symptoms of lues with which they are always accompanied. 

The information received in regard to the diseases which occurred 
previously to the development of these eruptions, are of less value in 
establishing the diagnosis than is often believed ; from this source 
presumptions only can accrue, which, hastily adopted as truths, might 
lead to serious errors. I have treated several individuals success- 
fully for true acne, by means of blood-letting and sulphureous baths., 
who had been recommended to undergo, or who had undergone a 
course of mercury, for the sole reason that they had had one or two 
attacks of venereal disease, and now bore about upon their shoulders 
certain violet-coloured spots, and sundry small cicatrices. 

The pustular inflammations, artificially excited in the skin of the 
trunk by the application of pitch plasters, with or without the addi- 
tion of tartrate of antimony, by frictions of croton oil, the juice of the 
euphorbia, latyris, &c, differ from acne, not only in the particular 
causes which excite them, but further, in their progress and external 
characters. They, in fact, have nothing in common with acne except 
their seat, which, like that of this disease, is primarily in the follicles 
of the skin. 

50S. Prognosis and treatment. — When the pustules and follicular 
swellings of acne are few in number, they are rarely thought of as the 

(a) With Copland (Diet. Pract. Med.) we would say, that the 
simple, indurated, and punctated species of acne are most frequently 
occasioned by uterine irritation and excitement, or an imperfect per- 
formance of the uterine functions ; by constipation ; by torpid condi- 
tions of the liver; and by the injurious addiction to onanism. 



182 



PUSTULE. 



subject of medical treatment, unless, indeed, they chance to be accom- 
panied with die pustules of rosacea or sycosis. In well-constituted 
youths and girls th.v frequently disappear of themselves, seemingly 
from die changes undergone by the constitution as the period of ma- 
turity is attained. The cold bath, frequently repeated, is of great 
service when the disease is connected with indulgence in pernicious 
practices, when there are no symptoms present of any chronic affection 
of tin- lungs or intestines. When acne can be traced to such causes 
as those hinted at, and the habitual excitement of the alimentary canal 
l iv tin- use or abuse of vinous or spirituous liquors, it is important, in 
the first place, to remove and prevent their further operation. . 

Should a considerable eruption of acne have appeared on the 
shoulders and bosom in a young and otherwise healthy individual, it 
will be proper at first to detract some blood, and to make use for a 
season of acidulated drinks and the cold bath, the effects of which the 
patient will strive to aid, by leading a regular and quiet life. The 
cold sulphureous bath may be afterwards employed with great advan- 
tage, every day, or every other day, alternately with the simple cold 
bath, and this is a plan which will generally be found to answer best. 
I have employed with no less benefit the cold sulphureous douche, 
especially in that form of the disease which is complicated with folli- 
cular concretions and indurations. I have not made many trials of 
the effects of sulphureous waters administered internally ; such as I 
have made, however, are not favourable to the practice ; besides, 
most patients show a repugnance to so disgusting a drink. Sulphure- 
ous waters may, however, be used at the same time internally that 
they are employed externally by way of bath or douche. The number 
of sulphureous baths necessary in any case, varies according to the 
extent and standing of the eruption, and the state of the constitution. 
When the neck, shoulders, back, and bosom are covered with tuber- 
cular indurations, the consequence of long-continued and repeated 
eruptions of acne, in individuals otherwise well constituted, the vapour 
bath always assists, and occasionally accomplishes the entire resolution 
of these indurations. 

Lastly, eruptions of acne have been observed appearing each year 
with the approach of spring, dying away in the autumn and winter, 
and at length vanishing not to be reproduced, from the sole influence 
of the progressive development of the organization, (a) 



(a) The treatment of acne will be modified by our knowledge of 
the cause. Thus, where it depends on uterine disease, asdysmenor- 
rhcea and arnenorrhcea, we must address our remedies to a removal of 
these. In some cases of this character, I have prescribed the iodide 
of potassium, alternated with syrup of sarsaparilla, with the happiest 
results. I could point to different married women, who had been 
previously sterile and annoyed at the same time with acne sim- 
plex and punctated, and sometimes assuming the appearance of 
rosacea, become mothers with this treatment, and lose almost entirely 
their cutaneous disfigurations. 

. The relief to the system that sometimes follows the eruption of acne 
will induce caution in the use of repellents for its removal, and at 
the same time suggest its connection with disordered digestion. The 
remedies adapted to this latter, will be first used; giving a preference 
to mercurial and saline purgatives, and antimonials in the first or 
acute stage — and rhubarb and magnesia, and alkalies and tonics in 
the second or chronic form. In some cases the mineral acids have 
been used with good effect. 

This treatment and simple regimen are the more necessary where 
disorder of the digestive organs has been the immediate exciting 
cause of acne, and where the symptoms of such disorder appear to 
be materially alleviated by the appearance of the eruption. 

Most stress is usually laid on the local treatment of acne, but not 
seldom in oblivion of correct pathological principles. In its first stage 
the eruption is the result of irritation and active inflammation ; and 
hence it ought not to be treated either by strong stimulants or repellents. 
At this time simple vapour, or frequent bathing of the parts with warm 
water and "gentle friction with the mildest kind of soap," constitutes 
by far the best local application, before matter has been discharged 
from the tubercle. " If any vestige of active inflammation remain, it 
should be soothed, and suppuration promoted by poultices and fb- 



Historical Notices. 

509. According to Cassius 1 the word acne is derived from d* f <>i 
axfiai vigores, and signifies that the eruption is usually developed about 
the age of maturity, and is frequently associated with a kind of vigour 
of constitution. This eruption appears also to have been designated 
by the names, vari, 2 ionthos, 3 puncta mucosa vultus (Darwin), and 
grutum seu milium (Plenck). It has been described by M. Alibert 
under the title of dartre pusfuleuse dissemirU'e.* It is a disease of 
little severity, without important individual varieties, and one of which 
it seems unnecessary to give the details in particular cases. 



Vocab. Bacckia, Acne rosacea. 

510. Rosacea is a chronic non-contagious inflammation affecting 
the follicles of the skin of the face, characterized by the successive 
eruptions of small isolated and acuminated pustules, the bases of which, 
indurated in different degrees, are surrounded by an inflamed areola. 
These pustules appear dispersed, especially over the cheeks, nose and 
forehead, and occasionally extend to the ears and upper parts of the 
neck. To these pustules succeed a dilated and arborescent state of 
the superficial blood-vessels in their vicinity, or small, hard, red, cir- 
cumscribed and excessively indolent tubercular indurations, the reso- 
lution of which is always brought about with extreme difficulty, if, 
indeed, it can ever be accomplished entirely. 

511. Symptoms. — In its most simple form rosacea appears in the 
shape of small red pustules disseminated over the face. They are 
evolved successively without local heat, or any other sensation than 
that of a very slight tingling in the skin. Each of these pustules 
arises, suppurates, and dries up or passes into the indurated state 
independently of those in its vicinity. The suppuration is slow; the 
tops of the pustules are not covered with a slight scab sooner than 
the middle of the second week. The pustules of rosacea are fre- 
quently seen intermingled with small black points which project more 
or less from the surface, and are formed by a thick solid unctuous 
matter accumulated within the follicles of the skin. Wlien these 

mentations ; and if any tubercle should be found assuming the blue 
colour without signs of matter coming forward, it should be freely 
punctured." After the evacuation of the tubercle and the temporary 
irritation from puncture is removed, Plumbe, whose advice I have 
just repeated, thinks that stimulants are plainly called for, and of 
these he gives the preference to spirituous lotions, and particularly to 
a solution of the bichloride of mercury in proof spirits, in the propor- 
tion of five grains of the former to eight ounces of the latter. With 
this the spots are to be lightly sponged. In acne indurata, they who 
have made trial of the remedy, will join Plumbe in his favourable 
opinion of the topical use of mercurial ointment, and I would add 
the recommendation of camphor accurately mixed with it. M. Biett, 
again, assures us that none of the resolutive preparations for acne 
indurata are comparable to the iodide of sulphur, mixed with lard : 
R- Sulphur, iodid. gr. xii ad xxiv; 

Adipis Ei ; 
M. ft. unguent. 
The good effect of all these means is much promoted by the vapour 
bath, directed in the form of a douche, on the eruption. 

A severe but efficient remedy is blistering the diseased surface, a 
practice first suggested by Ambrose Pare and revived by Darwin. — A 
solution of the muriate of ammonia is used with advantage in chronic 
cases of simple acne. 

Internally acne indurata may be treated by the use of iodide of 
potassium and iodide of iron together with vegetable syrups, as that 
of sarsaparilla. 

'Cassius. Naturales et medicinales quaastiones. Problem. 33. Zurich. 1562, 6vo. 

s Celsus. De re medica, lib. vi. cap. v. 

3 Pollux (Jul.). Onomasticon, lib. iv. cap. xxv. 

* Alibert. Precis theor. et prat, des malad. de la peau, t. i. p. 275. 



ROSACEA. 



183 



small points are numerous and closely set together, the skin of the 
nose assumes a thick and greasy appearance, and that of the cheeks 
becomes rough and uneven. 

Commonly, however, the pustules of rosacea are of larger dimen- 
sions than those now described ; they are then also more numerous 
and more closely crowded together; their form is conoidal, their base 
broad and hard, their colour of a ruddy violet ; they are indolent, and 
the pus does not appear at their apices till after the lapse of several 
weeks. They are occasionally assembled into clusters, and so closely 
set together that they seem to* form a flattened tumour. These pus- 
tules are most highly inflamed among individuals of a sanguine tem- 
perament and in the prime of life. They are excited by the slightest 
irregularity in diet, entering a hot room, &c, and under these various 
influences, they run their course more rapidly ; but they then usually 
succeed each other more rapidly and in greater numbers. In this 
form of the disease, the follicles and vascular rete of the corion are 
principally affected, and the subjacent cellular tissue occasionally 
shares in the swelling of the common integument. After their dis- 
appearance the majority of these pustules leave a livid mark behind 
them, and a depression in the part of the skin they have occupied, 
which is seldom, if ever, completely effaced. 

Another variety of rosacea belongs to the period of perfect man- 
hood. Some red spots, which have appeared on the nose and cheeks, 
become affected with a troublesome pruritus after meals, a few glasses 
of strong wine, or a little of any spirituous liquor. By degrees these 
red patches of the nose become habitual, spread, assume a more vivid 
hue, and before long look as if studded, here and there, with small 
pimples, which gradually increase in number, and spring up crop 
after crop, their yellow purulent heads contrasting strongly with the 
ruddy violet of the surrounding skin upon which they are evolved. 
This colour does not vary perceptibly to any great extent, although 
it looks rather deeper towards evening, after meals, and in the imme- 
diate vicinity of the pustules. The parts upon which pustules have 
sprung up repeatedly are swollen, hardened, and acquire the charac- 
ter of true tubercular indurations. The minute veins dilate and form 
blue lines which ramify irregularly through the substance and over 
the surface of the skin. The disease spreads upon the cheeks, fore- 
head and chin, and finally gains possession of the whole face ; the 
features enlarge, and the countenance is altered and disagreeable. 
When the disease has existed for a great length of time, the skin 
becomes uneven and rugous, and, whatever may be done, can never 
again be restored to its original and natural state. 

Besides these differences in the size, number, and course of the 
pustules, erythematous blotches and tubercular indurations of rosacea, 
the disease appears with considerable shades of variety according 
to the extent of integument it implicates, the length of time it has 
existed, and the nature of the affections with which it is complicated. 
In one case the pustules, limited to a small space, are few in number, 
isolated, and after a time leave no trace of their existence on the 
skin beyond a slight degree of redness ; in another they are very 
numerous, succeed each other rapidly, sprout over every part of the 
face, and even spread to the neck. When the disease acquires a 
great degree of intensity it is frequently followed by dark-red or 
violet-coloured tubercles of various dimensions; the conjunctivae 
inflame ; the gums become painful and swell, and the teeth suffer 
from a chronic form of inflammation which attacks the membrane 
of the mouth. 

In other cases of rarer occurrence than either of these, rosacea 
does not extend beyond the alae of the nose, upon which tubercu- 
lated excrescences or tumours, of a red colour, and considerable size, 
are developed. The whole of the tegumentary tissues of the nose 
are hypertrophied in these cases, so that this member of the face 
occasionally becomes of twice, and even three times, its usual size. 

512. Causes. — Rosacea most usually attacks men between the 
thirtieth and fortieth year of their age ; it is very frequently con- 
nected with some degree of chronic inflammation of the mucous 
membrane of the stomach and intestines ; its association with a dis- 
ordered state of the liver is more rarely demonstrated, notwithstand- 
ing the opinion to the contrary so incessantly revived. Females 
seem even more subject to rosacea than men, and are generally 
attacked about the critical period of life. The disease may also 



appear upon any accidental suppression of the menstrual flux, dis- 
appear with the return of this natural discharge, or coincide with 
simple dysmenorrhea. Rosacea is rarely aggravated by pregnancy ; 
and it occasionally improves or even vanishes entirely during the 
period of utero-gestation. Rosacea is often of hereditary origin, and 
may in many cases be traced through several successive generations. 

Indulgence in the luxuries of the table, violent or concentrated 
moral affections, certain professions which require constant applica- 
tion, and an attitude that favours the flow of the blood towards the 
head, or prevents its ready return from thence, are common causes of 
rosacea. The use of certain pigments or rouges and of cosmetics 
generally, causes the disease much less frequently than has been 
imagined. 

Cold and moist climates have been supposed to have an influence 
on the development of rosacea. The disease is certainly more com- 
mon in England and the north of Germany than in more southern 
climes; but the circumstance maybe explained from the mode of 
living followed there, the use of a highly stimulating regimen, and the 
custom of drinking strong wines, and large quantities of malt and 
spirituous liquors. 

513. Diagnosis. — Rosacea is easily distinguished from every other 
pustular disease developed on the face. The pustules of rosacea 
never attain the size, and are never covered with the adhering scabs 
proper to those of ecthyma. They do not run together, and never 
present thick incrustations like those of impetigo ; such crusts as 
they do exhibit are never laminated like those of eczema impetigi- 
nodes. 

The pustules of rosacea are not likely to be confounded with the 
papulae of lichen ; and the small scabs that form on the tops of its 
pustules can never be mistaken for the accidental thinner and more 
extensive incrustations, spread over a scaly surface, that distinguish 
the chronic and excoriated forms of lichen affecting the face. Pus- 
tules and tubercles of syphilitic origin are rarely evolved on the face 
only ; they are most commonly observed over the whole of the body, 
or, at all events, a large extent of its surface at the same time. 
Syphilitic psydracious and phlyzacious pustules have peculiar and 
distinguishing characters. When syphilitic tubercles do chance to 
exist exclusively on the face, they are usually seated around the alae 
of the nose, about the commissures of the lips, and are almost invari- 
ably cleft on the surface, so as to appear like morbid growths. They 
are, further, distinguishable by their shining aspect, their coppery 
colour and their tendency to ulcerate. The tubercles by which lupus 
commences, superficial and very slightly raised at first, will scarcely 
be confounded with the tubercles that occasionally succeed the pus- 
tules of rosacea. The tubercles of lupus increase in size, acquire a 
livid hue, extend from the nose to the cheeks, and, the subjacent 
tissues becoming affected, all are alike destroyed by the ulcerative 
process to which the disease naturally tends ; these are circumstances 
sufficient to render any mistake impossible. 

514. Prognosis and treatment. — We may hope to succeed in our 
treatment of rosacea, when the individual affected is still young, when 
the eruption is recent and of no great severity, and when it can be 
traced to irregularities in regimen. On the other hand, when the 
disease has arisen in an individual already arrived at maturity of 
years ; when it has continued long and has every year been getting 
worse ; above all, when it can be traced as a hereditary complaint and 
is very extensive, whether it be connected with a chronic inflamma- 
tory state of the digestive organs or not, the best directed modes of 
treatment will rarely prove efficient in preventing the evolution of 
fresh pustules, and will, with great difficulty, accomplish the entire 
resolution of the tubercles that have already been formed. 

The ordinary diet of those who are suffering under rosacea should 
consist of white meats, fresh vegetables and ripe and watery fruits. 
They should guard against exposure to much fatigue of body, any 
degree of nervous excitement, long-continued mental exertion of every 
kind, and they should carefully shun situations in which the tempera- 
ture of the air is high. 

Should the disease have appeared in a young and plethoric indi- 
vidual ; should the pustules be numerous, thickly set and confluent ; 
should the tubercles be inflamed and united by their bases, general 
blood-letting, repeated at due intervals, the reiterated application of 



184 



PUSTUL7E. 



9 behind the ears, to the temples and a la? nasi are generally 
beneficial. Ambrose Pare 1 recommends the bleedings practised in 
eases ot' rosacea to be copious in order to be efficacious: "The 
patient," says he, " who is attacked with gutta-rosea must be bled 
from the basilic vein, then from that of the forehead and next from 
that of the nose ; leeches must also be applied to several spots of the 
nil cupping-glasses with scarification put between the shoulders." 
Should rosacea appear to be connected with the disappearance or any 
irregularity of the menstrual or hemorrhoidal flux, the return of these 
evacuations must be solicited by the use of the hip-bath, and the 
application of leeches to the vulva or anus, at intervals corresponding 
with the periods of the habitual discharges. Diluents internally, the 
use of whey, a cooling system of regimen, demi-laveraents, the general 
tepid bath administered at a very moderate temperature or almost 
cold, fomentations with decoction of bran, warm milk, almond emul- 
sion, veal broth, and decoction of quince-seeds, often aid this plan of 
treatment in its favourable tendencies. 

I must add, however, that all these measures rarely prove adequate 
to effect the cure of rosacea, and that we are frequently compelled to 
call in the assistance of certain stimulating remedies in addition. The 
ancients were in the constant habit of using liniments, into which tur- 
pentine, vinegar, soap, myrrh and such articles entered in large pro- 
portions. At the present day, from the period of the first attack of the 
lighter and even of some of the severer forms of rosacea, it is cus- 
tomary, after having abstracted blood to a greater or smaller amount, 
to employ lotions of rose, lavender or sage water, to which from a sixth 
to a third of alcohol is added according to the state of the pustules. 
This practice is frequently followed by very good effects. A solution 
of from four to eight grains of the bi-chloride of mercury to a pound 
of rose-water and an ounce of eau de Cologne is also occasionally 
employed under the same circumstances with the best results. 

The sulphureous mineral waters of Bareges, of Aix in Savoy, of 
Cauterets, Schisnach, Harrowgate, Bath, &c, employed by way of 
fomentations, baths, and douches, are one of the most powerful means 
we possess in the treatment of rosacea of long standing. Baths of arti- 
ficial sulphureous waters prolonged for several hours, are scarcely 
inferior in efficacy. 

The nitrate of silver, and the hydrochloric acid have also been em- 
ployed to give a character of greater acuteness to the chronic eruption 
of rosacea. For my own part, I have abandoned the use of both these 
agents in the treatment of this disease. These, and such applications 
ought in every case to be preceded by the detraction of blood, and made 
in such wise as not to penetrate the skin too deeply, a precaution with- 
out which they are apt to be followed by erysipelas, ulceration and 
indelible cicatrices. The nitrate of silver is usually selected to cau- 
terize the pustules when they are isolated, the muriatic acid is preferred 
when they are confluent. 

After blood-letting has been duly practised, the steam douche may 
be advantageously employed to favour the resolution of the tubercles 
of rosacea. Directed for twelve or fifteen minutes at a time to the 
face, this application causes a rapid afflux of blood thither, after which 
the skin becomes softer and feels smoother than it did before. 

Pediluvia, with the addition of a small quantity of the nitro-muriatic 
acid, and the use of calomel internally, have been recommended in this 
disease, and I have known the practice occasionally to prove beneficial. 

The discussion of the tubercles may be farther solicited by the in- 
unction of ointments, of which the ammoniacal proto-chloride, or the 
proto-sulphate of mercury forms the basis, in the proportion of about 
a scruple of either of these salts to an ounce of lard. The iodide of 
sulphur is also occasionally successfully employed under the same 
circumstances, in the proportion of from ten to twenty grains, to the 
ounce of lard. 

To conclude this enumeration of remedial means, Guy de Chauliac, 
Ambrose Pare, and Dr. Darwin, have all at different epochs recom- 
mended a blister to the whole, or to a portion of the surface affected 
with inveterate rosacea. This measure is extremely uncertain in its 
efficacy, and few patients will probably be found willing to submit to 
die infliction. D 

In every case it is right to prolong the treatment some time after the 

1 De la Goutte-rose, lir. xxvi. chap. xlv. 



disappearance of the eruption. It is then that the cold sulphureous 
douche and aspersion act with peculiar efficacy. 

515. So long as rosacea was regarded as a depurative or purifying 
disease, so long was it the invariable practice to employ purgatives, 
the juices of the water-cress, scurvy-grass, beccabunga, wild pansy, 
&c, in its treatment. Remedies of this class are less generally made 
use of in the practice of the present day, if we except mild purgatives, 
which I am myself in the habit of prescribing with success, especially 
to individuals of a nervous temperament and habitually constipated 
in their bowels. 

Should rosacea appear to be complicated with any internal inflam- 
matory affection, such as a chronic gastritis or hepatitis, these diseases 
require to be combatted by measures adapted to their seat, their extent 
and their peculiar nature, (a) 

516. Rosacea declines and fades under the influence of diseases of 
some severity ; its cure has occasionally been succeeded by the deve- 
lopment of certain diseases which have then been attributed to its 
repercussion. 

Occasionally treated with temporary success by purgatives or 
mineral waters, rosacea almost always returns after medicines are 
abandoned, with a rapidity and regularity that induce despair. (6) 

Historical Notices and particular Cases. 

517. Femelius 1 has given a good definition of rosacea. Guy de 
Chauliac 2 has recommended the treatment of the disease by means 
of a cooling system of diet, bleeding from the frontal vein, the appli- 
cation of leeches within the nostrils, and purgatives. " If these means 
do not succeed," says he, " we must then blister with cantharides." 
It is consequently a mistake to attribute this piece of practice to Pare. 

Darwin 3 has described three varieties of rosacea, established ac- 
cording to their presumed causes (Gutta-rosea hepatica ; Gutta-ros. 
stomachica; Gutta-ros. hcereditaria). Sennertus 4 quotes a remarkable 
instance of hypertrophy of the nose and of tuberculation (vari) conse- 
cutive to rosacea. 

Numerous observations have been published in recommendation of 
blood-letting, 5 of the application of leeches to the nostrils, 6 of antimonial 
medicines, the application of blisters between the shoulders, 7 and of 
the preparations of sulphur. 8 

Several cases have also been detailed of gastro-intestinal inflamma- 
tions, 9 of amaurosis, 10 and of different other diseases attributed to the 
recession of rosacea. 

518. I limit myself to the details of two cases of rosacea, in which 
the methods of treatment most usually recommended were pursued. 
I also re-publish one of Ambrose Pare's cases, in which the bold 

(a) The blue pill, with extract of hyoscyamus, extract of taraxacum, 
sulphuro-saline waters, and iodide of potassium are useful remedies 
in rosacea, but they must be aided by a well-regulated and prolonged 
hygienic course. Liquor potassa?, in a dose of 15 to 30 drops, three 
times a day in milk or decoction of sarsaparilla, is often very ser- 
viceable in this and other skin diseases of the pustular and vesicular 
forms. Solution of the sulphate of iron is a good application, in 
rosacea as well as in sycosis : the same may be said of the sulphate 
of zinc, in the form of tepid solution, by means of rags moistened and 
applied to the part. 

(b) The acne syphilitica of other writers is described by M. Rayer 
in a subsequent part of this volume, § 871, under the head of " syphi- 
lida" by the term psydraceoits pustules. 

' Rubor faciei vel simplex et solitarius, et vel sine pustulis, vel pustules comiies 
habet. Ha? pustulae si iniensum ruborum habeant, gutia rosacea vocanlur, si dura 
et exgiuaj ex frigido et crasso humore ac velut in callum concretae, vari nominatur 
(Fernel. Universa medicina, fol., 1679, p. 442). 

2 Guy de Chauliac. (Traduction du Guidon, par J. Canappe. 18mo., p. 393.) 

3 Darwin. Zoonomia. Class ii. i, 4, 6.— Class iv. i, 2, 13, 14. 

4 Sennert. Pract. medic, lib. v.; part i. cap. 31. 

6 Baier. Pract. lib. viii. cap. 3. (Schenck. Obs. med. rar., lib. i. p. 194.) 

o Zacutus Lusitanus. Medic, nat. hist., lib. v. obs. 3.— Lorry. De morb. Cutan., 
p. 653. * 

7 Turner. Of the red face, pustulary eruptions. (Treatise of diseases incident to 
the skin, 8vo., 1736, p. 237.) 

8 Agricola. Comment, in Poppium de sulphure, p. 356. 

9 Gondret. Journ. complem. des sc. med., t. xxxix. p. 42. 

10 Klein. Interpres clinicus Francof ad Moen. 1753, 8vo. 



SYCOSIS. 



185 



practice adopted was crowned with the most complete success. I 
beg to say, however, that the remedy employed by this celebrated 
surgeon has been too much vaunted, and, as I have said, few patients 
will be found ready to hazard its adoption. 

Case LXXV. — Slight and recent rosacea, hypertrophy of the left 
ventricle of the heart ; treatment by means of blood-letting and mer- 
curialized spirituous lotions. — Mam'lle * * *, nineteen years of age, 
has been subjected to violent palpitation of the heart for the last five 
or six years, which recurs as often as she takes active exercise, or is 
exposed to any moral affection. The pulse is regular, but hard and 
full. The impulse of the heart is strong. Respiration is unembar- 
rassed ; the other functions, and particularly the menstrual flux, are 
regular. 

Nevertheless Mam'lle * * * complains occasionally of heaviness of 
head ; and within four months of the date at which my assistance was 
required, a slight rosaceous affection had appeared. The eruption 
consisted of but a small number of isolated rosy pustules accompanied 
with very little inflammation. The disease was not hereditary, and 
seemed constantly to improve after the recurrence of the menstrual 
periods, and after the application of the leeches which had been 
attached to the feet or the precordial region with a view to calm or 
to prevent an attack of palpitation. Several follicles, situated upon 
the ala; nasi and neighbouring parts of the cheeks, are distended with 
solid sebaceous concretions about a line in length. I prescribed 
fifteen leeches to the feet, and a wash to be applied three times a day 
to the face, consisting of two parts of rose-water and one of alcohol. 
This lotion appearing scarcely to stimulate the pustules in any degree, 
I ordered nine grains of the bi-chloride of mercury to be added to 
eight ounces of the mixture, a few days afterwards. At the end of a 
fortnight, the whole of the old pustules were gone and no new ones 
had been formed. The wash was continued for a fortnight longer. 
From this period a few pustules of rosacea had been from time to 
time developed on the face, but the progress of the disease has 
always been arrested by the application of leeches, a measure which 
the affection of the heart rendered repeatedly necessary, and by the 
pains which the patient always took to attack and modify the course of 
the nascent eruption by the use of the wash I had prescribed for her. 

Case LXXVI. — Rosacea successfully treated by blood-letting, and 
the hydro-sulphureous douche. — Madame * * *, thirty-four years of 
age, had never suffered from any chronic affection of the skin, when, 
after long-continued and violent grief, she was attacked at the end of 
the month of January, 1825, with a number of small red spots which 
appeared upon the nose and neighbouring parts of the cheeks, and 
before long became surmounted by small pointed pustules, the apices 
of which were filled with a whitish or yellow-coloured purulent fluid. 
This eruption left to itself made rather rapid progress. By the 12th 
of April the pustules were thickly set, and had spread over the nose 
and regions of the cheek-bones, the integuments of which were, 
besides, erythematous and flushed. At this period the patient was 
seized with a gastro-intestinal inflammation which, in spite of the 
most active treatment, continued for eight and twenty days. During 
the continuance of this disease, and under the influence of the deple- 
tory measures that were enforced, the rosacea got almost completely 
well. The eruption reappeared, however, gradually, shortly after the 
convalescence of the patient, and within two months, had regained 
the same degree of severity it possessed before the occurrence of 
the gastro-intestinal affection. Propitious circumstances had again 
restored to Madame * * * means of leading a quiet and agreeable 
life; the general health of the patient was good; the chances seemed 
peculiarly favourable for the treatment of the rosacea, and measures 
were accordingly taken on the 6th of July, 1825. 

The patient w r as bled from the foot to the extent of twelve ounces ; 
the bowels, habitually constipated, were regularly moved by the daily 
use of emollient glystcrs ; the patient drank two glasses of whey every 
day, bathed the affected parts night and morning with cow's milk, 
and every second day took a warm bath at 25° of Reaumur. Natu- 
rally inclined to the most temperate and regular system of life, the 
patient was anxious to make it still more rigorous, and took particular 
pains to avoid whatever might by possibility interfere with the success 
of the treatment. 

Its good effects were at first very marked : within two weeks the 
47 



erythematous spots which formerly overspread the cheeks had faded ; 
the pustules had shrunk or dried up, and the pruritus, of which the 
affected parts were the seat, was completely subdued. 

The same plan of treatment was continued for two months without 
other interruption than such as the recurrence of the menstrual periods 
rendered necessary, and without any other modification than the ap- 
plication of sixteen leeches to the temples. During this interval oi 
time, the efflorescence of the cheeks and alse nasi revived oftener than 
once without assignable cause ; fresh pustules were' also evolved ; but 
they were few in number, and speedily dried off". A fortnight later 
the integuments of the nose were still affected with some degree of 
redness, and slight desquamation. Madame * * * now took fifteen 
hydro-sulphureous douches, the steam being directed upon the parts 
affected by means of a properly constructed spout, with the greatest 
benefit. From this time, indeed, the rosacea might be regarded as 
completely cured. When the patient has any sensations of itching; 
in the ala? nasi similar to those that preceded the development of the 
rosaceous pustules in the first instance, by bathing the parts with the 
mercurial and spirituous wash recommended in the preceding case, 
(LXXV.) this symptom is appeased, and the formation of fresh pus- 
tules prevented. 

Case LXXVII. — Rosacea treated and cured by the application of 
a blister to the face. 1 A certain gentlewoman came to Paris, her whole 
face deformed with fiery pustules to such a degree that she was shun- 
ned by many as affected with leprosy, and being even interdicted 
from entering her parish church, lest she should infect the healthy. 
Calling Jacques Hollier and R. Gruaume, physicians, and Est. de la 
Riviere and Germ. Cheval, surgeons, to take her case into their con- 
sideration, it was determined that she was by no means affected with 
leprosy; and to cure her of her couperose, a blister of cantharides was 
ordered to be applied to the whole of the face. This I accordingly 
did. And three or four hours after the blister began to tell, she had 
an extraordinary sense of scalding in the bladder, with gripings, &c, 
so that she vomited, and made water, and went to stool incessantly, 
tossing herself hither and thither as if she had been in a fire, and out 
of her mind from the delirium of a fever, all of which surprised me 
very much. Seeing that these accidents arose from the cantharides, it 
was resolved, in consultation, to give the patient abundance of milk- 
to drink, and that injections should be thrown up as well to the neck 
of the womb as to the neck of the bladder. She was also bathed in 
water of moderate heat, in which linseed had been boiled, together 
with the roots and leaves of mallows, henbane, lettuce, &c. In this 
bath she remained long, finding her sufferings lessened by it. Being 
then laid in bed again, her loins and genitals were anointed with 
unguentum rosatum and oxycrate. By these different measures the 
accidents were all subdued. As to the face, it was completely blis- 
tered, and discharged large quantities of purulent sanies, by which 
it lost the great deformity of skin it presented before. After being 
cured, we gave the patient a certificate to the effect that she was in 
no wise leprous. And soon after, having returned home, she got 
married, and has since had several beautiful children; nor could any- 
one now perceive, for she is still alive, that she had ever had her 
face flayed. 



Vocab. Mentagra, Whelk. 

519. Sycosis is characterized by the successive evolution of a num- 
ber of small pointed pustules, similar to those of rosacea, and scattered 
singly or clustered together, over the chin, upper-lip, sub-maxillary 
region and lateral parts of the face. This eruption is pretty generally 
known under the objectionable title of mentagra. 

520. Symptoms. — Slight, partial, and passing pustular eruption:-: 
are usually observed to take place for several months, or even some 
years, upon the regions indicated, before a complete attack of sycosis 
occurs. In some rare cases, and almost always under the influence 
of appreciable causes, such as excesses in spirituous potations, the dis- 
ease unexpectedly attacks the whole of the inferior maxillary region. 

' Amb. Pare CEuvres. liv. 21. Des Venins, ful. Lyon, 1641, p. 500. 



186 



PUSTULE. 



The eruption is occasionally confined to the upper-lip, at other 

limes to one of the tides of the chin, to the lateral parts of the face, 

it to a pari only of the sub-maxillary region; the disease in other 

s the whole of the regions indicated above, simultane- 

, successively, and even extends to the roots of the hair in the 

nape of the neck (sycosis capillitii). 

The evolution of the pustules of sycosis is usually attended with a 
leling of heal and tension in the parts they are to occupy. At one 
Mine thej are disseminated and appear under the form of very small 
red points which become more and more prominent by degrees. On 
the second or third day of their formation the tops of these elevations 
grow white, and are filled with a pale yellowish pus; they subse- 
quently increase a little, but it is seldom that they surpass a millet- 
seed in size. Almost all of them seem traversed by a hair; they do 
not discharge like those of impetigo. Between the fifth and seventh 
day each pustule bursts spontaneously, its sides shrink, and a slight 
oozing takes place which gives rise to a brownish crust that scarcely 
adheres to the skin, and is confounded at its edges with the epidermic 
furfurae which are thrown off by the inflamed integuments in the vicinity 
of the pustule, (a) 

.V21. When the pustules are grouped or clustered in considerable 
numbers, the inflammation extends to the cellular membrane immedi- 
ately under the inflamed portion of corion, and gives rise to a true 
phlegmonous swelling. The chin, the sub-maxillary regions and the 
upper lip then present small hard, painful red tumours covered with 
pustules, or incrustations of considerable thickness, and a mixed yel- 
low and greenish-brown hue, which might very readily be mistaken 
for those of impetigo, without attention to the thickening of the in- 
teguments and swelling of the subcutaneous cellular tissue. 

In the greater number of cases, sycosis, like rosacea, invades in the 
shape of repeated partial eruptions which succeed each other at inter- 
vals more or less remote. When the pustules are throw T n out repeatedly 
on the same places, the inflammation extending from the corion to the 
subcutaneous cellular membrane, there occasions indurations, which 
before long present the appearance of voluminous tubercles. These 
are especially observed among the aged, and in subjects of a flabby 
constitution in whom the pustular inflammation has not been followed 
by a perfect resolution. When the eruptions have been copious and 
severe, and have succeeded each other rapidly, these tubercles increase 
in number, and spread over the whole extent of the chin. The new 
pustules which still continue to be evolved on the surface of these 
tubercles, or in the intervals between them, proclaim the original 
nature of the disease. It is then particularly that the confused mixture 
of pustules, tubercles, and incrustations, give a disgusting character 
to the appearance of sycosis. Arrived at this stage, sycosis is always 
an obstinate disease, the cure of which is never obtained but with 
great difficulty. 

The skin occasionally becomes very much altered, and swells to such 
a pitch as to appear covered with moist and vegetating tumours. The 
piliferous bulbs of the beard frequently participate in the inflammation; 
and if the disease continue long enough, patches of the integument of 
the chin, &c, are divested of beard entirely. This loss of the beard 
is usually only temporary ; at a subsequent period, new hairs, of a light 
colour and very weak at first, make their appearance, but gradually 
acquire the shade and strength of those that have fallen. The loss of 
portions of the beard in other instances is permanent. 

Sycosis may be confined to the upper lip. Several pustules agglo- 
merated upon this part give rise to a thick blackish scab, which often 
projects remarkably from the surface of the parts it covers. 

When the disease gets well, whether by a natural process, which 
very rarely happens, or under the influence of remedial measures, no 
new pustules are evolved, the incrustations are detached, and the 
tubercles decline in size and hardness. Some slight desquamation 

(a) "What has been termed sycosis, is nothing more or less than 
acne, or follicular obstruction and its consequences, occurring in parts 
covered by hair ; and though the necessity of distinction between it 
and the same state of parts not so covered be admitted, this circum- 
stance cannot justify a subdivision like that adopted of S. meuti and 
S. capillitii.'" Plurabe. The reference here is to the division of sycosis 
into two species by Willan and Bateman. 



occasionally takes place from the points formerly affected, which long 
continue red and livid, especially in individuals of broken-down con- 
stitutions. 

The shortest period that sycosis is known to continue is from one 
to two months ; it frequently remains for years, and in spite of the 
most rational methods of treatment that can be adopted. • It is further 
very apt to recur even after it has been cured, particularly in those 
individuals who commit errors in diet. 

522. Causes. — I do not imagine that sycosis is contagious : yet M. 
Foville assures us that he has seen several of the insane patients in 
the Hospital of Rouen, successively attacked with the disease from 
having been shaved with the same razor. Under certain circum- 
stances consequently it would appear that sycosis may acquire the 
contagious character. Pliny tells us that mentagra spread in Italy by 
contagion during the reign of Claudius. Was this the same disease 
as sycosis ? The disease makes its attacks more especially among 
youthful and adult male subjects of a sanguine or bilious tempera- 
ment, who have a strong thick beard ; it is, however, occasionally 
observed among the aged ; it then occurs more particularly among 
those who have been habitually exposed to strong heats, such as 
cooks, founders, refiners, &c. Indulgence in the luxuries of the tabic, 
the abuse of spirituous liquors and highly-seasoned food, want of due 
regard to cleanliness, irritating applications to the skin of the face, 
the use of a foul or rough-edged razor, seem all to favour the deve- 
lopment of the disease. It appears more frequently in the spring and 
autumn than at other seasons. It is rare among females, (a) 

523. Diagnosis. — It is of some importance to distinguish sycosis 



(a) In some instances an analogous affection to sycosis is met with 
in the pubes of both sexes. 

A variety of the disease, termed by M. Gruby mentagrophyte, is 
described as follows by Mr. Wilson (op. cit. pp. 301-2). 

" Sycosis contagiosum. — M. Gruby, of Vienna, who has recently 
distinguished himself by his researches into the vegetable nature of 
favus, and by the announcement of the discovery of vegetable forma- 
tions in other diseases, has just (September, 1842) addressed a paper 
to the Academy of France, on a new cryptogamic plant, existing in 
the roots of the hairs of the beard, and around that portion which is 
contained within the hair-follicle. By the transmission of the seeds 
of this plant the disease is rendered contagious, and he proposes for 
it the name of mentagrophyte. 

" M. Gruby gives the following account of the disease: — It is 
limited to the hairy part of the face, but is most frequently seen upon 
the chin, the upper lip, and the cheeks. It covers all these parts 
with white, grayish, and yellowish scales, which measure from two 
to six millimetres in breadth, and from three to eight in length. The 
scales are slightly raised in the middle, their borders are angular, and 
they are pierced at all points by hairs ; they are but loosely connected 
with the skin, but so closely with the hairs, that in removing a scale 
we at the same time pull out a hair. 

"Examination with the microscope discovers to us that the scales 
are composed of epidermic cells, but the whole of the dermic portion 
of the hair is surrounded by cryptogamic formations, which constitute 
a vegetable sheath around it, in such manner, that the hair implanted 
in this vegetable sheath may be likened to the finger surrounded by 
a glove. 

"It is worthy of remark, that these cryptogamia never rise above 
the surface of the epidermis ; they originate in the matrix of the hair, 
and in the cells of which the follicle is composed, and they ascend so 
as to surround all that portion of the hair included within the dermis. 
They present everywhere a prodigious number of sporules, which 
are adherent on the one side with the internal surface of the follicle, 
and on the other, with the cylinder of the hair ; to the former they 
are very closely connected. 

"Each plant is composed of a stem, of several branches, and of 
sporules. 

" This disease of the skin, continues M. Gruby, is an affection of a 
purely vegetable nature, and is deserving of occupying a place among 
those disorders — such as favus and aphtha — which consist in the 
development of parasitic plants, and which might, very properly, be 
termed nosophyta.'''' 



SYCOSIS. 



187 



from other inflammatory affections appearing on the chin, cheeks and 
lips, especially from ecthyma, impetigo figurata, pustular and tuber- 
cular syphilitic eruptions, and boils. 

The pustules of ecthyma are larger and more highly inflamed than 
those of sycosis. The scabs succeeding ecthyma are also broader, 
thicker, and more adherent, and this disease never gives rise to tuber- 
cular indurations. 

The small pustules of impetigo figurata scarcely rise above the 
level of the skin, and are not pointed like those of sycosis ; they also 
differ from the latter in the greater rapidity of their evolution, arid the 
more acute symptoms attending their progress. As regards the dis- 
position of the pustules in groups, both of these eruptions may present 
this arrangement. Nevertheless, in sycosis the pustules are most 
commonly isolated and distinct, whilst in impetigo figurata they are 
generally clustered and crowded together. The pustules of the impe- 
tigo burst from the third to the fourth day, and the sero-purulent fluid 
that escapes from them is quickly changed into yellow continuous 
incrustations, the thickness of which increases in the course of a few 
days. The pustules of sycosis again do not give way before the 
fifth, sixth, or seventh day, and the scabs that succeed them are thin, 
slight, and isolated. All these distinguishing features, however, are 
obscured when the pustular eruption of sycosis is considerable and 
accompanied with a pale yellowish-green secretion from the follicles, 
or when the course of the disease is very acute, and the pustules are 
confluent, or much crowded together. 

It is rare that the pustules of syphilis appear nowhere except on the 
lower part of the face ; they almost uniformly occur on the alse of the 
nose, on the forehead, and at the angles of the mouth. The pustules 
of sycosis, on the contrary, are often limited to the chin, and, indeed 
generally, to its inferior parts ; they are pointed, and arise on a bright 
red base, proclamatory of one of the more acute forms of inflamma- 
tion. Syphilitic pustules are flatter, spring from a coppery, dirty, and 
almost flabby ground ; they are not preceded either by the smarting 
or painful tensive feeling which announces the pustules of sycosis. In 
the tubercular state, sycosis might more readily be confounded with 
the same condition of the integuments proceeding from a syphilitic 
cause. Nevertheless, the tubercles of sycosis are conoidal in their 
form; their base penetrates more deeply than the corion, extending even 
to the subcutaneous cellular substance ; whilst those of syphilis are 
more rounded in their shapes, have a shining look, and appear to arise 
from the more superficial layers of the corion ; they are, farther, pri- 
mary formations, and not consecutive to pustules like those of sycosis. 
Moreover, the pustular and tubercular inflammations of the skin in- 
duced by syphilis, accompanied as they are, in the vast majority of 
cases, by chronic phlegmasia? of the throat and conjunctiva, and 
almost invariably preceded by severe nocturnal pains, present a group 
of symptoms that differ extremely from those that characterize sy- 
cosis. 

In furuncle the inflammation extends from the cellular tissue to 
the skin ; a sloughy core is expelled from an opening which always 
leaves a scar. In sycosis, on the contrary, the inflammation first 
attacks the follicles ; and the pustules only discharge a very small 
quantity of pus, by an opening which does not destructively impli- 
cate the skin, and which is speedily effaced. 

524. Prognosis. — The most experienced practitioner frequently 
finds it impossible for him to fix limits to the probable continuance of 
sycosis. At the very moment when the decrease in the number of 
the pustules, and in the violet hue of the skin, seems to promise a 
speedy recovery, fresh eruptions break forth without any assignable 
cause, and blight the expectations of the patient and his attendant. In 
other cases, again, when every appearance leads to the presumption 
that the disease will continue for years, it is found to yield readily to 
active measures combined with an appropriate system of regimen. 
Those cases of the disease generally prove most rebellious which 
in the chronic state preserve the pustular and primitive form of the 
inflammation. When this happens, the disease is justly to be re- 
garded as one of the most intractable to which the integuments are 
subject. 

Sycosis occasionally disappears in summer, commonly to return 
again in winter. 

525. Treatment. — The first measure in the treatment of sycosis is to 



clip the beard with curved scissors, the action of the razor being foun J 
constantly to aggravate the disease. 

If the disease be of recent date, and have attacked a strong and 
healthy man, if the pustules be numerous, and crowded in such a way 
as to indicate a great degree of acuteness in the inflammation, it will 
be proper to have recourse to blood-letting, general as well as local, 
and to repeat the operation at frequent intervals, being only careful to 
apply the leeches, used topically, to a portion of the integuments be- 
yond the limits of the eruption. If the disease continues unchanged, 
or if it revives after having once declined, the general abstraction of 
blood ought to be repeated, the operation being occasionally preceded 
by fresh applications of leeches around the chin. The measure in 
which blood is abstracted both locally and generally, is in every case 
to be regulated by the state of the constitution, the intensity of the 
inflammation, the extent and frequency of the pustular eruptions, and 
by the effects — beneficial or noxious, which the depletion exerts upon 
the general health. 

General baths and local emollient fomentations are to be employed 
at the same time, and a mild aperient is to be exhibited at intervals. 

When the disease has existed long, and repeated pustular eruptions 
have given place to a tuberculated and indurated state of the integu- 
ments, the local abstraction of blood will still be found useful ; under 
such circumstances, however, the measure is to be resorted to at. more 
distant intervals, and only in the robust and plethoric. It would be 
hurtful in individuals advanced in life, and of weakly constitution and 
lax fibre. 

When the tubercles of sycosis show no signs of resolution under the 
influence of emollient topical applications, continued during several 
weeks, we should then cause the parts affected to be well rubbed with 
some discutient salve of which the proto-nitrate, the deutoxide, or the 
protochloride of mercury forms the base. Ointments of the prepara- 
tions of sulphur, of iodine and of the alkalies, are also frequently 
employed with the same views. I have occasionally obtained the 
rapid resolution of the tubercles of sycosis by the inunction of the 
ointment of the hydriodate of potash and sulphur. It is always proper 
to suspend the use of this class of remedies for a season, upon the first 
appearance of a fresh crop of pustules. 

The vapour douche is also frequently employed with success in 
softening the tubercles of sycosis and promoting their resolution. 
Douches from a watering spout, of the sulphureous waters of Bareges, 
Cauterets, Aix in Savoy, Bath, Harrowgate, &c, are often found 
serviceable under the same circumstances. 

Among topical applications, in fine, and when the disease is of very 
old standing and has proved very rebellious, much good is occasionally 
effected by the employment of superficial escharotics. The concen- 
trated mineral acids, or solutions of the caustic potash have generally 
been the agents selected, (a) 

Laxatives are often employed successfully in the treatment of chronic 
sycosis occurring among the young and robust. Bitters and chalybeate 
medicines are found to answer better with individuals in the decline 
of life, and of a lax and flabby constitution. 

The muriate of gold, administered by way of inunction upon the 
gums and tongue, has repeatedly either accomplished or expedited 
the cure of very refractory cases of sycosis. 

Lastly, excellent effects are occasionally obtained from the prepara- 
tions of mercury, as well among those who have never, as among those 

(a) On this division of the treatment Plumbe remarks : " The 
attention to the part should be constant and unremitting, and should 
consist of warm fomentations frequently repeated during the day, with 
poultices, if they can be conveniently applied, at night. Every little 
tubercle should be punctured at its commencement, and every hair 
extracted from the part which may be got out without much pain 
This practice, strictly followed, is capable of removing the most pro- 
tracted and troublesome cases, without the use of any internal medi- 
cines beyond alterative aperients, and any dependence on internal 
remedies, unassisted by it, will inevitably lead to disappointment." — 
p. 67. 

He recommends as a comfortable and clean substitute for the razor, 
the razor-scissors, as they are called by cutlers who manufacture 
them. 



188 



PUSTULE. 



have previously suffered from venereal affections. It frequently 
happens that we are compelled to try the effects one after another of 
the whole circle of remedies that have now been mentioned, the disease, 
as has been said, commonly proving one of extreme obstinacy, (a) 

Historical Notices and particular Cases. 

Celsus, 1 .Etius, 2 and Paul of TEgina, 3 have described two varieties 
. cosis, one of which evidently agrees with the eruption which has 
just engaged our attention. Pliny 4 has drawn a striking and accurate 
picture of the disease under the title of mentagra, which he believed 
contagious. The term sycosis (from ovxor, a fig), only signalizes one, 
namely, the tubercular state of the disease; the word mentagra, how- 
ever, is even more objectionable, inasmuch as it is applicable to any 
or the whole of the eruptions which affect the chin, and could not be 
used to designate sycosis affecting the upper lip alone. 

Willan, Bateman, and their followers, have done wrong in classing 
sycosis among the tubercles. 

I have not been able to meet with the dissertation of Johrenius, 5 
who has written expressly on this disease. Alibert has described the 
affection under the title of dartre pustuleuse mentagra. Several cases 
of sycosis have been particularly detailed in different periodical pub- 
lications. 6 

Case LXXVIII. — Sycosis successfully treated by blood-letting, emol- 
t fumigations and an ointment of the nitrate of mercury . — A currier, 
38 years of age, of a vigorous constitution, and leading a laborious 
life, although passionately addicted to spirituous liquors, was attacked 
with sycosis in the beginning of May, 1825. I was consulted towards 
the end of July of the same year, and found the eruption to consist, 
1st, of a great number of small sharp-pointed pustules, the size of a 
millet-seed, with hard and inflamed bases, disseminated over the 
chin, the inferior maxillary region, and the lateral and superior parts 
of the cheeks; 2d, of some ten red, hard, and inflamed tubercles; 3d, 
of epidermic laminae and yellowish crusts, confusedly intermingled 
with the pustules and tubercles, and adherent to a strong black 
beard. These parts had long been the seat of painful, tensive sensa- 
tions and violent pruritus. The symptoms had at one time abated ; 
but, in consequence of several successive eruptions of pustules, the 
disease had lately gone great lengths, and the whole integuments of 
the chin seemed swollen. Several lymphatic glands situated under 
the mastoid processes were enlarged ; the principal functions of the 
body were performed with perfect regularity. 

I began by bleeding the patient to the extent of several ounces, 
and ordered cataplasms of crumb of bread, softened with the decoction 
of mallows and poppy-heads, to be applied to the parts of the skin 
affected. The patient took a pint of whey daily, with a drachm of 
soluble cream of tartar dissolved in it. A speedy improvement was 
the consequence of this practice. Twelve days afterwards, I had 
twenty leeches applied to the fore part of the neck, at some short dis- 
tance from the limits of the eruption. The soothing cataplasms were 
continued, and emollient and anodyne fumigations were four times 
administered. 

On the twentieth day of this treatment, the skin freed from incrus- 
tations and squamae, no longer showed any pustules ; but it was erythe- 
matous in some places, and very little change was found to have 
taken place in the forms and dimensions of the tubercles. I now 
desired the poultices to be discontinued, and soothing fumigations, 
and lotions with warm milk to be used in their stead. The beard 
was removed with curved scissors. On the forty-fourth day of the 
treatment, the tubercles appeared softer ; but the skin was still fur- 
fiiraceous in places where the tubercles had been evolved. The 



(a) Special diseases of the sebaceous follicles are treated of by M 
Rayer at § 1183 et seq. ' 

1 Celsus. De re medica, lib. vi. cap 3 
• Alias. Tetrab. I. Serm. 5, cap. 80, 'l90 
» Pauli .Egineia, lib. iii. cap. 22 
^Plinii second! natar. Historic libri, xnvii. Venet. 1509. Folio, lib. xxvi. cap. 

! Sfi? vJFKi s DiSS " i dC me " ,as , r4 ' 4t0 - Francc * ^ Viadrum, 1662. 
M.i.V Jain mo n W* £r^ T0L "£ P " 64 -J°"™- Hebd., t. iV. p. 79.-Revue 
Medic. Juin. 1330, p. 347—Journal complement, des sc. medic, t. xxxix. p 39 



patient was purged with Seidlitz water, and the tubercles were gently 
anointed with an ointment of the nitrate of mercury, the strength of 
the unguent being gradually increased by an additional dose of the 
salt. The cure of the disease, in this instance, was accomplished after 
two months and a half of treatment. 

Case LXXJX. — Pustular and tubercular sycosis, application of emol- 
lients and of the ammoniacal proto-chloruret of mercury. — N * * * * 
corpulent, and of a lymphatic constitution, was attacked, in the course 
of 1815, with slight rosacea, which yielded to sulphureous washes. 
In the month of March, 1824, several pustules, similar to those which 
formerly appeared on the cheeks, were observed on the chin, and rot 
well in the course of ten weeks, under the use of the same kind of 
lotions. A second eruption of small pointed pustules took place in 
the month of September following, not only on the chin, but on the 
inferior maxillary region likewise, which became covered with thin 
and slightly adherent incrustations ; fresh pustules made their appear- 
ance in the intervals between these, and the sulphureous washes 
usually employed by the patient with the best effects, seemed now to 
aggravate the mischief: the skin became more tense, more highly 
inflamed, and more thickly beset with pustules than ever. 

Consulted on the 14th of October, 1825, for the first time, I found 
but few pustules unbroken; the greater number were covered with 
dry scabs, retained by being entangled among the hairs of the beard. 
Several tubercles were disseminated amidst these incrustations the 
level of which they exceeded. The skin w r as of a red colour under 
the scabs, especially in the neighbourhood of the tubercles. The 
patient made little complaint of heat or itchiness ; and the affection 
of the skin seemed perfectly free from all complication. The scabs 
were soon detached and the tubercles softened by the application of 
emollient poultices. Small doses of calomel were at the same time 
prescribed internally. Eight days afterwards the only evident change 
in the state of the parts was their freedom from incrustations. The 
limits which the redness of the skin and the tubercles extended could 
now be more clearly perceived. The emollient topical applications, 
and the calomel internally, in doses of three grains daily, were never- 
theless continued ; but without any other effect, at the end of three 
weeks, than a decrease, in a very trifling degree, of the redness of 
those places which had been beset with pustules. The skin was soft 
and not painful; the chin was now repeatedly exposed, for several 
successive days, to the vapour of an emollient decoction; no fresh 
pustules were evolved. During the space of a month, N * * * * con- 
tinued to rub the tubercles gently with an ointment of the ammonia- 
cal proto-chloruret of mercury, the use of this salve being suspended 
whenever it appeared to be producing too great a degree of excitement. 
By this means the resolution of several of the small tumours was suc- 
cessfully accomplished. Some others, however, remain indolent, 
and the skin which surrounded them long continued furfuraceous, 
although it did gradually resume its natural appearance. Six weeks 
after the treatment now specified was entered on, with the exception 
of only four or five tubercles, the resolution of which could not be 
brought about, the integuments of the chin had returned to the con- 
dition they possessed before the invasion of the disease. 

Case LXXX. — Pustular sycosis in clusters ; tubercles ; cure accom- 
plished by means of bathing, bleeding, purgatives, and sulphureous and 
vapour-baths.— Thomas, aged fifty-one, entered La Charite on the 
10th of June, 1833, on account o'f sycosis. The patient is a sturdy 
vine-dresser, in the habitual enjoyment of good health. He lives 
well, and every day indulges in a small glass of brandy, never 
drinking unmixed wine save on Sundays and festivals. 

The sycosis was of but a few days' standing, having been pre- 
ceded by a considerable degree of itchiness, followed by sensations of 
pricking over the chin and region of the lower jaw. These parts, 
twenty-four hours after the attack, were puffed, and beset with num- 
bers of small tumours surmounted by pustules. 

June 11th. — On the lower maxillary region, numerous small, hard 
and prominent lumps of a deep red colour are observed. These im- 
plicate the whole thickness of the integuments, and even extend to 
the subjacent cellular tissue, which participates, over a very consi- 
derable space, in the inflammation of the skin. The tumours, which 
vary from the size of a pea to that of a large filbert, cause no sensa- 
tion of itchiness, but one of tensive, pricking and pulsatory pain. 



IMPETIGO. 



189 



Several of the tubercles are covered with dry, gray or yellowish- 
coloured, and, in some instances, cracked incrustations, which are 
entangled among the hairs of the beard. The general health is un- 
impaired, and Thomas makes no complaint besides the sycosis, except 
of an occasional slight headache. The patient was bled, took the 
temperate bath, and was put upon the use of whey. June 13th. — 
There was less uneasiness in the parts of the skin affected ; and the 
headache had left him. {Softening poultices to the chin.) 14th — 20th 
June. — Matters much in the same state, although the patient had 
been purged with castor oil, and a few of the tubercles were lightly 
touched with the nitrate of silver; several fresh tubercles, indeed, 
having appeared about the latter date, the patient was bled a second 
time, and the purgative repeated. These measures were followed by 
a diminution in the prickling and tension of the affected parts; and 
when the superficial eschars, produced by the caustic, were detached, 
the tubercles beneath them were found evidently shrunk, and showed 
no disposition again to become covered with crusts. In the same 
measure, however, as these older tubercles declined, others of more 
recent formation appeared in their vicinity, being constantly preceded 
by tumefaction of the subcutaneous cellular substance: wherever they 
were about to be evolved a red spot was apparent on the skin ; and 
at the time of these getting covered with pustules, the subcutaneous 
cellular substance became hard and swollen. 

A calomel and jalap purge was exhibited on the 23d and 26th, 
and on the 25th the patient was bled a third time. On the 28th he 
felt himself better ; but fresh tubercles still continued to make their 
appearance. 

On the first days of July a discharge of a yellow colour took place 
over the chin ; not, however, from the tubercles themselves, but from 
the spaces between them, which, by concreting, formed incrustations 
of the same hue. These scabs were rounded and conical, of no great 
size, somewhat transparent, and very like pieces of amber in their 
general appearance. This discharge, of a strikingly impetiginous 
character, did not continue longer than a few days, and never oc- 
curred again. 

From the 1st to the 13th of July, the warm bath, whey and alumi- 
nous lotions were continued, but without any good effect. On the 
17th the inflammation had lost so much of its acute character, that 
the sulphureous was substituted for the simple bath. During the 
month of July the patient was farther let blood, three several times, 
and took active purgative medicine as often. From the 2d to the 
9th of August, when the patient left the hospital, the vapour bath 
was tried every day, in the hope of hastening the progress of several 
stationary tubercles. The skin had now resumed its natural appear- 
ance in many places ; no fresh eruption of pustules had taken place 
for some time ; but the thickened portions of the subcutaneous genal 
and submaxillary cellular tissue were not yet completely resolved. 
The patient was seen, several weeks after his exit from the hospital, 
perfectly recovered, having taken no farther steps towards remedying 
his disease, save such as are usually included under the head of diet 
and regimen. 



IMPETIGO. 
Vocab. Crusted Tetter, Psydracia. 

527. Impetigo is a cutaneous affection unaccompanied by fever, 
characterized by the eruption of one or more crops of pustules, 
disseminated or collected in clusters, the contents of which dry up 
before long, and assume the form of yellowish rough and prominent 
incrustations. 

528. Symptoms. — Impetigo is a disease that may invade every part 
of the body. It appears under two principal forms: the small pus- 
tules that characterize it being in the one disposed in circular or oval 
groups (impetigo Jigurata, Willan) ; in the other disseminated over a 
surface of variable extent (impetigo sparsa, Willan). 

Each of these forms of the disease is acute or chronic, according 

as it consists in a single crop or in successive eruptions of pustules. 

Between these two principal forms of impetigo specified above, there 

occur a vast number of intermediate varieties, which are not unfre- 

48 



quently observed in the same individual when the disease appears on 
several regions of the body. 

529. Impetigo Jigurata, the dartre crustacee flavescente of Alibert, 
most frequently attacks children at the period of dentition, youths of 
either sex, and women of a lymphatic and sanguineous temperament, 
with a florid complexion and a fine skin. It very commonly appears 
in the spring ; and I have seen several young persons attacked periodi- 
cally at this season for three or four years in succession. 

It usually occurs without precursory symptoms. When acute, how- 
ever, it is occasionally preceded by pain of the epigastrium, general 
uneasiness, a feeling of lassitude, weakness in the limbs, &c. 

The disease is observed on the neck, trunk and extremities, but 
even more frequently on the face, and almost always on the middle 
of the cheeks ; from thence it is apt to spread to the whole of the 
malar region, and to the commissure of the lips in such a way as to 
form a circle upon the face. 

When impetigo Jigurata is evolved on the face, and it is watched 
from the period of its invasion, one or more small red and very super- 
ficial blotches are first perceived ; these gradually become more con- 
spicuous, and are soon affected with a considerable degree of pruritus. 
By and by these patches rise and become covered with small yellowish 
pustules, confluent or agglomerated, and but little elevated above the 
general level of the integuments. These clusters, of various dimen- 
sions, generally of a circular shape, and surrounded by a rosy circle, 
may continue isolated, or become connected by the development of 
fresh pustules in their circumference, or by the skin acquiring an ery- 
sipelatous tint in the spaces between them. The eruption is occasion- 
ally accompanied with severe pruritus and a degree of heat and 
tingling that amounts to smarting. 

After the lapse of three or four days, and occasionally sooner, the 
pustules burst, pour out a yellowish fluid which dries quickly and 
turns into thick crusts of a bright or greenish yellow colour, semi- 
transparent, slightly furrowed, very friable, and in appearance very 
similar to portions of candied honey, or to the concrete gummy exu- 
dations poured out by different trees. A considerable discharge con- 
tinues to go on under the crusts originally formed, the thickness of 
which is thus gradually very much increased, whilst their dimensions 
extend greatly beyond the limits of the pustules that first produced 
them. The skin in the circumference of the incrustations is red, and 
frequently presents several small and unbroken pustules the contents 
of which are scarcely consistent. The integuments under these 
crusts are of a bright red, and occasionally appear denuded of epi- 
dermis. 

When impetigo Jigurata is evolved in a young and well-constituted 
individual, or when the disease is slight, its duration is not necessa- 
rily protracted beyond an interval of more than three or four weeks : 
the heat of the skin gradually abates, the morbid secretion lessens 
by slow degrees, and before long ceases entirely ; the incrustations 
grow constantly drier, and being detached at length, leave one or 
more red spots or marks which commonly continue visible for more 
than a month, and are followed or not, according to circumstances, 
with a sensible desquamation of the cuticle. Small miliary specks, of 
a dull white colour, are at times observed upon the remaining red 
spots; these are owing to a number of sebaceous follicles distended 
with hardened secretions, or of which the walls have become altered 
and thickened. 

530. Impetigo Jigurata is occasionally met with confined to the 
eyelids, upon which prominent and conical-shaped incrustations are 
then produced. This variety of the disease is commonly complicated 
with a particular species of ophthalmia, or with an inflammatory affec- 
tion of the follicles of the cilia?. 

I have seen this form of impetigo prolonged downwards on either 
side of the under lip in a very regular manner ; and I have remarked 
it forming a streak upon the upper lip so as to appear like a pair of 
thick moustaches. 

Impetigo Jigurata of the face may become chronic under two 
forms: 1st, the development of the psydracious pustules is at one 
time successive ; fresh groups are thrown out in the neighbourhoo J 
of the yellowish crusts produced by the desiccation of the primary 
pustules or of the secondary crops developed in the circumference of 
the first pustular or incrusted clusters, the dimensions of which the) 



l!>0 



PUSTUUE. 



increase. In the latter case, the desiccation and cure commence in 
the centres of the several groups. _ _ , 

2d. Instead of spreading superficially, the inflammation in impetigo 
may penetrate the whole thickness of the skin, and even affect the 
subcutaneous cellular tissue. After the detachment of the incrusta- 
tions, a fresh discharge may give rise to the formation of new scabs 
of the same kind ; -and they may thus fall and be reproduced several 
times in succession, becoming, however, thinner and thinner on each 
renewal. The surface of the integuments under them is of a vivid 
red colour ; it subsequently becomes furfuraceous, and the inflamma- 
tion then seems to acquire something of a squamous character. 

When chronic impetigo figurata thus approaches its decline, if it 
he treated by an ill-timed recurrence to stimulants, or if the constitu- 
tion happens to suffer from any cause, the disease may be fastened, as 
it were, upon the skin for many months, and even for several years. 
The parts of the skin that have in this way been repeatedly affected 
with inflammation, become chapped, and occasionally even present 
superficial excoriations. 

531. The pustular groups of impetigo figurata of the face, although 
usually situated on the malar regions, may be observed occurring in 
other regions : they are occasionally thrown out on the upper lip, 
immediately below the septum of the nostrils, and upon the ala? nasi. 
In the latter case, the matter of the pustules may dry in such a way 
as to produce a conical depending scab, compared by Alibert to the 
stalactitic formations observed in certain caverns (Dartre crustade 
salactiforme). 

In impetigo figurata of the limbs, the groups of psydracious pus- 
tules, and the scabs that succeed them, usually circular on the fore- 
arms and hands, are of a larger size and less regularly round shape on 
the lower extremities. The pustules in these situations are evolved 
in the same manner as on the face, and are soon replaced by thick 
crusts of a greenish or brownish-yellow colour. When the disease 
has declined into the chronic state, it frequently happens that no un- 
touched pustule is anywhere to be seen ; but the partial eruptions 
that take place from time to time, and the particular shape of the 
crusts and of the red marks they leave behind them, is sufficient at 
any time to characterize this variety. 

When recovery takes place, the heat and itchiness of the skin 
diminish ; the discharge becomes less in quantity ; the crusts, last 
produced, are of superior thickness, their edges dry completely, and 
are occasionally marked out by a white epidermic border. Lastly, 
after the crusts have been detached, and are no longer reproduced, 
the skin, of a deep red in the first instance, becomes furfuraceous, 
and by slow degrees regains its natural colour and appearance. 

532. Instead of being arranged in circumscribed groups, the pus- 
tules and crusts of impetigo may appear irregularly scattered over 
the limbs, neck, shoulders, face, and external ears. This constitutes 
the second variety of the disease — the impetigo sparsa. 

1. Impetigo sparsa of the lower limbs is always a disease of long 
duration. One of the extremities may be attacked singly, or both 
may be implicated together, or in succession. 

The disease is characterized by small yellowish pustules which 
appear on the instep, ankles, and especially, on the outer part of the 
leg. The evolution of these pustules is accompanied with insup- 
portable pruritus. They soon burst and pour out a sero-purulent 
fluid, which is gradually changed into yellow-coloured laminated 
scabs of less breadth and thickness than those of impetigo figurata. 
In the spaces between them the skin is reddish, and the cuticle 
looks rough and shining ; a considerable discharge takes place from 
the pustules for some time ; but by and by this becomes smaller in 
quantity, under and in the vicinity of the crusts, which consequently 
acquire a more consistent and drier appearance. At the very time 
when they seem about to be thrown off, however, it frequently hap- 
pens that a fresh eruption of pustules takes place, accompanied with 
heat and violent pruritus ; and secondary pustular eruptions of this 
description may go on occurring from time to time, at various inter- 
vals, until the whole of one, or of both legs, from the knee to the 
ankle and dorsal aspect of the foot, are implicated. A sero-purulent 
fluid then flows abundantly from the surface of the skin, and by 
drying, encases the limbs in crusts. The crusts often acquire a great 
degree of thickness in the aged, and among individuals of shattered 



constitutions. They are then of a deep yellowish-brown colour, and 
might very properly be compared to the bark of certain trees (impe- 
tigo scabida, Willan). The legs are moved with pain anil difficulty; 
the incrustations split, the legs frequently become cedematous, and 
before long are furrowed by fissures, running in various directions, 
and of different depths. A yellowish, sero-purulent discharge exudes 
from these cracks, and forms additional incrustations that appear to 
gird and enclose the leg. If this hardened exudation be removed in 
part, or completely, by the continued use of emollient fomentations 
and cataplasms, the denuded corion which is then exposed, speedily 
furnishes a fresh supply of discharge, which, before long, concretes 
into a new incrustation. 

Arrived at this stage, impetigo sparsa of the lower extremities is a 
very obstinate disease, especially when it attacks the aged, the weakly 
in constitution, or the infirm and broken down in health. The inflam- 
mation occasionally extends to the toes and secreting matrices of the 
nails. The nails then become altered, and finally loosened from the 
skin (onychia impetiginodes). An cedematous infiltration of the legs, 
and ulcers, which commonly appear about the ankle, are common 
consequences of this affection. The surface of these ulcers is uneven, 
and discharges a sero-purulent fluid ; their edges are irregular, purple, 
or livid, and frequently crowned with small pustules full of sanguino- 
lent serum, or, otherwise, they are covered with yellowish crusts of 
varying thicknesses. 

When the progress of this inflammation is successfully arrested— 
the incrustations become dry, and, once detached, are not again re- 
produced. The skin in some places maintains a bluish, or purple-red 
tint, and, in others, where it has been attacked with ulceration, it 
presents reddish or violet-coloured indelible cicatrices. 

2. Impetigo sparsa of the superior extremities is most frequently 
found attacking the forearms; it does not differ from the disease 
situated on the legs save in being less severe, and more rarely com- 
plicated with cedema and ulcers when it has advanced into the chronic 
state. 

3. In acute impetigo sparsa of the face, the greenish-yellow incrus- 
tations dispersed over the cheeks and clinging to the beard in the 
adult, are not long of being loosened from the skin. If the inflam- 
mation extends to the nose, as it frequently does in childhood, the 
nostrils become plugged up with thick and dry incrustations ; the nose 
swells, and the disease then commonly passes into the chronic state. 

4. Impetigo sparsa may also attack the neck, ears, and hairy scalp. 
The tinea granulata of Alibert, and the porrigo favosa of Willan, 
signify one and the same variety of impetigo. Impetigo of the hairy 
scalp is occasionally met with among adults; but the subjects it most 
usually attacks are children, and then it appears most frequently about 
the posterior parts of the head, the entire surface of which may be 
implicated. The disease appears in the shape of minute pustules of 
a yellowish-white colour, irregularly scattered over the hairy scalp, 
their centres traversed by a hair, and accompanied with a high degree 
of inflammation and excessive pruritus. In the course of from two to 
four days, these pustules pour forth a fluid that frequently agglutinates 
a number of hairs together, and dries into small brownish, or grayish 
rough and irregular crusts or masses, which M. Alibert has compared 
to fragments of roughly pounded mortar, (a) These incrustations, 
become dry and friable, are detached from the skin, and remain ad- 
herent to the hair, which frequently appears filled with them. A very 
faint, sickly, and unpleasant smell is exhaled from the head, some- 
times of so powerful a nature when all attention to cleanliness is 
neglected, that the whole atmosphere of a room is contaminated with 
it. Pediculi multiply rapidly, and swarm among the hair, which is 
rarely lost in this disease, but very frequently matted or agglutinated 
into masses by the adhesive qualities of the discharge. 

Impetigo of the hairy scalp scarcely lasts longer than some months, 
and it most frequently gets well with proper treatment in the course 
of a few weeks. 

5. Instead of true impetigo, an eruption consisting of the pustules 
of this disease and of the vesicles of eczema is occasionally observed 
to take place (eczema impetiginodes). This form of the disease, which 

(a) And not unfrequently they may be said to resemble a gummy 
extract. 



IMPETIGO. 



191 



commonly proves very severe when it attacks the trunk and extremi- 
ties, frequently appears upon the wrists, spreads over the backs of the 
hands, the phalanges of the fingers, and even extends to the matrices 
of the nails; it may also spread in the opposite direction to the fore- 
arm, the bend of the arm, and even reach the nucha and face. More 
than one or two eruptions of pustules and vesicles usually follow each 
other successively. The vesicles are slower in their progress than 
the psydracious pustules, and commonly continue transparent for 
several days after their evolution. Each eruption is attended with 
much heat and intolerable pruritus ; and soon after its appearance, a 
sero-purulent fluid is discharged in profusion, which speedily concretes 
and dries into laminated yellowish, or greenish crusts. The skin is 
red and occasionally chapped. After a longer or shorter interval, the 
inflammatory symptoms subside ; the cuticle is detached in large 
pieces ; the incrustations fall, and the skin is long left in a rough, 
dry, squamous and rigid state. 

I have observed this form of the disease assuming the arrangement 
into circular clusters presented by impetigo figurata. The groups 
were composed of confluent or very closely crowded vesicles and pus- 
tules. When these raised patches were pricked, shortly after their 
formation, a limpid serous fluid escaped from the vesicles, and an 
opaque and purulent matter from the pustules. These fluids by drying, 
formed circular rugous scabs of a greenish-gray colour : the skin which 
they covered was tuberculated and unequally tumefied. I have, further, 
seen the oval-shaped clusters of the impetiginous eczemas get well 
from their centres towards their circumferences, the situations of the 
patches being at last proclaimed by a very conspicuous crusted and 
furfuraceous circumscribing ridge, (a) 

6. In the last place, impetigo may occur with a very decided in- 
flammatory character. The integument in the circumference of the 
groups is then of as vivid a red as it presents in erysipelas, (impetigo 
erysipelatodes, Willan,) and this state of things is often accompanied 
with general febrile symptoms. 

533. Various phenomena frequently appear connected with the 
local symptoms of impetigo : the lymphatic glands in the vicinity of 
the pustules may become swollen and painful ; the pruritus and morbid 
heat are occasionally so troublesome, that they prevent the approach 
of sleep, and impede the due performance of different functions of the 
economy. The disease, in fine, is frequently seen associated with a 
gastro-intestinal affection ; it is much more rarely complicated with any 
other form of internal lesion. 

534. Causes. Impetigo is not transmitted by way of infection, and 
its causes are very obscure. Children at the period of teething, espe- 
cially those of a lymphatic temperament and scrofulous constitution, 
are frequently attacked with impetigo of the face and hairy scalp 
(teigne granulee Alib.), or with the eczematous form of the disease, 
which is then generally entitled crusta lactea ; this complaint is more 
especially and frequently observed among the poor, ill-lodged, badly 
fed, and filthily disposed classes of society. 

Young persons of a sanguineous and lymphatic temperament, with 
a fine and delicate skin, are occasionally attacked with impetigo of 
the face, when they have been exposed to the bright rays of the sun 
in the spring and heat of summer. 

In young females whose catamenia are irregular, and among women 
arrived at the critical age, impetigo is apt to show itself either on the 
face or on the limbs ; in these circumstances, it very frequently attacks 
the upper lip immediately under the septum of the nostrils. 

Impetigo seems occasionally to be induced by the presence of some 
other inflammatory affection of the skin, particularly by repeated 
attacks of lichen agrius. The disease seems also, occasionally, to 
coincide with some derangement of the digestive functions ; and this 
is a complication that is met with very frequently in children during 
the periods of teething. To conclude, the small pustules of impetigo 
have now and then been observed to follow excesses of every kind, 
violent muscular exercise, acute and prolonged moral affections, 
grief, &c. 

535. Diagnosis. — Impetigo may present itself in the shape or stage 
of pustules and incrustations ; or the disease may be reduced to its 

(a) In the note to page 120, the diagnosis of eczema impeiiginodes 
is given by Dr. Carswell. 



traces — red marks covered with squamae, or stains of a yellowish-red 
hue ; it may farther be discovered in different places under each of 
these different degrees or appearances. The minute pustules of impe- 
tigo are readily distinguished from the large pustules of ecthyma, and 
from the artificial pustules produced by the tartrate of antimony and 
the inoculation of purulent matter. I have already given the elements 
of the diagnosis between impetigo, and acne and rosacea §§ 507-513. 
Impetigo of the hairy scalp is not liable to be mistaken for dissemi- 
nated favus (porrigo lupinosa, Willan), nor with that which appears 
under the form of circular patches (porrigo scutulata, Willan). The 
pustules of impetigo discharge, whilst those of favus, deeply situated 
within the substance of the skin, are rapidly changed into dry, yellow- 
ish-coloured, cup-shaped scabs. The crusts of impetigo are brown, 
or of a dull gray, like small pieces of dirty plaster, and never present 
those broad, thick, and continuous incrustations observed in favus 
confertus (porrigo scutulata, Willan). Lastly, impetigo of the hairy 
scalp is not contagious, and does not implicate the piliferous bulbs, 
like favus. 

It is more difficult to distinguish impetigo of the scalp from eczema 
impetiginodes of the same region. The principal diagnostic features 
of each of these inhere in the dissimilar aspects of their incrustations. 

The pustules of sycosis, often isolated, and always prominent, are 
larger in size, and not so yellow in colour as those of impetigo when 
it attacks the chin ; the impetiginous eruption, also, is always very 
much crowded, and secretes abundantly. The scabs of sycosis are 
drier, and of a deeper colour than the incrustations of impetigo ; they 
are likewise only reproduced after a fresh eruption of pustules. The 
crusts in impetigo are of a greenish-yellow hue, thick, semi-transpa- 
rent, and reproduced without any renewal of the eruption. Tubercles 
and indurations are encountered in sycosis, — alterations that are never 
seen in impetigo. 

When the vesicles of scabies become purulent, or when they are 
accidentally complicated with pustules, they are always much larger, 
and more elevated than the small psydracia of impetigo. 

The red and scaly spots consecutive to the formation, or to the fall 
of the crusts of impetigo, may be distinguished from inflammatory 
affections originally squamous in their nature, such as lepra, psoriasis 
and pityriasis, by the circumstance of the squamae in these latter mala- 
dies being accompanied by no discharge, and by their having been 
preceded neither by pustules nor incrustations. Those pigmentary 
yellowish-coloured spots, so frequently observed after the cure of 
syphilitic eruptions and confluent psoriasis, are very seldom seen after 
the invasion of impetigo. The pustules of impetigo can never be 
mistaken for those of syphilitic origin covered with black, and firmly 
adherent scabs which conceal ulcers to which indelible cicatrices 
succeed (vide Syphilis). Lastly, impetigo with its pustules, dissemi- 
nated or collected into clusters, and its thick, rough, and yellowish- 
coloured incrustations cannot be mistaken for eczema in any of its 
forms, with its vesicles, its lamellar crusts, or the thicker squamae of 
its latter stages. 

536. Prognosis. — The prognosis in impetigo is generally more 
favourable than in eczema, lepra, lichen, &c. The disease, with the 
acute type, wherever situated, commonly gets well in the course of 
two or three weeks. The duration of the chronic form of impetigo is 
influenced by the number of eruptions, the state of the constitution 
generally, and the existence of other particular conditions, such as 
amenorrhcea, pregnancy, period of life, presence of scrofula, &c. I 
have seen the disease appear in a woman each time she was preg- 
nant, resist the most energetic remedial measures, and get well spon- 
taneously a short time after the confinement. 

Chronic impetigo on the hairy scalp, of the upper lip, and other 
regions covered with hair, is often a very intractable disease, espe- 
cially when the patient is advanced in life, when he is of a scrofulous 
constitution, or when his health has suffered in any way. 

537. Treatment. — When impetigo appears with a character of 
acuteness on the face or hairy scalp of a child during the process of 
dentition, it is generally advisable to restrict remedial measures to 
simple attention to cleanliness : the eruption occurring under these 
circumstances is frequently accompanied with a signal improvement 
in the state of the constitution, which might be prevented from taking 
place by any thing like active remedial measures. I have seen the 



102 



PUSTULE. 



ill-timed medication and cure of these impetigos, then entitled crusted 
tetters (darirtt crustacirs), followed by diseases of different degrees 
. ritj ; in othe* cases, the appearance of the pustular eruption 
med to mo to act advantageously on various old-standing dis- 
eases of an obstinate character. 

On the other hand, the treatment of certain impetigos is to be con- 
ducted on the principle of effecting some modification in the consti- 
tution. I have had opportunities of satisfying myself on this point, 
by treating successfully with the preparations of iron, sulphur, and 
iodine, several impetiginous eruptions befalling individuals labouring 
under scrofula. In other cases where the impetigo has been preceded 
by amenorrheea or dysmenorrhea, I have derived great advantages 
from the preparations of iron and other emmenagogues. 

When the state of the constitution affords no particular indication 
of cure, impetigo, on its appearance, and as often as the eruption is 
attended with a great degree of redness of the skin (impetigo erysipe- 
latodes), or is distinguished by the abundance of its pustules, is to be 
treated by means of general blood-letting in adults and individuals in 
the flower of life, and by leeches in children and the weakly in con- 
stitution. Should amenorrheea or dysmenorrhea complicate the dis- 
ease, the vena saphena should be opened, or leeches should be 
applied around the external organs of generation, especially when 
emmenagogues have been tried in vain. These bleedings will occa- 
sionally require to be repeated. They usually prove detrimental to 
individuals of a scrofulous or weakly habit of body. Whatever the 
temperament of the patient, the blood abstracted is almost invariably 
found to be buffy. 

The local or general simple tepid bath at a low temperature (86° or 
92° F.); and frequent ablution with cold water, milk, decoction of 
bran, almond emulsion, decoction of mallows, digitalis, poppy-heads, 
fcc,., are used with advantage in this first stage of impetigo. At a 
later period, aluminous, saturnine, or alkaline washes, and the appli- 
cation of the ointments of the oxide of zinc, and of the acetate of 
lead, contribute to accelerate the cure, which often takes place 
without the necessity being felt of having recourse to any other 
measures. 

In acute impetigo of the region of the beard, or hairy scalp, the 
hair must be removed with sharp scissors, and the diseased surfaces 
laid bare. This variety, like all the others, requires to be dealt with 
by means of emollient applications, and occasionally of blood-letting. 
Depilation, the utility of which is incontestable in favus, is always 
injurious in acute impetigo of the hairy scalp, or of the skin; neither 
is this measure ever necessary in the chronic impetigo of these regions. 
Saline purgatives, such as the acidulous tartrate of potash, and soda, 
the sulphate of magnesia, the sulphate of soda, &c, in doses of from 
two drachms to half an ounce daily, are also frequently employed with 
advantage. 

When impetigo has lost its acute character, or when it has become 
decidedly chronic, the incrustations are best got rid of by means of the 
steam douche, which seems very often to have the effect of warding 
off a fresh eruption. It is even found advantageous to recur to the 
vapour^douche shortly after the formation of the crusts of impetigo in 
any stage of the disease whenever the skin appears but little inflamed. 
These douches directed upon the parts affected, before the formation 
of scabs, that is to say, during the pustular state of the eruption, or 
when any considerable degree of inflammation still lingers around the 
incrustations, are almost always injurious. I have frequently substi- 
tuted, with good effect, the simple bath and ordinary emollient cata- 
plasm, at a very moderate temperature, for the vapour bath and douche 
generally recommended in these cases. 

2. It is seldom that local blood-letting and emollient and sedative 
applications are very actively employed in cases of chronic impetigo ; 
although the practice, assisted by gentle laxatives, when the state of 
the digestive organs offers no bar to their exhibition, is one which, 
in analogous circumstances, has unquestionably been very frequently 
crowned with success. 

When the skin is but slightly inflamed, and not very irritable, the 
artificial or natural sulphureous baths of Bareges, Lotiesche, Cauterets, 
Bath, Harrowgale, fcc., are often resorted to with advantage at a tem- 
perature of from 95° to 100° F., and this is not only in the cases of 
the elderly and weakly, but in those of individuals in the spring and 



vigour of life, possessed to all appearances of an excellent constitution. 
The time of continuing in these baths ought to be gradually prolonged, 
and ultimately carried to the length of several hours each time (§ 127). 

The sea-water and the alkaline bath are generally less beneficial ; 
yet it does sometimes happen that taken every day, or on alternate 
days, along with the fresh water bath, they act more beneficially than 
the sulphureous bath. Alkaline washes are usually prescribed at the 
same time ; and these may be combined and alternated with the use 
of acidulous lotions. 

Dr. A. T. Thomson has recommended the medicinal hydrocyanic 
acid in impetigo. I have tried it in the proportion of two drachms to 
half a pound of distilled water, as a lotion with some success. I 
cannot affirm, however, that its action was more salutary than that of 
the sulphuric or nitric acid largely diluted with water. Should the 
skin chance to become excoriated, these hydrocyanic acid lotions 
must be laid aside ; and in no case are they to be used but with 
extreme reserve. 

Ioduretted-sulphureous lotions have been particularly recommended 
by M. Alibert. They appear to be more especially useful in cases of 
impetigo attacking subjects of a scrofulous constitution. 

In chronic and inveterate impetigo, when the eruption extends to 
but a small surface, the parts affected are frequently cauterized to 
good purpose with a solution of the nitrate of silver, with the iwtassa 
cum calce in substance, or the dilute hydrochloric acid. 

I have also occasionally used with good effect, under similar cir- 
cumstances, an ointment consisting of a scruple of the proto-nitrate of 
mercury to an ounce of hog's-lard. 

I have very seldom ventured on the application of a blister to sur- 
faces affected with impetigo, although this measure has been recom- 
mended and employed with advantage. 

Compression is an auxiliary measure which I have frequently insti- 
tuted with the happiest results in impetigo scabida affecting the lower 
extremities and complicated with cedema, ulcers, varicose veins, fee. 

Charcoal was formerly lauded as a topical application in the treat- 
ment of impetigo, and particularly when the scalp was the part affected ; 
I have not made the action of this article a subject of such particular 
study as to be enabled to speak from personal experience of the degree 
of good which results from its application. 

538. There are other medicinal substances whose action on the 
evolution and progress of impetigo is incontestable. I have treated 
very obstinate impetigos successfully by the nitric acid in doses of half 
a drachm daily, in a pint of barley-water sweetened to the taste. 
When this sherbet seems to distress the stomach, it is generally enough 
for patients to suspend its use for a few days, and to take a warm bath 
at convenient intervals, in order to be enabled to resume it. It very 
seldom happens that this medicine is continued for a month or six 
weeks without accomplishing a cure. 

I have, in fine, seen a small number of very old and inveterate 
cases of impetigo which have only yielded to antimonial and arseni- 
cal medicines. These remedies are of course to be administered 
with every precaution for the patient's safety ; their use being sus- 
pended during an interval of several days, as often as their action 
on the system appears to be becoming excessive. In this way all 
notable and permanent injury, as well to the digestive organs in par- 
ticular as to the system at large, is avoided, without the curative 
effects of the medicines being in any degree diminished. 

Several other compound and simple medicines of various degrees 
of activity, such as the juice of the apium graveolans, the decoction 
of sarsaparilla, of dulcamara, of the ulmus pyramidalis, of the root of 
the arum maculatum, &c, have been used with success in certain 
forms of chronic impetigo (crusted tetters) ; but the individual cases, 
in which the use of these substances is preferable to those I have 
mentioned more particularly, have not yet been very satisfactorily 
ascertained, (a) 



(a) Considering the temperament and constitution of those who 
are most frequently attacked with impetigo, we cannot refuse to it a 
scrofulous origin or at least a complication with scrofula ; — and, in so 
regarding it, we shall be led to the employment of the remedies gene- 
rally thought to be best adapted to that disease. Of course a prefer- 
ence will be given to mild laxatives, the use of the mineral acids, and 



IMPETIGO. 



193 



Historical Notices and particular Cases. 

539. If, at the present day, impetigo be an affection but little 
known to a number of practitioners, we have to thank the confusion 
that still reigns in the nomenclature of the diseases of the skin ; the 
various senses in which this word has been used (Vocab. impetigo), 
and the multiplicity of expletives that have been introduced to desig- 
nate the acute or chronic, the pustular, encrusted, furfuraceous or 
erythematous state of the disease, the varieties in appearance it as- 
sumed as it affected the trunk, hairy scalp or extremities, may be 
fairly charged with the principal blame as causes of this prevailing 
ignorance. 

The Greeks appear to have referred to this disease under the title 
of 4w$a ixx^b^. 1 Celsus 2 has included under the name of impetigo, 
not only the pustular disease we have just been discussing, but two 
other squamous affections, namely, lepra and psoriasis. Willan 3 was 
the first who gave an accurate account of impetigo ; he fell into a 
mistake, however, in describing impetigo of the scalp as a particular 
disease, under the title of porrigo favosa (Vocab. porrigo). M. Alibert, 
who had described impetigo affecting the trunk, under the title of 
dartre crustace'e, and impetigo of the scalp, under that of teigne 
granuUe, in his u Precis des Maladies de la Peaw," has more recently 
designated the first of these forms of the disease, by the name of 
mHitagre, and the second by that of porrigo granulata. 

Impetigo has long been designated in France under the title of 
dartre crouteuse, or crustacde, and in England, under that of humid 
or running tetter. 

Impetigo of the scalp has been described by Forestus 4 under the 
head of favus, a term which, at the present day, is applied to another 
disease ; it has been particularly, but erroneously noticed, as already 
stated, by Willan, under the name of porrigo favosa, and by Alibert, 
under that of teigne granuUe. 5 

The Latin translators of iEtius 6 signalize impetigo of the face under 
the denomination of ulcus melicerida. 

Callisen 7 describes impetiginous eczema under the title of herpes 
pustulosus. 

Dr. A. T. Thomson 8 has published some observations on the 



iodine, and especially the iodide of iron, and, at times, cinchonic 
preparations. 

In the acute stage of impetigo, or where it is accompanied with 
fever, reliance can only be had on antiphlogistic remedies, both general 
and topical, as recommended in the text. Dr. Crampton has treated 
a series of cases of impetigo capitis, and other forms of scalp affections, 
almost entirely by constitutional remedies, of which the principal 
ones were purgatives and the warm bath. 

Mr. Erichsen (Practical Treatise on Diseases of the Scalp), coincides 
with M. Rayer in his high estimate of nitric acid ; and he also uses 
the nitro-muriatic. 

In the more obstinate cases which resist the milder treatment, and 
which, happily, are comparatively few in number, recourse may be 
had to the bichloride of mercury in the dose of a sixteenth of a grain 
united to extract of hemlock, or Fowler's solution in minute doses. 
Donovan's solution, in doses of five to twenty drops, has cured some 
old cases of impetigo. 

Plumbe lays great stress on the local treatment, in the frequent 
removal of the diseased secretion ; the benefit from which, if carried 
into effect by frequent ablution of the part with warm water, is incal- 
culable. " By this plan, in conjunction with the exhibition of simple 
alteratives, entirely rejecting any thing in the shape of ointments or 
other greasy applications, the disease will be often entirely subdued." 

In using the hydrocyanic solution, the favourite lotion of Dr. A. 
T. Thomson and Plumbe, the caution in the text is worthy of all 
attention and observance. 

' Aeiius. Tetrab. Serm. iv. cap. 130. 

2 Celsus. De re medica, lib. v. cap. 28, § 17. 

3 Willan. Practical treatise on porrigo, &c, 4lo. LondoD, 1814. 

4 Forestus. Observ. et curat., lib. xxviii, folio de favo, p. 3)5. 

6 Monagr. Des dermatoses. 

f Aetius. Tetrab. Serm. iv. p. 167. 

7 Callisen. Chirurg. Hodiern., § 612. Art. Herpes. 
i Lond. Med. and Physic. Journal, February, 1822. 

49 



external use of the prussic or hydrocycanic acid in the treatment 
of impetigo. Cases of, and remarks on, this disease have been 
consigned in several periodical publications, 9 and inaugural disser- 
tations. 

Marcolini 10 has described lepra, and not impetigo, under the latter 
title. The observations of Sauvages, and of Peter and Joseph Frank, 
on impetiginous affections are very obscure, and convey no ideas but 
of diseases badly defined and imperfectly described. 

Case LXXXI. — Acute impetigo of several parts of the skin; rapid 
cure by blood-letting, vapour baths, and purgatives. A master mason, 
twenty-seven years of age, of a sanguineous temperament, came to 
consult me on the 12th of April, 1826, on account of a disease of 
the skin, under which he had laboured for nearly six weeks. On 
the left cheek there were two humid crusts, an inch in diameter, of a 
yellow colour, prominent, and with circumferences slightly inflamed. 
A crust of the same sort, but of smaller dimensions, was seen on the 
chin, and on the right cheek, there existed a cluster of small psydra- 
cious pustules. A fourth incrustation, the size of a double sovereign 
piece, was observed on the back of the left hand. And on the fore- 
arms and insteps, four additional isolated scabs, of a yellowish-brown 
colour, dry, adherent to the skin, and from an inch to an inch and a 
half in diameter, were remarked. In other respects this individual 
enjoyed excellent health. I bled him to the extent of twelve ounces 
from the arm, and prescribed the sulphurated lemonade for his drink. 
Eight days afterwards three simple vapour baths were taken. The 
scabs were detached, and red marks, of the same dimensions, alone 
indicated the situations they had occupied on the skin. I then pre- 
scribed a couple of doses of sulphate of magnesia, half an ounce to 
each, dissolved in a weak infusion of senna leaves. The use of the 
tepid bath a few times confirmed the cure, which in this case was 
accomplished by the twenty-fifth day of the treatment. 

Case LXXXII. — Impetigo figurata of the leg; occurrence of the 
same disease five years afterwards on the face, cured by the steam 
douche ; an analogous eruption proving salutary in a child. — I wa 
asked on the 18th of September, 1831, to see M'lle * * *, aged 
twelve years, of a sanguineous lymphatic constitution, who had been 
troubled for the last twelve days with a slight excoriation of the right 
leg. On the anterior aspect of the tibia, there was a small inflamed 
surface an inch and a half in diameter one way, by an inch the other. 
The skin here was red, moist, denuded in its epidermis, and presented 
a great number of small pores, similar to those that are observed in 
impetigo figurata, when the incrustations have been removed a short 
while after their formation. The inflamed surface was discharging 
a yellowish, sero-purulent fluid. A number of small yellowish, or 
white-coloured pustules, which scarcely rose above the level of the 
skin, were observed in the circumference of this excoriated spot, and 
under it, a small cluster of psydracious pustules was remarked. The 
pustules had appeared without any assignable cause. 

The health of M'lle * * * was excellent. The affected parts were 
occasionally the seat of pruritus, so violent in its character, that the 
young lady had the greatest difficulty to restrain herself from scratch- 
ing them, although she knew that such indulgence would certainly 
be followed by an aggravation of her complaint. I recommended 
that the parts should be frequently bathed, during the course of the 
day, with Goulard's wash, and that the excoriations should be dressed 
with saturnine cerate, and kept covered with a crumb of bread cata- 
plasm softened with decoction of mallows. This simple dressing 
allayed the itchiness, and lessened the inflammation. No fresh pus- 
tules appeared to be forming. M'lle now took a few sulphureous 
baths, and made a rapid recovery from her slight attack of impetigo 
figurata. In the month of April, 1826, after long-continued appli- 
cation to her studies, M'lle * * * was a second time attacked with 
impetigo, which on this occasion made its appearance on the face. 
Several small clusters of yellow and slightly prominent psydracious 

9 Observ. d'impetigo figurata des joues guerie par l'arseniate de polasse (Journ. 
hebdom., t. iv. p. 77). — Impetigo sparsa (Kevue medicale, Juin, 1830, p. 346). — 
Impetigo des joues disparu sous l'influence d'une autre maladie (Lancette franchise, 
t. p. 145). — Eczema impetigineux avec ophthalmie (Bull, des sc. medic, de Ferrjssac, I 
xxiv. p. 177). — Note on the exterior use of the cod-liver oil in the impetigo scabida 
(Lond. Medic. Gazette, v. x. p. 796).— Riviere. Diss, sur la melitagre, 4to. Paris, 
1830. 

10 Marcolini. Sopra alcune impetigini memoria, folio. Venezia, 1820. 



194 



PUSTULE. 



pustules wen evolved m succession during fifteen days, on the cheeks, 
'hin, upper lips, ears, and ala of the nose, each of which was speedily 
converted into yellowish crusts, very similar in their colour to the 
gummy exudations of certain trees. The integuments at the base of 
These ('histeis were not inflamed. The disease in this instance yielded 
in the course of twenty days to the use of the steam douche. 

During the same year, a child of three years old, the brother of 
•!,is young lady, who had long laboured under a chronic inflamma- 
tion of the mucous membranes of the ccecum and colon, was attacked 
with a similar impetiginous affection of the skin of the face. The 
appearance of this eruption having coincided with the entire cessa- 
tion of the cceco-colitis, I did not take any immediate measures for 
its cure. After continuing about two months and a half, the impetigo 
seemed, if the expression may be allowed, to have exhausted itself, 
and now left no traces of its presence, save a few red blotches 
upon the face. The child had not for a long time enjoyed such 
health as it did subsequently to this attack. 

Cask LXXXIII. — Traces of impetigo sparsa on the upper extremi- 
ties; impetigo Jigurata on the limbs ; tuber culations of the skin covered 
with crusts; dysmenorrhea; cure. — Marie Hale, aged thirty-one, 
married, and having had two children. Since her last confinement, 
eight years ago, she has been irregular in her catamenia, and the dis- 
charge has been scanty; she now suffers from leucorrhcea, which 
becomes more abundant on the return of the menstrual period. 

Towards the end of the year 1829, she had the first attack of a 
disease of the skin, similar to that she is now labouring under (impe- 
tigo), from which she recovered, after having been under treatment 
for three months and a half. Two years subsequently (1831), the 
patient had a second attack of the same complaint, and about a 
month before her admission into the Hopital de la Charite, on the 10th 
of March, 1833, she was seized for the third time, with the same 
cutaneous affection. An eruption of small pustules made its appear- 
ance successively on the outer part of the right and then on that of 
the left thigh, spreading to the knees of the same side. The pustules 
were yellow on their summits, and, bursting, discharged a quantity 
of yellowish fluid, which concreted into greenish-looking scabs. 
The forearms, the lower third of the arm, and the posterior surface 
of the right ear, were also, in their turn, affected with the same kind 
of pustular eruption. The pruritus was not very distressing, and the 
appetite had not sensibly fallen off. At the period of her entrance 
into the hospital, several crusted patches, rounded, dry, hard, rough 
and uneven, of a yellow, or yellowish-green colour, and raised about 
three lines above the level of the skin, were perceived in the situations 
mentioned. These scabs were, further, thinner in their circumfer- 
ence than towards their centre, and were loose for about a space of 
two lines around their edges, being simply in contact with the surface 
of the dermis which looks red and dry in these situations, although, 
upon the removal of the whole of the incrustation, which is easily 
affected, it then looks moist and tender, and of a vivid punctuated 
red colour. Under some of the scabs, a number of small rounded 
white points are remarked which resemble nothing more closely than 
those white bodies which are occasionally seen on blistered surfaces. 
Under others, the corion is uneven, and presents a tuberculated 
or mammillary appearance. The incrustations are of very various 
dimensions, from two or three lines to an inch and a half in breadth. 
They also vary somewhat in their appearance in different places. (A 
drachm of subcarbonate of iron.) 

March 11th. — The patient was put upon the use of barley-water 
with the addition of half a drachm of nitric acid to each pint of fluid. 
Emollient poultices were ordered to the forearms, and the chalybeate 
was continued in doses of thirty-six grains. 13th. — The forearms 
were less scaly (alum wash) ; prickling and unpleasant scalding. The 
iron and nitric acid were ordered to be continued, the latter in the 
dose of a drachm daily. The alum-wash was found to irritate the parts 
to which it was applied too much, and was consequently discontinued, 
the emollient cataplasms being resumed in its stead; on the 19th the 
simple warm bath was prescribed. 

19th.— The tender skin was anointed with hog's lard, and this 
measure, together with the daily use of the warm bath, was continued 
to the 7th of April. At this date the improvement was very con- 
spicuous ; the skin was now less fiery, and the crusts and squamae of 



the thighs had not been reproduced. As the menstrual period ap- 
proached, the baths were discontinued. On the 10th the catamenia 
not having made their appearance, sixteen leeches were applied to 
the external parts, which bled freely. On the 11th the patient was 
found pale and weak. The baths were resumed on the 15th, and on 
the 21st the nitric acid, of which the patient began to complain, was 
replaced by the citric acid, and the vapour bath every other day was 
substituted for the hot-water bath. The iron was continued as before. 
The patient was getting well rapidly. For the last twelve days no 
squamae had been reproduced ; the skin in the parts affected assumed 
a pale ro3y hue ; it was now soft and pliant, although still in a less 
degree than in health, — it no longer looked clear and shining ; the 
mammillary tubercles had disappeared from the left thigh. In the 
course of the month of March, the leucorrhcea was diminished in 
quantity; the catamenia appeared some days earlier than anticipated, 
and, proving scanty, a few leeches were applied by way of substitute. 
On the 10th of May the parts of the skin that had been affected, were 
almost completely natural in their appearance. 

Case LXXXIV. — Eczematous impetigo occurring during pregnancy ; 
loss of the hair and nails ; ewe. S. Lainee, nineteen years of age, of 
a sanguineous temperament and robust constitution, presented herself 
among the out-patients of the Hopital St. Antoine on the 14th of Sep- 
tember, 1828. She gave us to understand that in her childhood she 
had been affected with a cutaneous affection, precisely similar to that 
under which she now laboured, and that she had had a second attack 
in the course of the year 1827, during her first pregnancy. Seven 
months and a half gone in a second pregnancy, she became for the 
third time affected with an eruption of small psydracious pustules 
which were scattered over the surface of the trunk, and especially of 
the abdomen, and surrounded at their bases by a pretty distinct areola. 
A number of pustules of the same kind appeared here and there col- 
lected into groups, and around these the rosy circle was more par- 
ticularly conspicuous. A number of greenish scabs or incrustations, 
not quite so thick as those of impetigo generally are, were also 
remarked in various situations. These adhered strongly to the skin, 
and were encircled by a violet-red coloured line. Lastly, between 
these incrustations several spots were remarked of a dirty violet hue, 
the surface of which was either smooth or covered with slight squamae ; 
they had, however, been formerly furnished with crusts similar to 
those of other districts of the skin. 

Between the 18th and 21st of September, many groups of pustules 
appeared on the trunk and extremities, whilst others that existed pre- 
viously were drying off. On the 25th the eruption had increased to 
such an extent as to render blood-letting necessary, which was accord- 
ingly practised to the amount of twelve ounces. On the 28th the 
trunk, (the abdomen in particular) was covered with irregular round- 
shaped scabs, from an inch to an inch and a half in diameter, yellow- 
ish in their colour, rather moist and of considerable thickness. The 
intervals between the scabs were occupied with many small pustules, 
irregularly scattered, or congregated into groups of six, eight or ten 
together; the patient could not move in her bed without suffering 
acute pain, so completely was every part of the body beset with 
recent pustules or covered with older incrustations ; she also endured 
a great deal from a sense of prickling and of increased heat in the in- 
teguments generally; the pulse was hard, the tongue of the same 
vivid red which is seen in scarlet fever, the thirst very great. On 
the 22d the face was flushed, the features swollen, the pulse full and 
frequent, and the pustules still more numerous than yesterday, covering 
the arms completely, and with the previously existing incrustations 
producing so much stiffness that it was found impossible to straighten 
them sufficiently to perform the venesection which was held neces- 
sary. 

From the 30th of September to the 2d of October, the inflammation 
of the skin ran very high ; portions of the cuticle, from the confluence 
of the pustules, were raised in different places, so as to resemble puru- 
lent bullae. In the evening of the day last named, (2d of October) 
the patient was taken in labour, which went on through the 3d, during 
the afternoon of which day the patient became delirious and alarmingly 
ill. She was bled to the extent of ten ounces. She was delivered 
during the night and immediately fell asleep. 

On the 4th, the patient still complained of a feeling of general heat 



FAVUS. 



1'95 



which, however, was less troublesome than it had been. The tongue 
had now lost the preternatural redness which it had exhibited during 
the whole course of the disease. The progress of the eruption appeared 
to have received a check ; the lochia flowed naturally. 

On the 6th a few fresh pustules made their appearance on the face, 
and on the seventh several purulent deposits, were observed under the 
cuticle of the palms of the hands and soles of the feet. The incrusta- 
tions over the trunk generally were now either removed or in progress 
of being cast off. Tile fall of the crusts was succeeded by the detach- 
ment of large epidermic lamina? from the surfaces that had been 
affected. 

The patient complained greatly of pain and heat in the lower extre- 
mities, the epidermis of which, entirely detached from the cutis vera 
beneath, by the motion and rubbing of the parts, formed a sort of pro- 
minent roll about the middle of the leg. The exposed corion was red 
and humid. The purulent exudations, which had taken place in the 
palms and soles, were for the most part confluent, and formed conti- 
nuous flat vesications in these places. From the 6th to the 12th, the 
eruption and consequent stages of scabbing, detachment of the crusts, 
and desquamation of the cuticle, were repeatedly renewed ; the epi- 
dermis of the soles of the feet was thrown off in a single piece on the 
day last mentioned. The nail of one of the toes was at this time half 
loose, and before the end of the first week in December the whole of 
these appendages were detached in succession. 

The loss of the epidermis was followed by that of the hair on the 
coronal and parietal regions. 

On the 15th of December the patient had completely recovered. 
The nails and hair grew again at a later period, (a) 

(a) The following description of disease and cure by Dr. Carswell 
is instructive. 

" The next case is one of impetigo, which occurred in a boy ten 
years of age, of sanguineous temperament. He had generally enjoyed 
good health, although he has had two or three times an eruption on 
the head. The first occurrence of the eruption was two years ago, 
just after the death of his father, who, he said, had an eruption on 
the head at the time of his death, and from whom he supposed he 
caught it, although a brother and sister, equally exposed with himself, 
had no eruption. 

" The present eruption occurred two months ago, a few pustules 
only occupying a small spot, which discharged a good deal, and 
gradually spread. 

" On his admission there was an eruption on the top of the head, 
on the left side, consisting chiefly of incrustations, of a dry, rather 
brittle appearance, of a dirty, yellowish-gray, or brownish colour, 
intermixed with, and spreading amongst the hair. The elementary 
character of the eruption was not seen on any part of the head at this 
time, but it soon after appeared in the form of the acores pustule ; 
that is to say, a small prominent pustule, larger than the psydraceous, 
containing a yellow-coloured fluid pus, which, after a short period 
burst, and spread its contents amongst the hair, which became con- 
verted into yellowish-gray or brown crusts. By means of these 
characters we recognized the presence of impetigo. The prominent 
pustule, with its fluid contents, were sufficient to establish the diag- 
nosis, and to distinguish the eruption from porrigo favosa and porrigo 
scutulata, the two contagious forms of pustular eruptions of the scalp. 
When we can accomplish this important point, we need not trouble 
ourselves to find out whether an eruption of the scalp is one of porrigo 
larvalis, or porrigo granulata, as they have improperly been called, 
as both of these eruptions are modified forms of impetigo, or of eczema 
impetiginodes, and are not propagated by contagion. 

" The general health of this boy was good, and remained so while 
he was under treatment, except on one occasion, when he had fever 
for two days, from derangement of the bowels. The treatment con- 
tinued for about the same length of time as in the preceding case. It 
was commenced by the removal of the hair, and the application of 
poultices. The patient was allowed full diet, and the bowels were 
regulated by small doses of calomel and rhubarb every alternate night. 
The removal of the hair on the affected parts was accomplished by 
the daily use of the alkaline ointment, and washing with warm water 
and soap. 



FAVOS. 

Vocab. Porrigo favosa, <$rc. ; Tinea favosa, 

540. The Romans made use of the word favus to signify the cell or 
collection of cells of the waxen comb in which bees store up their 
honey. From some analogy in point of form, the word has been im* 
pressed into the service of medicine and used to delineate a chronic 
inflammatory affection of the skin, essentially contagious in its nature, 
and principally characterized by the appearance of its scabs which are 
of a clear yellow colour, very dry, strongly adherent to the skin, circu- 
lar and cupped, and either isolated, or agglomerated into continuous 
masses with raised and inverted edges, the surface of which presents 
numerous characteristic depressions. (6) 

" On several occasions, however, the eruption spread, or appeared 
on previously healthy parts of the head, and also on the ears, by the 
formation of pustules, to which the same means of treatment was 
applied. After this had ceased to occur, and the inflammatory stage 
had subsided, the zinc ointment was employed for some time; and, 
lastly, the nitrate of silver, which completely checked the further 
progress of the disease. 

" The affected parts of the head did not present that baldness and 
glossy appearance of the skin, which were observed in the cases of 
porrigo favosa. On the contrary, the hair was only thinned and 
shortened, and the skin presented numerous dark points, indicating 
the protrusion of others from its surface. In most cases of impetigo, 
which constitute a great number of the pustular eruptions of the scalp, 
the treatment employed in this case will prove successful, when the 
general health is not impaired, and proper attention is paid to food, 
clothing, and exercise. In debilitated and scrofulous children, how- 
ever, general treatment requires special attention. Besides attending 
to the circumstances just mentioned, and regulating the biliary and 
intestinal secretions, the warm or shower-bath, according to circum- 
stances, must be employed, combined with mild tonics, together with 
the use of those remedies which act in a special manner on the 
capillary circulation, and thereby promote the important functions of 
secretion and absorption. And no remedy in our possession exercises 
such a speedy and beneficial operation in this respect as the iodide of 
iron, particularly when aided by the other general means to which I 
have alluded. In debilitated, scrofulous, and especially anemiated 
children, its remedial agency is often remarkable. I need not remind 
you that its use is counter-indicated in all cases of gastro-intestinal 
irritation, and even where local inflammation of a sthenic character 
is present. These states must first be subdued by proper antiphlo- 
gistic treatment." 

(b) The student of dermatology is not a little embarrassed by the 
different divisions, as well as names of some of the pustulce, and 
particularly of the impetiginous and favous, or porriginous forms. 
The five genera of pustular diseases, according to the arrangement of 
Bateman, viz: impetigo, porrigo, ecthyma, variola and scabies, have, 
as this writer properly remarks, " nothing in common in their character, 
except the appearance of pustules in some state of their progress ; for 
some are contagious and others not, some are acute, and others 
chronic." Of the four varieties of pustules ; phlyzacium, psydracium, 
achor, and favus, the first three are chiefly used as expletives in 
description, while the latter is, by M. Rayer, employed to characterize 
a distinct form or species, which corresponds with the tinea favosa 
of his first arrangement, the teigne faveuse of Alibert. 

" Phlyzacium is a pustule commonly of a large size, raised on a 
hard circular base of a vivid red colour, and succeeded by a thick, 
hard, dark-coloured scab. Psydracium is a small pustule, often 
irregularly circumscribed, producing but a slight elevation of the 
cuticle, and terminating in a laminated scab. Many of the psydracia 
usually appear together, and become confluent ; and after the discharge 
of pus, they pour out a thin watery humour, which frequently forms 
an irregular incrustation. 

" Achor and favus. These two pustules are considered by the 
majority of writers from the Greeks downwards, as varieties of the 
same genus, differing chiefly in magnitude. The achor may be 
defined a small acuminated pustule, containing a straw-coloured 



196 



PUSTUUE. 



B41. Symptoms.—] on principally on those regions of the 

common integument of the body which lie over a dense and strongly 
reticulated stratum of cellular tissue, abundantly provided with pilifer- 

OUS follicles. It is therefore very commonly seen on the hairy scalp, 
from whence it sometimes extends to the temples, forehead and eye- 
brows, more rarely reaching to the shoulders, the lower parts of the 
scapular regions, the elbows and forearms, situations in all of which, 
however, it is occasionally met with ; I have even seen it extending 
over the whole of the back part of the trunk as far as the sacrum, and 
attacking the knees, and upper and inner parts of the legs in a child, 
twelve years of age, whose hairy scalp escaped completely. The 
hands and forearms may also he exclusively implicated ; but the disease 
in such cases may almost always be traced to the accidental inoculation 
of the contagious discharge upon these parts. 

The pustules and scabs of favus are in one instance disseminated, 
in another they occur disposed in circular or oblong clusters; accord- 
ing to these different appearances two varieties of the disease have 
been established: 1, favus dispersus ; 2, favus confertus. 

D 12. Favus dispersus (porrigo lupinosa Willan). This form of the 
disease, according to Willan and Bateman, makes its attack under 
the form of very minute pustules, not very evident to the naked eye, 
scarcely rising above the level of the skin, and from the very day of 
their formation covered on their apices with a small yellow scab. 
These pustules, in fact, contain the merest globule of pus, which is 
not shed on the surface but concretes and dries in the interior. I 
have myself seen these small yellow pustules in several cases of favus. 
Their existence, however, has been disputed by Messrs. Mahon and 
Baudelocque. The latter allows, nevertheless, that the favous matter 
is deposited in a fluid slate within the hairy bulbs. The difference 
of opinion, consequently, seems to turn upon a variety of meaning 
attached to the word pustule. Whatever the mode of formation of 
the pustules, this is certain, that the matter of favus is not long of 
appearing on the exterior in the shape of crusts, which at the very 
earliest period of their existence present a small cup-shaped depression 
in their centre. The dimensions of these crusts increase, still preserv- 
ing the circular form and depressed centre peculiar to them. They 
occasionally attain a magnitude of five or six lines in diameter. Some 
short time after the appearance of the first incrustations, others are 
commonly evolved in their vicinity or in other regions of the body. 
When very numerous and coherent, the scabs of favus by their aggre- 
gation compose continuous incrustations of considerable extent, on the 
surface of which the capped form of the individual crusts may fre- 
quently be recognized. Should it happen, indeed, that this peculiar 
shape is lost through the copiousness of the secretion around them, 
by carefully removing the superficial layers, each particular favus, 

matter, which has the appearance, and nearly the consistence of 
strained honey, and succeeded by a thin brown or yellowish scab. 
'The favus, or xw>v is larger than the achor, flatter, and not acumi- 
nated, and contains a more viscid matter; its base, which is often 
irregular, is slightly inflamed; and it is succeeded by a yellow, semi- 
transparent, and sometimes cellular scab like a honeycomb ; whence 
it has obtained its name." Bateman's Practical Synopsis. 

Impetigo is characterized by the appearance of the small pustules 
denominated psydracia; while porrigo (of Willan and Bateman) is 
principally distinguished by an eruption of the pustules denominated 
favi and achors. Objection has been made, and with good reason, to the 
abuse of the term porrigo, since some of its forms, viz ; P. larvalis, and 
P. favosa, are now ranked under the impetigines and constitute impetigo 
figurata or capitis (impetigo eczematos) ; and P.furfurans belongs 
to one of the varieties of eczema, rather than to the favi; while P. 
decalvans is more a result of prior disease of the scalp than a disease 
itselt: it is one of the varieties of alopecia. Hence there are but 
three forms of porrigo left, favosa, lupinosa and scutulata, which, as 
both M. Rayer and Mr. Wilson judiciously remark, should be merged 
in the species of favus,— the two varieties of this latter, F. dispersus 
and F. confertus corresponding with P. lupinosa and P. scutulata. 
These remarks on porrigo, apply with equal force to tinea, and we may 
join in the expression of the wish of recent judicious and experienced 
dermatologists, that the former should be, as the latter is become, an 
obsolete term. 



centrally depressed and isolated, may still be very distinctly made 
out. 

The cup-shape, assumed by the crusts of favus, have caused them 
to be compared, as already stated, to the cells of the honeycomb, to 
the depressions, observed on the seeds of the lupine (whence the 
denomination porrigo lupinosa of Willan), or to the capsules of certain 
lichenous plants that grow on trees. When the crusts of favus are 
recent they are of a yellow or tawny colour. As they grow older and 
drier they gain a clear yellow or whitish cast, they then crack, shiver, 
and become reduced to a powder which bears a considerable resem- 
blance to pulverized sulphur. They then present nothing like regu- 
larity of form. These crusts are deeply set in the skin, to which they 
adhere firmly by their edges. 

According to M. Baudelocque their primary seat is under the epi- 
dermis. 

When a crust of favus, of recent formation, is removed with such 
care as to cause no effusion of blood, it is found to present a round 
nipple-shaped elevation, surmounted by a contracted, and, as it were, 
strictured portion, which enlarges until it terminates at the surface of 
the skin. On a point of this mammillated surface a slender, conical and 
moist prolongation is occasionally seen. In the corresponding point 
the skin presents a small, smooth depression, proportioned in size to 
the crust, from whence a serous yellowish and transparent fluid exudes. 
If the crust, thus detached during life, be of older date, its deep sur- 
face no longer presents any nipple-like projection, and its thickness 
at its centre and around its edges is very nearly uniform. The outer 
central depression corresponds with a slight convexity of the inner 
aspect of the incrustation. Under the older crusts the skin presents 
a circular depression, wider and generally of less depth than in the 
favi of more recent formation. Freed from a recently formed scab, 
the skin speedily regains its natural thickness, and the cuticle is repro- 
duced without any remaining cicatrice when no new crust is formed. 

The large incrustations of favus, formed by the agglomeration of 
several contiguous scabs, are not generally observed to possess any 
particular form or regular disposition of parts. Their deep or inner 
surface presents several slight projections separated by linear depres- 
sions. The skin under these incrustations presents a number of small, 
superficial, lenticular depressions separated by linear elevations and 
inequalities corresponding with the depressions observed on the inner 
aspect of the incrustations. Under the depressed points the skin is 
occasionally reduced to half a line in thickness ; the papilla? are red 
and denuded, but not ulcerated even in those situations where the 
crusts appear buried in the skin. On each of these depressions a 
minute red central point is perceived, which is often traversed by a 
hair, and a small red circle which corresponds with the margin of 
each particular scab. To conclude, I have occasionally found the 
skin softened and of a violet-red colour under very old incrustations 
in favus. (a) 

(a) " The yellow substance which constitutes the crusts of favus 
has been satisfactorily proved, by recent investigation, to be an 
organic growth of simple structure, and bearing a marked resemblance 
to those inferior numbers of the vegetable kingdom, denominated 
mould. The structure of these crusts appears first to have attracted 
the attention of Remak, who had observed, so early as 1836, their 
composition of ' fungoid filaments.' Professor Schoenlein, of Zurich, 
next called them to notice in a paper in Muller's Archiv. for 1839, 
on the pathology of the impetigines, in which he makes no doubt of 
the fungous nature of the substance, and he illustrates his communi- 
cation by a rude figure of the appearance which they presented in his 
observations. In pursuance of Schoenlein's researches, they were 
examined by Fuchs and Langenbeck, of Gottingen ; more recently 
they have been studied by Dr. Gruby, of Vienna, who expresses 
himself to have been ignorant of the labours of Schoenlein. Dr. 
Gruby has, moreover, given a clear and lucid description of the 
growth, which he regards as a parasitic plant, and has determined it 
to belong to the genus mycodermis. The following is an abstract of 
a paper, from the pen of Dr. Gruby, on this subject, in Muller's 
Archiv. for the present year : — 

" ' The cup-shaped crust of favus is situated upon a depression of 
the dermis, and is covered by a sheath of epidermis, which is thickest 



FAVUS. 



197 



The smell of the scabs and incrustations of favus is singularly like 
that of the urine of the cat. When they are softened with emollient 
cataplasms the smell changes and becomes faint and sickly, and some- 
thing similar to that of bones which have been boiled with their liga- 
ments. The crusts thus detached are speedily reproduced with the 

on its concave, and thinnest on its convex surface. Immediately 
within the epidermis is a thin layer of amorphous substance, composed 
of minute molecules; this layer is dense, of a sulphur-yellow colour, 
and forms a capsule, which is in contact by its external surface with 
the epidermis, and by its internal surface with a fungous growth. 
The parasitic growth is attached by means of its roots to the yellow 
capsule, while its stem and branches extend inwards towards the 
centre of the capsule, and constitute the whitish-gray and porous 
contents of the crust. The roots and branches of the mycoderm are 
smooth, cylindrical, transparent tubuli, which divide dichotomously 
from point to point. The interior of the tubuli is filled with a granular 
substance, and divided here and there by transverse septa. At the 
ends of the branches are situated the seeds of the plant which are of 
a yellowish-white colour, and either collected into an irregular assem- 
blage, or disposed in the form of a garland. The diameter of the 
branches of the mycodermis is 70V0 to 2I0 of a millimetre ; that of the 
molecules contained within the tubuli, Torrnr to T „Vo mm - 1 an d that 
of the seeds, sfs- to iho mm. Dr. Gruby has detected seeds in the 
follicles of the hair, and impacted in the ducts of the sebaceous 
glands.' 

"To ascertain the degree of contagious power of the mycodermis, 
Dr. Gruby inoculated various mammiferous animals, birds, reptiles, 
and insects, but unsuccessfully; he was equally unsuccessful in his 
own person, but succeeded, after seventy-six attempts, in reproducing 
the mycodermis in a cryptogamic plant. 

"Mr. Busk, in a paper entitled 'Observations on Parasitical 
growths on Living Animals,' in the Microscopic Journal, (No. 10,) 
has given an excellent figure of the mycodermis. He represents the 
branches as consisting of a series of oblong cells connected by their 
extremities. 

" However closely the fungous growth here described may resemble 
a plant, its vegetable nature is very far from being established. The 
simplest forms of animals are composed, like the mycodermis of cells, 
variously connected together; and subsequent research may prove 
the growth under consideration to be of a similar nature. To my 
mind there is nothing improbable in the supposition of the origin of 
the growth from morbidly developed epidermic cells of the hair- 
follicle, or from the corpuscules of the sebaceous substance. In a 
preceding section of this work, I have shown that the latter are sus- 
ceptible of considerable alteration, and that in this state they assume 
an appearance widely different from that of their normal condition. 
Mr. Busk also entertains doubts with regard to the vegetable nature 
of the mycodermis, and deduces an opinion favourable to his opinion, 
from the chemical analysis of the crusts of favus, given by Thenard, 
who found them composed of 

Albumen .... 70 

Gelatine .... 17 

Phosphate of lime . 5 

Water and loss . . 8 

100 
" Dr. Carpenter, in his ' Principles of Physiology,' (p. 453,) speak- 
ing on the same subject, remarks — " It has been assumed that the 
organization is vegetable, because it (mycodermis) consists of a mass 
of cells capable of extending themselves by the ordinary process of 
multiplication. But it must be remembered that the vesicular organi- 
zation is common to animals, as well as to plants, being the only 
form that manifests itself at an early period of development in either 
kingdom, and remaining throughout life in those parts which have 
not undergone a metamorphose for special purposes. Hence, to 
speak of porrigo favosa, or any similar disease, as produced by the 
growth of a vegetable within the animal body, appears to the author 
a very arbitrary assumption; the simple fact being, in regard to this 
and many other structures of a low type, that they present the simplest 
or most general kind of organization." W T ilson (op. cit. p. 322-4.) 
50 



characters that are proper to them. According to Thenard, they con- 
sist of seventy of albumen, seventeen of gelatine, five of phosphate ot 
lime, eight of water and loss in every 100 parts. 

The skin occasionally preserves its healthy characters between the 
crusts of favus ; but, when the groups are numerous or much crowded, 
it frequently presents a morbid redness, and undergoes repeated furfu- 
raceous desquamations. 

In the majority of cases, and when the disease is properly treated, 
the depressions in the skin disappear after the fall of the scabs; the 
situations occupied by these, however, being still indicated by the 
presence of small-violet coloured spots, which disappear at length. 

The skin may become ulcerated in old cases of favus affecting the 
scalp (tinea favosa). Small sores two or three lines in diameter, 
occasionally succeed the primary depressions. Under the larger 
incrustations the skin now and then presents an assemblage of small 
ulcers, separated from each other by crevices of varying depth. 

The alteration and fall of the hair are the usual consequences of 
favus when it attacks parts provided with this appendage of the skin. 
The hair reproduced by the bulbs that have been affected is thin, 
white and woolly. Those parts that have lost their hair long continue 
smooth and shining. If the disease remains unsubdued for several 
years, the baldness may become general and permanent. Lastly, 
the skin has been seen altered or destroyed through its whole thick- 
ness, the hair bulbs and subcutaneous cellular substance the seat of 
small abscesses, and the inflammation extending to the periosteum 
and bones of the cranium, which have even been found changed in 
a greater or less degree in their structure. 

543. Favus of the hairy scalp often causes a chronic inflammation 
of the glands of the neck and occiput. This effect is by no means 
constant, however; I have seen individuals who had long laboured 
under this form of favus without experiencing any such consequence. 
It is important not to confound these secondary inflammations of the 
lymphatic glands with those affections of the same parts, which indi- 
viduals of scrofulous constitution are so apt to suffer from, before and 
altogether independently of the appearance of favus. 

Pediculi are usually found in vast numbers among the crusts of 
favus; and children seem to enjoy a sort of ecstasy in tearing their 
scalp with their nails. The blood mixed with the discharge poured 
out in these and similar cases, by drying, forms incrustations of a 
colour different from that presented by the ordinary crusts of favus. 

When favus appears on other regions of the body, the inflamma- 
tion usually penetrates less deeply, it terminates much more rarely by 
ulceration, and its cure is much more readily accomplished. 

Favus of the trunk and extremities is almost never attended with 
any other inflammatory affection of the skin ; and unless it happens 
to be inoculated by accident it is very seldom seen complicating 
other cutaneous diseases. I have, however, had a man under ray 
care, with impetigo sparsa of the lower limbs, who presented a single, 
but perfectly characteristic, crust of favus on the outer part of one of 
his legs. 

I have met with favus developed solely on the cheeks and on the 
chin. 

544. Favus confertus. — Favus and the cup-shaped crusts which 
characterize it, are occasionally seen upon the hairy scalp arranged 
in such a manner as to form circular clusters and regular rings. This 
variety of favus has been described by Willan as a particular species 
of porrigo (porrigo scutulata, the pustular ring- worm of several writers 
and the vulgar, tinea annularis, &fc). At the present day it is im- 
possible to consider this eruption otherwise than as a variety of favus. 

Favus confertus as it affects the scalp, is also frequently seen 
existing at the same time, and with the same external form, on the 
forehead and neck. It is characterized by circular, red-coloured 
patches, on which appear numerous small yellowish points (pustules, 
Willan), buried within the substance of the skin, not prominent, and 
generally traversed in the centre by a hair. These small yellow 
points, much more numerous in the circumference than in the centre 
of the circular patches, are soon succeeded by scabs which unite in 
such a manner as to form incrustations of a breadth corresponding 
to the extent of the eruption, and commonly circular in their shape. 
Dry and friable, these incrustations are detached from time to time in 
small pieces, which bear a strong resemblance to the crumbling mortar 



198 



PUSTUUE. 



oft wall that ia going to decay from the effects of age and moisture. 
The hair, the bulbs of which are often affected from the commence- 
ment of the disease, speedily becomes thin, looks dry, and falls out 
on the slightest touch. 

If this form of fevns be left to itself, not only do the areas of the 
primary groups extend, but new ones are formed either spontaneously, 
or in consequence of the successive inoculation of the matter or pow- 
der of the original clusters. When these groups become very nume- 
rous they often get blended by their corresponding edges, and then 
appear as extensive and irregular patches. The circular character of 
the primary clusters, however, is still indicated by the portions of 
arcs of a circle distinguishable in the circumference of the larger 
incrustations. The hairs break off short, or are thrown out by the 
roots ; but are soon succeeded by others, which are shed like the first. 
If the hair follicles are destroyed or seriously altered, the baldness 
remains permanent. 

Favus confrrtus may denude several different parts of the scalp in 
succession. There is always room to apprehend the development of 
fresh incrustations, so long as any redness remains and a furfuraceous 
desquamation goes on in the parts that have been affected. Recovery, 
on the contrary, is at hand when the skin becomes less and less in- 
flamed after the fall of the incrustations, and is only affected with 
very slight eruptions, successively at longer and longer intervals 
from each other. 

545. I have observed that the intellectual faculties frequently ap- 
peared to be very limited in the individuals affected with favus ; 
others again seemed prematurely stricken with the signs of old age. 
Favus of the scalp may be accidentally complicated with otitis, 
ophthalmia and coryza. One of the severest of these complications, 
however, is that with a chronic inflammation of the mucous mem- 
brane of the stomach and bowels. Bayle has remarked the occur- 
rence of a chronic enlargement of the mesenteric glands, and several 
other lesions, which, however, on a careful review, do not seem to 
be more frequent in subjects affected with favus than in those labour- 
ing under other diseases. In inveterate favus, which has continued 
beyond the periods of childhood and youth, the nails of the feet and 
hands are occasionally found to exhibit particular alterations : they 
increase in thickness, become very much elongated, look rough on their 
surface and acquire a yellowish colour, analogous in some degree to 
that presented by the crusts of favus itself. 

546. Alterations of Structure. — Duncan and Underwood assigned 
the bulbs of the hair as the seat of favus. According to Sauvages it 
principally affects the sebaceous follicles; this opinion was adopted 
by Murray, "porliorem sedem mali in folliculis dictis pinguidinosis, 
vel ipso lextu celluloso qua?rendam arbitrior," and has been lately- 
reproduced in the following terms by the Messrs. Mahon. " An in- 
flamed follicle gives out a morbid humour which becomes dry, fills 
and distends its cavity and at last causes its rupture and destruction. 
The depression in favus is nothing more than the orifice of the follicle 
which is now become visible ; and the renewal of the disease is 
brought on by the evolving of a fresh favus on adjoining follicles, 
which compressed by the dilatation of the part, cannot be filled and 
distended nor break and be destroyed until after the renewal of this 
one. The object of the favus is in part, to destroy the bulb of the 
hair, which when brought about, the diseases disappears." 

The frequency of favus in those situations where the hair is most 
abundant, — the scalp, especially, and the regular presence of several 
hairs in each favous scab, induced M. Baudelocque to believe that 
the disease was evolved in the piliferous bulbs. The matter of favus 
deposited within the cavities of these follicles, according to him, 
concretes and forms a nucleus, which he designates under the objec- 
tionable title of tubercle. The secretion going on, he adds, concretes 
around the central nucleus, increases its size, and soon fills, and even 
distends the cavity of the follicle. The favous deposit, seeking a 
passage to the exterior, now penetrates the neck of the follicle, but 
being retained by the cuticle at its orifice, there" dries into one with 
the duct. Ihe same process is repeated as each fresh quantity of 
secretion attempts to escape; so that the solid part, conical at first, 
becomes broader by degrees, and ends by being changed into a 
cylindrical body, and then into a slightly convex superficial crust in 
proportion as the orifice, by being enlarged and, as it were everted 



approaches the level of the bottom of the follicle, the cavity of which 
is thus finally transformed into a superficial excavation. Lastly, the 
neck and orifice of the follicle cannot increase without the skin that 
surrounds them being pressed back upon itself in all directions, under- 
going some slight increase in thickness, which is always in proportion 
to the degree of condensation endured. 

The central depression in the crusts of favus is not the effect of 
accident. According to the author just quoted it depends on the 
conjunction of the following circumstances: — 1st. The presence of a 
central cylindrical nucleus, confined by the cuticle, with which it is 
connected exteriorly in such a way as not to be capable of being 
elevated; 2d, the forcible detention of the favous secretion in the 
space around the central nucleus, the sides of the follicle and the 
epidermis; lastly, a gradual elevation of the detached epidermis, and 
consequent increase of height in the interval within which the favous 
fluid is confined. 

The progress of the disease causes all trace of the whole of these 
conditions to be lost. When the cavity of a follicle, by the dilatation 
of its neck and orifices, is converted into a slightly concave superficies, 
if the secretion still goes on, the fluid by accumulating under the 
scab pushes it outwards, and forces back the corion towards the sub- 
cutaneous cellular membrane and circumjacent parts. The cuticle 
then gives way around the whole circumference of the incrustation, 
which is thrown off unless it happens to be retained by the hairs 
which pass through it ; the follicle then resumes its original form ; 
the cuticle is renewed, and the cure might be spontaneously accom- 
plished did no new favous pustule make its appearance to continue 
the disease. When the rupture of the cuticle is only partial, the favous 
incrustation continues adherent to the skin ; the secreted fluid oozes 
out, spreads and dries in the circumference of the primary scab, 
the diameter of which it thus increases, but, no longer encountering 
any cause of limitation, being no longer moulded in any peculiar man- 
ner, it forms prominences and depressions, which contrast strongly 
with the regularity of the central and primary scabs. It is by these 
inequalities that the point at which the epidermis has ceased to regu- 
late the desiccation of the discharge may be ascertained. 

547. In this explanation, M. Baudelocque, in common with many 
anatomists, has assumed that the epidermis, instead of penetrating into 
the interior of the piliferous follicular depression as far as the bulb, is 
reflected upon the hair near to the external orifice of the follicle. Mr. 
Chevalier, and several other anatomists, in whose opinions I myself 
concur, believe that the epidermis descends into the cavity of the fol- 
licle as far as the bulb of the hair, before being reflected along it. 
The following hypothesis, consequently, appears to me more tenable, 
and more in harmony with the disposition of the parts. I agree with 
M. Baudelocque that the orifice of the follicle is plugged by the favous 
matter drying and adhering strongly on the one hand to the neck of 
the hair, and on the other to the epidermis, which is reflected at the 
entrance of the follicle. The secretion of fluid going on continually 
from the inner surface of the follicle, which becomes gradually more 
and more distended, it may be supposed that the thin and but slightly 
extensible epidermis which is reflected into the follicle, gives way 
under that part where it is intimately connected with the kind of 
stopper formed by the concrete favous matter ; farther, that this matter 
penetrates between the dermis and cuticle which is detached, and that 
it forms, by drying, a circular incrustation, prominent in its circum- 
ference and depressed in its centre around the central nucleus. 

Be this as it may, it is, nevertheless, easy to distinguish the follow- 
ing particulars after death, in well-marked favus of the hairy scalp. 
On the inner aspect of the skin, a certain degree of redness corre- 
sponding to the clusters of the disease, and a certain number of small 
yellowish-white coloured deposits of a solid substance, perfectly 
identical with that composing the external incrustations. The minute 
swellings penetrate the substance of the true skin, and cellular mem- 
brane by an elongated tapering extremity. A hair is very frequently 
seen issuing from these favous deposits. 

548. The presence of a hair in these collections, their seat, their 
form and their size are so many particular circumstances inducing me 
to believe that the favous matter is deposited in the dilated cavities of 
the cuticular conduits of the hairs ; at the same time, the very slender 
and finely tapering form of the deep extremities of the deposits leads 



FAVUS. 



199 



me to suppose that the greatest quantity of the matter, thus concealed 
within the substance of the skin or in the cellular membrane beneath 
it, is not contained in the proper cavity of the piliferous follicles. 

The degree in which the structure of the skin is changed in favus 
varies extremely, according to the standing and condition of the dis- 
ease. In the more recent cases the conduits of the follicles are simply 
dilated by the accumulation of the favous fluid. In some cases we 
might be tempted at first sight to regard the skin as destroyed through 
its entire substance, were we not aware that the return of the integu- 
ments to their natural condition, and the cure of the complaint, 
advanced to the same state, without a trace of cicatrice, demonstrated 
the fact of there having been no important change undergone, far less 
any actual loss of substance experienced. 

After inveterate favus of the scalp, the skin of the cranium, in un- 
healthy children, may ulcerate and become resolved in parts into a 
kind of fibrous reticulation surrounding numerous perforations of the 
corion, at the bottoms of which the pericranium is occasionally seen 
inflamed, and even the bones of the skull exposed and in a state of 
caries. («) 

549. Causes. — Next to eczema and impetigo, favus is the most 
common of the chronic inflammations that affect the hairy scalp ; it is 
not observed in the same proportion on other regions of the body. 
Favus attacks both sexes indiscriminately and may make its appear- 
ance from infancy till a very advanced period of life. By far the 
greatest number of invasions, however, occur in the seventh, eighth 
or ninth year, but especially in the seventh. In the elderly and bald- 
headed in whom the piliferous follicles are atrophied or have dis- 
appeared, favus is almost never developed on the scalp. The soles 
of the feet and palms of the hands also enjoy immunity from this 
disease. 

Favus is a contagious disease, and is readily communicated among 
children who make use of the same comb or brush, especially if any 
slight excoriation happen to exist on the scalp. In the first edition of 
this work I quoted a remarkable instance of the inoculation of favus. 
Here is a second of the same kind. A woman living in the Rue de 
Bucherie, was in the daily habit of carrying about one of her children 
who laboured under favus. She was by and by attacked on the fore- 
arm that supported the head of the child, with a small cluster of favus, 
the yellow, dry, and cupped incrustations of which were perfectly 
characteristic. This woman and her child had been sent to me by 
Messrs. Olivier (d'Angers) and Bricheteau, who had satisfied them- 
selves, before I saw the cases, that no pustules or crusts of favus 
existed on any part of the body. The disease in this instance, evi- 
dently contracted by contagion, was removed by rubbing the parts 
affected with the nitrate of silver. The Messrs. Mahon have also 
published several remarkable cases of favus transmitted by contagion. 
Several others may be found in the Journal Hebdomadaire, torn, iv, 
p. 72. This disease is held sufficient cause of exemption from military 
service in France. 

I have farther to add, that the same law which obtains in the case 
of many other diseases, transmissible by contact or inoculation, holds 



(a) Mr. Erichsen (op. cit.) believes favus to be a modification of 
tubercle. 

" Favus, in its elementary form, differs from pustule, — 1st, in the 
favous matter being poured out upon a free surface, and not upon or 
within the cutis, and under the cuticle : — 2d, the favous tubercle is 
frequently chronic, existing in an imperfectly developed state for a 
length of time, which is never the case with pustule. Favous matter 
differs from pus, — 1st, in concreting very quickly after it is poured 
out, even before exposure to the air : — 2d, in its chemical composi- 
tion ; favous matter containing much more earthy salts, and coagu- 
lated albumen, than pus. Favus and tubercle agree in their seat [the 
lining membrane of the hair-follicles appearing to Mr. E. to partake, 
in a great measure, of the characters of mucous tissue], in the manner 
of their formation (both being eliminated in a fluid state, but solidify- 
ing very quickly,) in their mode of growth (by eccentric deposition, 
and not by any increase from within), in form, colour, and chemical 
composition; in most of the causes that predispose to, or excite them ; 
in the age at which they most frequently occur; and in the colour of 
the cicatrices which are left." (p. 117.) 



good in regard to the contagion of favus. The application of the 
crusts of favus to the skin is not invariably followed by the inoculation 
of this disgusting disease. 1 

Favus confertus, or pustular ring-worm (porrigo scutulata, Willan,) 
commonly attacks children from the age of two years to the time of 
puberty. Willan had seen one child in a school communicate the 
disease to fifty others in the course of a month. In this instance he 
condemns, with great reason, the filthy practice, so often pursued in 
establishments for the education of youth, of using the same comb for 
the whole of the children. I once attended a little boy, five years old, 
affected with this eruption whose mother contracted a number of pus- 
tules on her fingers from washing his head twice a day with an 
emollient decoction. The two sisters of this child, with whom he was 
constantly in contact, were attacked with similar pustules on the 
upper lip, and on the fingers. 

Neglect of proper cleanliness, and the presence of some other in- 
flammatory affection of the hairy scalp appear to predispose to both 
varieties of favus ; the disease may also arise spontaneously, and inde- 
pendently of contagion. According to the Messrs. Mahon, annular 
favus is a more frequent disease in the south than in the north of 
France. The complaint is very common in England. 

550. Diagnosis. — Eczema, impetigo, and pityriasis of the hairy 
scalp, have at different times been assimilated with favus, and de- 
scribed under the same generic name of tinea. To have escaped this 
error, it would have been enough to have reflected that the former 
diseases do not alter their nature from being evolved on the scalp, and 
that favus occasionally appears exclusively on the trunk. Had there 
been even a total want of general features distinguishing it from these 
diseases, the contagious nature of favus ought to have prevented 
pathologists from associating it with such affections as eczema and 
impetigo. Of all the diseases of the skin, however, favus is the one 
the external characters of which are without dispute, the least equivo- 
cal. No other affection is characterized by the evolution of minute 
pustules which do not rise above the level of the skin, and no other 
is proclaimed on the exterior by dry, circular, cup-shaped incrustations. 

In the hope of obtaining exemption from military duty, attempts have 
frequently been made by the young men in France to simulate favus, 
by producing with the nitric acid yellow stains or eschars on the hairy 
scalp ; but these spots want the characteristic depression in their centre, 
and no one familiar with the appearance of the actual disease could 
possibly be duped by such artifice. The small pustules of favus 
confertus (porrigo scutulata) buried in the skin and covered with 
incrustations almost from the moment of their formation, cannot be 
confounded with the pustules of impetigo, the secretion of which does 
not form true crusts till after the lapse of several days, and then the 
majority of them are rounded and much less adherent to the skin than 
those of favus. Farther, impetigo is not contagious, and rarely causes 
the loss of the hair, whilst favus on the contrary is propagated by the 
powder of its incrustations, and frequently occasions baldness. The 
red patches of herpes circinnatus at the commencement, and those of 
lepra divested of their squamae might be mistaken, if cursorily examined , 
for the red spots which precede the appearance of the crusts of favus 
confertus ; but these crusts by their formation speedily dissipate all 
doubt on the subject. 

551. Prognosis and Treatment. — Favus may get well spontaneously 
after a continuance of several months, or terminate naturally by the 
fall of the hairs of the affected follicles. Most frequently, however, 
the disease, abandoned to itself, continues unmitigated for several 
years. It is in general so much the less under the control of treat- 
ment, as it implicates a larger extent of the surface of the scalp, and 
as it is complicated with other more serious diseases. 

When favus is evolved spontaneously towards the decline of an 
acute or chronic affection of some severity, or when it has attacked 
feeble and weakly children whose health has improved since its 
appearance, — in these rare cases all treatment must be indefinitely 
suspended. By this advice I would not be esteemed as giving in to 
the opinion of an English writer who has classed favus among those 
cutaneous diseases which exert a salutary influence on the constitution ; 
I am satisfied, on the contrary, that favus almost always interferes with 

i Gallot. Recherches sur la teiqne, p. 64, et suivantes (premier, dieuxeme et 
quatri&rae fails), 8vo. Paris, an. xi. 



200 



PUSTULE. 



Ihe clue development of the physical powers and the moral and intel- 
lectual faculties of those children who have been long and severely 
affected with it. If some cases of serious disease supervening on the 
cure of favus have been quoted, an infinitely greater number of instan- 
unproved health and of greater vigour of constitution have been 
recorded after recovery from this disgusting disease. To secure these 
happy consequences, the regimen and plan of life pursued by patients 
require particular attention, especially when the disease appears 
among individuals of scrofulous constitution and who are suspected to 
have tubercles in their lungs. 

. If favus has appeared exclusively on the trunk, or on the 
extremities, in consequence of direct exposure to infection, and the 
scalp continues exempt, the disease in the majority of instances, will 
be found to yield to the use of plain, alkaline or sulphureous bathing. 
If the whole of the disease consists in a few scattered incrustations, 
after having succeeded in removing these, the parts affected must be 
touched with the nitrate of silver. The black crusts or eschars pro- 
duced by the action of the caustic, become depressed or cup-shaped, 
like those of favus, and after their fall, leave a mere superficial circu- 
lar red mark, which is itself effaced before long. In some obstinate 
cases the concentrated acids — the nitric, sulphuric, and hydrochloric 
acids, have occasionally been employed as escharotics with advantage. 

Favus of the hairy scalp, is an infinitely more rebellious disease 
than that of the trunk and extremities. The number of cases in which 
the simple warm bath, emollient fomentations and douches, alkaline 
or sulphureous baths, and washes of artificial mineral waters, might 
be employed with advantage, would be much more considerable, were 
we summoned to treat favus shortly after its invasion. General bath- 
ing, fomentations with linseed tea, and the application of emollient 
cataplasms to the head, after it has been carefully shaved, are very 
efficacious in removing old incrustations, and in lessening the redness 
of the skin, especially when the eruption is confluent ; alone, however, 
these measures seldom accomplish a complete cure. This happy issue 
is less rarely brought about by the additional action of a couple of 
blisters applied to the arms, and kept open for two or three months. 
In the year 1817, I made a great many trials of this mode of treating 
favus, which is free from the dangers with which various other plans 
of treatment have been taxed. 

In old standing cases of favus of the scalp, every method of treat- 
ment into which the avulsion or removal of the hair does not enter as 
an element is incomplete and unworthy of being entitled curative. The 
depilation in this case, is a measure as indispensable, as is the removal 
of the nail in certain varieties of onychia. This is the circumstance 
with which those physicians and surgeons have been struck, who 
have dwelt on different depilatory methods of treating favus. 

The oldest system of this kind, consisted in tearing out the hair 
violently by means of some adhesive plaster, which was applied or 
spread over the scalp. To prepare this plaster, it was customary to 
mix four ounces of rye flour in a pint of cold white- wine vinegar; the 
mixture was set upon the fire and stirred continually, whilst half an 
ounce of the deuto-carbonate of copper (verdigrise) in powder, was 
added ; it was boiled for an hour, after which, four ounces of black 
pitch, the same quantity of rosin, and six ounces of Burgundy pitch 
were added. When all these ingredients were melted and incorpo- 
rated, six ounces of antimonial ethiops in fine powder (an alloy of 
mercury and antimony, obtained by long trituration), were thrown 
into the mixture, which was stirred till it had acquired what was held 
a proper consistency. The plaster thus prepared, was spread upon a 
stoutish black cloth, which was slit in different directions before being 
applied, to prevent it forming any crease, and to admit of its being 
subsequently removed in stripes. 

The plaster was applied to the head, after having got rid of the 
incrustations by softening them with cataplasms, and having clipped 
off the hair as close to the skin as it could be done with scissors. 
After the lapse of three or four days, the plaster was removed rapidly 
the contrary way of the hair, and a second was put on, which was 
likewise removed in the same manner three or four days after its ap- 
plication. The plaster was subsequently renewed every second day, 
taking care to have the head shaved, when this measure appeared 
necessary. As may be conceived, and as was intended, these plasters 
each time they were renewed, tore out a quantity of hair more or less 



considerable. The first applications were attended with cruel suffer- 
ings ; the agony became less and less severe as progress was made 
in the treatment. Nevertheless, the pain was still so great at a month's 
end, that children might be heard screaming dreadfully when the 
plaster was removed ; after the third month, the pain of the dressing 
became less intolerable. 

It is undeniable, that by this method a certain number of cures were 
obtained, and these in severe cases, and after various other reme- 
dial measures had failed. But the action of the pitch-plaster cannot 
be kept confined to the diseased hairs only, and the avulsion of the 
healthy hair is both unnecessary, and extremely painful. In con- 
nexion with this procedure, I shall only add farther, that the Messrs. 
Mahon inform us, that they saw a child die two days after having had 
this horrible operation performed on its scalp. 

With a view to avoid the extreme pain attending the process of 
tearing out a great many of the hairs in the same moment of time, we 
have been recommended to extirpate them one by one by means of a 
small pair of forceps contrived for the purpose. 1 But this procedure 
which lasts infinitely longer than the other, is in itself excessively 
painful when the hairs still adhere to their bulbs ; and, indeed, can 
only be employed in those rare cases in which favus is confined to a 
very small portion of the scalp. 

Of all the depilatory methods proposed, that of the Messrs. Mahon 
is unquestionably the best. The effects of their procedure are to 
cleanse the surface of the hairy scalp, to keep it in a state of the 
greatest freedom from all impurities, to modify the diseased skin in a 
very beneficial manner, to cause the fall of the hair without pain, and 
to be invariably followed by recovery. 

554. The Messrs. Mahon begin their treatment by having the hair 
cut ofl" at the distance of about two inches from the surface of the 
scalp ; it is not made shorter, in order that it may be the more readily 
caught, and removed when loose, by the comb ; the incrustations are 
got rid of by means of hog's-lard and poultices of linseed flour ; the 
head is then washed with soap and water. The same process is 
repeated during four or five days in succession, or until the surface of 
the scalp appears quite clean. The second step is then taken in the 
treatment, the end of which is to accomplish gradually, and without 
the infliction of pain, the fall of the hair over all the places affected 
with favus. These parts are anointed every day with a depilatory 
ointment ; and this application is continued for a longer or shorter 
time according as the disease is inveterate or more slight and recent. 
On those days on which none of the depilatory preparation is applied, 
a fine comb is passed repeatedly through the hair, which is found to 
fall out without pain. After this treatment has been continued for a 
fortnight, a few pinches of a depilatory powder are scattered amongst 
the hair once a week, the comb being carefully used to the diseased 
parts the day after, and a fresh quantity of the depilatory ointment 
applied. This procedure requires to be continued during a longer or 
shorter space of time according to the state of the disease. The same 
system is pursued during a month or six weeks, when more active 
depilatory agents are employed over the parts affected, every day for 
a fortnight, and subsequently twice a week so long as any redness of 
the skin remains. 

555. Between the year 1807 and 1813 four hundred and thirty- 
nine individuals of the female sex, attacked with favus, were success- 
fully treated according to this plan, at the Bureau central des Hopi- 
taux de Paris, the mean time of each case continuing under treatment 
being fifty-six days. During the same interval four hundred and 
sixty-nine boys were cured by the same means, the mean term of the 
treatment extending to fifty-three days. The hair was found to be 
regularly reproduced on those parts that were thus artificially made 
bald, when the progress of the disease had not destroyed the piliferous 
bulbs. 

Numerous cases detailed in the books of the Bureau central, prove 
farther that favus which had resisted various other methods of treat- 
ment yielded to this. Among these are instances in which even the 
severest measures had been fruitlessly pursued for one, two, four, five, 
and even six years. 

As a substitute for the pommade epilatoire of the Messrs. Mahon, the 

1 By Mr. Plumbe. 



FAVUS. 



201 



composition of which they have not made publicly known, the sub- 
carbonate of potash or soda, in the proportion of one or two drachms 
to the ounce of hog's lard, may be advantageously employed, the 
affected parts being rubbed during ten minutes every day with this 
ointment. If the integuments appear considerably inflamed, the parts 
may then be washed with a solution of two drachms of the subcarbo- 
nate of potash in a pint of water, and the hair will speedily be 
detached without pain. 

556. An immense number of topical applications, some of them 
almost inert, such as charcoal and the black oxide of manganese, 
others possessed of more or less active properties, such as poultices of 
hemlock, of mulberry-leaves, dulcamara, &c, ointments of cantha- 
rides, of the nitrate, and of the proto-chloride of mercury; blisters ; 
solutions of the sulphate of zinc, sulphate of copper, sulphate of iron, 
deuto-chloride of mercury, and nitrate of silver, sulphuret of potash 
(1 dr. to 1 lb. of distilled water), and of the same salt combined with 
white soap, lime-water, and alcohol (R. potass, sulphuret dr. ii. 
sapon. alb. dr. i^ ; aqu. calcis gvii ; alcoh. rectif. dr. i) ; the Pom- 
made de Banyer (R. oxid. plumb, semivit. gii, alum, calcin. ^iss ; 
proto-chlor. hydrarg. oiss adepis, lbs. ii ; terebinth, venet. lb. ss) ; 
the ointment of the ioduret of sulphur, &c, &c, have all been recom- 
mended in the treatment of favus of the hairy scalp, but with such 
various and uncertain success, that none of them can be put in com- 
petition with the procedure adopted by the Messrs. Mahon.^cr) 

(a) Of local applications in favus confertus or porrigo scutulata, Dr. 
Wigan (Medical Gaz., 1843, and Bullet. Med. Science, 1844), declares 
concentrated acetic acid to be by far the best, and of itself all sufficient. 
He was not aware that Bateman, in one edition, refers, in a note, to 
the use of vinegar by Oribasius and iEtius, by the achores and in that 
brought out by Dr. A. T. Thomson, after speaking of the good effects 
of the application of sulphuric acid, he adds : " The acetic acid, or 
aromatic vinegar, which acts as a more gentle, yet very effectual 
caustic, has proved an effectual remedy in a few instances." 

Dr. Wigan's method is thus described : " Unless the quantity of 
hair on the head is exceedingly small and offers no obstacle to the 
complete examination of the skin, I insist on the head being shaved 
very carefully, twice. 

"The reason is obvious: with a moderate quantity of hair you may 
be curing the parts which first attract notice, while others which have 
been infected are gradually progressing to a visible disease, and the 
cure is thus indefinitely prolonged. I do not, however, object to a 
little circlet of hair round the face if there be no sign of disease appa- 
rent in it, and if it be carefully washed with hot common vinegar. 
This is a concession to parental vanity which may be safely made, 
and without which sometimes it would be impossible to obtain confi- 
dence. 

"My remedy is Beaufroy's concentrated acetic acid — pyroligneous 
acid, as it is still called — though no longer made from wood. 

"As a preliminary, however, I use the acid diluted with three 
times its weight of water. I call this the detector acid. 

" On its application a number of spots which looked perfectly 
healthy become red patches. They are indications that infection had 
been taken, but had not gone through its stages, which period I 
believe (after great experience) to be eight days. This assertion is 
not lightly hazarded. 

"Having by this reconnaissance ascertained the numbers and posi- 
tion of your enemy, your course is clear. One vigorous assault, and 
there is an end of the matter. With a piece of fine sponge, either 
tied to the end of a stick or held in a pair of silver sugar-tongs, I 
imbue each spot thoroughly with the concentrated acid for the space 
of three or four minutes, and the business is finished. 

" The only reason why it is necessary to see the patient again, is, 
that as a crust is generally formed, and as an appearance of " worsen- 

' Any plan which combines the removal of the hair b;/ gentle means, that is to say, 
after it is already loosened from the roots, with undeviaiing attention to cleanliness for 
about two months, will be found generally to cure favus. I have seen more than one 
case of this disease get well by the regular use of simple soap and water, with the 
employment of the small toothed comb night and morning for a month or six weeks. 
Patience, perseverance, and cleanliness, are the sheet anchors in all the successful 
plans of treating this obstinate disease, as they are evidently in that pursued by the 
Messrs. Mahon. — R. W. 
51 



Historical Notices and particular Cases. 

557. Favus was long conjoined, and even confounded with differ- 
ent other chronic inflammatory affections of the hairy scalp, under the 

ing" takes place, the friends require to have their confidence renewed 
from time to time by explanation and encouragement. I have often 
applied the acid more than once, but it was always (I firmly believe) 
unnecessary, when the preliminaries above stated had been gone 
through properly upon the shaved and tested head. 

"The crust gradually grows up with the hair, which soon sprouts 
again if the eruption be recent, and as soon as a pair of fine scissors 
can be inserted underneath, it should be removed ; but this should 
not be done prematurely, lest a sore place be produced. 

"When first proposed, a good deal of correspondence took place 
respecting the plan with those who had tried it without success. I 
found, however, that in every case they had either used a much weaker 
acid (it is sold of all strengths), or that they had continued the use of 
it long after the disease was cured, and thus produce that not very 
rare result, ' disease of the doctor.'' In the latter cases it w r as only 
necessary to discontinue the acid, and wash the head with warm 
water." 

Certain new remedies in the treatment of favus and psoriasis are 
described by Mr. Wilson, and from his work I derive the following 
notices: — 

" On the preparation and therapeutic virtues of Anthrako- 
kali. — Anthrakokali was introduced by Dr. Polya, of Pesth, about 
two years back, as a specific in certain diseases of the skin, and was 
made the subject of a short treatise by Dr. Jacobovics. It was 
administered by Dr. Polya as an internal medicine, and was especially 
employed against tettery affections, which this gentleman conceived 
to originate in a peculiar constitutional disorder. Anthrakokali, in 
the hands of Dr. Polya, produced the same specific effects, in relation 
to the tettery principle, that mercury effects in the case of syphilis, 
sulphur in the instance of scabies, and iodine in that of scrofula. 

"According to Dr. Polya, anthrakokali acts upon the entire system, 
producing a temporary increase of the local affection. It gives rise 
also to violent perspirations, and produces a general state of feverish- 
ness, under which the disease is cured. Thus it would appear, that 
by exciting a disease greater than that which it is employed to cure, 
it works its beneficial effects. 

" On the reputation which this substance obtained in the hands of 
Dr. Polya, Gibert made trial of it in Saint Louis. Administered 
internally, he obtained none of the marked results described by its 
proposer ; and after a fruitless experiment of several months' dura- 
tion, gave it up as useless. Gibert next used anthrakokali as a local 
application, in the form of ointment: he found it less stimulant than 
the ordinary alkaline ointment, but yet sufficiently resolutive. As a 
general principle, he remarks, ' the anthrakokali is a stimulant well 
suited to those cases in which we commonly employ sulphur and 
alkalies. It can only be used in the second stage of tettery affections 
— namely, in that in which the acute period has yielded to the chronic 
state, the latter being, nevertheless, subject every now and then to 
re-excitement.' For this reason, we find him lauding the effects of 
the anthrakokali, in a case of psoriasis inveterata, which had assumed 
an inflammatory activity under the use of an ointment of ioduret of 
ammonia. Thus, it would appear, that the anthrakokali deserves a 
place only among our more common stimulating applications, and is 
to be resorted to in cases where moderate stimulation is alone required, 
or where the morbid surface has become used to other forms of stimu- 
lant. 

"My own practice is a complete corroboration of the results ob- 
tained by Gibert. I have not ventured to use the remedy internally, 
after perusing the account given of its effects by Dr. Jacobovics, but 
I have found it an ordinary stimulant as a local application. An 
additional stimulant is, however, often of considerable value in our 
treatment, after we have employed without success the forms which 
we are most accustomed to prescribe. I have frequently observed a 
morbid surface, which has remained unchanged for weeks under the 
use of a given resolutive, suddenly assume a favourable aspect when 
treated by another with which the tissues are less familiar. 



202 



PUSTUUE. 



generic titles of tinea and porrigo. The translators of the works of 
Haly Abbas appear to have indicated favus under the name of tinea 



" The mode of preparation of anthrakokali is as follows : — 
U. Carbonate of potass . . . 180 parts 

Boiling water 2500 " 

After the solution of the alkaline salt, add hydrate of lime, in sufficient 
proportion to leave the potass free. Filter the fluids, and evaporate 
in an iron vessel until the surface assumes the appearance of oil. 
Then add l.~>0 parts of coal in fine powder, stirring it with the liquid 
until it be well mixed. The iron vessel is then to be removed from 
the fire, and the stirring is to be continued until the contents are con- 
verted into a black homogeneous powder. The anthrakokali should 
then be placed in well-stoppered bottles, in a dry place, in order to 
exclude moisture. 

"Dr. Polya also prepares a sulphuretted anthrakokali, by adding 
with the coal fifteen parts of sulphur also, in fine powder. This latter 
preparation is more active than the simple anthrakokali. 

"Anthrakokali is delitescent, and very soluble in water. Its solu- 
tion is of a deep brown colour, throwing down a black flaky precipitate 
with a mineral acid. The colour of the solution of the sulphuretted 
anthrakokali is blackish-green. 

"Dr. Polya asserts, that the anthrakokali is a chemical compound 
of potass and coal, and that in the form of solution, the latter is 
actually dissolved in the water. The test of this solution is the con- 
tinuance of the fluid of its brown hue, without the occurrence of any 
precipitate. Gibert, however, denies this chemical combination, and 
regards it as a simple mechanical admixture. The coal, he says, 
separates from the fluid by precipitation, until the latter loses the 
whole of its colour, and none of the former remains behind. 

"Dr. Polya prescribes two grains of the powder, three or four 
times a day in liquorice powder, or carbonate of magnesia. The 
ointment prepared by Gibert consists of 

U. Anthrakokali, gr. xvj. 

Axungise, 3j. 
M. 
To be applied with or without friction, as the case may demand, 
twice in the day. 

" On the preparation and therapeutic virtues of Fuligokali. 
— Soot has long enjoyed a reputation as a stimulant remedy in chronic 
diseases of the skin; it has for many years been used as a popular 
application in diseases of the scalp, and very recently has been recom- 
mended with much praise in the treatment of favus. 

" Fuligokali is a compound of soot and potass, in imitation of 
anthrakokali. It was first prepared by M. Deschamps, a chemist of 
Avallon, and has been made the subject of experiments, attended 
with considerable success, by M. Gibert, in Saint Louis. M. Gibert 
has employed the fuligokali both internally and externally, and finds 
it superior to anthrakokali. As an external application, in the form 
of ointment, it is resolutive, detersive, and stimulant. 

" The mode of preparation of the compound is the following: — 
R. Caustic potass . . 20 parts 

Soot 100 " 

Water . . . . q.s. 
Boil the mixture for an hour; cool, filter, evaporate, and dry. The 
fuligokali is obtained in the form of scales or powder, and must be 
kept in well-stoppered bottles in a dry place. 

" A sulphuretted fuligokali is obtained by the following process : — 
R. Soot .... 60 parts 
Caustic potass . 14 " 
Sulphur ... 4 " 
Heat the sulphur and potass with a little water, and after their solu- 
tion, add the soot. Evaporate, dry, and close the resulting compound 
in well-stoppered bottles, and keep it in a dry place. 

"The ointment used by M. Gibert is composed of a scruple to half 
a drachm of the salt to an ounce of lard. In larger proportion it is 
highly irritating. 

"Soot is a substance which is variable in its composition, and 
must differ according to the circumstance of being procured from 
the combustion of wood or coal. Its principal constituents are :— 
Acetate, sulphate, and carbonate of lime, 



lupinosa ;' a denomination which has been adopted by Willan, who 
has described a second variety of favus, which appears in the shape of 
clusters or rings under the name of porrigo scutulata. 2 M. Alibert 3 
has given a good description of favus, on the characters of which 
Messrs. Gallot, 4 Cooke, 5 Luxmore, 6 Plumbe, 7 and Mahon, 8 have pub- 
lished interesting observations. I have given a drawing of a remarkable 
case of this disease, in the atlas of pathological delineations illustrative 
of this work. 

The seat of the eruption of favus has been placed by Fr. Bayle 9 in 
the subcutaneous cellular tissue, and with greater reason in the hair- 
bulbs by Astruc, 10 Murray, 11 and M. Baudelocque. 12 

An analysis of some of the secret remedies of the Messrs. Mahon 
has been published by M. Braconnot. 13 Many cases of the disease 
have been detailed, and numerous remarks on its nature inserted in 
various periodical publications. 14 

Case LXXXV. — Favus in a child at the breast; treatment by Messrs. 
Mahon. C. M. Charesse, aged three months, was brought to the 
Bureau Central, on the 14th of February, 1826. This child had been 
attacked with favus a month after her birth. On the left parietal 
region, there was an incrustation two inches in diameter, of a pale 
yellow colour, dry, prominent, presenting numerous cupped depres- 
sions, and evidently formed by the agglomeration of numerous favous 
scabs. There were besides several other incrustations of smaller 
dimensions on different parts of the head. 

The child was in excellent health. Entrusted to the care of the 
practitioners mentioned, the incrustations and hair over the affected 
parts were removed within ten days, without any pain. The skin then 
looked red, dry, and shining, but free from sores or cicatrices. No 
fresh crop of pustules was developed, and a very short continuance of 
the treatment was found sufficient to complete the cure. 

Case LXXXVI. — Favus cured by emollient applications and blisters. 
A female infant, of very weakly constitution, and whose mother had 
died consumptive, was returned to its surviving parent, affected with 
scalled head, four months at least before the time at which I saw it. 

Hydrochlorate of ammonia, 

Chloride of sodium, 

A brown, bitter, extractive matter, 

An empyreumatic tar, 

A bitter, volatile oil, possessing a strong odour of soot, 

A fatty matter, containing oleic and stearic acid, 

Carbon. 
The potass solution dissolves the volatile principle of the soot, together 
with its aqueous extract. It contains, consequently, its active princi- 
ples. 

" It is probable that both the anthrakokali and the fuligokali owe 
much of their therapeutic value to the alkali which forms their basis. 
I have employed the fuligokali in several cases, and particularly in 
psoriasis palmaris, and with better success than I had obtained by the 
usual remedies." 

1 Quinta est species, Lupinosa, sicca et colore alba, lupino similis, a qua quasi 
cortices et squama; fluunt albae (Haly-Abbas, Theorice, lib. viii. cap. 18). 

2 Willan. A practical treatise on porrigo, 4to. Lond. 1814. — § porrigo lupinosa 
— § porrigo scutulata (Scald head or ringworm of the scalp). 

3 Alibert. Precis theorique et pratique des maladies de la peau, t. i. p. 3. 

4 Gallot. Recherches sur la teigne, 8vo. Paris, 1805, p. 14, et suivantes. 

6 Cooke. A practical treatise on tinea capitis contagiosa, 12mo. Lond. 1810. 

6 Luxmore. Observ. on the nature and treatment of tinea capitis, or scald head, 
12mo. Lond. 1812. 

7 Plumbe (Sam.). A practic. treatise on diseases of the skin. London, 1824, 
p. 41. 

8 Mahon. Recherches sur la siege et la nature des teignes. Paris, 1829, 8vo. 
Art. Teigne faveuse. 

» Bayle (Fr.). Problemat. physic, medic, 87.— Bonet. Sepulcretum. lib. iv. sect, 
xii. addit. obs. vi. 

10 Astruc. De tumoribus, p. i. 

11 Murray. Pr. de medendi tineae capitis ratione paralipomene. Goetting 
" Baudelocque. Recherch. anatom. et medic, sur la teigne faveuse. 

medic. Paris, Octobre 1831.) 

13 Bulletin des sciences medicales de Ferussac, t. xxii. p. 409. The analysis is in 
the following words: The powder No. 1 of the Messrs. Mahon, is composed of wood- 
ashes procured from firewood in the usual way. The powder No. 2 is composed of 
the same ashes, with a little reddish sand coming from the fireplace. The powder 
No. 3 resembles the preceding one last described. An impure sub-carbonate of 
potash consequently. R. W. 

'< Journ. hebdomad., t. iv. p. 72.— Revue medic, Juin 1830, p. 345.— Gaz. medic, 
1831, p. 321.— Gaz. des hopitaux, 1833, p. 174. 



1783. 
(Revue 



FAVUS. 



203 



On different parts of the hairy scalp, about thirty favous crusts could 
be counted. These were nearly half an inch in diameter, dry, of a pale 
yellow colour, prominent, with projecting edges and depressed centres; 
their superficial layers were whiter and more friable than their deeper 
parts, and they varied from one to several lines in thickness. The skin 
which surrounded them was neither red nor inflamed. Many of them 
were traversed by hairs. When they were detached, the corion under 
them was found red and slightly moist. Two small pustules existed 
on the parietal region, which scarcely passed the level of the integu- 
ments, and were covered with a slight scab on their apices. The head 
was shaved, and the affected regions covered with a linseed-meal 
poultice. The crusts soon became soft, and were easily removed ; I 
bathed the tender parts regularly every day with a decoction of linseed. 
Before a week had elapsed, the surface of the scalp was rendered 
perfectly clean. I then applied a blister to each arm ; these were kept 
open for three months. The fomentation was continued every day, 
and the favus was completely cured without any depilatory or other 
means than those mentioned, being tried. The blisters were then 
allowed to heal up, but in a very gradual manner. 

Case LXXXVII. — Favus transmitted by contagion. 1 An Officier de 
Sante was consulted in behalf of two little girls, whose cervical and 
sub-maxillary lymphatic glands were enlarged. He conceived that 
this state was induced by tinea, which had not been expelled from the 
system, and pursued a method of cure based upon this assumption. 
The poultices which had been applied to procure the removal of the 
incrustations of favus of the scalp, under which two sisters laboured, 
were actually applied to the heads of these poor children, one of whom 
was nine, and the other six and a half years old. These poultices were 
kept applied for a week, and were softened by being sprinkled every 
day with warm water, and covered with a fresh poultice externally ; 
they became at length so offensive, that they had to be removed. On 
the sixth day, a number of small white pustules were perceived on the 
scalp of the younger child, which, on being pricked, discharged a 
whitish purulent fluid, and in the course of a few days, became covered 
with light gray scabs. 

It was not till six days after the removal of the cataplasms, that a 
small red spot was perceived nearly at the distance of two inches from 
the incrustations mentioned. This spot, after a couple of days, was 
observed to be full of pus, which in concreting formed a very dry 
favous scab, the size of a millet-seed, circular in its shape, raised at its 
edges, and depressed in its centre ; 2 it extended gradually, so as to be 
two lines in diameter at the end of eight days, and more than four lines 
after the lapse of two months. 

The elder child did not contract favus ; and the parents after a long 
perseverance in the poultices, perceiving that the enlargement of the 
glands did not disappear, consulted a physician, who prescribed a 
course of remedies adapted to scrofulous cases. 

C^se LXXXVIII. — Ulcerated favus ; complications; death. A. 
Courtet, aged three years, had been long affected with favus, when he 
was admitted to the Hopital des Enfans maladies, on account of pneu- 
monia of both lungs, and a chronic affection of the ccecum and colon. 
The child was exhausted by this complication of diseases. He looked 
wan, and was emaciated to the last degree. Consumed by hectic fever, 
the child was evidently sinking fast. The favus, already of long stand- 
ing, was in a state of ulceration, and a fortnight after his reception, he 
died. Sectio cadaveris. The hair is thin. On the surface of the scalp 
appear : 1, several favous incrustations well characterized, cup-shaped 
and very adherent to the skin, which is red, and inflamed beneath 
them ; 2, a large incrustation on the top of the head, nearly three inches 
in diameter, prominent, presenting several cup-shaped depressions, 
and evidently formed by the agglomeration of several favous crusts ; 
3, in front of this larger incrustation, the skin presents a perforation 
nearly an inch in diameter. The subcutaneous structures in the 
vicinity of this perforation are destroyed, and to an extent so much 
the more considerable, as they are nearer to the bones of the cranium. 

The sub-mastoid lymphatic glands are red and swollen. Petechias 
and ecchymosed spots are conspicuous over various parts of the body. 
The ventricals of the brain are distended with serum. The trachea 
and bronchi are flooded with a yellowish mucus. Both lungs are 

1 Gallot. Rech. sur a teigne, 8vo. Paris, 1805. 

2 This spot (bmiton) was certainly a pustule of favus. 



hepatized. The mucous membrane of the large intestines presents a 
number of grayish spots, and that of the lower part of the rectum is 
affected with several ulcers ; in the cellular substance behind, and to 
the right side of the gut, a small abscess full of grayish-coloured puru- 
lent matter is discovered, (a) 

(a) Cases of favus related by Dr. Carswell in the Lancet (1839). — " Of 
the five cases of diseases of the skin to which I propose to direct your 
attention to-day, there are, as I have said, two of porrigo favosa, the 
only two cases of this kind we have had in my wards during the last 
six months. One of the cases was an example of the worst form of 
porrigo favosa; that is to say, of great extent and of long duration. 
The other was more limited, and of much shorter duration. There 
was no difficulty in recognizing the physical characters of the disease 
in either, although they were much more marked in the former than 
in the latter, both as to the cup-shaped appearance and colour of the 
pustules, and the patches formed by their extension and subsequent 
union. But as some of you may not be aware of what constitutes the 
elementary character of porrigo favosa, I may repeat what I stated on 
a former occasion, that this contagious pustular affection of the scalp 
consists in the presence of what is called the favous pustule. This 
pustule is formed by the deposition of a minute quantity of pus, which 
concretes almost immediately into a pale yellow or straw-coloured 
substance, having a defined circular edge, hardly, if at all, rising 
above the surface of the skin, and surrounded by a slight blush of 
red. The successive effusion and concretion of the matter proceed 
from the centre towards the circumference, in which direction they 
accumulate, and thereby raising the circular edge of the crust, and 
giving to it that cup-shaped appearance by which it is recognized. 
The size of these crusts or concretions, varies from one to two lines, 
to half or three-quarters of an inch in diameter. They are distinct at 
the commencement, but become confluent during their progress, and 
are sometimes confounded together into a large, dry, brittle mass, 
resembling a mixture of sulphur and plaster. Even in this state, 
however, of agglomeration, traces of the primitive or elementary 
character of the disease are perceptible, viz., numerous round or 
irregular depressions, indicating the situation and number of the 
original favi. The most of these appearances you will recognize in 
the description given of the following case of porrigo favosa. 

"William Tobin, set. eighteen, was admitted on the 6 th of April. 
He is of a scrofulous habit and sanguineous temperament, and has 
enjoyed very good health, with the exception of headache, induced 
by the eruption on the scalp, which first appeared eight years ago, 
and has continued up to the present time, gradually getting worse, 
being attended with considerable itching and smarting, especially in 
warm weather. 

" On admission, the head was the seat of an extensive eruption, occu- 
pying the upper, anterior, and posterior parts, and the patient stated 
that at one time it extended over the eyebrows. On all these parts the 
eruption does not present the same characters. On the upper, ante- 
rior, and lateral parts of the head, towards the temples, it presents 
the characters of porrigo favosa; over the occiput, those which bear 
a resemblance to the granular form of impetigo. On this part the 
hair is plentiful, but short and crisp, whereas on the former parts few 
traces of it remain. The most advanced part of the favus eruption 
presents patches, distinct from each other, five in number, and from 
one to two inches in diameter, of an irregular, but somewhat circular 
figure. The margin of each patch is uneven, thick, and elevated; 
its surface rough, dry, and fissured, of a yellowish-white colour, 
very much resembling a mixture of sulphur and mortar, more ele- 
vated in some parts than in others ; of a loose texture, and in many 
places cellular, assuming the appearance of honeycomb. Besides 
these large patches, constituting the advanced form of the disease, 
and the result of the accumulation of the concrete secretion, and 
agglomeration of the original pustules, these latter are seen in a few 
situations, presenting their elementary characters; that is to say, they 
appear in the form of small, flat, straw-coloured pustules, quite dis- 
tinct, with an elevated border, depressed centre, and slightly inflamed 
base. The intervening skin over a great part of the scalp" is red, in 
several parts greatly congested, and traversed by numerous varicose 
vessels. There is considerable itchiness, but no great heat. Nume- 



204 



PUSTULE. 



rous large pcdiculi burrow in the fissures and sulci of the larger 
patches, and among the roots of the hair, on the posterior part of the 
bead. The whole surface exhales an offensive and nauseous odour. 

" The lymphatic glands of the neck and left axilla are greatly en- 
larged and very hard. The general health is pretty good ; appetite 
very good ; tongue clean ; bowels regular ; urine not albuminous ; 
impulse of heart too strong and too extended. 

" From the remarks I have made on the elementary characters of 
this form of pustular eruption of the scalp, you will readily recognize 
in the description of this case, the porrigo favosa. There is no other 
pustular eruption with which it could be confounded, except the por- 
rigo scutulata ; and here the mistake would be of little importance, 
as it is a disease of the same nature, similar in its elementary charac- 
ters, arising, like the former, in the favous pustule, — communicable, 
like it, by contagion, and requiring the same means of treatment. 
The porrigo favosa is a disease which, when once seen, can hardly 
ever be confounded with any of the other and more common non- 
contagious pustular eruptions of the scalp ; all its physical characters 
are so peculiarly well marked, and leave a defined and lasting im- 
pression on the mind. Those of you who have not seen this case 
when the patient was admitted, and before the incrustations were 
removed, may now obtain an accurate idea of the original appear- 
ance of the disease, so faithfully represented by Mr. Tuson in the 
wax model before you. 

"The extent of the disease in this case, the great length of time 
which it had existed, and especially the extremely unhealthy condi- 
tion of the scalp in general, were circumstances which combined to 
render the cure both tedious and difficult. It is easy to remove the 
incrustations, however extensive, by repeated poulticing; but the 
morbid condition of the tissue of the scalp, and of the bulbs of the 
hair, often resist, for a long period, the most assiduous and judicious 
use of remedies. It is not so much the reproduction of the original 
disease that retards the cure, as the repeated production of other pus- 
tular and vesiculo-pustular eruptions, the consequence of the diseased 
state of the skin. It is this latter, therefore, which we have chiefly 
to combat in bad cases of porrigo favosa, and to which, in this case, 
after the removal of the incrustations, the principal part of the treat- 
ment has been directed. After the application of poultices for two 
days, the scalp was completely cleansed of the incrustations. The 
hair was clipped short, and for some time the poultices were con- 
tinued during the night, and the water-dressing applied during the 
day. Under this simple antiphlogistic treatment, considerable im- 
provement followed, and was afterwards farther advanced by the 
occasional application of leeches to the most inflamed and congested 
parts of the scalp. With the same view, and also to diminish the 
tension and turgescence of the scalp, and effect the obliteration of 
the vessels with which it was so thoroughly penetrated, scarification, 
by means of a fine scalpel, was had recourse to, but could not be 
persevered in to any extent, in consequence of the great pain com- 
plained of by the patient. I expected to have derived great advan- 
tage from this method of treatment, which I have found extremely 
successful in chronic cases of circumscribed impetigo of this part of 
the body, accompanied by great thickening and vascularity of the 
scalp. It removes the tension of the affected part, diminishes the 
swelling, empties the enlarged vessels, and affords a free issue to the 
puriform secretion, which is either infiltrated, or exists in the form of 
numerous small abscesses. 

" During the early progress of the case, copious eruptions of achorous 
pustules took place from time to time. This was occasioned chiefly 
by the use of the linseed poultices, and which always happens when 
not made of the fresh material. This occurrence, however, was 
obviated by using the potatoe poultice instead, the pustules which 
now make their appearance from time to time, being comparatively 
tew m number. During the last two weeks, or more, these poultices 
have been applied at night, and a lotion of the subacetate of lead, or 
the simple water-dressing, during the day. Leeches, also, from eight 
to ten in number, have been applied several times, to the most in- 
flamed parts, during this period. 

" The improvement which has been effected by these antiphlogistic 
means has been very considerable ; but there is yet much to be done 
to accomplish a cure of the disease. Although the tumefaction and 



vascular turgescence of the scalp have nearly disappeared, there are 
still much redness and tension, which will require the same means of 
treatment for some time to come. When these morbid conditions 
have been still further reduced, and should we retain this patient a 
sufficient length of time in the hospital, as an in-patient, we may 
then employ, with advantage, various stimulating, or otherwise, 
modifying agents, such as alkaline and sulphureous lotions, the 
nitrate of silver, and other remedies of this kind, which experience 
has shown to be useful in the last stage of severe cases of porrigo 
favosa. 

"In the treatment of this case we have not had recourse to the 
removal of the hair, recommended by several dermatologists, as a 
necessary part of the treatment of this disease. I am not disposed 
to attach much importance to this practice. At all events, the remo- 
val of the hair may be accomplished much more easily and speedily 
by the use of the alkaline ointment, or lotion, recommended by Biett, 
than by any of the means formerly employed. The ointment may 
consist of from one to two drachms of the sub-carbonate of potash, 
or of soda, to an ounce of hog's lard ; and the lotion of the same 
quantity of these salts to a pint of water. 

"I may remark, that the parts which were covered by the incrusta- 
tions remain perfectly bald ; the skin is quite smooth and glossy, and 
presents a somewhat reticulated aspect. Owing to the long duration 
and severity of the disease, there is no probability that the hair will 
ever be reproduced. In milder cases this sometimes happens, the 
new hair, however, having a somewhat woolly and crisp appearance. 

"No general treatment has been employed in this case further than 
attention to the state of bowels, and the use of the iodide of potas- 
sium, which was indicated from the scrofulous enlargement of the 
lymphatic glands of the neck. It is doubtful whether any favourable 
change has followed its administration. If these glands are less hard 
than formerly, they are certainly not diminished in bulk. 

" Causes. — I may say a few words on the supposed causes of por- 
rigo favosa. It is, in itself, contagious, communicable by contact; 
but it occurs in many instances independently of this source, under 
a variety of circumstances, as to age, sex, and constitution. Biett 
states that its development is excited under a variety of circum- 
stances, such as a deficiency of the necessary articles of food ; misery 
and filth ; living in unhealthy, ill-aired, damp situations. That it 
occurs chiefly in persons of a soft, lymphatic, and highly scrofulous 
constitution, although it may be met with in young persons present- 
ing all the attributes of health and strength. Under such circum- 
stances, it is obvious that we are, as yet, ignorant of the real cause 
of this disease, as well as of that state of the constitution which ren- 
ders individuals susceptible of its contagious influence ; for it is not 
always transmissible by contact, as has been proved by experiment ; 
and many boys in the same school, equally exposed with those who 
contract it, escape altogether free from it. 

"The second case of porrigo favosa is a good example of the 
disease, occurring in an otherwise healthy child, of five years of age. 
We have not been able to obtain a full history of the case. The 
father is said to have had a scorbutic eruption on the face. A brother 
and sister have had eruptions on the head, but the precise nature of 
them has not been ascertained. 

" The eruption in this child had existed nearly five months, and 
he was treated for some time as an out-patient. When admitted 
into our wards, a number of favous pustules, and patches of incrus- 
tations, of a pale, yellowish-gray colour, of a brittle consistence, the 
largest not more than the fourth of an inch in diameter, occupied the 
upper and posterior parts chiefly of the scalp. They were accompa- 
nied by very little redness of the surrounding skin ; no exudation, or 
other morbid appearance of the rest of the head. The general health 
was good ; there was no enlargement of the abdomen, no derange- 
ment of the digestive organs ; appetite good ; sleep natural. 

" The elementary characters of the porrigo favosa were readily 
recognized in this case, although not so marked as in the former one. 
Several of the pustules presented the depressed centre and elevated 
border ; and the incrustations, the dry, plastery look and colour pe- 
culiar to them. 

" The favourable state of the general health, the limited extent of 
the disease, and the absence of inflammation of the scalp, except in 



ECTHYMA. 



205 



ECTHYMA. 

Vocab. Ecthyma, Phlyzacia [Papulous Scall]. 

558. Ecthyma is a non-contagious inflammation of the skin, cha- 
racterized by largish prominent pustules, seated on a hard, circular, 
bright-red base. 

These pustules, entitled phlyzacia by Willan, are almost always 
distinct, and usually make their appearance in succession, on one or 
several regions of the body. When they dry up they become covered 
with thick brown-coloured and adherent crusts: these, after their fall, 
leave red marks on the skin, the centres of which very commonly 
present a small cicatrice. 

Willan has described four species of ecthyma: ecthyma vulgare; 
ecthy. infantile; ecthy. lividum; ecthy. cachecticum; founded on the 
various appearances of the eruption, the intensity of the accompanying 
inflammation, the more or less rapid progress of the pustules, and the 
state of constitution of the individual affected. These modifications 
of the disease do not, however, seem to me, to be adopted on grounds 
sufficiently stable to give them a title to be recognized at the present 
day as more than mere varieties, and I prefer the simpler and more 
practically useful division of the disease, into, 1st. acute, and 2d. 
chronic ecthyma. 

559. Symptoms. Ecthyma occurs on every region of the body ; but 
it is principally observed on the shoulders, neck, extremities and 
breast; it very rarely appears on the hairy scalp. I have seen it 
forming a kind of belt round the trunk. It occasionally invades 
almost the whole surface of the body, but is much more frequently 
confined to a single region. 

560. In its most simple, but also rarest shape — that, namely, which 
is acute — ecthyma is proclaimed on some region or regions of the body, 
(those of the neck and shoulders most frequently,) by large, distinct, 
hard, conoidal, and painful red elevations, the size of which varies 
between that of a lentil, and that of a large pea. Their base, which 
is of a vivid-red, spreads at the same time that the prominence of 
their summit increases. A purulent point is before long seen in 
their centre. In this state, the larger pustules bear a considerable 
resemblance to small boils. When suppuration is fairly established, 
they often present a little black point, which at a later period is suc- 
ceeded by a larger brown-coloured crust, very adherent to the skin, 
and set or incased as it were within its substance. The eruption of 
the pustules of ecthyma is completed within a few days. 

In this mild form of ecthyma, to which the species entitled vulgare 
by Willan, belongs, the crusts are detached within a week or two. 
After their fall, a few marks, from six to eight lines in diameter and 
of a livid-red colour, remain on the skin, in the centre of each of 
which a small cicatrice, having some analogy to that of a small-pox 
pustule, but differing from it in being shallower, is usually perceived. 

On a careful examination of the structure of the pustules of ecthyma 
at different periods of their development, we find 1, that in their first 
stage {red elevations) there is merely sanguineous injection, with 
conical tumefaction of the corion ; 2. that in the apex, more rarely 

the immediate vicinity of the patches, were circumstances which 
augured a speedy, and, probably, permanent cure of the disease. 
The incrustations were removed by poultices, and the head cleansed 
by frequent ablution with warm water and soap. The alkaline oint- 
ment was afterwards used for some time to effect the removal of the 
decayed hair, and also to stimulate the less inflamed parts of the 
diseased cutis. And, lastly, the nitrate of silver was applied to 
those points where fresh pustules appeared, or where the skin was 
excoriated. No trace of the eruption remained at the end of six 
weeks, except complete baldness of the parts which the former had 
occupied. Full diet was allowed, and the bowels were regulated by 
occasional small doses of calomel and rhubarb. 

" The success which followed the use of the nitrate of silver in 
this case, was partly attributable to the circumstance of the disease 
having ceased to spread, although it certainly also arrested the de- 
velopment of several pustules which appeared during the progress of 
the treatment." 
52 



over the whole surface of the elevations, and under the cuticle, there 
is an effusion of a certain quantity of purulent serum ; 3, that in the 
third stage, which follows immediately after, there is a kind of pseudo- 
membranous matter deposited in the centre of the elevation, which 
is now evidently perforated; 4, that after the voidance of this matter 
and the removal of the cuticle, the pustule appears under the form of 
a cup-shaped cavity, surrounded by a hard, thick, puffed edge ; 5, 
lastly, that on the following days this thickened margin subsides, at 
the same time that a slight cicatrice is formed under the crust, the 
centre of which is fixed within the point where the perforation had 
been observed. 

When the pustules of ecthyma are coherent, a circumstance that 
happens but rarely, two pustules thus conjoined may seem to form 
only one, the circumference of which is irregular in its shape. The 
epidermis is then raised over a large extent of surface ; and if, after 
having removed this, the purulent serum, with which the epidermis 
is bathed, be wiped away, two circular and contiguous borders are 
perceived, in the centres of which a small perforation with a false 
membrane at the bottom is distinguished. 

The development of the pustules of acute ecthyma is accompanied 
by rather severe pain of a lancinating kind, especially when the 
pustules are clustered upon a single region of the body. The pain 
in this case seems analogous to that which usually precedes and 
accompanies shingles. The lymphatic glands in the neighbourhood 
of these pustules are occasionally swelled and painful. 

The pustular inflammation of ecthyma may be preceded or com- 
plicated with disorder in the functions of the digestive organs, which 
occasionally continues after the cure of the disease. It is seldom that 
this variety of ecthyma is accompanied with fever. 

561. Chronic ecthyma is a much more common disease than that 
which has just been described, and consists in several successive 
eruptions, which appear on the neck, extremities, and occasionally 
even on the face, at intervals more or less remote from each other. 
Each of these eruptions presents features in its course analogous to 
those which distinguish acute ecthyma. Whilst several of the pus- 
tules are appearing under the form of large red elevations, others are 
suppurating, and others are drying off and cicatrizing. It is not un- 
common for several eruptions of such phlyzacious pustules to take 
place over different regions of the body within the space of a few 
months. 

Besides this particular mode of making their appearance, the pus- 
tules of chronic ecthyma occasionally exhibit peculiar characters. In 
persons advanced in life, of indifferent constitution, affected with 
ulcers, &c, very large pustules are occasionally observed to be pro- 
duced, with bases very similar in appearance to those of furuncles. 
The voluminous elevations which signalize their earliest stage, have 
a deep red tint from their first appearance ; the skin swells very 
slowly; the cuticle, distended with a blackish or sanguinolent serum, 
gives way at the end of six or eight days ; the centres of the eleva- 
tions soften, and become covered with a thick crust, which is promi- 
nent, black, very adherent, set, as it were, within a rim of the skin, 
and is not loosened before the lapse of several weeks. 

When this crust is accidentally detached, or when it is removed 
by means of topical applications, it is found to conceal a small ulcer. 
Left to itself, this ulcer hardly becomes covered with a fresh scab ; 
its surface discharges a sanious fluid. 

These small ulcers may continue open for a very long time, and 
even spread, especially when they are situated on the lower extremi- 
ties. When they are at length healed up, they leave cicatrices 
behind them, which long continue of a livid or violet colour. 

In weakly and ill-fed children, attacked with chronic inflammation 
of the abdominal viscera, or convalescent from small-pox, this variel y 
of ecthyma (Ecth. infantile, Willan) is frequently observed with this 
peculiarity, that the pustules are generally of very inferior size. 

562. When there exists but a small number of pustules on tie 
surface, when several successive eruptions have taken place at inter- 
vals rather remote from each other, and the disease is altoo-ether 
uncomplicated, chronic ecthyma is not accompanied by morbid symp- 
toms of a general nature. The rather frequent complication or 
coincidence of chronic inflammatory affections of the thoracic and 
abdominal viscera with ecthyma, among children and the aged of 



206 



PUSTULE. 



indifferent constitution, explains the circumstance of the generality 
of authors having spoken of such symptoms as anorexia, pain of the 
rtrium, irregularity of the bowels, cough, headache, pains in the 
: imbs, sense of lassitude, loss of muscular strength, &c, as forming 
part of the disease when it attacks these two classes of subjects. 

Willan and Bateman have mentioned concomitant inflammations 
of the conjunctiva and mucous membrane of the pharynx ; but I am 
led to believe that the greater number of the ecthymas of this descrip- 
tion of which they speak, were due to a syphilitic cause (Vide syphi- 
litic phlyzacia). 

Ecthyma occasionally occurs during the exacerbations of lichen 
prurigo, scabies, and several other chronic inflammations of the skin ; 
and the disease is a very frequent attendant upon convalescence from 
sraall-pox. 

The continuance of chronic ecthyma, dependent on the number of 
successive eruptions that take place, and the state of the constitution, 
occasionally extends to a period of three or four months. The con- 
comitant affections, if any exist, may get well before the pustules or 
continue after their disappearance. 

563. Causes. — Ecthyma attacks individuals of every age and of 
every variety of constitution ; (a) it occurs at all seasons, but is met 
with more particularly during spring. A cold and damp habitation, 
filthy clothing, and indifferent food are causes common to this and 
a great number of other affections of the skin. Ecthyma is not 
a contagious disease, and its appearance may correspond with a dis- 
ordered condition of the functions of the stomach and bowels. 

564. Diagnosis. — Whether ecthyma be acute or chronic, and consist 
in one or several successive eruptions, its voluminous and prominent 
pustules present characters which at all times prevent their being 
confounded with the other diseases of the skin. Mistake is impossi- 
ble when its large pustules are compared with those of impetigo, of 
rosacea and of favus. When the pustules of acne and of sycosis 
present a large, hard, and red base, they might more readily be 
taken for pustules of ecthyma; but the pustules of the two former 
are evolved on indurated rather than on inflamed bases, and their 
modes of development and termination are very different from those 
of ecthyma. 

The pustules of ecthyma are neither umbilicated nor contagious, 
like those of variola and vaccinia. 

Ecthyma occurring in unhealthy subjects, might be readily con- 
founded with a certain variety of pustular syphilis (ecthyma syphili- 
ticum). This uncertainty, however, can only occur in those cases in 
which the eruption of the pustules of ecthyma has taken place in a 
slow and successive manner (chronic ecthyma). Further, syphilitic 
phlyzacia are seldom surrounded by an areola so broad as the pustules 
of ecthyma ; the colour in each class of pustules is also different, 
being of a purplish or livid red in ecthyma, and commonly coppery 
in the syphilitic affection. The scabs of syphilitic phlyzacia are 
usually of considerable thickness, frequently nearly black and almost 
uniformly circularly furrowed. The ulcers that succeed them are 
deep and excavated, and are constantly followed by depressed and 
indelible cicatrices. Lastly, it is very seldom that syphilitic pustules 
are not accompanied by other venereal symptoms calculated to throw 
light on their true character; without these, indeed, the real nature of 
many phlyzacious eruptions would frequently remain obscure, especi- 
ally when they are developed among the cachectic and ruined in 
constitution. 

The small pointed pustules of scabies have no analogy with the 

(a) The majority of cases of ecthyma occur in young men, who, 
with constitutions originally not of the strongest class, had" imprudently 
indulged in excesses and irregularities to a very great extent, accom- 
panied by privation of rest and other depressing circumstances. Very 
frequently in such cases it is mistaken for a venereal eruption, and 
the patient himself is readily made to believe in an opinion which his 
habits have made so probable. If mercury be had recourse to, under 
these circumstances, the disease is much aggravated, the dried scabs 
of which it is constituted grow on the part rapidly, becoming of a 
dark-brown colour, exceedingly hard and of a conical form, repre- 
senting in fact on a minute scale, the characters of the disease termed 
Rupia. Plumbe (op. at., p. 303 . 



large pustules of ecthyma ; when these two eruptions occur accidentally 
in the same individual, it is always easy to detect the complication. 

565. Prog7iosis. — The prognosis in ecthyma varies according to the 
number of eruptions, the state of the constitution, the nature and gravity 
of the concomitant lesions, the age of the patient, the evident possibility 
or impossibility of removing from beyond the influence of the causes 
that appear to have produced the disease, &c. Acute ecthyma always 
gets well in the course of two or three weeks ; chronic ecthyma may 
continue for many months. 

566. Treatment. — If the eruption in acute ecthyma is confined to a 
few scattered pustules, and exists without complication in an indi- 
vidual otherwise well constituted, diluents must be prescribed, the use 
of the simple cold or temperate bath enjoined, whilst a regular and 
unstimulating plan of life is pursued. If the eruption proves more 
copious, and is attended with much pain, if it appears complicated 
with furuncles, and the individual affected is young and vigorous, a 
general bleeding should be practised, and the cool and temperate 
bath repeated more frequently. 

The health of those who are labouring under chronic ecthyma 
having frequently suffered from various other inflammatory affections 
of long standing, these are the serious diseases, the grave disorders 
of the constitution which it is of the last consequence to watch and 
attempt to subdue. A light, nutritious and restorative regimen, suited 
to the state of the digestive organs and of the constitution ; aromatic 
or sulphureous baths prolonged in various degrees, and repeated two 
or three times a week, or alternated with baths of some saline mineral 
water, added to tonic and chalybeate medicines internally, must form 
the elements of the curative plan in such complicated cases. 

When chronic ecthyma appears in an infant at the breast, it is of 
the highest importance to ascertain the qualities of the milk it is re- 
ceiving; a change of the nurse may become essential to ensure the 
success of the general therapeutic means employed ; this measure 
alone, indeed, frequently suffices to give a favourable modification 
to the constitution, and, as a consequence of this, to cure the com- 
plaint. 

The ulcers which chronic ecthyma occasions when it attacks the 
lower extremities of elderly persons, have generally an unhealthy 
appearance, and are very slow in getting well. It is often found 
necessary to stimulate these by touching them with the nitrate of 
silver, or by bathing them repeatedly with some aromatic decoction, 
by using a solution of the chloride of lime as a wash, or powdering 
them with cream of tartar, (a) 



Historical Notices and particular Cases. 

567. The word ecthyma, employed by Hippocrates, 1 in a sense 
which the translators have interpreted by the Latin pustula, is applied 
in many passages to eruptions, the description of which is so incom- 
plete that by some they have been held to be small-pox, by others a 
species of typhoid exanthema. 2 

Willan was the first modern writer who gave the title of ecthyma 
to the disease that has just been described, the characters of which he 
has portrayed with great distinctness. But few cases of the disease 
are to be found in our periodical publications. Several incomplete 
accounts of eruptions of a great number of small furuncles ; of pustular 
and crusted tetters (dartres) ; of a singular disease of the skin, &c, give 
mere occasional glimpses of one or two of the characters of ecthyma. 



(a) Deprived of the use of mercury in ecthyma, for reasons assigned 
in the text, we can, in requital, have recourse to an alterative scarcely 
less diffusive and searching in its operation, and yet safe in its general 
and ultimate effects. Iodine is the article to which I refer. Its salt the 
iodide of potassium, and in the more decidedly cachectic or chronic 
forms of the disease, the iodide of iron will meet the desired indica- 
tions. As a topical remedy the ointment or the liniment of the iodide 
of potassium, will come in aid of the substances mentioned in the 
text. 

1 Hippocrates. Epidem., lib. iii. 

2 Forestus. De febri pestilente in qua ecthymala et exanthemata apparebant, lib. 
vi. p. 240. 



ECTHYMA. 



207 



I subjoin a few particular cases of the disease, and several others may 
be found in the dissertation of M. Asselin. 1 

Case LXXXIX. — Acute ecthyma of the scalp. A young woman, after 
feeling the hairy scalp excessively itchy for some days in the begin- 
ning of August, 1820, was attacked in this part with ecthyma. Large 
phlyzacia, containing a purulent fluid, were evolved over the entire 
surface, and especially on the frontal and occipital regions of the 
scalp. This inflammation was attended with painful swelling of the 
lymphatics of the neck. The pustules were not visible except when 
the hair was parted. After continuing for seven or eight days, they 
all became covered with crusts, which, on falling off, discovered 
brown and violet-coloured marks on the surface of the skin. The 
integuments in every other situation were perfectly healthy ( Venes. 
ad iviii ; infusion of endive for drink); after the lapse of a week eight 
leeches were applied around the back part of the neck, and three doses 
of purgative medicine were subsequently prescribed at intervals of 
four days ; at the end of a month no traces of the disease remained, 
except a number of violet-coloured marks in the situations which had 
been occupied by the pustules. 

Case XC. — Successive eruption of large ecthymatous pustules on the 
left lower extremity; pulmonary catarrh. Antoine, forty-two years of 
age, consulted me on the 1st of March, 1826, on account of some 
large pustules with inflamed bases, which had appeared three weeks 
before on his left thigh. 

On the 10th, the following circumstances were observed: 1. A 
very large pustule near the inner condyle of the femur, covered on 
its summit with a small black point. This pustule, with its areola, 
is nearly three-quarters of an inch in diameter. 2. Another still 
larger pustule, on the fore part of the thigh, the suppurating surface 
of which is from three to four lines across, whilst its base, formed by 
a broad areola, is hard, tumid and deep. These pustules are the 
seat of severe lancinating pains. On the fore part of the thigh there 
exist a dozen spots or marks, of a reddish-brown colour and circular 
shape, which have been produced, according to the patient's account, 
by the pustules that first made their appearance. 

The patient complained of nothing save of a slight pulmonary 
catarrh, which had not prevented him from following his business of 
a hat-maker; (mucilaginous drink; the warm bath; magnes. sulph. 
§ss.) This prescription was repeated three times in the course of six 
days. The tops of the pustules became covered with yellowish- 
brown scabs. The warm bath and mucilaginous drink were con- 
tinued for a week. The crusts were detached without the expulsion 
of any sloughy core, and left two small cicatrices on the skin sur- 
rounded by a dusky violet-coloured areola. No fresh pustules were 
thrown out. 

Case XCI. — Ecthyma ; successive eruption of phlyzacious pustules 
on the left forearm and nucha; cceco-colitis. On the 20th of March, 
1822, I had a little girl, eleven years of age, brought to me, on 
account of a number of pustules which had made their appearance 
on the left forearm. They were in different stages; three were 
nascent, and consisted in mere red and papular-looking elevations, 
surrounded with broad areolae ; five were in the state of true phlyza- 
cious prominent pustules, and about three-quarters of an inch in 
diameter, including the areolae. Their bases were hard and deep, 
their summits filled with a purulent sanies. One was excoriated, 
from having been torn by the patient with her nails. Three others 
of the same size, surrounded with dusky areolae, were covered with 
prominent scabs of a greenish-brown colour, and very adherent to 
the skin. These pustules were affected with shooting pains of con- 
siderable severity. Three violet-coloured marks were also visible 
on the skin, less depressed than those of small-pox, but about the 
same size. This eruption was unaccompanied with fever; the tongue 
was clean, the appetite good ; yet the abdomen was distended and 
tympanitic ; and for the last eight or ten days, four or five liquid 
dejections had been passed every four and twenty hours. Slight 
pressure in the course of the colon evidently occasioned pain (six 
leeches to the verge of the anus ; mucilage ; tepid bath of an emollient 
decoction ; diet ; beef-tea with bread). The intestinal symptoms yielded 
to this treatment in little more than a week. The nascent pustules 

1 Asselin. Essai sur 1'ecthyma, 4to. Paris, 1827. 



advanced; the scabs of the others were detached. A fortnight after 
her first visit, a fresh crop of five or six pustules made ks appearance, 
one of which acquired such dimensions, that at first sight it might 
have been mistaken for a boil. The treatment was continued, and 
these pustules declined like those that had gone before them. The 
disease seemed ended, when a third eruption made its appearance on 
the nape of the neck, and in the course of the next fortnight many 
phlyzacious pustules were successively evolved on the occipital region 
of the scalp. Some of the lymphatic glands of the neck inflamed ; the 
affected parts were painful, and the sleep of the patient became dis- 
turbed (tepid mucilaginous baths every other day ; cataplasms of mal- 
lows to the nucha). Three weeks of this system sufficed to put an 
end to these symptoms; the pustules disappeared, leaving small 
violet coloured spots behind them, and the little patient got qui'e well. 

Case XCII. — Ecthyma cachecticum ; phlyzacious pustules succes- 
sively developed on the forehead, trunk and extremities ; tympanitis. 2 
" J. H., aged twenty-three years, a sailor, was admitted into the Penn- 
sylvania Hospital on the 7th of May, 1825. He stated, that, in the 
month of February, while in Havana, without his having experienced 
any constitutional indisposition, he was suddenly affected with an 
eruption on his forehead. It commenced in the form of small pus- 
tules, the summits being of a whitish colour, the bases red and 
inflamed. The disease successively extended to other parts of his 
body, affecting the trunk and the extremities ; his hands, feet, and 
the flexures of the joints, however, remained perfectly healthy. 
At the period of making the record, it is stated, that in some 
instances, the pustules had been converted into dark brown scabs, 
of various extent, from one-eighth to half an inch in diameter. 
This was particularly observable on the forearms. On the breast, 
the pustules presented the character of concreted pus, and had not 
assumed the brown colour. On his forearms, the skin surround- 
ing the eruption was generally inflamed, and of a dark cochineal 
red. On the breast, the hue was more various, affording all the 
shades from the light lake to the dark cochineal red. On this 
part of his body there was noticed a discoloration of the skin, re- 
sembling the pityaris of Willan ; and spots of a colour between the 
ash and pearl-gray, were perceived more especially upon the trunk, 
which were supposed to be cicatrices, the seats of former scabs that 
had desquamated. At the period of his admission, his ankles were 
swelled, and we observed tumefaction and tenderness of the gums, 
from which there occasionally issued a little blood. His muscular 
strength was impaired ; his appetite was good, and his alvine dis- 
charges regular; his skin was warmer than natural, and dry; his 
pulse 100, small, and wiry. He was put on the free use of fruit, and 
fresh lemon-juice, and his body was regularly washed with warm 
water and bran. 

" From this treatment, on the 25th of May, there was an apparent 
improvement in his general health ; his skin had become soft and of 
natural temperature ; his pulse 100, and no longer wiry. He had, 
however, suffered more hemorrhage from his gums, which had been 
restrained by a gargle of myrrh. Many of the scabs had fallen off, 
leaving slight depressions, at first, of a faint red colour, and which 
afterwards became of an ash or pearly-gray, as expressed in the first 
report. He was now directed to take a fluid drachm of the tincture 
of sulphuric acid, with a pint of an infusion prepared with quassia, 
serpentaria and orange-peel. 

" On the 1st of June, the eruption had nearly disappeared from the 
forehead. On the trunk, and the extremities, more of the scabs had 
fallen off, and the colour of the skin had considerably faded. 

" On the 8th of June, though the eruption was evidently disappear- 
ing rapidly, it was deemed necessary to vary the prescription, in con- 
sequence of the man's having become tympanitic. His abdomen was 
tumid and elastic, and afforded no fluctuation on percussion. He 
stated that the distension was most obvious in the morning ; that he 
was much troubled with flatulence, and that he experienced great 
relief, accompanied by an evident diminution of the swelling, on the 
discharge of wind. His urine was natural, both in colour and quantity ; 
his bowels open ; his tongue clean ; his pulse 100, and feeble. He 
was now directed to take the carbonate of iron and the resin of <maia- 

2 Thos. T. Hewson, M. D. Case of ecthyma cachecticum. (North Amer. Med. and 
Surg. Journ., Jan., 1826.) 



208 



PUSTULE. 



cum; of each ton grams, with five grains of powdered capsicum, 

mi. < a day, instead of the acidulated bitter infusion. The 
ablutions with warm water and bran were continued. These means 
operated beneficially ; the tympanitic affection subsided ; the scabs 
continued to (all off; and a considerable portion of the skin had 
resumed a healthy colour. On the 15th, however, in consequence of 
his bowels being very frequently disturbed, it was deemed advisable 
to substitute ten grains of powdered gentian, in the place of the resin 
of guaiacum. In this form the medicine was continued until the 
22a, when he requested permission to leave the hospital ; at which 
period he was reported to be nearly well." 

" The case I have recorded, will be readily recognized as the 
ecthyma cachecticum of these writers. In some features, shades of 
difference will be perceived, perhaps not essential, but only indicating 
an individual variety, and, probably, dependent on the same dis- 
ordered state of the system. The pityriasis which I have noticed, 
has been frequently observed, in connection with slight disturbance of 
the constitution ; and is by no means incompatible with that condition 
which is found to precede and to accompany the eruption of ecthyma. 
The spots, of a pearl or ash-gray colour, which appeared on the de- 
squamation of the scabs, have not been described by those who have 
written on the pustular diseases of the skin ; nor do I recollect to have 
observed such before. They may, therefore, be deemed purely acci- 
dental, or as marking some peculiar condition of the skin in the indi- 
vidual whose case has been noticed. Slight febrile symptoms are 
generally observed to usher in the first appearance of the eruption, 
and some degree of hectic or erethism accompanies the progress of 
the disease. Languor, depression of spirits, and prostration of the 
muscular powers, are ranked among the accompanying symptoms. 
Weakness of the digestive organs is likewise a usual attendant. In 
this man, the appetite is stated to have been good ; yet the tympanitic 
affection of the bowels affords sufficient evidence, that the function of 
these organs was imperfectly performed. The swelling of his ankles, 
and the hemorrhage from his gums, exhibit proof of a depraved con- 
dition, approaching to scurvy. The duration of the disease corre- 
sponded with general observation, two and four months frequently 
elapsing before the cure can be effected. 

" The previous history, or a knowledge of the causes leadingtothe 
production of the disease, cannot be collected from the present case. 
Very particular inquiries were made ; but with all their general repu- 
tation for frankness and candour, we often find sailors little entitled to 
confidence, in the narrative they give of their real habits, or of the places 
they have frequented. This defect of evidence excited in some who 
witnessed the case, strong suspicions of its connection with a syphilitic 
taint. Against this error, it is of importance to guard ; for too many 
persons affected with such eruptions, have been subjected to repeated 
and unavailing courses of mercury. That syphilis, in its secondary 
forms, ever assumes the character of ecthyma, has been denied by 
some very intelligent practitioners ; and it will be readily conceded 
by every man of experience, that the diagnostic signs of the syphilitic 
forms are extremely equivocal, and that, in most instances, ecthyma 
can be traced to causes totally independent of such contamination. 
Though frequently observed in persons whose constitutions have been 
impaired by the previous ravages of the disease, or by the debilitating 
processes employed for its removal, it yet remains to be proved that 
the appearance of ecthyma can be essentially traced to a syphilitic 
origin. Should the alliance be established, we may hope, from the 
prevailing spirit of investigation, and from the minute attention paid 
to pathological distinctions, that the discriminating characters will not 
remain veiled in obscurity. From a careful perusal of the best writers, 
and from attentive observation in the treatment of ecthyma, I am in- 
clined to believe, that in most instances, the cure will be most speedily 
accomplished without the use of mercury, though this mineral con- 
stitutes one of the most efficient remedies in certain defedations of the 
skin. Where there exists a discrepancy of opinion among those 
whose experience is entitled to respect, it is incumbent on us to 
examine scrupulously, and to weigh all the circumstances, in order 
to attain an accurate knowledge of the curative indications to be ful- 
filled. 

" Under the impression, that the production of ecthyma is con- 
nected with a state of cachexia, our efforts will be directed to the 



removal of this condition, and to the imparting of a due degree of 
tone and vigour to the system. To this end, on many occasions, a 
regulated diet, consisting of such articles as afford a nutriment bland 
and easy of digestion, will prove sufficient. At the same time, atten- 
tion should be paid to personal cleanliness, in the use of the tepid 
bath ; or this purpose may be conveniently accomplished by frequent 
ablutions with warm water and bran. With the same intention, we 
find various farinaceous decoctions, and water impregnated with vege- 
table mucilage, as obtained by boiling the bark of the slippery-elm 
highly recommended. These topical means facilitate the desquama- 
tion of the scabs, and by softening and cleaning the cuticle, assist in 
restoring the skin to a sound and healthy condition. 

" When the strength has been more deeply impaired, benefit will 
be derived from the administration of the vegetable tonics ; as, the 
decoction of cinchona, serpentaria, sarsaparilla, &c, either simple, or 
in the more compounded preparations. To these, the mineral acids 
are often advantageously added. I have lately visited a patient, 
affected with the disease, after a severe attack of typhus. The man's 
face was greatly disfigured, and he was rendered a most loathsome 
and disgusting object. In this case, yeast, exhibited to the extent 
of a pint and a half daily, has afforded the most positive relief, actin^ 
as a grateful cordial ; while the mildest officinal bitters, and the con- 
serve of roses, excited intolerable distress, in consequence of the 
extreme tenderness of his mouth and throat. 

"In persons labouring under constitutional irritation, the decoction 
of sarsaparilla, in combination with antimonials, has proved eminently 
serviceable. But on many occasions, our chief reliance must be 
placed in the free exhibition of opium, cicuta, stramonium, or other 
narcotics. 

" In the more protracted forms of ecthyma, change of airand gentle 
exercise will contribute essentially in strengthening the system, and 
in shortening the disease." («) 



(a) In place of an abridgment of this case, I have inserted the 
original paper by Dr. Hewson, with the omission of a few remarks 
on the terminology of the disease. 

The following case is given by Dr. A. T. Thomson, in his edition 
of Bateman's Synopsis: — " The patient, an unfortunate German gen- 
tleman, having fallen ill of a fever, lost all his employment, and 
became so depressed both in mind and body, that he sunk into a 
cachectic state of habit, and was soon attacked with ecthyma. He 
applied to me on the 27th of June, 1828, two months after the disease 
had made its appearance. The eruption covered the whole of the 
body, with the exception of the hands and the face. The stinging 
sensation was also accompanied with itching, or rather a tingling, 
which induced an involuntary desire to scratch, by which not only 
the heads of the pustules were rubbed off, but large portions of skin, 
in some places two inches in length, and nearly an inch in breadth, 
were torn off by the action of the nails during the sleep. Those pus- 
tules which had run their course had left dark stains behind, so that 
the greater part of the entire skin was covered with these and the 
crusted pustules. When the pustules were early rubbed, black dots 
of effused blood remained. The thighs were covered with ulcers. 
The body was greatly emaciated ; there was a regular evening exacer- 
bation of fever ; the tongue was clean, but red and glazed ; the skin 
felt dry and harsh ; and the patient stated that the delirium attending 
the fever and the depression of mind had driven him nearly to 
commit suicide. The bowels were irregular. The following medi- 
cines were ordered : 

K- Pulv. Jacobi veri gr. iij ; 
Extracti stramonii gr. | ; 

. — Hyosciami gr. iij : fiat pilulae ij. 

Hora somni omni nocte sumendae. 
K- Magnesiae sulphatis 3j ; 

Magnesias carbonatis 9j. M. 
Pulvis omni mane suraendus. 
R- Acidi sulphurici diluti f3xij ; 
Tincturse opii f3iv. M. 
Suraanter rr[xx ex cyatho decocti corticis cinchona? cordifoliac 
ter quotidie. 



ARTIFICIAL PUSTULES. 



209 



PUSTULES PRODUCED ARTIFICIALLY. 

568. Different substances, when inoculated or applied to the sur- 
face of the skin, may cause the development of pustules of various 
forms and dimensions. Several of the eruptions thus artificially ex- 
cited, have been made the subjects of particular study by more than 
one pathologist. 

569. Pustules from the inoculation of animal matters . The title of 
spurious variola or false small-pox used formerly to be applied to 
those pustules which followed the inoculation of variolous matter 
which had become altered or deteriorated by drying, keeping, &c, 
which in a word, had lost its contagious and specific properties. 
Pustules of a like description, engendered by the inoculation of the 
vaccine virus which had lost its peculiar properties, have since been 
entitled spurious cow-pox. The pustules thus excited have, however, 
no analogy with the pustules of small-pox or of cow-pox ; on the 
contrary they bear a great resemblance to the pustules that follow 
wounds with a rusty instrument, impregnated with some irritating 
animal matter. These pustules usually get well spontaneously in the 
course of a week or two. They occasionally end in ulceration when 
they have been irritated by the neglect of proper cleanliness or the 
application of stimulating local applications. By touching their apices 
with nitrate of silver, the inflammation of their bases is lessened, and 
their cure is expedited. 

570. Pustules from the external application of certain vegetable sub- 
stances. Several vegetable substances, externally applied, have the 
property of exciting accidental pustules which either appear alone or 
complicated with vesications and papulae. A patient of mine, affected 
with dropsy, for whom I had prescribed the inunction of half a drachm 
of the extract of aconite incorporated with half an ounce of lard, was 
attacked soon after commencing the use of this application with an 

" When the irritation is severe, let the surface be sponged with hot 
water. Let the diet be milk, fresh-boiled vegetables, and a moderate 
share of mutton under-cooked. 

" July 5th. — Few fresh pustules have appeared ; and the dark colour 
of the blotches is much less. The new pustules contain a mild pus. 
The bowels are regulated by the aperient ; and although the fever 
still returns every evening, yet the delirium which attended it has 
disappeared. He feels, occasionally, as if a cloud had settled upon 
him, and cut him off from all external impressions. The tingling 
and irritation are less, and return only in paroxysms, during which 
he still tears off large portions of the skin. 
Cont. medicamenta. 

&■ Plumbi acetatis 3ss ; 
Acidi hydrocyanici f3iij ; 
Ung. cetacei 3iij. M. 
Fiat unguentum partibus cutis nudatis applicandum. 
" 18th July. He is much better in every respect, and the irritation 
is so much abated, that he can now sleep without excoriating his 
body. He is gaining both in flesh and strength. 
Perstet in usu medicamentorum. 
"August 2d. — The eruption is nearly gone, and the skin is regain- 
ing its natural aspect. He complains of watchfulness, and great 
depression ; but the want of employment and distress of mind seem 
to be counteracting the full powers of the medicines. 
Cont. medicamenta. 

K- Camphone gr. v ; 
Pulveris Jacobi gr. iij ; 
Extracti hyoscyami gr. iij. 
Fiant pilulae ij, h. s. sumendae. 
" From this time the disease rapidly abated, and having discon- 
tinued his applications to me, he became fat, got into health, and is 
now in Germany. 

"The chief feature in the treatment of this case is the combination 
of the tincture of opium with the diluted acid, and the external appli- 
cation of the hydrocyanic acid, in the form of ointment. The opium 
thus combined seemed to allay the irritation, and certainly augmented 
the tonic power of the bark ; whilst the ointment deadened the insup- 
portable itching which had caused the tearing of the skin." 
53 



eruption of prominent pustules, full of an opaque yellowish fluid, and 
surrounded by an areola of the most vivid red. These were asso- 
ciated with solid papular elevations, slightly prominent and contain- 
ing no fluid, between which the skin preserved its natural tint and 
appearance. 

Accidental pustules of this kind may become excoriated. Vial 
mentions the case of a man who had his face made raw from having 
rubbed it with the juice of the euphorbia cyparissias. 

571. Pustules from the application of certain inorganic substances. 
The most remarkable of these pustules are such as follow the applica- 
tion of the tartrate of antimony to the skin, either alone, or mixed 
with hog's lard. In so far as form and size are concerned the pus- 
tules produced by this means have some resemblance to those of 
variola and ecthyma. 1 Artificial eruptions of this kind are usefully 
excited in a great number of different diseases ; of course it does not 
enter into the plan of this work to consider these under a therapeutical 
point of view; I only take the opportunity of stating that hooping- 
cough and chronic inflammation of the larynx are those complaints in 
which they have always appeared to me to be attended with the best 
effects. 

These pustules, at their height, are flattened, and of the size of 
lentils. They contain a pseudo-membranous deposit and some puru- 
lent serum. They almost invariably present a small brown point in 
their centre. Their base is surrounded by an areolar blush two or 
three lines in diameter, which is lost insensibly in the natural hue of 
the skin, or blends with the areola of the neighbouring pustules when 
they are very close to each other. 

On the few next days after their appearance they continue to 
enlarge ; the fluid they contain becomes thicker and whiter ; their 
central brown spots grow larger and acquire a darker hue. If the 
cuticle be removed with a view of examining the interior of these 
pustules, a sub-epidermic pseudo-membrane is found, deposited on 
the surface of the papillae of the corion, which appear elongated, 
injected and often infiltrated with blood. The central crusts become 
larger and larger, the areolae diminish, and the desiccation is com- 
pleted before any long period elapses. On the following days the 
crusts are thrown off, leaving small violet-coloured marks and indeli- 
ble cicatrices of a circular shape upon the skin. 

The pustules are occasionally intermingled with others of smaller 
dimensions, of a semi-globular form and not depressed in the centre. 

The pustules produced by the application of tarfrate of antimony 
are formed with greater or less rapidity, according to the irritability 
of the skin and the quantity of the salt employed. They are larger 
and more painful when they follow the application of the pure tartar 
emetic to the skin by means of a Burgundy pitch plaster, than when 
it is incorporated with lard or spermaceti ointment. In elderly and 
weakly persons the pustules have usually a violet or livid tint ; they 
are then ecchymosed, and contain a quantity of sanguinolent fluid; 
under these circumstances they bear a great resemblance to the pus- 
tules of ecthyma cachecticum and the bullae of rupia. A woman thirty 
years of age entered the hopital St. Antoine on account of a chronic 
peritonitis and an ulcerated state of the bowels, accompanied with 
profuse diarrhoea. I directed the surface of the abdomen to be rubbed 
with the ointment of the tartrate of antimony, which caused the erup- 
tion of a crop of large, violet-coloured, sanguinolent pustules, some 
of which were as broad as the bullae of rupia. The fluid they con- 
tained dried up into black and very adherent incrustations. This 
woman having died, I had an opportunity of examining the state of 
the skin upon which they were developed. I found it softened and 
perforated towards the centre of the different scabs. 

I have oftener than once remarked pustular eruptions upon the 
genital organs of those patients who had been directed to rub the 
chest or abdomen with an ointment of the tartrate of antimony. Such 
eruptions have always appeared to me to be owing to a small quantity 
of the unguent having been inadvertently carried to these parts, the 
integuments of which being soft and moist, and abundantly supplied 
with follicles, may be supposed peculiarly susceptible of the action of 
this stimulant. These adventitious eruptions, however, have been 

' Jenner. On the influence of artificial eruptions in certain diseases, 4to. Lorn!. 
1807. Lombard. Note sur l'eruption du tartre stibie a I'exterieure. (Gaz. Medic, 
1833, p. 246.) 



210 



FURUNCULI. 



attribal •<■ observers to a secondary effect of the tartrate of 

antimony absorbed into the system. 1 

Pustular eruptions produced by arsenic. Girdlestone informs 
M thai he has seen eruptions of the skin succeed the use of arsenical 
preparations. The following is anew instance of this kind. Joseph 
Hubert, two days after having pounded a large quantity of arsenious 
acid, was attacked with an eruption which was already of eight days 
standing when he entered the hopital de la Charite. The whole of 
the face was covered with crusts of a yellowish-green, some of them 
isolated, others confluent, under which the skin looked red. In the 
spaces between the crusts, small psydracious pustules were perceived 
lure and there, analogous to those of impetigo ; the eyes were watery 
and slightly inflamed; the features were still swelled, but less so 
than they had been on the second day of the eruption. Some small 
clusters of pustules and similar crusts were disseminated over the 
hands, arms, scrotum and root of the penis. None were discovered 
on the hairy scalp or trunk. The patient had no fever; the tongue 
was white, the abdomen not particularly sensible. He was bled 
from the arm, and the use of whey and of a bland diet speedily 
restored him to health. 



IV.— FURUNCULI; FURUNCULAR INFLAMMATIONS. 

Vocab. Furunculi. 

573. The cells of the corion are penetrated at all points by small 
conical prolongations, derived from the subcutaneous cellular mem- 
brane. These everywhere accompany the vessels and nerves which 
proceed from the inner aspect of the skin towards its superficies, there 
to form the papillae and vascular rete. Inflammation of one of these 
prolongations gives rise to the diseases entitled hordeolum or sty, and 
furunculus or boil; the simultaneous and confluent inflammation of 
several of these appendices constitutes anthrax or carbuncle. 

574. The proper cutaneous tissue constantly participating to a 
greater or less amount in the inflammation of these processes of the 
cellular substance, I have felt called upon to devote a particular 
chapter to the consideration of the furuncular inflammations. They 
are .three in number: sty, boil, and carbuncle, and approximate so 
closely in their causes, seat, progress, and termination, that they may 
be regarded as mere varieties of one and the same form of inflam- 
mation. Left to themselves, these affections always terminate in the 
mortification and subsequent expulsion of one or more of the small 
cellular cones of the dermal tissue, which are then designated by the 
title of cores. This peculiar termination of furuncular inflammation 
is generally ascribed to the resistance offered by the fibrous corion to 
the expansion of the cone of inflamed cellular membrane, which con- 
sequently undergoes a kind of strangulation, and perishes. 

575. The occurrence of furuncular inflammation is frequently con- 
nected with the existence of a disordered condition of the stomach 
and bowels ; this form of disease is scarcely ever the effect of mere 
irritation applied immediately to the skin. 2 

576. The three affections composing this group are distinct from the 
other phlegmasia? of the skin in their seat, which is in the cellular 
substance of the reticulated texture of the corion. They differ from 
the gangrenous inflammations properly so called, inasmuch as they 
do not appear under the influence of any specific cause, and in the 
circumstance of the sloughing that does occur, being attributable, in 
great measure, to the anatomical structure of the parts affected. Furun- 
cular inflammations consequently present a particular curative indica- 
tion, namely : to relieve the strangulation of the cellular appendices 
thatjienetrate the reticular texture of the corion. 

577. Hordeolum and furuncle are two diseases of such common 
occurrence, so universally known, and generally so unimportant, that I 

' Gazelle Med.. 1832, p. 842. 

■ Yet the application of blisters, &c, is frequently followed by tbe subsequent de- 
velopment of boils in the situations they occup le d. Vide % 581.— R. W. l 



have deemed it needless to give the details of any particular case of 
either of them. 



FURUNCULUS. BOIL. 



Vocab. Boil, Furuncle. 



578. Furuncle is an inflammatory swelling of the skin and cellular 
substance, of no great size, circumscribed, conical and prominent 
hard, very red, hot and painful, and terminating in the formation of a 
very small quantity of matter and the expulsion of a mass of mortified 
cellular membrane, known under the name of a core. 

Furuncles are observed to occur most frequently on the buttocks 
thighs, arm-pits, the back, nape of the neck, and anterior parts of the 
abdomen. 

579. Symptoms. — The disease begins by a small hard and conical 
tumour of a vivid, or violet-red colour, which, although probably not 
larger than a pea when first discovered, may, within a few days, attain 
the size of a large walnut. The pain which accompanies the develop- 
ment of a boil, has been compared with some justice, to that which 
would follow the passage of a drill or gimblet through the skin. From 
the fourth to the eighth day, the boil rises in a point ; its apex becomes 
white, then softens, and finally gives way, when a small quantity of 
sanguinolent pus escapes, and the top of the sloughy substance is ex- 
posed. This opening in the skin is commonly as minute as if it had 
been made with a fine probe ; even in furuncles of the largest size it 
scarcely exceeds a line in diameter, although the slough beneath is 
frequently several lines in breadth and thickness. This slough or core, 
formed of a small piece of the cellular membrane infiltrated with pus, 
is thrown out between the tenth and twelfth day. After its expulsion, 
whether this have been spontaneous, or accomplished by means of 
pressure, the tumour seems pierced from its apex to its base, by an 
open-mouthed cylindrical cavity. The pain now ceases, the swelling 
disappears, the skin collapses, the cavity left by the core fills up, and 
after the cure, which is accomplished between the twelfth and fifteenth 
day, no trace of the disease is left, save a small depressed cicatrice of 
an irregular round shape and a dusky red colour. 

Between the common furuncle, the summit of which exhibits one 
small opening only, and well-marked and sloughing anthrax, there is 
a disease of an intermediate description, in which the apex of the 
tumour is pierced with a number of small orifices that ultimately unite 
and compose a single opening of an irregular circular shape and con- 
siderable magnitude. This affection has by several pathologists been 
denominated furunculus anthracoides . 

The development of one furuncle is frequently followed by the 
appearance of several others, each of which pursues its course unin- 
fluenced by those in its vicinity. The size of these is various ; one 
in particular is usually much larger than any of the others. 

580. Furuncles are not commonly attended with fever, unless the 
individual boils be extremely large, or their number very great. When 
they appear on the perineum, between the anus and scrotum, the urine 
is generally passed with pain and difficulty. When they occur on the 
nucha, shoulders, or buttocks, they frequently occasion acute inflam- 
mation of the lymphatic vessels and glands of the neck, axillae, and 
groins. 

581. Causes. — Frictions performed with irritating ointments, want 
or due attention to cleanliness, the use of sulphureous, mercurial, 
alkaline, and other baths ; several inflammatory affections of the skin, 
such as small-pox, and ecthyma ; the application of blisters, and the 
deeper inflammation produced by a seton, &c, may occasionally he 
observed causing the production of boils. They seem also at times 
to appear simultaneously with slight chronic inflammatory affections 
of the digestive organs ; but they also very frequently occur without 
any appreciable cause, and particularly at the termination of other 
diseases. 

582. Diagnosis. — Furuncle does not differ from Hordeolum save in 
the circumstances of size and situation ; hordeolum being always of 
inconsiderable dimensions, and situated on the edge of the eyelid. 
The small boils of the penis and prepuce are exactly similar to sty in 
the circumstances of form and size. Anthrax in fact is itself no more 



HORDEOLUM. 



211 



than an agglomeration of confluent furuncles : the inflammation has 
then attacked a surface of some extent, and a mass of the cellular 
prolongations have been at once stricken with sphacelus. The small 
abscesses occasionally observed in the skin after the absorption of 
purulent matter, differ from furuncles in their progress, their flattened 
form, and the absence of a sloughy core. (Case XCIII.) 

583. Prognosis. — Furuncle is by no means a serious disease ; it is 
one indeed which frequently appears to form a crisis in other acute 
and chronic affections. It occasionally happens, however, that among 
the aged, and individuals of a bad habit of body, repeated eruptions 
of boils are observed to take place whilst the constitution is gradually 
giving way. 

584. Treatment. — It has been said that furuncles might be arrested 
in their progress by cauterizing them with the lapis infernalis. The 
operation is by no means very painful, but the truth is, it seldom 
proves effectual ; and as patients generally prefer such palliative 
measures as bathing the part affected with tepid fomentations, and 
the application of emollients and narcotics, we are generally content 
with endeavouring to prevent any fresh eruptions, leaving such as 
already exist to pursue their course, for it very rarely happens that 
boils are of such a size or so severely inflamed as to require the local 
abstraction of blood, or the division of the skin. When one or more 
of these tumours prove very painful, however, the simple division of 
the integument is the most speedy and efficacious measure in bringing 
relief that can be adopted. A bread and milk or linseed-meal poultice 
is the best, as it is the topical application most frequently employed 
in the treatment of boils. When one crop of boils appears repeatedly 
after another, the morbid disposition which engenders them is fre- 
quently checked by the exhibition of an emetic, or a few doses of 
slightly purgative medicine for several days successively. Yet it 
sometimes happens that these means prove unavailing, and it is only 
after effecting a modification in the constitution by appropriate regi- 
men, and perseverance in a course of medicine for several months, 
that we succeed in putting a stop to these eruptions. 

Fosbroke recommended large doses of the diluted sulphuric acid, 
in a proper vehicle, as a very effectual means of subduing the pain of 
boils already existing, and of preventing the appearance of fresh erup- 
tions. He carried the dose of this medicine the length of six drachms 
daily. 

Historical JVotices and particular Cases. 

585. Celsus 1 has left us a very good account of furuncle. Bichat 2 
made a particular study of its structure. Fosbroke 3 and M. Daynac' 
have severally published observations on the disease. M. Guersent/ 
under the name of furoncle atonique, appears to me to have described 
a variety of ecthyma. 

The following case of a number of abscesses appearing in the sub- 
stance of the skin in consequence of the absorption of purulent matter, 
seems well calculated to display the characters which distinguish 
this rare form of disease from furuncle. 

Case XCIII. — Jlbscesses in different parts of the body and in the sub- 
stance of the s/dn, appearing in the form of an eruption. Morize, 
aged forty, entered La Charite on the 9th of November, 1832. All 
that could be learned from the patient amounted to this, that he had 
been ill for a few days only, and that he felt pain in the right arm and 
elbow. His expression of countenance was evidently altered, but 
nothing much amiss was discovered after a careful examination. The 
pulse was not rapid, and the state of the digestive organs and thoracic 
viscera seemed satisfactory. The patient consequently attracted little 
attention for several days — he was held to be affected with articular 
rheumatism of no great severity. Unexpectedly however, an abscess 
the size of a small walnut was discovered below the elbow joint. It 
was not very painful, and not being opened it shrank and disappeared 
spontaneously a few days afterwards. The pulse at this time was 
frequent, the tongue moist, the cast of countenance morbid. The 

' Celsus. De re medic.1, p. 236, lib. v. sect, xxviii. Ed. Fouquier et Ratier. 

2 Bichat. Anat. generale, t. iv. p. 687. 

3 Edinb. Med. and Surg. Journ., v. xviii. p. 64. 
* Revue medicate, Septembre 1829, p. 416. 

6 Archives gener. de medec, t. i. p. 336. 



patient complained of general uneasiness and of wandering pains in 
the limbs. His state was now deemed alarming, although this did 
not appear to depend on any particular affection of the viscera con- 
tained in the great cavities. Four days before his death, Morize sank 
into a state of prostration ; the pulse became small and rapid, the 
tongue hot, dry, &c. ; at the same time a number of small spots resting 
on a hard basis appeared upon different parts of the surface. Two 
days before his death, an abscess was discovered in the region over 
each cheek bone, the skin of which had previously been red, swelled 
and inflamed. At the same time there appeared upon the neck and 
upper parts of the chest, a multitude of small tumours the size of a 
pea or a little larger ; the bases of these were in general hard, their 
summits soft; but several of them were uniformly softened throughout. 
The patient got worse and worse, and at length died in a state of low 
delirium. On examining the body after death, the following appear- 
ances were discovered. 

Externally. — An abscess over each cheek bone as large as a wal- 
nut, containing a quantity of reddish-gray pus. On the neck several 
tumours the size of a pigeon's egg. Nothing was discovered when 
the muscles were cut into. The thighs and legs were beset, in the 
same way as the parts already mentioned, with small cutaneous and 
larger subcutaneous abscesses. An incision carried through the mus- 
cles of the leg laid open an enormous abscess, which seemed to have 
destroyed the whole of the tibialis anticus, and denuded the bone in 
its vicinity. Another abscess of somewhat smaller size was discov- 
ered in the same situation in the left leg. Three others, the size of 
large walnuts, were detected in the substance of the gastrocnemii 
muscles. 

Articulations. — Both of the shoulder, elbow, and wrist, hip, knee, 
and ankle joints, contained a considerable quantity of yellowish or 
rather greenish fluid, thicker than the proper synovia, and more like 
mucous than serum. 

The brain was healthy. The left lung was covered with a thin 
layer of a recent pseudo-membranous deposit. The substance of the 
lung was loaded posteriorly ; in other parts it was perfectly crepi- 
tating. In the lower part of the superior lobe of the right lung there 
was found an abscess as large as a hazel-nut. The heart was healthy, 
as were the large vessels of the thorax and abdomen. The abdomi- 
nal viscera, except the spleen, 6 which was very soft, were natural. 

586. There is the greatest analogy between this case and two 
others, which will be found embodied in the memoir of Dance on 
phlebitis. 6 



HORDEOLUM. 



Vocab. Hordeolum, Sty. 



587. Hordeolum or sty is a small furuncular tumour of the eyelids, 
observed most frequently near the free edge of the upper lid, and the 
greater angle of the eye. 

588. Symptoms. — Sty may occur as an acute or as a chronic com- 
plaint. In the former case it appears in the shape of a tumour, the 
size of a barley-corn, oblong, rounded, prominent, of a deep-red 
colour, and tipped on its apex with a small yellow speck of suppura- 
tion. This small tumour, which is attended with acute pain and con- 
siderable swelling of the eyelids, bursts and discharges a little clear 
and serous pus. The opening of the skin soon closes, and a second 
white point makes its appearance upon the tumour, which ultimately 
giving way, permits a sloughy core to escape with the effect of imme- 
diately putting an end to the whole of the morbid symptoms. 

The second variety of sty consists of a small hard, red, and in- 
dolent tumour, which, after having remained stationary for several 
weeks, is at length attacked with inflammation of a more active 
description, when it terminates in the same manner as the variety 
previously described. 

589. Whatever the course of hordeolum, it still presents two very 
marked and apparent peculiarities. The tumour at one time projects 
more exteriorly than towards the eyeball, in which case it impedes 
the vision but little, and the skin is free to give way and suffer the 

6 Arch. gen. de med., t. xviii. 






FURUNCULI. 



core to escape. At another time, however, the sty, projecting on 

irmce of the eyelid, irritates the ball of the eye by its 

nt friction upon the" conjunctiva. In this case the raucous 

membrane of the eyelid becomes softened, and is finally perforated 

i rer the most prominent point of the tumour. 

Cmm t. — The occurrence of hordeolum is frequently observed 
to coincide with a deranged condition of the digestive functions. This 
furuncular inflammation consequently is very commonly observed 
among individuals addicted to the pleasures of the table or to spiritu- 
als potations. The disease appears occasionally with something 
like the regularity of a periodical distemper. Females have also 
been known to be troubled with it for several months before the 
appearance of the catamenia, and to suffer repeatedly at each recur- 
rence of this evacuation. 

&91. Diagnosis anil prognosis. — Hordeolum differs from the rest 
of the furuncular inflammations in its seat, its small size, and the 
slightness of the general and local symptoms that attend it. 

592. Treatment. — An attempt may be made to cut short the pro- 
gress of sty by applying pounded ice to the eyelid from the moment 
the disease is discovered ; few, however, will be found ready to sub- 
mit to this application, which, moreover, has not been known to 
succeed completely in any one instance in which it has been used. 
When the sty is very much inflamed a small cataplasm of roasted 
apple or crumb of bread, applied between the folds of a fine muslin 
rag, relieves the pain, and seems to hasten the expulsion of the core, 
a consummation which, when it is long looked for in vain, is occa- 
sionally brought about by the aid of a slight degree of pressure to 
the base of the tumour. When hordeolum occurs in an individual of 
scrofulous constitution, Weller advises the application of cataplasms 
of hemlock and saponaria, with the addition of camphor, to prevent 
the occurrence of the small induration which is one of the frequent 
consequences of this complaint. 

As in furuncle, relapses are frequent in hordeolum. The only 
mode of preventing these is to attack, by appropriate regimen and 
medicinal means, those constitutional causes which appear to have an 
influence on the development of the disease, (a) 

Historical Notices. 

593. Celsus 1 has pointed out hordeolum very distinctly. Scarpa 2 
and Weller 3 have given good accounts of its characters and mode of 
treatment. 



Vocab. Anthrax, Carbuncle. 

594. Anthrax is an acute inflammation simultaneously affecting 
several of the contiguous cellular cones that penetrate the reticula- 
tions of the true skin. It appears in the form of a circumscribed very 
hard and very painful tumour of a deep red colour, accompanied with 
a sensation of burning heat, and is invariably terminated by the morti- 
fication of a mass of the cellular substance and the destruction of the 
corresponding portion of integument. 

595. Symptoms. — Anthrax is most commonly developed on the 
nape of the neck, the back and shoulders, the parietes of the abdomen 
and thorax, and on the buttocks and thighs. The disease often be- 
gins in the shape of a small tumour but a few lines in diameter, and 



(a) When suppuration has taken place, the sty may be punctured 
with a lancet. Scarification with the shoulder of this instrument and 
rubbing the part with mercurial ointment, have, within my own experi- 
ence, caused a resolution of the inflammation, and thus abbreviated the 
disease. In scrofulous subjects, touching the parts with lunar caustic 
will hasten the cure after suppuration, and act in a degree also as a 
preventive. ° 

• De re med., lib. vii. cap. 7. 

» Delle princ. Malattie degli occhi, 8vo. Ed 5ta p a . isic tv,„ i k t 
Brigss. 8vo. Lond., 1806. ta " Fav '' 1816, Tran s>- ty J. 

'Weller. Krank. d. Mensch. Auges. 3tte. Aufl. 8vo BpH 1S2« Tr,„*i k vr 
teath, 8 vols. Svo. Glasg., 1821. *un.,»vo. Berl., 1826. Transl. by Mon- 



very similar to a common boil, save when its apex is covered, as 
occasionally happens, with a sanguinolent bleb. Anthrax, however, 
is sometimes seen, even from its very commencement, of much larger 
dimensions, in which case it advances with such rapidity, as in eight 
or ten days to have acquired a diameter of as many inches. In the 
same measure as anthrax spreads, it becomes more prominent and 
penetrates more deeply. It continues extremely hard through its 
whole extent up to the period at which the cellular tissue is attacked 
with mortification. After this, the circumference still remains very 
firm, and the base continues to spread, whilst an obscure fluctuation 
may be discovered in the centre of the tumour. The violet tin) of 
the skin does not disappear with pressure ; the heat, which is sharp 
and .scalding at first, especially about the centre of the tumour, does 
not decline until after the formation of one or more openings ; finally, 
the pain, alternately gravative and tensive, extends to the circum- 
ference of the indurated base. 

When anthrax is left to itself the skin which covers the tumour 
acquires a violet or bluish tint, and after the lapse of some days, hav- 
ing become thin and softened, it gives way in several places, when a 
small quantity of bloody pus, mingled with shreds of mortified cellular 
membrane, is discharged. It may also be stricken with death over 
some considerable extent, and present the black colour and insensi- 
bility characteristic of sphacelus. On the succeeding days the inflamed 
skin is successively softened in various other points, and new perfo- 
rations take place, from the bottoms of which whitish sloughs of cellu- 
lar membrane may be extracted. The modified cellular substance 
never assumes the black colour of the gangrenous skin. The perfo- 
rations enlarge, either from the destruction of the integuments in their 
circumference, or by becoming united together. They all continue to 
pour out a little thick pus which is rendered sanguinolent, apparently 
by the accidental rupture of some minute artery or vein. When the 
perforation in the integument is considerable, the sloughy cellular 
substance exhales a fetid odour, which however is very different from 
that usually disseminated by animal substances in a state of putrefac- 
tion. By slow degrees the sloughs are detached, the discharge be- 
comes more abundant and less thick, and the pain, heat, and tension 
diminish. After the detachment of the mortified parts the superficial 
fasciae are occasionally found perforated, denuded or eroded; the 
integuments in the circumference of the anthrax are loosened, thinner 
than natural, of a bluish colour, and in some places so much disor- 
ganized as to be incapable of reuniting with the subjacent tissues. 

If the disease terminates favourably, a cicatrice is formed in part 
from the ulcerated surface, and in part by the reunion of the loose 
flaps of skin. This cicatrice is always irregular, puckered and de- 
pressed, and long retains a dusky-red or brownish hue. It is occa- 
sionally intersected with thick bands which occasion considerable 
deformity and render certain motions difficult. 

596. Anthrax often makes its appearance without having been 
preceded by any evident disorder of the principal functions. Patients, 
however, do occasionally complain for a few days before its develop- 
ment of anorexia, lassitude, chills or shivering fits, and other symp- 
toms usually observed on the invasion of acute diseases. When the 
tumour is voluminous it is very regularly attended with febrile symp- 
toms of greater or less intensity ; there are restlessness and want of 
sleep ; the skin is dry, the urine high coloured and scanty, the belly 
is bound, and the head is heavy and painful. 

597. These general symptoms attendant upon anthrax may be com- 
plicated with various others according to the regions of the body upon 
which the disease occurs : 

1st. When it is developed on the lateral or fore parts of the neck 
patients complain of dyspnoea, cough, and sense of heat in the larynx 
and trachea ; the face is also flushed, and there is headache of the 
most violent description. 

2d. When the parietes of the thorax are the seat of the disease the 
inflammation may be repeated, as it is said, in the pleura or lungs, 
and occasion pulmonary symptoms of various degrees of severity. 

3d. Lastly. Anthrax attacking the parietes of the abdomen is occa- 
sionally greatly increased in severity by the sudden occurrence of 
peritoneal inflammation. 

598. Various forms of cutaneous inflammation may appear along 
with and complicate anthrax. Furuncle, of all these complications, 



ANTHRAX. 



213 



is undoubtedly the most common. Boils, indeed, very generally pre- 
cede the attack of anthrax ; they, however, even more constantly 
succeed the disease, appearing in crops around the circumference of 
the tumour. 

599. Causes. — Children and the youthful are much more rarely 
affected with anthrax than adults and the aged. The disease is fre- 
quently seen attacking females about the critical period of their lives. 
It may arise from the application of acrid and irritating substances to 
the skin, the bites of insects, or filthiness. It occurs still more com- 
monly as one of the sequelae of measles, small-pox, and several other 
diseases of the skin. Like erysipelas, anthrax has also been seen as 
a consequence of the prolonged influence of certain causes which 
appear to act primarily on the digestive organs. 

Anthrax is more frequent in the spring time and summer than in 
autumn and winter. 

600. Diagnosis. — Anthrax is easily distinguished from the other 
furuncular diseases. Boils present but a single opening, and are 
smaller in size and more conical in shape than anthrax ; they also 
commonly occur in succession, several following one after another. 
Anthrax, on the contrary, from the time it is perceived, presents a 
flatter, less pointed and broader tumour than furuncle, and at a later 
period is perforated with several openings on its surface. The dif- 
ferences that exist between these two diseases must not, however, 
be made greater than they actually are ; anthrax being in fact no more 
than a tumour formed by the agglomeration or confluence of several 
furuncles, a fact which was first demonstrated by Baron Dupuytren, 
and made generally known by the publication of his lectures on 
clinical surgery. 

At a time when pathological anatomy had not yet made us familiar 
with the structure and true nature of anthrax, the disease was often 
confounded with another affection, the anthracion or malignant pus- 
tule, which has frequently been described under the same name. The 
anthracion, however, belongs to another order of diseases, and I shall 
by and by have occasion to speak of its distinguishing characters. 

601. Prognosis. — When anthrax is of moderate size and the indi- 
vidual attacked appears otherwise of a sound constitution, it is un- 
attended with danger. But the disease may have the most unfavour- 
able issue when it is of large dimensions and is situated on the parietes 
of the thorax or abdomen, the viscera or lining membrane of which 
may be attacked with fatal inflammation. 

The prognosis generally is unfavourable in the aged, in whom a 
considerable extent of the skin is frequently observed to become 
gangrenous. 

602. Treatment. — To whatever cause anthrax may be traced, it is 
necessary to attack the disease in the very beginning, by blood-letting, 
proportioned in amount to the age and habit of the individual, and to 
the intensity and extent of the inflammation. A number of leeches 
ought also to be applied around the circumference of the swelling, 
and the bleeding from the bites of these encouraged by some emolli- 
ent tepid fomentation, or the application of cupping-glasses. These 
measures may require to be repeated oftener than once. 

Compresses dipped in the coldest water applied to anthrax, and 
frequently renewed, will be found singularly efficacious in allaying 
the pain. This application is much better than any form of warm 
cataplasm or emollient fomentation, which rather increase or keep up 
than allay pain by augmenting the morbid heat of the skin. 

After the due employment of blood-letting and cold applications, 
the best means of putting an end to the inflammation and relieving 
the tension of the skin, at our command, consists in making a simple 
crucial incision through the centre, completely across and to the 
bottom of the swelling. This will generally be found sufficient in the 
smaller-sized carbuncles; but those of larger dimensions may require 
a much greater number of incisions to set every part of the tumour 
free. These incisions give immediate relief from the strangulation 
under which the parts involved in the swelling suffer, and the blood 
that is lost lessens the inflammation and prevents the threatened gan- 
grene of the skin and processes of cellular substance that penetrate 
it, from taking place. The incisions, further, facilitate the discharge 
of purulent matter, and the escape of the mortified masses of cellular 
membrane; they also give prompt relief to the local pain, as well as 
54 



to the general phenomena thereby induced ; to conclude, they abbre- 
viate most materially the natural duration of the disease. 

In dressing the part subsequently, the flaps must be gently com- 
pressed every day, so as to squeeze out the matter that may be formed 
and the shreds of cellular substance that may have become loose ; 
the immediate surface of the wound may be covered with a piece of 
soft lint or linen rag spread with some mild cerate, and the whole 
enveloped in an emollient cataplasm. When the ulcer tends to 
cicatrization it is occasionally found necessary to remove the loose 
flaps of integument which have suffered too much to be brought to 
re-unite with the subjacent cellular membrane; attention must also be 
paid to keep the cicatrice as smooth and regular as possible. 

603. At the commencement and during the progress of anthrax 
patients ought to be restricted to the regimen observed in acute 
diseases. When the tongue is yellow or white, and a bitter taste 
is complained of in the mouth, with but little thirst, many have 
advised the exhibition of a purgative or an emetic. I have not my- 
self had recourse to either of these remedies in any case of anthrax I 
have encountered. I have always seen the functional disorders of the 
digestive organs, on account of which they have been recommended, 
disappear of themselves in the same ratio as the inflammatory affec- 
tion of the skin drew towards a close. And yet the unquestionable 
utility of these remedies in cases of furuncular eruption might induce 
us to give them a trial under certain circumstances. 

It seems almost unnecessary to add that the diseases which may 
accidentally complicate anthrax, such as peritonitis, pleurisy, &c, 
themselves require peculiar treatment, which indeed must be so much 
the more active, as their association with an acute inflammation of the 
skin commonly renders their progress more rapid. 

When the disease has come to an end, a few sulphureous baths are 
almost always of service, especially to the aged. (a) 



(a) In some cases of anthrax, of considerable severity, too, I have 
found a simple incision made down to the healthy tissue at the base 
of the tumour, suffice. Dressing with ointment of chloride of lime 
is good. After an emetic or purging, quinine and nutritive stimu- 
lants are often indicated, and, in place of opium, hyoscyamus or conium 
and camphor are preferred, when the first mentioned remedy disa- 
grees with the patient. The following is a judicious summary of the 
treatment of anthrax. 

" Free and early incision is to be made, usually of the crucial form, 
throughout the whole extent of the diseased mass ; this evacuates the 
purulent formation, affords an exit for the sloughs when loose, and 
limits infiltration. But this is not enough. Potassa fusa follows the 
bistoury, and is used freely; by it the dying parts are at once con- 
verted into a dead eschar, healthy separation is accelerated, and injury 
of the system from absorption of the deleterious products of humid 
putrescence is almost at once arrested ; and, further to insure fulfil- 
ment of the last indication, the slough, as it loosens, is to be carefully 
removed by knife or scissors. The practice seems severe, but no 
other will prove in all respects successful ; and the more advanced 
the case, the greater the necessity for its adoption. Less pain is 
occasioned than might be supposed, the greater part of the cauterized 
tissues being already in a gangrenous state. Poultice is applied till 
the slough is discharged; then water-dressing, early medicated to 
meet approaching debility. 

" The constitutional treatment is never thoroughly antiphlogistic. 
At the commencement, evacuants are necessary ; for the stomach and 
bowels an emetic and purgation ; for the liver, mercury, cautiously 
administered ; then occasional alteratives, as perhaps the hydrargyrum 
c. cretS. Early tonics and stimuli are required — bark, wine, ammonia, 
brandy, turpentine enemata, according to the features and exigencies 
of the case. So long as the power of swallowing remains, the 
remedies are to be perseveringly administered; for, provided the 
suitable local treatment has been practised, patients often rally suc- 
cessfully, even though previously in extremis. Omit the use of the 
bistoury and potass — and all constitutional care, however skilful and 
unwearied, will not arrest the tendency to collapse, or avert a fatal 
issue. 

" These strong expressions, in favour of strong remedies, are of 
course applicable only to the more serious and urgent cases. There: 






GANGREN7E. 



Historical JVo&ttJ and particular Cases. 



The word dU^o| in the Hippocratic writings does not appear 
■ .1 very determinate meaning, inasmuch as some commentators 
hare held it applicable to carbuncle and others to variola. 1 The 
description of the 4>^a 2 of Celsus seems much more applicable to 
furuncular anthrax than that which he has given of the disease he 
entitles carbunculus. 

Furuncular anthrax or carbuncle, the disease we are now discuss- 
ing, and malignant pustules or anthracion, were long considered in 
fiance as varieties of the same disease. Baron Dupuytren was the 
lirst who drew the precise line of distinction between them, and who 
demonstrated the analogy of the variety of anthrax entitled benign to 
the common furuncle. This fact has been well authenticated by 
M. Cadet. 3 He gives three cases of anthrax evolved on the nucha 
and shoulders. I am myself possessed of the details of several ; 
from among them I select one in which the disease occurred on the 
parietes of the abdomen, and which I attended along with M. Adelon. 
Among other remarkable peculiarities, the summit of the tumour in 
this case was covered from its first appearance with a broad, flat, 
sanguineous vesicle, the presence of which might have caused it to 
be regarded for a moment as a malignant pustule. 

Case XCIV. — Inthrax.— Baron M***, almost fifty-five years of age, 
of a bilious and plethoric temperament, and subject to gout, sum- 
moned me on the 12th of October, 1822, on account of an inflamma- 
tory swelling which had made its appearance, without known causes, 
on the left hypogastric region. This swelling had been evolved three 
days previously in the shape of a small, hard, deeply seated pimple, 
highly inflamed, extremely painful, and having the look of a common 
boil. A broad, fiat, bloody vesicle had formed on the surface of 
this small tumour on the second day after its appearance. This cir- 
cumstance having excited fears lest the case should prove one of 
malignant pustule, a grain of caustic potash had been applied to the 
inflamed part. 

When summoned, I remarked the following particulars: a flattened 
oblong tumour, of a deep red colour, hard to the touch, very hot and 
very painful, nearly three inches in its transverse diameter, and an 
inch and a half from above downwards across its middle, occupied 
the anterior and inferior part of the abdomen. A small eschar six 
lines in diameter appeared on its middle, which had been produced 
by the application of caustic. The disease appeared to be of a purely 
local nature, and was unaccompanied by any appreciable disorder of 
the chief functions of the body (fifteen leeches applied circularly at 
the distance of an inch from the tumour; cool emollient cataplasms, and 
to promote the bleeding from the leech bites, a warm bath). These 
measures only gave very momentary relief. During the following 
day and night the inflammation made rapid progress both in superficial 
extent and in depth. The pain became excessively severe ; the red- 
ness of the skin, verging on a violet, spread transversely, and the 
tumour, next day less flat than heretofore, formed a longitudinal 
swelling, similar to that which is produced by pinching up a broad 
roll of the skin. The patient was now troubled with pains of the 
bowels and retching, the pulse had got full, and the belly was tense. 
I proposed and immediately performed the incision of the tumour. 
Its lengthened shape, however, induced me to confine myself to a 
single transverse cut, which passing through the entire thickness of 
the skin and subcutaneous cellular substance, was at least six inches 
in length, and extended from beyond the bounds of the inflamma- 
tion, at either end, near the median line to the middle of the left 
flank. The incision was followed by the discharge of a consider- 
able quantity of blackish blood, a marked diminution of the pain, and 

are many examples of the disease, in which the swelling is but small, 
and constitutional disorder proportionally slight; in these simple 
incision suffices ; in a day or two the slough is discharged, and granu- 
lation advances favourably.— Miller's Principles of Surgery, Am. 
edit., pp. 225-6. T—VB¥i 

' Willan. An inquiry into ihe antiquity of the small-pox, p. 67. 
* Celsus. De re medica, lib. v. sect, xxviii. n. 9. 

» Cadet. Diss, stir l'anthrax, 4to. Paris, 1833 Lecons de M. Dupuytren. (Lan- 

cette Frai^aise, 21 Mars, 1833.) 



relief of the abdominal symptoms, the occurrence of which had caused 
me serious alarm. (Cool emollient poultices to the tumour; eau sucree 
for drink; low diet.) 

The wound continued during four or five days from this time to 
discharge a quantity of purulent and bloody fluid. The oval formed 
by the anthrax began to contract from the third day after the opera- 
tion, but the lips of the wound presented an appearance peculiar to 
this disease. On their edges a number of white points were distin- 
guishable, formed evidently by the summits of the conical-shaped 
sloughy cores; several, indeed the greater number of these, could be 
laid hold of with the forceps, and taken away without pain ; others 
still adhered by their deep extremities. These conical-shaped cores 
were of a yellowish-white colour, and pretty tough. ' On the eighth 
day after the operation the edges of the wound were irregularly in- 
dented, and presented numbers of small semicircular notches in the 
points which the cores had occupied. The wound was dressed regu- 
larly till the 2d of November, with a perforated pledget spread with 
cerate, compresses of lint, and an emollient cataplasm. A sloughy 
core made its way out at a point near the middle of the inferior half 
of the swelling. The ragged or toothed condition of the lips of the 
wound certainly retarded the cicatrization, which was nevertheless 
completed by the 18th of November. 

Two small furuncles appeared : the one on the epigastric region, 
the other near the umbilicus. They both got speedily well sponta- 
neously. 

From this time to the 1st of August, 1826, Baron M * * * had no 
attack of gout ; neither did he suffer from certain fits of pain in the 
bladder, which used occasionally to alternate with the paroxysms of 
this disease. 



V.— GANGRENE. GANGRENOUS INFLAMMATIONS. 

605. The distinguishing characters of the gangrenous diseases of 
the skin are their origin in a specific cause, and their rapid termina- 
tion in gangrene. 

The disease entitled Anthracion, Persian fire, and Malignant Pus- 
tule, may be taken as the type of this group, in which may be included 
pestilential bubo, typhoid gangrene, and the gangrenous affection of 
the cheeks and genital organs of children. 

I shall here confine myself to a description of Anthracion, and 
indicate the features that distinguish it from the rest of the gangre- 
nous affections- 



ANTHRACION. 
Vocab. Anthracion, Carbuncle, Malignant Pustule, Persian Fire. 

606. Anthracion appears in the shape of a large vesication or bleb, 
full of a sero-sanguinolent fluid ; under this a small lenticular indura- 
tion is formed, which is itself speedily surrounded by a phlegmono- 
erysipelatous areolar swelling, a larger or smaller portion of which is 
before long stricken with gangrene. 

607. Enaux and Chaussier, 1 and a great many pathologists who 
have followed them, are of opinion that anthracion constantly follows 
inoculation, being produced by the contactof this gangrenous tumour, 
or of the offal of animals which have been affected by the disease. 
In support of this view they appeal to the following facts : 1st. An- 
thracion has been seen most frequently among smiths, veterinarians, 
shepherds, graziers, tawers, tanners, butchers, knackers, matress- 
makers, &c, in a word, among individuals who have the care of 
animals, or who handle their carcasses and offal. 2d. Anthracion 
appears exclusively on such parts of the body as are habitually un- 
covered, such as the face, neck, hands, arms, &c, or upon others 

4 Enaux et Chaussier. Maniere de trailer les morsures des animaux enrages, et 
de la vipere, suivie d'un precis sur la pustule maligne, 12mo, 1785. 



ANTHRACION. 



215 



which have been exposed accidentally. 3d. The disease has been 
more especially observed during epizooties with an eruption of bubos. 

The same pathologists conceive that the sanguinolent serum poured 
out by the disease is one of the means by which it is propagated. 

We are even informed that the blood of a sheep labouring under 
the disease having flowed over the back of a shepherd's hand, gave 
occasion to the development of anthracion, and that a butcher was 
attacked with the same formidable malady in the tongue, merely from 
having taken the knife, with which he was skinning an ox that had 
died of the disease, between his teeth for a few seconds. These state- 
ments are in perfect accordance with the results obtained by M. 
Leuret, 1 in his experiments on the changes undergone by the blood in 
different diseases. 

Some would even persuade us, that the blood of an animal, not 
labouring under any gangrenous disease, but altered from other cir- 
cumstances, may occasion anthracion when applied to the skin of man. 
In confirmation of this, the cases of two butchers of the Hotel Royal 
des Invalides are quoted, who were attacked with anthracion from 
having killed and prepared the carcasses of a couple of oxen, over- 
driven, but in other respects perfectly healthy. The truth of this 
opinion, however, is extremely problematical. 

Thoraassin tells us that a woman, whilst engaged in dressing the 
gangrenous bubo of her husband, having touched her cheek with her 
fingers, soiled with some of the discharge from the sore, became 
affected within two hours with anthracion, in this situation, which 
spread with an alarming rapidity. 2 Hufeland speaks of a woman who 
caught the disease from having lain with another female labouring 
under anthracion. On the other hand, M. Jemina, 3 on the authority 
of his father, of different other practitioners, and of various experi- 
ments, communicated to Malacarne, (Brera. Giornale, vol. i., p. 460,) 
maintains that anthracion contracted from the contact of an animal 
affected with the disease, cannot be transmitted from one individual 
of the human species to another. In confirmation of this view I may 
state here, that one of my pupils, M. Bonet, of Poictiers, had the courage 
to inoculate himself with the matter of anthracion, without suffering 
any inconvenience from the operation. 

It would appear, further, that anthracion is occasionally evolved 
sporadically in the human subject. No one doubts that the nine 
cases of gangrenous pustule (pustule gangreneuse) detailed by M. 
Bayle 4 are instances of true anthracion ; yet this very accurate ob- 
server informs us, " That almost the whole of these patients were 
certain of never having touched the remains of any animal which had 
died of malignant pustule (charbon), and that those who had lately 
eaten any animal food w r ere certain of having partaken of no flesh that 
was suspected." M. Davy la Chevrie 5 has given six cases of anthra- 
cion, and in none of them is there any mention made of the patient 
having contracted the malady fft>m another individual, or from a dis- 
eased animal. 

Anthracion is believed to be pretty common in several districts of 
France ; — in Lorraine, Franche-Comte, and especially in Burgundy. 
The disease is rarely seen in Paris. I have, however, met with it 
among tanners, butchers, and, more frequently still, among workmen 
who manipulate leather, and matress-makers. During the three 
years that I was attached to the Hopital St. Antoine, I saw several 
cases which all came from the same manufactory, in which the busi- 
ness of cleansing and preparing hair, imported from Russia, was 
carried on. 

608. Symptoms. — When anthracion is communicated by way of 
contagion, the interval that elapses between the time at which the 
infection was received and the appearance of the gangrenous spot of 

' Leuret. Recherches et experiences sur les alterations du sang, 4to. Paris, 
1826. 

2 Thomassin. Diss, sur le charbon malin de Bourgogne ou la pustule maligne, 
8vo. Basle, 1782, p. 31. 

3 Journal gen. de medecine, t. 54, p. 144. 

4 Bayle (G. L.). Considerations sur la nosologic, la medecine d'observation et la 
medecine pratique, suivies d'observations pour servir a l'histoire des pustules ma- 
lignes, 8vo. Paris, 1802. 

« Davy la Chevrie. Diss, sur la pustule maligne, 4to. Paris, 1807.— I ought to 
add here that in a great number of cases evidently belonging .to anthracion in their 
symptoms, it has been impossible here to trace the disease as having been transmitted 
by contagion. See the case of M. Littre, quoted lower down, and that of M. Carret, 
(sur une gangrene de la levre attaquee infructuesement par le feu et suiviede mort). 
Recueil de la socie'te de Sante de Lyon, 8vo. 1798, p. 308, &c. 



the skin, varies from a few hours to five or six days. Making the 
gravity of the symptoms the basis of a division, the whole of the cases 
of anthracion that occur may be arranged under three heads : 1st, 
slight anthracion, with circumscribed mortification ; 2d, severe an- 
thracion, with diffused mortification; M, fatal anthracion, with alter- 
ation of the blood, and affection of one or several of the viscera. 

609. 1st. — Anthracion with circumscribed mortification. The ani- 
mal poison which produces anthracion is occasionally limited in its 
effects to the excitement of a trifling degree of inflammation which I 
have seen several times, and which M. Davy la Chevrie has described 
under the title of pustule maligne prominente. It begins with a sero- 
purulent elevation, the base of which, hard, tense and deeply-seated, 
is not long of being surrounded by a phlegmono-erysipelatous inflam- 
mation. The central point of the tumour is attacked with gangrene, 
but it rarely happens that the mortification extends beyond this its 
primary seat ; the morbid process stops spontaneously, and almost at 
its outset. Case XCVI belongs to this variety. 

610. 2d. — Anthracion with diffuse gangrene. This variety begins 
with a considerable degree of pruritus which is succeeded by the 
appearance of a red spot like a flea-bite. The vesicle, of the size of 
a millet-seed at first, soon acquires larger dimensions, and, if not 
ruptured by the patient, bursts spontaneously. Twenty-four or thirty- 
six hours after the attack, a small, hard, and circumscribed nucleus, 
having the form and size of a lentil, is perceptible under and around 
the seat of the vesicle ; in the circumference of this a soft, but still 
resisting swelling, of a reddish or livid colour, covered by and by 
with secondary sero-sanguinolent vesicles, at first isolated, but speedily 
becoming confluent, is developed. The central point, now of a 
brownish hue, extremely hard and very insensible, becomes gangre- 
nous. The inflammation extends to a considerable distance ; the 
neighbouring skin is red and shining ; the subcutaneous cellular tissue 
is puffy, tense, and to appearance emphysematous. The diseased part 
is benumbed, without proper sensation, and the gangrene advances 
with rapidity. 

If the disease ceases to make further progress, an inflamed circle of 
the most vivid red appears around the eschar ; the tumefaction which 
had spread extensively diminishes at the same time, and the patient 
feels something like an agreeable warmth accompanied with a pulsa- 
tory motion of the part affected. The pulse revives ; the strength 
increases ; occasionally some degree of fever occurs which is speedily 
resolved by a gentle perspiration ; suppuration sets in between the 
living and dead parts, and the detachment of the eschar leaves a sup- 
purating surface of various extent in different cases. 

Should the disease, on the contrary, tend to an unfavourable issue, 
general symptoms of great severity occur : the pulse is small and con- 
tracted ; the patient complains of a feeling of anxiety ; he is attacked 
with fainting fits ; the tongue is dry and brown ; the features are 
shrunk ; the skin is parched ; the eyes are glassy ; the moral courage 
and physical strength are gone ; cardialgia and low delirium precede 
the fatal termination. 

The duration of the different stages of this variety of anthracion is 
uncertain ; that of the incubation varies between one and two hours 
and several days ; the second, characterized by the formation of the 
primary vesicle, extends to an interval of from twenty-four to thirty- 
six hours ; the third, marked by the evolution of the central nucleus 
and the appearance of the areolar tumour, does not generally exceed 
a few hours; the fourth and last, announced by the occurrence of 
gangrene and other local and general symptoms of different degrees 
of severity, varies from one to several days according to the issue 
which the disease is to have. 

611. 3d. — Anthracion with alteration of the state of the blood or 
affection of the viscera. — In this variety, the symptoms advance with 
frightful rapidity ; death occasionally intervenes within the first eighteen 
or twenty-four hours from the invasion of the disease. The alteration 
of the skin is occasionally of no great amount ; and the fatal termina- 
tion and the formidable symptoms that precede the catastrophe are 
only explicable on the supposition of some change having taken 
place in the state of the blood, or the occurrence of gangrene in some 
of the principal viscera. (Vide Cases XCVI and XCVII.) 

612. Anthracion, further, is not without its varieties according to 
the regions of the skin upon which it is developed. 



' 



216 



GANGRENE. 



1st.— Amhracion of the face is not merely accompanied with a 
phlegmonous erysipelas of the features, hut the puffing and inflamma- 
tion occasionally extend to the neck and fore part of the chest. When 
i lids are "the primary seat of the affection, it occasions an enor- 
mous' and verv painful tumefaction of the face, accompanied with 
intense headache or delirium, occasionally with the loss of the eye, 
always by the eyereion of the eyelids, which are then frequently 
formed hy the orhicularis muscle and the conjunctiva alone. When 
the upper eyelid is the only one implicated, the lower is often seen 
to be carried somewhat further up than usual, in consequence of the 
efforts made by the patient to preserve the eyeball from the action of 
the light ; there is an abundant flow of tears ; the transparent cornea 
inflames and speedily becomes opaque. To remedy the destruction 
of the eyelids consequent on this affection, it has been proposed to 
restore them by means of an operation on the same principles as those 
of the Rhinoplastic or Taliacotian process. 

Wherever muscular fibres are contiguous to the skin, it is observed 
that there the gangrene extends less deeply. Nevertheless, when the 
lower lip is attacked with anthracion, this part is apt to be destroyed 
through a considerable extent, either by the disease or the action of 
die caustics employed with a view to arrest its progress. The deform- 
ity that results is attended with the constant and involuntary flow of 
the saliva. 

2d. The development of anthracion on the neck is accompanied by 
a phlegmono-erysipelatous inflammation which impedes respiration 
and deglutition. Besides these, there are various other symptoms 
present, such as ptyalism, nasal hemorrhage, swelling of the face, &c. 

3d. Anthracion attacking the parietes of the thorax is always ac- 
companied with inflammation of the subcutaneous cellular tissue of 
the thorax and axillre. 

4th. When the back of the hand or instep is the seat of the disease, 
every part of the limb is successively attacked with phlegmono-erysipe- 
latous inflammation. 

613. When anthracion becomes not merely a local but a general 
disease, unequivocal symptoms of an altered condition of the blood, 
of pulmonary (Cases XCVI and XCV1I) or gastro-intestinal inflam- 
mation of an unfavourable description, or of the absorption of pus 
into the system, are observed. 

In a case of gangrene of the lower lip, presenting all the symp- 
toms of anthracion, M. Littre, 1 found pus within the veins of the face, 
and a number of small abscesses in the substance of the lungs. 

614. Alterations of structure.— Cases XCVI and XCVII will be 
found to illustrate not only the nature of the alterations induced by 
anthracion in the skin and cellular membrane, but several which 
occur in the state of the blood, and in the lungs and stomach, analo- 
gous to those which Chabert met with in the bodies of animals that 
had died of this disease (charbon). M. Viricel informs us that he 
found anthracion in the colon. M. Lembert 2 has given a good de- 
scription of the gelatinous appearance of the serous deposits which 
are constantly found in the subcutaneous cellular substance, and oc- 
casionally in the cellular tissue of the mediastinum. A quantity of 
sanguinolent serum is very commonly found within the serous cavities 
in fatal cases of anthracion. 

615. Diagnosis. — At its first appearance, and w T hen it is still undis- 
tinguished by the hard and unequal elevation surmounted by a san- 
guinolent vesication, anthracion might be mistaken for the inflamed 
and painful induration produced by the bite of certain insects ; these 
bites, however, may always be recognized by the presence of a minute 
central, and yellowish-coloured point. 

Furuncle, at its commencement, shows no pustular or vesicular 
bleb on its summit, similar to that of anthracion, which, moreover, is 
speedily surrounded by a diffuse and emphysematous-looking inflam- 
mation, very different from any thing that is seen in furuncle. 

W hen anthracion has acquired a very large size, and gangrene, to 
a greater or less extent, has taken place in a portion of integument, 
the disease can only be confounded with phlegmonous and gan- 
grenous erysipelas, with the gangrenous affection of the cheeks and 
labia majora occasionally met with in children, 3 or with the bubo of 

' Journ. Hebdomad. Seplembre, 1829, p. 449. 

' Revue Medicate, 1830, p. 481. 

* BaroD, Memoire sur une aflection gangreneuse de la bouche, particuliere aux 



the plague. Phlegmonous erysipelas, however, is not preceded by a 
pustule or a sanguinolent vesicle in a particular point, and is not con- 
tagious ; the disease, in fact, only ends in gangrene through excess 
of action ; it is often treated successfully by blood-letting, a measure 
which is always prejudicial in anthracion. 

Anthracion differs from the gangrenous aflection in the checks of 
children in this: that the mortification in the latter malady begins on 
the inside of the mouth and only extends consecutively to the skin, 
and in the origin of the disease in this instance being altogether inde- 
pendent of contagion. 

The local characters of anthracion bear the greatest similarity to 
those of the pestilential carbuncle ; the latter, however, is preceded, 
and accompanied by the series of general and particular symptoms 
characteristic of the plague. 

Several fruitless attempts have been made to distinguish anthracion 
from the malignant carbuncle of animals, especially from that which 
attacks sheep and other woolly cattle. 4 The disease in animals is, in 
effect, characterized by the occurrence of a very voluminous uncir- 
cumscribed tumour, which yields to pressure, crepitating like emphy- 
sema and exhaling a peculiar putrid odour. The centre of the swelling 
is black, as if burned or carbonized, its circumference is infiltrated 
with a brownish or yellowish-coloured fluid, and is distended with a 
very fcetid gas ; the substance of the heart is commonly found soft- 
ened, and its external surface marked with spots of ecchymosis in 
the course of the blood-vessels; the blood contained in the heart and 
great vessels is generally fluid ; in the veins it is very black, and 
occasionally in clots of a black or yellowish-white colour, the con- 
sistence of which is soft and gelatinous. The lungs, covered with 
small superficial ecchymoses, present here and there a number of 
black spots penetrating their substance deeply, and produced by a 
kind of local sanguineous infiltration. The inner coat of the stomach 
and intestines presents, in different places, blackish spots and promi- 
nences in the course of the vessels, formed by blood effused between 
the two inner coats, or under the peritoneal covering of these parts. 
The villous coat of the stomach is also occasionally found ecchymosed; 
the liver and spleen are gorged with blood ; a degree of emphysema 
is often observed about the kidneys ; no change is appreciable in the 
state of the nervous system. Now, in the anthracion of the human 
subject, the alterations that take place in the skin and subjacent cel- 
lular membrane are precisely the same as those discovered in the 
bodies of animals that die of malignant carbuncle. I have, further, 
had various opportunities of investigating extensive morbid changes 
in the organs of digestion and respiration, and in the condition of the 
blood, in the human subject, precisely similar to those which have 
just been described as occurring among animals. Lastly, the discharge 
that takes place from malignant carbuncle in the brute, applied to the 
skin of man, produces anthracion ; the identity of these two affec- 
tions consequently appears to me incontestable. 

I shall by and by take occasion to speak of the analogy that sub- 
sists between anthracion and the Siberian carbuncle. (Vide Siberian 
carbuncle, in Vocab.) 

616. Prognosis. — The first variety of anthracion, which is fre- 
quently described by writers, gets well spontaneously ; the gangrene 
ends of itself. This happened in the case of a child, wffio was brought 
into the Hopital de la CharitS, in the year 1826, affected with anthra- 
cion of the upper eyelid. 

The second variety is more serious ; but its progress may very cer- 
tainly be arrested by the use of caustics. The disease in the third 
variety is mortal, and may end fatally within twenty-four or thirty-six 
hours from the time of its appearance. 

Whatever the form assumed by the disease, anthracion is always 
more serious when it attacks the head, neck, or eyelids, than when it 
appears on the extremities. It is very generally believed, also, that a 
very high or very low temperature aggravates the disease. 

Anthracion occurring in women during pregnancy very commonly 
causes abortion. 

617. Treatment. — As soon as the existence of anthracion is ascer- 

enfans (Bulletin de la - faculte de medecine de Paris, 8vo. 1816.— Isnard. Essai sur 
une affection gangreneuse particuliere aux enfans, 8vo. Paris, 1818. 

« Hurtel d'Arboval. Diciionnaire de medecine el de chirurgie veterinaires, 8vo. 
Paris, 182C. Art. Charbon. 



ANTHRACION. 



217 



tained, the part affected must be deeply scarified and extensively 
cauterized. To be effectual, the incisions must implicate the whole 
of the mortified tissues, without, however, extending beyond the dead 
or dying parts. In the beginning of the disease the vesication must 
be opened, the fluid it contains absorbed with a little lint, and the 
denuded part covered with a dossil of a corresponding size, dipped 
in the liquid muriate of antimony, or with a small fragment of caustic 
potash, kept in its place by means of a strip of sticking plaster and a 
proper bandage. Five or six hours afterwards, this application must 
be taken away and the eschar covered with a piece of lint spread with 
the unguentum resinosum or some salve of a similar description. Next 
day, if it is found that no vesicular areola has been formed around the 
eschar, if the patient complains of but little pain, without smarting or 
pungent heat, we may conclude that the cautery has included the 
whole of the disease ; if, on the contrary, a hard and deep-seated 
tumour has appeared around the primary seat of the disease, and 
symptoms of phlegmono-erysipelatous inflammation are present, the 
caustic must be applied again, taking the precaution first to remove 
the gangrenous parts, after dividing them by a crucial incision. This 
procedure is also proper when the slough which forms the centre of 
the swelling has already become hard and impermeable like a piece 
of dried hide; this must necessarily be removed to admit of the action 
of the caustic being expended on parts not yet sphacelated, after which 
they are to be covered with a tonic cataplasm. 

The value of escharotics in the treatment of anthracion is incon- 
testable. They are indicated so long as the gangrene shows a dis- 
position to spread, or as its limits are not clearly defined. There are 
cases, however, in which these means, even when they have succeeded 
in checking the local disease, prove unavailing in warding off a fatal 
termination. When the peculiar contagion of anthracion has extended 
its influence to the blood, when it has caused a gangrenous affection 
of the stomach, or pneumonia of a bad character (Cases XCVI and 
XCVII), or otherwise, when pus has been absorbed into the system 
after the occurrence of gangrene, the disease is invariably fatal in its 
effects. 

618. Acidulated diluents and wine mixed with an equal quantity 
of water are the remedies that are most commonly exhibited internally. 
The tartrate of antimony and purgatives have been recommended as 
calculated to subdue certain gastric symptoms. I have not myself 
had any opportunity of observing the effects of these medicaments in 
anthracion. They may possibly prove useful in the third variety of 
the disease against which merely local measures are always unavailing. 

In several cases of the least serious kind of anthracion, and when 
there was no symptom of constitutional infection present, after having 
cauterized the part affected, I have used compression successfully as 
a means of removing the erysipelato-phlegmonous inflammation sur- 
rounding the gangrenous point. 

I have also tried the local application of leeches in a case of promi- 
nent anthracion, without any serious ill effects, indeed, yet with such 
results as would prevent me from prescribing local blood-letting in 
any future case of the kind. 

I have seen several cases of anthracion occurring on the forearm, 
which were attended with gangrene of such extent and depth as to 
require the amputation of the limb at a point above the diseased 
structures ; the greater number of these cases terminated fatally. 

The deformity and destruction of parts, consequent on the ravages 
of anthracion, frequently require surgical operations for their restora- 
tion. M. Lallemand 1 has given the details of the case of a little girl 
attacked with anthracion of the face in whom, by means of a very inge- 
nious process, he succeeded in restoring the loss of substance which 
had happened in the under lip. (a) 

(a) Closely akin to anthracion, if not one of its varieties, is gangre- 
nous erysipelas, as described in pp. 66 and 67 of this volume, and 
the " Diffuse Cellular Inflammation" of English writers. Dissecting 
wounds and abscesses belonging to this order are especially apt 
to prove dangerous and fatal, if the subject examined had died of 
peritoneal inflammation. Mr. Nunneley describes the disease as a 
variety of erysipelas under the head of " cellular variety." 



55 



Archives gener. de modec, t. iv. p. 242. 



Historical Notices and particular Cases. 
619. Celsus describes anthracion under the name of carbuncle. 2 Guy 

" The cellular variety, like that which equally involves both skin 
and cellular membrane, varies much in its violence, and owing, per- 
haps, to its being principally seated in the cellular membrane, which 
is the especial locality of true phlegmon, in mild cases, it presents us 
with a very near approach to circumscribed phlegmon. The mischief 
varies from little more than a whitlow, or a suppurating absorbent 
gland, to that form of the disease which induces a destruction spread- 
ing over almost half the subcutaneous cellular membrane of the body. 
So also does the rapidity of the disease differ much; in some cases it 
proves fatal in a few hours, in others not for many weeks, when the 
patient dies rather from the effects of the disorder than from the com- 
plaint itself. • 

" In the majority of cases the constitutional symptoms are preceded 
by some local affection, but not invariably, for at times the constitu- 
tional derangement appears without any local complaint, and the 
patient seems to be suffering under typhus fever, for which, 3 indeed, 
in more than one case, the disease has been mistaken ; yet, even in 
these cases we may generally avoid the error, for in simple typhus 
the disorder only reaches its height after some time, but in this affec- 
tion at a much earlier period, usually in a short time, as two or three 
days. There is intense local pain in the punctured part, if a puncture 
has been the exciting cause, with enormous diffuse swelling, and 
more or less redness. 

" When the disease arises from venesection, the wound in the vein 
sometimes heals and remains so ; at others, after having healed, it 
again opens; but more commonly it does not close at all, but remains 
open, the edges becoming thick, irritable and gaping, and there is a 
discharge of a thin, semi-purulent matter. 4 From this point the 
disease spreads as from a centre, though more towards the shoulder 
than towards the hand. Sometimes, although venesection may 
appear to have been the immediate exciting cause, the punctured 
vein is not found to have been implicated. In most cases, if the 
disease arises from the application of poison, as the bite of a serpent, 
or from a wound received in the examination of a body, there is a 
small vesicle or pustule which forms at the wounded spot, and which 
Dr. Colles appears to regard as possessing specific characters. How- 
ever extensive the suppuration may be, there is seldom much in the 
immediate vicinity of the wound. In most cases the violence of the 
disease seems to be expended about the axilla and in the region of 
the pectoral muscles. The redness of the skin is not so conspicuous 
in this as in the preceding variety; it is, however, never altogether 
wanting; in all cases, at one period or another, the skin participates 
in the disease, sometimes very extensively. At times vesications 
occur, though not so frequently as in the cutaneous variety, which, 
indeed, we should not expect, inasmuch as they are the effect of the 
external surface of the dermis being inflamed. The large vesica- 
tions which appear at a later period are more like the phlyctense pre- 
ceding gangrene of the skin, which changes colour and undergoes 
precisely the same processes which were spoken of in the cellular- 
cutaneous variety. In one circumstance only does the gangrene in 
this variety differ from that which occurs in the former, namely, that 
the muscles are much more frequently affected. On account of the 
inflammation being deeper seated, it oftener passes beneath the fascia, 
when the muscles become soft, black, and completely disorganized. 
It is a matter of doubt if this arises from the muscular structure itself 
being inflamed, as Dr. Duncan supposed : to me it rather appears to 
result from the same circumstances as gangrene of the skin ; in both 
cases the cellular matrix, in which the nutrient vessels and nerves 
pass to their distribution, is destroyed, and with it the vessels and 
nerves ; as a necessary consequence the death of the part ensues." — 
■Nunneley on Erysipelas, pp. 147-8, Am. edit. 

2 Celsus. De re medica, ed. Ralier et Fouquier, lib. v. sect, xxviii. n. i. 

3 Duncan in Edinburgh Med. Chir. Trans., vol. i. p. 602. Dr. Colles in Dublin 
Hospital Reports, vol. iii. p. 209. 

1 In the milder forms of this disorder, which follow venesection, and which every 
practitioner must have often seen, this opening in the integuments serves as a vent 
through which the discharge takes place, when, after a few days of fever and irrita- 
tion, the patient recovers. 



218 



GANGRENE 



iuliac' notices the principal features oi' the disease. Thomassin, 
lasier have given us interesting remarks on anthra- 
■ ■nerallv. .M. C'oslallaf has related the history of a case of the 
the upper eyelid without any surrounding erysipela- 
attended with alarming symptoms. M. Blandin 3 has 
published a ease of anthracion excited by contact loith an animal affected 
with no gangrenous disease, and eared by the application of the acidu- 
lous nitrate of mercury. M. Lisfranc 4 has made several remarks in 
favour of the actual cautery which he prefers to any form of potential 
caustic. 

Anthracion has been seen complicated with oedema of the glottis ; 5 
additional observations on the disease and its complications may be 
found inserted in various periodical publications. 

Case XCV. — Circumscribed anthracion ; cauterization; compression. 
P. Monserant, Tawer, 26 years of age, and of good constitution, entered 
the Hopital de la Charite, on the 12th of September, 1833. This man 
had been engaged in working among hides stripped from animals that 
had died of disease, when on the 4th of September, he perceived, 
without any premonitory symptoms, a small pointed spot surrounded 
with a red areola very like that which follows the bite of a gnat on 
the palmar aspect of the right forearm. Next day another small, very 
hard and non-vesicular spot made its appearance on the back of the 
hand of the same side. The first was so itchy that the patient soon 
tore it with scratching; the excoriation speedily become covered with 
a small black eschar, which two days afterwards was nearly two lines 
in diameter. Up to this period no constitutional affection had been 
perceived, but on the 7th, the arm began to swell, the axillary glands 
to grow painful, and febrile symptoms of considerable severity, at- 
tended with lassitude and pains in the back and limbs, set in, together 
with urgent thirst and a loss of appetite. Diluents, and emollient 
cataplasms seemed to relieve this state of affairs. The arm became 
less painful in the neighbourhood of the eschar which was surrounded 
by a circle of the cuticle detached by the effusion of a little purulent 
fluid beneath it. 

When the patient gained admission into the hospital the constitu- 
tional symptoms had declined greatly. The right forearm presented 
an eschar five or six lines in diameter, depressed, dry, black, hard, 
surrounded by a very narrow red circle, which itself was circum- 
scribed by a reddish areola covered with small epidermic squamae. 
Although the distension of the skin was not considerable, the arm was 
still swollen, shining and red, especially on the dorsal aspect of the 
hand, and the forearm pitted on pressure. The patient made little 
complaint of pain, but rather of an unpleasant feeling of tension. The 
pulse was not increased in rapidity. After dividing the eschar, the 
part was touched with chloride of antimony, and the whole arm was 
firmly bandaged from the fingers to the axilla. The night between 
the 12th and 13th was good, and in the morning the patient was 
found almost entirely free from fever. The swelling of the arm had 
diminished, and the redness of the skin was succeeded by a yellowish 
tint, which gradually acquired a degree of intensity equal to what is 
observed after the resolution of an ecchymosis. Every thing went on 
favourably under the same plan of treatment: the slough becoming 
detached on the 18th, and the wound being healed over on the 30th 
of September, the patient was discharged. 

Case XCVI. — Anthracion with gangrenous ulceration ; death. Ch. 
Chibot, a hair manufacturer, entered the Hopital St. Antoine, on the 
28th of May, 1829. This man had been out of health for some time. 
On the 23d he was so unwell that he could not go to his work. On 
the 2Gth the feeling of weakness and prostration increased ; he was 
troubled with cough and retching. Nearly a month before his recep- 

| "C'est pustule phlemonique male, vesicante et brulante. Le lieu ou elle est 
noire et encendree, ayant rongeur obscure et douleur et ardeur et vesication a I'en- 
viron.de laquelle vient, quant est rompue,eschare telle comme fait venir combustion 
et cautere. (Le Guidon, trad, par J. Canappe, 8vo. Lyon, 1538, p. 87, du Car- 
noncle.) r 

* Journ. Hebdomad., t. i. p. 61. 

' Journ. Hebdomad., i. iv. pp. 417-19, 

« Journ. Complement, des sc. medic, t. xxxix. p. 304. 

6 Journ. Complement, des sc. mi-dic. t xxxix p 321 

« Decaris. Pustule maligne gu,ne par ie phosphore a la dose de trois grains dis- 
sous dans une once d ether, par 24 heures (Revue medic, t. xv. p. 429)._SchVan 
A mst-deux personnes guenes par des lotions avec la decoction d'ecorce de chene 
g Hahnemann sans cauterisation. (Revue medic, t. xvi. p. 463.) 



tion into the hospital he had had an eruption of itchy spots upon the 
elbow which became more troublesome than usual on the day he first 
felt seriously indisposed. According to the patient, weakness, pros- 
tration and spitting of blood are symptoms of frequent occurrence 
among the workers in hair. His daughter had died after an illness of 
five days with symptoms of this description, and one of his fellow- 
labourers had sunk some time previously, in two days. A young man 
18 years of age, who worked along with the patient had been success- 
fully treated for anthracion of the thigh in the Hopital St. Antoine. 

Chibot on the day of his entrance was extremely weak, and had 
fainting fits. The left lateral region of the neck is of a pale red, and 
slightly shining ; there is a degree of puffiness on the same side, under 
the clavicle and towards the roots of the hair, where there is observed 
a gangrenous spot, the size of a split pea, which had been preceded 
by a pimple or spot, destroyed by the patient with his nails. A yel- 
lowish and not very consistent fluid, which stains the pillow, is poured 
out by the little ulcer, in the vicinity of which a number of small 
pustules, full of a somewhat turbid liquid, are perceived. The surface 
of the sore, when touched, causes no sensation of pain. A great degree 
of swelling extends over the whole of the left side of the neck, the 
ramus of the low r er jaw, the shoulder, involving the clavicle and ex- 
tending down both behind and before upon the chest. The touch 
conveys a feeling as if a quantity of fluid were effused into the cellular 
membrane under the skin, the sensation of oedema being in some 
places very distinct, whilst in others it seems as if a gaseous body 
were displaced by the fingers, as in emphysema. The base of the 
tongue is loaded with a yellow fur ; the abdomen is slightly painful 
to pressure. The patient coughs at times ; the thorax, generally sono- 
rous, is however less so on the right than on the left side. The pulsa- 
tions of the heart are weak. The patient complains of oppression, of 
a sense of sinking about the praecordia, as if the heart were compressed, 
and of wandering pains in the limbs. The pulse at the wrist is small 
and shrunk ; the feeling of weakness is extreme, so that the patient 
cannot sit up, but sinks immediately like a lifeless mass, retaining the 
same position in which he happens to fall. The patient is haunted 
with the notion that he will not recover. (Decoction of bark edulco- 
rated.) 

At 4 o'clock the prostration had increased; I touched the whole 
surface of the sore with the red-hot iron. (A tonic draught with bark 
and ether ; weak wine and water.) 

30th. — The patient has had no sleep, but feels a little better ; he is 
not so much sunk as yesterday, and the constriction of the chest is 
less. Pain in the abdomen, increased by pressure ; right side of the 
thorax expanding little ; no cough nor expectoration ; posteriorly a 
slight degree of crepitating rattle can be perceived ; diarrhoea. A little 
broth, which the patient had taken, as well as the tonic draught, were 
rejected by vomiting ; the wine and water could alone be retained. 
(Wine and water, decoction of bark.) 

31st. — The patient says he feels better ; he pretends that the wine 
intoxicates him ; the pulse continues small. Towards evening the 
oppression increased, the pulse became imperceptible, and the patient 
died during the night, having retained his faculties to the last. 

Sectio cadaveris, 28 hours after death. The nervous centres and 
their membranes were healthy. The right lung, although gorged, was 
soft, crepitating, and torn with difficulty, especially about its middle ; 
the upper part was sound, and nothing escaped on its being divided. 
The blood and tissue of the lung in other situations appeared amalga- 
mated. The cut surface looked black, and nothing was removed from 
it by scraping with the scalpel. The left lung was healthy. The heart 
was natural ; its right cavities were filled with blood from which a few 
bubbles of air escaped. 

When the abdomen was laid open, about a pint of yellowish liquid 
made its escape ; by pushing the bowels aside, a darker-coloured puri- 
form fluid was observed between the stomach and liver ; on the convex 
surface of the latter viscus there were some shreds of false membrane, 
loose, transparent and tearing readily. The omentum majus and outer 
surface of the stomach were of a red colour, owing to the accumulation 
of blood in the veins. Black points were scattered here and there 
over the small intestines. The stomach was four times as large as it is 
in the natural state, and appeared distended with fluid ; but it was 
nearly empty, its walls being in many places more than an inch and a 






PAPUUE. 



219 



half in thickness, and communicating to the touch the same sensation 
as the parietes of the abdomen when pinched between the fingers. Its 
mucous membrane presented six round or oval-shaped patches, black 
in the centre, yellow in the circumference, upon some of which the 
membrane could still be traced, although it was softened, and remova- 
ble with the slightest touch, as if it had been in a state of putrefaction, 
which, however, did not appear to be the case, as no gangrenous odour 
was emitted. The mucous membrane was separated from the subja- 
cent cellular membrane (which was thickened, loaded, and covered 
with intermingled red patches and white points), by a thick black fluid. 
The disorganized patches were surrounded by a yellowish areola, of 
varying breadth, where the mucous membrane was more consistent. 
Some of these were of the size of a crown piece, others considerably 
smaller. The mucous membrane generally tore with ease, — its natu- 
ral wrinkles were effaced and it could be marked or traced upon with 
a very slight degree of pressure ; the cellular membrane under it was 
thickened, and in a state at once of emphysema and oedema. 

At the distance of two or three inches below the duodenum, which 
was healthy, there was a dusky-red spot in the small intestines, on 
which the mucous membrane was somewhat softened. A little lower, 
one of the valvulse conniventes formed a dusky-red ridge, from the 
deposition within the subjacent cellular membrane of a quantity of 
blackish fluid which could be forced out by pressure. 

On cutting through the external gangrenous tumour which had 
been cauterized, the cellular substance around it was found infiltrated 
and somewhat redder than natural. Towards the middle of the neck 
a quantity of blood was found effused into and between the fibres of 
the muscles, the cellular substance, &c, penetrating every tissue 
nearly to the depth of the vertebra. The larynx was even stained. 
The glands of the neck were also red and enlarged, and full of dark- 
coloured blood. The structures on the right side of the neck as well 
as all the other organs of the body appeared natural. 

Case XCVII. — Anthracion of the eyelids. Extensive gangrene; 
death. — Josephe, a carder of matresses, on the 12th of July, observed 
a small red spot, the size of a pin's head, on the outer angle of her 
left eye. On the 16th, this spot spread and caused some swelling of 
the eyelids and cheek. On the 20th, the whole of the upper and 
under eyelid, including the eyebrow and part of the temple, over 
an extent of an inch and a half in perpendicular by about the same 
amount in longitudinal extent, were stricken with sphacelus, and 
covered with a moist, brown, sanguinolent and deep slough. The 
outer part of the orbit was swollen and emphysematous, and the 
cheek, forehead, and upper part of the neck were tumid, hard, and 
of a violet-red colour in the vicinity of the slough. These parts were 
not affected as in phlegmonous erysipelas with any preternatural heat. 
The eyelids thick, stiff and as black as charcoal, but still moist, 
could not be separated from each other ; so that the state of the eye- 
ball could not be ascertained. The pulse was very small; the ex- 
tremities were cold. The breathing appeared natural ; the intellectual 
faculties were untouched. The mode in which this gangrenous affec- 
tion commenced ; the transformation of the spot that was first dis- 
covered into an eschar; the erysipelatous areola without morbid heat, 
with which it was surrounded — all these circumstances combined, 
led me to believe the case one of anthracion, a diagnosis, the 
accuracy of which was subsequently confirmed by the post-mortem 
examination. An incision was carried along the lower eyelid in the 
direction of the cheek bone : it was nearly an inch deep, scarcely 
attended with any pain, and gave exit to a quantity of blackish blood. 
By separating the lips of the wound a line formed by the black and 
dry skin was first perceived, and under it, a dark-coloured layer, 
infiltrated with blood and insensible. A second transverse incision 
of less depth than the first, lest the eyeball should have been impli- 
cated, was made across the eyelid ; and a third incision, more than 
half an inch deep, was carried from the alee nasi obliquely towards 
the lower end of the lobe of the ear. This cut bounded the violet 
hue of the skin inferiorly. Along the two outer thirds of this cut the 
skin appeared simply red and erythematous, not sphacelated, and the 
adipose cellular membrane under it looked healthy. At its inner 
third, on the contrary, the cellular membrane presented three or four 
brownish spots, like ecchymoses. From the lower end of this incision 
a fourth was carried obliquely upwards towards the upper part of the 



anti-tragus; it was about a third of an inch in depth. A certain 
quantity of dark-coloured blood flowed from this incision, the bleed- 
ing from which was encouraged by tepid fomentations. Dossils of 
lint, dipped in a strong solution of the acid nitrate of mercury, were 
then passed repeatedly along the surface of the different incisions 
The portion of healthy skin included between the incisions was not 
touched with the caustic. M. Beaumetz, my dresser, sponged away 
the blood and sanies that flowed from the incisions ; his hands re 
maining soiled during 55 minutes without any ill effect. Dry lint 
was then introduced between the lips of the wounds, and compresses 
impregnated with a solution of chlorate of lime applied over the 
sphacelated parts {decoction of bark ; sulphate of quinia 12 grains). 
The patient was placed with her head well raised. 

For two days this plan was pursued, and the gangrenous affection 
of the cheeks appeared to be arrested ; but it then began to extend ; 
gastric symptoms appeared ; pneumonia made silent progress and the 
patient died. 

Sectio cadaveris 30 hours after death. The interior of the cranium 
presented nothing remarkable. On the left side of the face the parotid 
gland was hard and yellowish. The portio dura of the 7th pair, at 
the point of its escape from this body, was unchanged ; it looked 
slightly greenish where it passed through the gangrenous cellular 
membrane ; by pulling this nerve gently it could be isolated from the 
surrounding softened structures. The veins presented no peculiar 
morbid appearance. The branches of the external carotid artery 
were unaltered. The gangrene extended below the level of the 
inferior incision. The skin being softened, greenish, readily separaf 
ing from the subjacent tissues, and exhaling the peculiar odour 
characteristic of gangrene. The subcutaneous cellular substance of 
the eyelids and malar region was gangrenous, black, and impregnated 
with a greenish-coloured sanies. The masseter muscle was greenish 
on its outer surface ; but its fibres, where they are in relation with 
the bone, were red and healthy. The orbicularis palpebrarum was 
in great part softened and gangrenous. The periosteum of the upper 
jaw and os frontis and parts round the orbits, was stripped off with 
the same ease as it is from bones that have undergone the process of 
maceration. The gangrene had extended to the whole of the soft 
parts in the same vicinity. There was, however, no trace of inflam- 
mation there, — no redness, no formation of pus. The conjunctiva 
was destroyed and the transparent cornea, generally opaque, was per- 
forated with a triangular gap in its centre. The sclerotic coat and 
retina were healthy as were the deeper parts contained within the 
orbit. In the mouth an oval patch of the mucous membrane on the 
affected side was destroyed, and the parts with which this was in 
relation were green in colour. The larynx and trachea were un- 
changed. The lungs were gorged in some places, hepatized in others, 
and when cut into, the surface looked gray, purulent matter flowing 
from it when scraped with the scalpel. The heart and great vessels 
seemed healthy. The stomach presented numerous dotted red patches, 
an appearance which was also remarked in the small intestines and 
ccecum. Nothing remarkable was discovered in any other part of the 
body. 



VII.— PAPULA ; PAPULAR INFLAMMATIONS, (a) 

Vocab. Papulsc. 

620. This group of cutaneous diseases is characterized by papula, 
that is to say, by hard and solid elevations, attended with pruritus, 

(a) These are placed by Mr. Wilson, under the head of " Deposi- 
tee Inflammation of tfie Dermis." We subjoin his reasons for this 
arrangement. 

" By the term ' depositive,' which I have selected only in the 
absence of a more suitable word, I mean to express that condition of 
the inflamed dermis in which plastic lymph is exuded by the capillary 



220 



PAPULA. 



which is always troublesome, and at times intolerable. These papula? 
end by resolution and t'urt'uraceous desquamation, and accidentally in 
•nations. 

621. The number of papular inflammations usually reckoned, 
amounts to three : lichen, strophulus, and prurigo. They might, how- 
ever, with perfect propriety be reduced to two, strophulus being a 
mere modification of lichen peculiar to the new-born infant and suck- 
ling. . 

622. Papular affections may be confined to a single region of the 
body, upon which they occur disseminated or in clusters. The papulae 
of lichen are red or inflamed ; those of prurigo are nearly of the same 
hue as the skin in general ; those of strophulus are of a vivid red, or 
of a dull white like the wheals of urticaria. The papulae of lichen 
are scarcely so large as the head of the smallest sized pin ; those of 
prurigo are somewhat broader ; those of strophulus are very various 
in their dimensions. Papular inflammations have this peculiarity, 
that the pain they occasion is almost uniformly of the itchy kind. 
Lichen in its course may appear with the acute or chronic type ; in 
prurigo the eruption is always thrown out slowly and in successive 
crops ; strophulus presents very remarkable intermissions and exacer- 
bations. 

These three diseases may end in resolution or in desquamation ; 
chronic lichen is frequently followed by very severe and obstinate 
excoriations. 

623. It is only necessary to touch and to incise papulae to be 
satisfied that they are solid and consistent, consequently that they are 
very different from vesicles and pustules, to which they bear some 
analogy in the particulars of size and form. 

The investigation of the minute anatomical structure of these small 
granules is a subject of some difficulty. Their opacity and solidity, 
no fluid being perceptible in their interiors, even with the magnifier, 
are important features, besides those of a mere external nature already 
enumerated. But it still remains matter of uncertainty which of the 
elementary tissues of the skin contributes essentially to their forma- 
tion. Several writers have supposed that the nervous papillae of the 
skin, enlarged in their dimensions, were the parts more particularly 
interested ; but this opinion appears by so much the less likely, as 
the fact is that papulae occur but rarely on those districts of the skin 
which are most distinctly and abundantly supplied with papillae, as 
on the palm of the hand and cushions of the fingers. Papulae again 
have been supposed by Mr. Plumbe to be produced by the effusion 

rete into the tissue of the dermis, so as to give rise to the production 
of small hard elevations of the skin, or pimples. In the preceding 
groups of diseases we have seen simple congestion of the papillae of 
the dermis, effusion of the serous portion of the blood on the surface 
of the dermis, formation of pus on the surface of the dermis ; but the 
alteration now under consideration is different from the whole of 
these ; there is no inordinate congestion, there is no serous effusion, 
and no generation of pus. As far as my observation of the patho- 
logical characters of the present disease enables me to determine, 
there is effusion of plastic lymph into the tissue of one or more of the 
papillae of the dermis, constituting a pimple of small size. 

" The pathognomic symptoms accompanying pimples correspond 
moreover with the supposition of such a pathological structure ; they 
are accompanied by incessant itching, a sensation which may easily 
be explained by reference to the moderate degree of pressure pro- 
duced upon the nervous plexus of the papillae by the effused lymph, 
or, probably, by the distension of the neurilemma of the nerves by 
the more fluid parts of the lymph, so as to affect the nutrition of the 
nervous substance. Pruritus is unquestionably a degree of pain, but 
it is one of a mild kind, and such as we see for the most part in 
papular eruptions of the skin, or when the dermis is returning to its 
natural^ state after inflammatory congestion of its tissue, or, again, 
when foreign substances, such as scabs and crusts, effused fluids, 
parasitic animalcules, &c, lie in contact with the skin. 

" The diseases which are here characterized by the designation 
' depositive inflammation of the dermis,' correspond with the order 
papula? of Willan ; and in this instance no difference of opinion exists 
among dermatologists as to the morbid affections admitted into the 
group." 



of a very minute quantity of lymph into the dermoid tissue, with 
which this fluid unites when it is not re-absorbed : it is true that by 
pricking the larger papulae of strophulus deeply with a needle, and 
squeezing them firmly between the fingers, a very minute globule of 
transparent serum may occasionally be expressed ; but by resorting 
to the same procedure in cases of lichen and prurigo I have never 
succeeded in forcing out any thing but a drop of blood. 

624. Strophulus appears particularly among new-born infants, 
lichen among children and adults, prurigo among children and the 
aged. None of these affections is contagious, but those who have 
been once attacked almost always experience returns of the disease 
under which they had laboured, at intervals more or less remote from 
each other, and it is observed that these relapses are particularly apt 
to follow atmospheric changes. 

625. The papular are very distinct from the exanthematous inflam- 
mations, which present coloured blotches, not circumscribed eleva- 
tions ; they are not less evidently different from the bullous, vesicular 
and pustular forms of cutaneous affection, in which a serous or puru- 
lent fluid is effused between the external surface of the corion and the 
cuticle. Notwithstanding this, however, to discriminate between the 
papulae of acute lichen and the minute vesicles of scabies and eczema, 
the eruption requires to be examined with great attention, and even 
to be pricked with a pin. 

When the papulae have been destroyed by scratching, or when they 
are replaced by furfuraceous patches or excoriations, the diagnosis is 
frequently so obscure, that accuracy is only at length obtained by the 
occurrence of fresh elevations, the formation of which being watched 
and discovered, that of those which may have gone before is in- 
ferred. 

626. The papular inflammations are generally diseases of no great 
severity ; though they are occasionally extremely rebellious. Various 
plans of treatment are practised in these cases, the activity of which 
ought to be in proportion to the extent and inveteracy of the eruption. 
Lichen agrius is one of the most obstinate of all the diseases of the 
skin. 



Vocab. Lichen, Papulse. 

627. Lichen is characterized by the simultaneous or successive 
eruption of itchy papulae, reddish in their colour or of the natural hue 
of the skin, most commonly clustered together, but occasionally scat- 
tered, and occupying a particular region, or disseminated over the 
whole surface of the body. This affection usually ends in a furfura- 
ceous desquamation ; it terminates more rarely in superficial and very 
obstinate excoriations. 

To make the description of the disease as complete as possible, 
Bateman reckoned six varieties of lichen, five of which had been 
determined by Willan. Some of these are marked by a particular 
arrangement of the papulae, others by various modifications in the 
colour and in the intensity of the eruption. Lichen simplex, L. pilaris, 
L. circumscriptus, L. agrius, L. lividus, L. urticatus. A lichen tropi- 
cus has also been since admitted, a title under which the whole of 
the lichens developed within the tropics, and exasperated by the 
effects of excessive temperature have been included. These, how- 
ever, do not actually constitute diseases different from one or other of 
the varieties already recognized. 

The different forms of lichen occasionally occur with the acute 
type ; but they are much more frequently chronic in their progress. 
_ 628. Symptoms. — 1st. Lichen simplex may appear confined to a 
single region of the body, — to the face, neck, arm ; or it first attacks 
one or other of these, the face and arm for instance, and spreads 
within the course of three or four days to the trunk and lower extremi- 
ties, attacking particularly the external and posterior aspects of the 
limbs. 

Lichen simplex acutus is characterized by small solid elevations of 
a red colour, not transparent, frequently acuminated, containing neither 
pus nor serum, and seldom exceeding a millet seed in size. This 
eruption is attended with a disagreeable sensation of tingling, espe- 



LICHEN. 



221 



cially during the night. The eruption, irregularly scattered over the 
skin, continues unchanged for seven or eight days, after which its 
red colour changes, and it ends in furfuraceous desquamation. 

Lichen is seldom ushered in by constitutional symptoms, — fever, 
general uneasiness, &c, except in those cases in which the eruption 
is very abundant. 

Although each individual papula does not continue longer than a 
week, lichen simplex may remain as a disease during many months, 
and even during several years. It then consists of a succession of 
eruptions, — Lichen simplex chronicus. "Whilst one is disappearing 
another is evolved, and the disease in this way invades many differ- 
ent regions of the body, one after the other. Frequently when the 
cure seems accomplished, a fresh crop of papula? breaks forth, in one 
case apparently from some change in the weather, in another from 
some moral cause, or some error in diet. In the majority of instances 
the fresh eruption is not heralded any more than the first attack by a 
febrile paroxysm ; this phenomenon in fact is only observed during 
the course of the disease when the eruption is extremely abundant, 
or is complicated with some other inflammatory affection. Willan 
was mistaken when he imagined that lichen simplex was always pre- 
ceded by febrile symptoms, and gave this circumstance a place in his 
general definition of the disease. 

Lichen simplex may pass into the state of lichen agrius ; the papula? 
are then surrounded with a slight reddish areola, and appear to be- 
come confluent; the whole of the eruption does not always share in 
this exacerbation, which is occasionally observed to give a favour- 
able turn to an eruption of long standing. 

2d. Lichen pilaris. This variety does not differ from the preced- 
ing save in this : that the papula? are evolved on points of the skin 
which are traversed by hairs. The bulbs of these seem occasionally 
to participate in the inflammation, which is always deeper than in 
lichen simplex. Lichen pilaris is almost always chronic in its nature ; 
it is not uncommon to see it continue for several years. 

3d. Lichen circumscriptus. This variety is characterized by one 
or several clusters of papula?, pretty regularly circular in their shapes, 
and bounded by a well-defined edge. It occurs with particular fre- 
quency on the back of the hand, on the forearm, ham of the leg, and 
region of the sternum. The course of this variety is nearly the same 
as that of lichen simplex ; it is, however, somewhat less obstinate. 
Some of the patches remain stationary for a certain time, and then 
get well spontaneously from the centre towards the circumference 
of the groups. Others of the patches, again, extend gradually, by 
means of fresh circles of papula?, which, thrown out around the first 
formed, increase in size, and finish by becoming blended with them. 
Eruptions of papula? clustered together in this way are in general less 
inflamed than the scattered granules of lichen simplex ; I have fre- 
quently remarked them nearly of the same colour as the skin. At the 
same time that the edges of the groups extend, their centres become 
level or smooth, acquiring a pale rosy colour, with a slight tinge of 
yellow intermixed, and a furfuraceous aspect. Whilst the first formed 
clusters are undergoing the process of desquamation, new patches 
are developed, which terminate in the same manner as those that 
have gone before them. The disease is in this way prolonged in- 
definitely. In some cases the papula? are arranged in small stripes, 
so as to simulate a rough line, which I have seen forming a kind of 
collar in front of the neck, extending from one ear to the other, — 
lichen gyratus. 

4th. Lichen agrius is distinguished by its prominent and acumi- 
nated papula?, of a vivid red colour, and running one into another 
over an erythematous surface, itself surrounded by a very marked 
red blush. The eruption of the papula? in this variety is frequently 
accompanied with a febrile state, which commonly yields when this 
is accomplished. These papula? cause a burning and intolerable 
sense of itchiness, especially during the night, and which is exaspe- 
rated by irritation of every kind. The pruritus occasionally amounts 
to a kind of torture; patients not content with scratching themselves 
with their nails, which they do incessantly, seem to feel peculiar 
pleasure in tearing their skin with the roughest brushes they can lay 
their hands on. By these measures, as may be imagined, the points 
of the greater number of the papula? are torn off; the skin becomes 
red and bleeding ; a serous fluid exudes from the torn apices of the 
56 » 



papula?, and concretes in the shape of yellowish crusts somewliai 
rugous to the eye, but soft and very slightly adherent in tact. IMS 
advanced and very severe form of lichen agrius has been assimilated 
by Alibert with the excoriations of eczema, and included by him in 
his description of the dartre squameuse humide. 

In the severe lichen agrius of old standing, the skin is dry, rugous, 
hard, and cleft with deep furrows, especially about the bends ot the 
arms and hams, when these parts have been the seat of the eruption. 
These altered surfaces long remain dry and unyielding even under 
the influence of the vapour bath. 

Lichen agrius is a form of disease that is pretty frequently encoun- 
tered. It has no more certain term of continuance than the varieties 
that have already been enumerated. It may come to an end in the 
course of eight or ten weeks, or continue for months and even for 
years, the eruption never presenting more than simple remissions more 
or less remarkable. The disease is very apt to recur on changes in 
the state of the weather, when it has existed long on any one place, 
or when it has already attacked the same district of the skin oftener 
than once. 

During the continuance of lichen agrius pain in the epigastrium, 
nausea, vomiting, diarrhoea, and several other functional disturbances 
of the digestive organs are occasionally complained of. 

5th. Lichen urticatus is a variety which was first described by 
Bateman, and by him added to those already admitted by Willan, 
being designated on account of the analogy which it bears in several 
particulars to urticaria. Lichen urticatus is observed occurring more 
especially on the neck and lateral parts of the face ; it is frequently 
attended with febrile symptoms, and appears and disappears within a 
short space of time. The papula? which characterize it are of an 
irregular shape ; they very much resemble the swellings produced by 
the bites of bugs or gad-flies, and are mixed with small inflamed and 
itchy papula?. Whilst these first-formed papula? are ending in reso- 
lution, or 'desquamation, others are appearing successively on the 
trunk and extremities, where they become confluent, and form small 
patches. Lichen urticatus is a rare disease ; I have never met with 
it except during the heats of spring and summer. In young children 
the strophulus candidus appears to correspond with this variety of 
lichen in adults. 

6th. Lichen lividus. Under this title Willan has described a papu- 
lar eruption of a dusky or livid colour, occurring principally on the 
extremities, and being unattended with febrile symptoms. It is apt 
to return after having disappeared, and may thus continue during an 
interval of several weeks. This variety of lichen is very uncommon. 
I have myself only seen two cases of it, both of which occurred in 
individuals whose constitutions had suffered from moral causes, as 
well as physical privations of every description. 

7th. Under the head of Lichen tropicus have been included the 
whole of the varieties already enumerated, but developed under the 
influence of a tropical temperature. The papular disease engendered 
under tropical latitudes has been successively studied by Bontius, 
Cleghorn, Johnson-, &c, whose several descriptions of the malady 
differ in no essential circumstance. In these countries, says Bontius, 
when the body has been covered with perspiration, an eruption of red 
and rough papula? is apt to take place over the whole surface from 
the head to the feet, attended with a very troublesome pruritus. This 
disease attacks those persons more particularly who have recently 
arrived from colder climates ; but no one is at all times exempt from 
liability to its invasion. When the skin is torn by the nails, excoria- 
tions frequently follow, which prove very rebellious to every form of 
treatment. The pruritus, according to the same author, is best alle- 
viated by keeping the parts attacked covered with folds of linen 
dipped in water, mixed with vinegar or orange juice. This appli- 
cation at first causes acute pain, but this soon passes off, and the 
pruritus then becomes more endurable. 

Cleo-horn expresses himself nearly in similar terms: the cutaneous 
eruption entitled prickly-heat is so common in warm countries, that 
almost all suffer in a greater or less degree from it during the hotter 
seasons of the year. Children, however, seem more subject to it 
than the grown up and the aged. The eruption consists in an im- 
mense number of small round and red elevations which appear on 
different parts of the body, particularly after active exercise. Whilst 



222 



PAPULA. 



the eruption continues, the only inconvenience suffered arises from 
the pruritus attending it; but if it happens to be driven in by expo- 
sure tn cold, liv using the cold bath, or committing any imprudence 
in regard to diet, very serious symptoms may ensue. The moment 
thai feelings of general uneasiness, pain in the head, excessive heat 
of the surface, &c., proclaim the recession of the lichen, blood-letting, 
and aperient and cooling acidulated diluents are to be had recourse to. 

Dr. James Johnson was himself attacked with lichen tropicus. 
" The sensations," says he, "arising from prickly-heat are perfectly- 
indescribable, being compounded of pricking, itching, tingling, and 
many other feelings, for which I have no appropriate appellation. It 
is usually but not invariably accompanied by an eruption of vivid red 
pimples, not larger in general than a pin's head. This eruption often 
disappears in a great measure when we are sitting quiet and the skin 
is cool ; but no sooner do we use any exercise that brings out a per- 
spiration, or swallow any warm stimulating fluid, such as tea, soup, 
or wine, than the pimples become elevated so as to be distinctly 
seen, and but too sensibly felt. Many a time I have been forced to 
spring from the table and abandon the repast I had scarcely touched, 
to writhe about in the open air; and often have I returned to the 
charge with no better success. 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, 
and if there were any water at hand, to sluice it over me, for the 
purpose of allaying the inexpressible irritation." 1 

Hillary recommended that the evolution of the eruption should be 
favoured by the use of warm diluents, tea, coffee, &c. Dr. Johnson 
with greater reason sees no advantage in suffering from such a disease ; 
and to prevent it entirely he advises Europeans arriving in India and 
warm climates to clothe themselves lightly, to avoid all exertion during 
the heat of the day, to live temperately, &c. In every instance in 
which this excellent author observed the recession of the lichen tropi- 
cus he could trace it to the occurrence of some other disease of greater 
or less importance. 

629. The essential and distinguishing features of lichen are its red 
and inflamed papula? ; when other alterations are observed occurring 
at the same time as these papulae, they constitute true complications. 
Thus, amidst the papulae of the various species of lichen, and espe- 
- -.ally of lichen agrius, a number of small adventitious vesicles, are 
occasionally perceived, similar to these of scabies or eczema. The 
presence ot these vesicles might even mislead in the establishment of 
a diagnosis, without attention to the circumstance of their appearance 
anteriorly to the evolution of the papulae, and to their numerical amount, 
which is much inferior to that of the papulae. Such vesicles must be 
regarded as a temporary complication, produced by the intensity of 
the papular inflammation of the skin. Lichen is occasionally observed 
to complicate scabies, when this disease attacks a young, plethoric, 
and robust individual. It happens more rarely that psydracia appear 
and blend with the papulae of lichen, in which case the diagnosis is 
attended with great difficulty. Incrustations of various thickness and 
extent speedily cover a part of the diseased surface, and may cause a 
truly lichenous eruption to be mistaken for an eczema impetiginodes ; 
it frequently happens, indeed, that it is only after the disappearance of 
these adventitious inflammatory affections that the really papular cha- 
racter of the principal eruption can be clearly ascertained. I have also 
met with lichen complicated with ecthyma and furuncle. 

Lichen is very rarely observed to be replaced by any other form of 
eruption. 

After several relapses, or when lichen has continued long on any 
region, the skin always wears a dirty or grayish-yellow aspect, and 
becomes to a remarkable degree thickened and rough, so as to appear 
even scabrous. 

630. Independently of the varieties which lichen presents, according 
as the papulae which characterize it are scattered or arranged in clusters 
are slightly or very much inflamed, are thinly sown or so thick as to 
be confluent, u presents several peculiarities according to the region 
ot the body upon winch it is evolved. 

1st. Lichen of the face is common during summer among individuals 
whose features are habitually exposed to the burning rays of the sun. 

> lofluence of Tropical Climates, 3d edit., p. 17, 8vo. Load, 1821. 



The furfuraceous desquamation with which it terminates has been 
described by several French pathologists under the title of dartre fori- 
neuse. When lichen of the face becomes chronic, the skin of the nose, 
malar regions and chin, which is the usual scat of this eruption, 
becomes yellowish, dry, and furfuraceous. It is readily flushed by the 
influence of external warmth, spirituous liquors, the approach of the 
menstrual period in females, &c, and then assumes a coppery-red 
colour. This variety of the disease is extremely intractable, especially 
in women arrived at the critical age. 

2d. Lichen of the extremities occurs particularly on their posterior 
and outer aspects, and in the bends of the arms and popliteal regions; 
the inner aspects of the legs and arms are often observed totally 
unaffected when the surfaces directly opposed to these are covered 
with papulae. The arms and forearms of cooks, founders, smiths, &c, 
habitually exposed to high temperatures, are frequently attacked with 
lichen simplex, or an artificial papular eruption having the same 
characters. 

3d. Lichen of the genital organs and margin of the anus is the most 
rebellious and insupportable of all the varieties of this eruption. It is 
frequently difficult to distinguish this eruption from eczema of the same 
parts when it has advanced into the furfuraceous state, or is attended 
with a sero-sanguinolent discharge as it frequently is § 353. Still a 
few papulae may almost always be detected in the neighbourhood of 
the furfuraceous, red or excoriated surfaces when the case is one of 
lichen. 

4th. Lichen very seldom attacks the hairy scalp primarily ; but 
when the disease is evolved on the nucha, forehead or temples, it may 
spread to the neighbouring regions covered with hair. A violent 
pruritus and furfuraceous desquamation are then the principal charac- 
ters of the disease. 

631. Causes. — Lichen attacks individuals at every period of life. 
Children of a bilious habit, adults and individuals of a nervous and 
irritable temperament are particularly predisposed to it. Infants at the 
breast are often attacked during dentition with eruptions having the 
characters of lichen. The temperature of the atmosphere during spring 
and summer, has a very marked influence on the appearance of this 
eruption, which is observed to recur in some individuals regularly for 
several years during the hottest season. Lichen agrius most usually 
appears among individuals addicted to the use of spirituous liquors. 
Gastro-intestinal inflammations and the causes which produce them 
are occasionally observed to precede the appearance of the eruption. 

632. Diagnosis. — It seems impossible to mistake even the most 
copious eruption of lichen simplex for the efflorescence of measles, 
scarlet fever and the other exanthemata. There is too marked a dif- 
ference between the blotches or stains of these diseases and the ele- 
vated papulce of lichen. Scabies and prurigo are the affections with 
which lichen simplex is most apt to be confounded. In prurigo, 
which like lichen is a papular disease, the papulae are larger, flatter 
and nearer the natural colour of the skin — they are not red and flushed 
like the eruption of acute lichen ; prurigo is attended with a burning 
pruritus, whilst the morbid sensations attending lichen are usually of 
a tingling and tickling description ; in lichen, indeed, it is common 
enough for patients to make no complaint of pruritus except when the 
body has been exposed to heat, or the system has been stimulated by 
some imprudence in diet, particularly by the ingestion of some spiritu- 
ous or fermented liquor. The distinguishing character of scabies is 
the vesicular form of its eruption ; lichen, on the other hand, is papular 
in its origin and progress. The vesicles of scabies are almost always 
distinct, scattered over the inner aspects of the arras, forearms and 
wrists, between the fingers, and upon the front of the abdomen. The- 
papulae of lichen are generally agglomerated, and appear in preference 
on the outer and posterior aspects of the extremities. In some rare 
cases, the hands are the seat of lichen simplex ; but these papulae are 
then commonly clustered on their dorsal aspects, whilst the vesicles 
of scabies are principally observed between the fingers. The papulae 
of lichen, especially when they are confluent, are surrounded by 
minute, thin and flimsy squamae ; the vesicles of scabies are never 
covered except by small scabs. Lorry, whilst speaking of lichen, 
under the title of papulce, gave long ago the principal characters 
which distinguish it from scabies. He says: " The eruption of papu- 
lar syphilis (lichen syphiliticus) resembles that of lichen urticatus in 



LICHEN. 



223 



point of size ; but it is coppery in colour, is not the seat of incessant 
pruritus, and is accompanied with other symptoms of lues." 

When patients labouring under lichen agrius tear the summits of 
the papulae, there exudes a sero-sanguinolent fluid which dries up 
into small thin and adhering scabs ; no true incrustation, however, is 
ever formed in lichen such as is observed covering the pustules of 
impetigo. 

The characters of lichen circumscriptus are generally so well defined 
that it is next to impossible to confound this with any other papular 
or squamous eruption. And yet when the patches of lepra are coming 
to a close, when the skin has regained its natural condition in their 
centres, and their edges are divided into a multitude of minute red 
points, raised above the level of the integuments, they might be mis- 
taken for the remains of lichen circumscriptus. But by carefully 
examining these points, whose shape is irregular, they will soon be 
seen to want the characters of papula;. 

The diagnosis of lichen agrius presents some difficulty when the 
eruption is so crowded that the individual papulae cannot be perceived. 
On the margins of the patches, however, a certain number of papulae 
may always be detected, which then proclaim the actual nature of the 
disease. The confluent and lacerated papulae of lichen agrius might 
very readily be mistaken for the superficial excoriations consequent 
on an eczema, did not the few papulae or vesicles that almost uni- 
formly escape uninjured in the circumference of these excoriations 
reveal the kind of malady with which we have to do. The thickening 
of the skin that takes place in lichen agrius is another feature which 
by itself very commonly serves to distinguish this disease from any 
other with which it is at all likely to be confounded. 

The small pustules of impetigo are occasionally clustered like the 
papula? of lichen agrius ; but in the lichen the scabs that occur are 
very thin and adherent, whilst in the impetigo they are thick and 
easily detached. Psoriasis has well-marked characters that distin- 
guish it from lichen agrius. The successive desquamation that so 
particularly characterize psoriasis, happen along with a thickening of 
the corion, and especially of the cuticle, which is never observed to 
the same amount in lichen. Further, a number of papulae are almost 
invariably found on the margins of lichenous patches even when the 
disease is of the most violent description, and has been most severely 
irritated. 

The pustules of rosacea are inflamed at their base like the papulae 
of lichen agrius, but they do not ulcerate ; each of them contains a 
minute globule of pus, whilst the papulae of lichen are solid, and dis- 
charge from their excoriated points a sero-purulent fluid which moistens 
their surface. The papulae congregated on any region, whatever its 
extent, advance simultaneously, become confluent, and are attended 
with an irritation which extends to the corion, but rarely to the sub- 
cutaneous cellular membrane ; in rosacea of any severity the irritation 
always extends to the cellular tissue, and there leaves enduring traces 
of its presence. Lichen agrius of the face frequently attacks the fore- 
head, face, and lips ; rosacea has its principal seat on the nose and 
cheeks. Rosacea is attended with a kind of tingling which becomes 
more marked and more troublesome after meals, on approaching a 
fire, and in warm places. The pruritus of lichen agrius of the face 
is more violent and seems more deeply seated ; it occasionally becomes 
intolerable during the night and after the ingestion of any stimulating 
fluid. The discharge from the small acuminated pustules of rosacea 
often changes into thin scabs which are speedily detached ; the ex- 
coriated papulae of lichen agiius of the face also become covered 
with minute scabs, but they are thinner, broader and blend more 
generally with the furfurae of the epidermis than those of rosacea. 

653. Prognosis. — The continuance of simple lichens occasioned by 
the heats of summer varies from one to two or three weeks. 

When lichen is the effect of causes unknown, or which have not 
acted directly upon the skin, it is generally difficult to speak with any 
degree of certainty with regard to the period of its probable termina- 
tion. It is occasionally very obstinate, and may continue, whatever 
the disposition of the papula?, for several months and even during 
several years. Lichen is in general the more troublesome and the 
less under the influence of remedial means, as it is of older date and 
has been characterized by successive eruptions occurring in indi- 
viduals further advanced in years, and with more seriously shattered 



constitutions. Lichen agrius of the face is commonly very rebellious 
and particularly apt to recur. I have scarcely seen more than two 
or three cases in which this papular inflammation appeared to be 
critical and salutary ; to individuals otherwise in good health it is an 
insupportable affliction, rendering their lives truly miserable. 

634. Treatment. — I could easily quote many cases of lichen sim- 
plex, and of lichen circumscriptus and lichen urticatus in which cures 
were accomplished by the sole effects of regimen, — by a regular and 
unexciting plan of life. 

Whatever the form of lichen, whether the papulae are widely 
scattered, or collected in clusters, if the disease be of recent date, 
acute in its character and of no great extent, a cooling regimen, 
slightly acidulated diluents and the use of the temperate bath, or of 
the cold river bath during summer, generally prove sufficient to make 
it disappear, and this without risk of ulterior ill effects. The tepid 
and hot bath frequently aggravate the symptoms of the eruption, par- 
ticularly of the variety entitled urticatus. 

When the disease has withstood this plan of treatment, recourse 
must next be had to the internal administration of the nitric, muriatic 
and especially of the sulphuric acid in large doses. These mineral 
acids, when they seem to engender any considerable degree of irri- 
tability of the digestive organs, must, however, be replaced by some 
of the less active vegetable acids such as the citric and acetic. As 
a final measure and when the papulae are extremely numerous, agglo- 
merated and confluent in various places, as they are in the lichen 
agrius, if the patient be young and of good constitution it may be 
necessary to detract blood once or oftener. General blood-letting is 
indeed an indispensable measure when the eruption is not confined 
to any determinate region of the body, such as the hand, face, &c. 
When blood is abstracted locally, the leeches employed must always 
be attached beyond the circle of the eruption ; as without this pre- 
caution the irritation of their bites is apt to aggravate instead of 
relieving the local inflammation. All topical applications should be 
of the mildest description, and used cool or cold to the affected parts 
Soothing washes, and gelatinous or mucilaginous baths, are generally 
useful when applied at low temperatures. Patients should, at the 
same time, be put upon the use of one of the acids which have been 
mentioned, combined as a sherbet, and should be advised to dress 
themselves with soft under garments and such clothing as will not 
tend to excite or increase the heat of the body. 

The effects of these various means ought to be seconded by a regi- 
men of greater or less severity according to the state of the constitu- 
tion. Patients must at all events abstain from spiced food of every 
kind, spirituous liquors, in a word, from all that could possibly tend, 
by its stimulating qualities upon the stomach, to produce at a later 
period any thing like a determination to the skin. 

635. Wlien lichen consists of several successive eruptions, and has 
assumed the chronic character, if the constitution of patients appears 
to have suffered from age or any other cause, the practitioner should 
be careful to strengthen it as much as possible by the exhibition of 
tonics, and the recommendation of a suitable regimen, even before 
he thinks of attempting to treat the eruption. 

When the disease is of very long standing, and affects the integu • 
ments deeply, the affected parts are often slightly anointed with the 
following ointment with the greatest advantage : R. Adipis suil. Si ; 
Sulphur, sublim. 3i; Potassae subcarb. 3ss. Emollient temperate 
baths are to be used at the same time, and after some little interval 
has elapsed they may even be taken slightly alkaline. Under similar 
circumstances I have frequently prescribed either of the following 
unguents with excellent effects: R. Adipis suil. Si ; Colomelan. 3i; 
Camphorae gr. xviii: R. Adipis suil. oi; Hydrarg. deuto-ioduret gr. 
x. M. I have also occasionally succeeded in giving relief from the 
pruritus by cauterizing the affected parts of the skin very slightly 
with nitrate of silver, or by the use of vinegar and water as a lotion 

The vapour bath, very detrimental in acute lichen, becomes ex- 
tremely beneficial in the chronic state of the disease, especially when 
the surface of the skin feels very dry. I have treated a great many 
cases of these eruptions by the combined use of the vapour bath, and 
the internal exhibition of the muriatic acid sherbet. 

Sulphureous baths, so generally and indiscriminately recommended 
in the treatment of cutaneous affections, are constantly hurtful in acute 






PAPULAE. 



lichen, ami ven seldom serviceable in the chronic form of the dis- 
These baths maj even cause a lichenous eruption; it is by no 
mc in-, an pnfrequenl circumstance to see lichen agrius appearing 
among individuals under treatment for scabies by means of sulphure- 
ous water bathing. Nevertheless, I have obtained the cure of several 
cases of obstinate hereditary lichen, apt to return at frequent intervals, 
by ell'ecting a material modification of the constitution by the use of 
artificial sulphureous water baths prolonged during several hours every 
day. Results of a similar description have been observed from the 
natural baths of Louesche and Schinznach. 

In lichen agrius advanced to the state of excoriation, the mineral 
acids ought constantly to be prescribed, unless, indeed, the irritable 
state of the digestive organs seems to contra-indicate their use. They 
should be taken in doses of from half a drachm to two scruples a day, 
in a pint of water sweetened to the taste. They cause a diminution 
in the watery secretion poured out by the torn papulae, and appease 
the pruritus. 

A certain number of cures have also been obtained by the exhibi- 
tion of saline purgatives frequently repeated, or of four or five grains of 
calomel combined with eight or ten of rhubarb, or the same quantity 
of jalap ; to me, however, the mineral acids have generally appeared 
more efficient as therapeutic agents in this class of complaints. 

When chronic lichen has withstood these various plans of treatment 
in an individual otherwise in good health, exempt from visceral 
affections, &c, when the disease is hereditary, is dispersed over a 
large surface of the body, and occasions distressing insomnia, we 
must then have recourse to some of the preparations of arsenic, and 
continue this class of medicines for a long time in graduated doses, 
it being always understood that they shall produce no manifestly 
injurious effects on the constitution. I have succeeded in removing 
several circumscribed lichens of old standing by the internal use of the 
solution of the arseniate of soda, and of sulphurated alkaline inunc- 
tions. These remedies, however, it must be presumed, are only to 
be employed in the small number of cases in which all other means 
have been fruitlessly enforced, and the disease has attained such 
severity that patients, worn out and reduced to despair, insist on 
getting rid of their infirmity at all hazards. It is further neces- 
sary, before prescribing these active medicines, to inquire particularly 
into the state of the digestive organs, only to increase the doses very 
gradually, and above all not to exceed from fifteen to twenty drops 
daily of Fowler's, or a drachm of Pearson's arsenical solution for an 
adult, in some mucilaginous fluid. Should such old and obstinate 
eruptions decline at all in severity and become endurable, it is often 
prudent not to expose patients to the evils that may result from the 
use of arsenical preparations. It is very necessary to be on our guard 
against any determination, speedily and at all risks to subdue these 
inveterate affections of the skin. When they have appeared before 
the age of puberty, they may get well of themselves a few months or 
a few years later, or at all events with the assistance of medicines 
less dangerous in their action. In adults, too, and individuals of 
riper years, an appropriate regimen pursued during several months 
frequently renders a cure easy which had formerly appeared impossi- 
ble even under the influence of the most active medicinal means. 

History and particular Cases. 

636. Hippocrates classes the lichens with prurigo, psoriasis, and 
lepra, without specifying the particular characters of each. 1 Accord- 
ing to De Gorter 2 — " In hoc loco Hippocrates per lichenas intelligit 
talem cutis fcedationem,in qua summa cutis pustulis siccis prurientibus 
exasperatur." By dry pustules De Gorter himself evidently under- 
stands papula. Celsus appears to have referred to lichen in his de- 
scription of papula, 3 and Lorry in very recent times has treated of 
this disease under the same title. The Latin translators of the 
Greek writers have erroneously rendered the word lichen by impetigo, 
Celsus having already used the Latin term in another acceptation, 
which is adopted at the present day to signify a pustular inflammation. 
It is not unimportant to observe in this place that F. Platerus has 



' Prorrh. ii. p. 05. Ed. Foes, an. 1595.— m e i naBc 
• Medicina Hippocrat., aph. xx. lib. 3. 
a De Medicina, lib. v. cap. 28. 



, p. 85. 



spoken of lichen under the name of scabies sicca. " Scabies sicca 
seu scabrities, qua? pustulis siccis e quibus nee sanies nee pus emanat, 
se prodit cutemque asperam reddit et erosam cum pruritu plus minusvc 
molesto." 4 Others have mentioned the disease under the title of 
scabies agria. Willan and Bateman were the first who gave an 
excellent description of lichen. Several of Alibert's observations 
relative to his dartre furfuracfe volante appear to assimilate them- 
selves to the lichen ; he has, however, recently described the disease 
under the name of prurigo lichenoide oufurfurant. Bertrand Lagresie 
has detailed a case of it under the very objectionable title of dartre 
miliaire. 

Bontius, 5 Cleghorn, 6 and Dr. James Johnson 7 have severally studied, 
the disease as it occurs within the tropics. 

I shall now give a few cases of the principal varieties of lichen ; 
others may be found by referring to the Journal Hebdomadaire, t. vii. 
pp. 436, 459, the Revue Medicale, Juin 1830, p. 541, and the Lan- 
cette Frangaise, 1831, t. v. p. 581, &c. 

Case XCVII. — Lichen simplex of the face. Max. Degr., mason, 
seventeen years of age, came into the Hopital Beaujon, on the 11th of 
September, on account of a coryza, a slight bronchial affection, and a 
lichenous eruption of the face. For four or five days the patient had 
complained of intense pruritus of the face, the skin of which had in 
several places become rough and uneven, and it was easy to perceive 
that the lower part of the countenance was beset with numbers of 
small red and solid elevations. The greater number of these were 
acuminated, others were semi-globular. The recent papula? were 
principally situated on the chin. In one place they were dissemi- 
nated, in another collected into clusters ; many were visible -which 
the patient had deprived .of their heads with his nails. The great 
majority presented a small brown scab which might have been 
covered with the head of a pin ; several were already free from this 
incrustation, which was succeeded by a small red point. The parts 
of the integument upon which these alterations appeared were covered 
with furfurae, and beset with small untouched papulae. This mix- 
ture of papula? intact, and of papulae lacerated, or in a state of 
desquamation, was particularly remarkable upon the cheek and about 
the commissures of the lips ; on the upper lip the papulae were shrunk 
and replaced by a furfuraceous desquamation. Neither with the 
naked eye nor with the assistance of a magnifier could either pus or 
serum be detected in any of the entire papulae. 

No other region of the body presented any trace of a similar erup- 
tion. Under the sole influence of the antiphlogistic regimen, the 
use of the cool bath and of diluents, the papular inflammation of the 
face, coryza and slight bronchitis with which it was complicated, had 
completely disappeared by the 22d of September, 1826. 

Case XCIX. — Lichen of the trunk and extremities. M. Rousset 
was admitted a patient at the fourth dispensary on the 19th of August, 
1822. The papular inflammation under which the patient laboured 
had appeared towards the end of June of the same year, by a number 
of small pruriginous elevations upon the right thigh. The eruption 
spread on the following days to the opposite side of the loins and 
thorax. For some time Rousset gave little heed to this affection, but 
it at length became so troublesome, and was attended with such 
violent pruritus, that in his own words, " he would gladly have 
stripped off his skin to be rid of it." This state was unaccompanied 
with fever, or any derangement of the principal organs. 

A very great number of minute red, acuminated, solid elevations 
containing no fluid, were conspicuous on both the upper and lower 
extremities, and scattered over the trunk. The fingers passed over 
the surfaces of the skin that were thus affected, distinguished in- 
equalities similar to those of shagreen. The papulae, crowded toge- 
ther and disposed in irregular clusters on the forearms, were dis- 
seminated over the arms; on the anterior part of the chest, the 
eruption, confluent in some places, formed in others broad red papular 
patches, separated from each other by intervals of healthy skin. 
These clustered patches, where the papulae were confluent, were the 

4 Praxeos, t. ii. p. 674. 

5 De Medicina Indorum, cap. xviii. 

6 On the Diseases of Minorca, chap. iv. 

7 On the Influence of Tropical Climates on European Constitutions, 8vo. London, 
4th ed., 1824. 



LICHEN. 



225 



points in which the patient complained of the pruritus as most intole- 
rable. Here and there, between the inflamed papulae, small surfaces 
were remarked upon which a furfuraceous desquamation was going 
on ; traces of scratches and a number of small black scabs that might 
have been covered with the head of a pin, and corresponded to the 
heads of papulae the apices of which had been removed with the 
nails, were also observed in different situations. (Barley water with 
honey; V. S. B. ad 3xii ; vegetable diet.) The effects of this treat- 
ment were very remarkable. On the 22d of August, however, there 
still remained a great number of papula? upon the skin, but the pru- 
ritus was very supportable — (same drink and diet; warm bath.) The 
warm bath was taken twice, and followed each time with a fresh 
eruption of papulae. The pruritus was increased during the day by 
exposure to heat and exercise. On the 24th of August he was again 
bled from the arm to the same extent as before : next day the papulae 
most recently evolved were shrunk ; in other places the affected skin 
was covered with a furfuraceous desquamation, and the freshest 
papulae within a short time became affected with the exfoliation. On 
the 10th of September the patient had recovered completely. 

Case C. — Lichen ; blood-letting and diluents; cure. Regnault, a dyer, 
25 years of age, in the habitual enjoyment of good health, consulted me 
on the 26th of August, 1822, on account of an eruption which had 
made its appearance, under the form of numerous small red and solid 
elevations, on the forehead, arms, and breast, between the 12th and 
14th of the month. The parts affected were extremely itchy, and the 
sensation was much exasperated by exposure to the heat of a fire. 
Where the eruption was very close, as upon the forehead, the skin 
had a punctuated appearance, and the finger passed over it, detected 
numerous irregularities occasioned by the prominence of the individual 
papulae. On the forearms and wrists the eruption occurred in irregular 
clusters of various sizes, which felt like pieces of fish-skin. A certain 
number of the papulae composing the whole of these groups were 
shriveled and succeeded by a furfuraceous desquamation ; these 
patches, indeed, formed true papular rings, in the centre of which the 
skin looked mealy and somewhat yellowish in colour. The papulae 
in the neighbourhood, and those generally that were most remote from 
the centre, were of a vivid red. The heat of the skin was not essen- 
tially increased, and the functions of the whole of the principal organs 
were performed with perfect regularity. The patient was put upon a 
course of diluents, and was bled twice. Within a fortnight he had 
recovered completely. 

Case CI. — Lichen circumscriptus. Gelatinous baths and purgatives. 
Madeleine J. D. Fleury, 18 years of age, of a nervous temperament, 
was presented to me on the 5th of March, 1826, for my advice on 
account of lichen circumscriptus. The disease had commenced in 
February, 1825, by a cluster of elevations on the left leg, and since 
this epoch others had appeared on almost the whole surface of the 
body. Various remedies had been fruitlessly tried for this eruption. 
The application of an ointment of red-precipitate had increased it 
greatly. A blister had been applied to the arm and kept open for five 
months. On the 15th of March, 1826, the following appearances 
were distinguished : — 

1st. Over the face, and especially the forehead, cheeks and ears, 
broad mealy-looking spots or patches, on the surface of which several 
papulae were apparent. No affection could be discovered of any part 
of the hairy scalp. 

2d. On the body, and particularly on the nipples, several clusters 
of papulae of an oval or irregular shape, the centres of which were in 
a state of desquamation. On the back several other clusters of various 
sizes, composed of papulae, some of which were red and inflamed, and 
others, probably of old standing, presented a slight yellow tinge. 

3d. On the upper extremities, and particularly on the outer and 
posterior parts of the forearms, several papular clusters an inch and 
a half in diameter were distinguished, whose centres were desqua- 
mating. The papulae nearest the cenlre were yellowish, those more 
remote were red and inflamed. On the print of a blister, several very 
distinct papular elevations were very conspicuous. 

4th. On the lower limbs traces of a similar papular eruption were 
not less apparent. Some of the groups were here fading, of a yellowish 
or brownish hue, and covered with furfura?; others were fiery, their 
primary form being still very distinct. 
57 



Although the papulae in general did not appear very violently in- 
flamed, the eruption was attended with very troublesome pruritus, 
particularly when the heat of the surface was increased by exercise oj 
the warmth of a bed. The skin was rough and dry on the parts 
affected. Twenty-five gelatinous baths, and a purge administered 
every fifth day, had a singular influence in diminishing the eruption. 
Several fresh clusters of papulae, nevertheless, made their appearance 
on the trunk and extremities ; but twenty more of the gelatinous baths 
being taken, the skin presented no further trace of eruption. 

Case CII. — Lichen of the bends of the arms and hams. Inunction of 
an alkaline sulphur ointment. N * * *, six years of age, had laboured 
from her birth, under a lichen agrius. In other respects the child was 
in apparent good health. On the 14th of June, 1814, this patient 
presented the following morbid appearances : — the skin of the face, 
except that of the chin and lips, was healthy. The latter parts were 
not swollen, but their integument was dry, rough and mealy, and here 
and there presented slight superficial chaps, a few papulae, scarce]) 
inflamed, and some, the summits of which had been torn off", and were 
now covered with small dark-coloured incrustations. On the upper 
extremities the papulae were confluent and clustered ; at the bends of 
the arms the skin was red and inflamed, and surmounted by a number 
of papulae in different states, entire, or torn on the tops. Several small 
chaps and scratches were also visible, and different points were affected 
with furfuraceous desquamation. On the legs an eruption of papulae, 
altogether analogous, was evident, scattered over the outer and back 
parts of the thighs, agglomerated in the hams, where the skin was red 
and dry, and chapped and torn with the nails in different places. The 
child complained of violent pruritus, and during the night tore herself 
with her nails. I prescribed the gelatinous bath and citric acid sher- 
bet, which were continued for a month, without any other effect than 
some diminution of the itching and of the redness of the skin in the 
folds of the arms and popliteal regions ; for as one crop of papulae 
terminated in a furfuraceous desquamation, others were evolved. I 
now determined to try stimulus of another kind to the skin than that 
to which it had been so long accustomed. The affected parts were 
rubbed daily with an alkalescent sulphur ointment. These frictions 
which were continued for about ten minutes, were not attended at the 
time with any unpleasant sensation ; but in about a quarter of an hour 
afterwards, the little patient complained of rather a violent sense of 
scalding in the parts to which the ointment had been applied. This 
ointment had not been used above eight or ten times before a general 
redness of the skin replaced the papular clusters. This excitement 
disappeared in the course of twenty-five days, and the skin of the 
bends of the arms resumed its natural appearance. The eruption 
proved more obstinate in the hams ; but it yielded there eventually, 
and by the 15th of Sept., 1824, the patient was quite well. 

Case CIII. — Liclien of the genital organs, §c. Blood-letting, whey, 
and vinegar washes. — N. Martin, an omnibus driver, aged forty-eight, 
drinking wine and spirits freely, but not to the extent of intoxication. 
Within ten years he had contracted the itch thrice. 

On his admission into the Hopital de la Charite, on the 23d of 
November, 1833, he had already laboured, for a fortnight, under a 
lichenous eruption which spread over the genital organs, and upper 
and inner parts of the thighs, extending back all the way along the 
cleft that separates them. Over-indulgence in spirituous liquors had 
some time previously produced congestion towards the head, for 
which the patient had been let blood three different times, at short 
intervals. A more sober life had recently prevented the recurrence 
of this symptom, when a sensation of heat and itchiness began to be 
felt around the anus ; it was of no intensity at first, but increased so 
much within a few day that the patient felt compelled to endeavour 
to relieve himself by frequent scratching. The eruption soon spread 
to the penis and scrotum, and the pruritus was now so violent that 
the patient was glad by tearing himself with his nails to replace this 
sensation by a more endurable one of painful smarting. Lotions witl 
a solution of the super-acetate of lead did no good. The slightes' 
freedom in regimen rendered the pruritus insupportable. The patien' 
at length was entirely deprived of sleep ; the heat of the bed increased 
his misery to such a degree that he lay without covering of any de- 
scription. The surface of the diseased skin has always been dry, of 
an intense red colour, furrowed by traces of the nails, hotter than 



22G 



PAPULA. 



'Ik- neighbouring pads, ami shining in the centre of the clusters. 
The extent of the disease is indicated by a kind of raised edge, 
rough to tin' touch, and composed of coherent and not very distinct 
papula. The penis and scrotum are uniformly red. No traces of 
any functional disturbance could be detected. (V. S. B. ad gxii; 
tasuns of nitric arid sherbet ; fomentations with cool decoction 
of altliea ; temperate bath ; milk and vegetables for diet.) 

Nov. 24th. — The patient was sensibly better, the pruritus less 
urgent ; hut he had slept very little. The blood abstracted presented 
a thin buffy coat ; the coagulum, however, was very much contracted. 
The treatment indicated was continued till the 28th, and the affected 
parts were twice anointed with lard. The patient feeling himself 
worse was bled again on the 29th. This measure gave relief, but only 
for a few hours ; this time the blood was not buffed. On the 30th, 
vinegar washes were resorted to with a view to allay the itching. 
The npplication of compresses dipped in this wash was found imme- 
diately to moderate the pruritus ; it was necessary, however, to renew 
them frequently, and the colder they were the patient felt the greater 
relief. Dec. 6th. — The redness of the skin was greater, and a kind 
of smarting sensation had succeeded to the violent pruritus. The 
lotions were now discontinued. Dec. 7th. — The temperate water- 
baths were replaced by those of watery vapour, and these were 
repeated constantly till the 11th, when, as they seemed to excite the 
patient too much, the skin acquiring a purple red colour, they were 
discontinued, and the simple water-bath recommenced; the nitric 
acid drink was carried the length of three pints daily. Dec. 18th. — 
The pruritus now was not incessant ; the patient slept through a con- 
siderable part of the night; the red colour of the skin had faded, and 
the boundary of the parts immediately affected was less conspicuous: 
whey was substituted for the nitric acid drink on the 22d. He also 
took a small quantity of magnesia, his bowels being slightly consti- 
pated. On the 27th, Martin was bled for the third time, and with 
great relief to all the symptoms; the disease, indeed, now got rapidly 
well. The baths were continued, the vinegar wash renewed with- 
out injury, the diseased skin in various places began to assume its 
natural colour, and the limits between the healthy and affected sur- 
faces were no longer visible along the upper parts of the thighs ; the 
itching also became slight and transient. In getting well the erup- 
tion followed a course the reverse of that of its development, disap- 
pearing first from those places that had last become affected. During 
the fifty-three days he was under treatment, the patient took forty-six 
simple and six vapour baths. The nitric acid drink was continued 
for twenty-nine days, to the extent at least of three pints daily; it was 
then replaced by the whey which seemed to produce better effects. 
The venesections, especially the last, were beneficial ; the application 
of the hog's lard was of no service , the vapour bath proved evidently 
too stimulating; lastly, the vinegar lotions gave great relief. 



STROPHULUS. 
Vocab. Tooth-rash, Strophulus, Gum [Red-gum]. 

637. Strophulus is a cutaneous eruption which frequently occurs 
in children at the breast, characterized by red or white itchy papula? 
of various sizes, evolved in succession, most commonly on the face 
and lower limbs, occasionally vanishing and recurring in an intermit- 
ting manner, and ending in resolution or furfuraceous desquamation. 

638. Causes. — Strophulus commonly makes its appearance during 
the earlier months of infancy, and also in the course of cutting the 
first set of teeth. The disease seems occasionally to be traceable to 
the irritation of rough woolen clothing, the exposure of the body to 
too great a degree of warmth, and want of due attention to cleanli- 
ness. In the majority of cases, however, strophulus is evidently 
either preceded or accompanied by some gastro-intestinal disturbance, 
induced by cramming the child with too great a quantity of food, or 
with food of improper quality, to the irritation of teething, &c. 

639. Symptoms.— The papula? of strophulus, in their dimensions, 
colour, number and arrangement, present various shades of difference, 
from which the eruption acquires a considerable diversity of appear- 



ance in different cases. These have been indicated by Willan by 
particular titles. 

1st. The papula? are sometimes of a vivid red, prominent, scat- 
tered over the cheeks, forearms, and dorsal aspect of the hands, and 
intermingled with erythematous patches of varying extent — strophulus 
intertinctus [red-gum]. These papula? and red patches occasionally 
continue for several days, without the health of the infant appearing 
to suffer in any way ; they occasionally vanish in the morning to re- 
appear in the evening. Lastly, when the eruption is permanent, it 
begins to fade within a week or two, when the surface of the parts 
affected looks of a pale yellow colour, and becomes covered with a 
furfuraceous desquamation. 

2d. Sometimes, on the contrary, the papula? are small and white— 
strophulus albidus of Willan — and now and then appear surrounded 
by a slight blush ; they then most usually occur on the face, neck, 
and breast, and are in general more prominent than those of the pre- 
ceding variety. 

3d. Lastly, the white papula? of strophulus may appear with larger 
dimensions than those that have just been mentioned, and without 
any surrounding redness of their base — strophulus candidus, Willan. 
Their surface is smooth, shining, and of a duller white than the skin 
in their vicinity. These large papula? are commonly scattered at 
o-reat distance from one another over the loins, shoulders, and upper 
parts of the arms. 

640. Besides these differences in point of size and colour, the 
papula? of strophulus present yet two particular dispositions: 

1st. The eruption may be very thick upon the face, trunk and ex- 
tremities — strophulus confertus, Willan. On the face, the papula? in 
this variety are smaller and more confluent than in the strophulus in- 
tertinctus ; their colour is not so bright, and they are more generally 
prominent ; they end within a week or two in a furfuraceous desqua- 
mation. On the trunk the eruption appears especially on the back 
and loins ; there the papula? are larger and less closely crowded 
together than on the face. If they be punctured deeply with a 
needle, a globule of transparent serous fluid may occasionally be 
squeezed out of them ; this fluid is not deposited under the epider- 
mis as in the vesicular eruptions, and is re-absorbed during the pro- 
gress of the disease. On the upper extremities, as also on the neck 
and shoulders, the papula? usually form irregular clusters ; they end 
in a furfuraceous desquamation, and the skin in the affected parts 
continues for some time of a yellowish-gray colour. The papula? 
evolved on the lower extremities always give rise to pruritus of a 
very violent description. They appear especially upon the calves 
of the legs, the thighs, buttocks and loins, in successive eruptions, 
which occasionally recur during several months. 

2d. The papula? of strophulus, finally, may appear on different 
regions of the skin in small circular clusters — strophulus volaticus, 
Willan. In each of these groups the number of papula? usually 
varies from six to ten ; they, as well as the interstices, are of a vivid 
red. After continuing four or five days, they begin to shrivel, grow 
sallow-looking, and finally end in a furfuraceous desquamation. The 
groups appear in succession on the face, trunk, and extremities. The 
eruption, which is very similar to the lichen circumscriptus of adults, 
may continue for several weeks. 

641. These varieties of strophulus are often observed affecting the 
same child at one time. The white papula? of the strophulus albidus 
are frequently seen mingled with the red papula? of strophulus inter- 
tinctus ; lastly, the papula? may be crowded and confluent in several 
places, constituting strophulus confertus, whilst in others the volumi- 
nous and thinly scattered elevations of strophulus candidus are ob- 
served to prevail. 

642. Whatever the form assumed by the eruption, strophulus is 
always accompanied with severe itching, a symptom which, as it is 
increased by the warmth of bed, is frequently productive of insomnia. 
Various symptoms produced by gastro-intestinal irritation, or the pro- 
cess of teething, are frequently associated with those characteristic of 
strophulus. 

643. Diagnosis. — The papula? of strophulus are always either 
whiter or redder than the healthy skin that surrounds them ; those of 
prurigo, when they are intact, are nearly of the same colour as the 
integuments. Further, each of the successive eruptions of which 



PRURIGO. 



227 



strophulus consists, has the course of an acute disease ; prurigo ap- 
proaches chronic disorders more nearly in its characters. 

It is difficult, on the other hand, to establish satisfactory distinctions 
between strophulus and acute lichen. The shades of difference 
observed in these two diseases are ascribable to the differences in 
the age of the individual affected. The papulae of acute lichen may, 
in fact, have the red colour, and appear either scattered or collected 
into groups, like those of strophulus. The latter malady, however, 
is more frequently marked by periodical intermissions and exacerba- 
tions, and is more intimately connected with the process of dentition 
than lichen. Further, the pale grayish-yellow tint that occasionally 
succeeds the disappearance of the papula? of strophulus, is not nearly 
of such long continuance as that regularly observed to follow lichen, 
in which, indeed, the colour is often of the most decided coppery-yel- 
low. To conclude, strophulus is never seen terminating by excoria- 
tions similar to those that follow lichen agrius. 

Strophulus confertus is distinguished from papular erythema by the 
greater size of the patches in the latter, and their being attended with 
but little pruritus. 

644. Prognosis. — Strophulus in itself is a disease of no gravity. 
When it appears associated with gastro-intestinal inflammatory affec- 
tions, it is to these that the attention is to be particularly directed. 
These two diseases frequently alternate during the whole progress of 
the process of dentition, and the functional disturbance of the alimen- 
tary organs is often seen to abate with the evolution of the papulae of 
strophulus. 

The papulae of strophulus vary in the period of their duration, from 
one of a few hours to one of several days ; that of the eruption may 
extend over several weeks, according as the action of the causes 
which have produced it is intermittent and transient, or permanent. 

645. Treatment. — When strophulus, in an infant otherwise healthy, 
appears to have been evolved under the influence of causes acting 
directly on the skin, the first indication naturally is to remove these 
or make them unavailing. 

The pruritus maybe appeased for an instant by dabbing the papulae 
with cold salt and water, or vinegar and water. But when strophulus 
is symptomatic of inflammation of the digestive organs, or exists at 
the same time with such a disease, it is of primary importance to 
endeavour to subdue this internal affection by dietetic means adapted 
to the state of the digestive organs, by giving up all food save such 
as is supplied by the mother or nurse, and even by substituting sugar 
water in part for this, when febrile symptoms make their appearance ; 
lastly, in diminishing the irritation of the external surface by the daily 
administration of baths of the decoction of bran or althea root, at a 
moderate temperature. 

646. The cold bath lessens materially, and occasionally even cuts 
short almost at once, the papular inflammation of strophulus ; but it is 
apt to increase the phlegmasiae of the digestive organs which so fre- 
quently complicate the disease when it occurs during the process of 
teething. 

Purgatives employed under similar circumstances are most gene- 
rally detrimental. They occasionally produce vomiting and obstinate 
diarrhoea. It is also well as a general rule to abstain from the emetics 
and tonics recommended in strophulus by Willan, on account of the 
gastro-intestinal affections that so commonly occur along with the 
disease, and in which medicines of the classes mentioned are rarely 
admissible. (a) 

Histoiical Notices and particular Cases. 

647. Strophulus is even better known to mothers and nurses than 
to the physician. Those authors who have treated particularly of the 
diseases of infancy, have only spoken generally and vaguely of the 
eruption, under the name of tooth-rash, red-gum, Sue, frequently show- 
ing, by the names adopted, that it was held especially to depend on 
the irritation of teething, or on some affection of the alimentary canal. 

(a) The objection to purgatives in strophulus can only apply to 
those of an irritating nature ; laxatives, such as rhubarb and magnesia, 
epsom salts in small doses, and castor oil will be generally found 
serviceable. 



Lorry 1 regarded strophulus as a variety of lichen. Russel 2 evidently 
indicated the strophulus intertinctus under the title of red-gum. Sau- 
vages 3 describes another variety — the strophulus volaticus, under the 
name of feu volage. Willan- 4 was the first who gave a truly good 
description of the disease, (a) 

The different appearances which strophulus may assume in a par- 
ticular case, are readily assimilated to one or other of the varieties of 
the disease described by Willan. The following case will prove that 
if it be important to study the whole of the various forms assumed by 
this eruption, in order to render the account of it more complete and 
striking, it is of no less importance to avoid isolating them too much 
from each other, seeing that each may show itself in succession one 
after another in the same child during an interval of time more or less 
considerable. 

Case CIV. Various forms of strophulus. — A lady two months after 
her confinement, having been exposed to great fatigue of body and 
much anxiety of mind, seemed to lose the quality of excellent nurse, 
which she had hitherto proved herself; her child became restless 
during the night, crying incessantly, &c, and soon showed symptoms 
of gastro-intestinal derangement, combined with a papular eruption 
of strophulus upon the skin. This two-fold inflammation was treated 
by the daily use of the temperate bath ; the mother also took a few 
temperate baths ; her usual diet was not altered, this being habitually 
very regular, and she soon regained her strength ; the child too thrived 
once more, but the strophulus continued for between four and five 
months, disappearing and recurring at uncertain intervals ; now in the 
shape of red and inflamed papulae upon the face and arms (strophulus 
confertus or strophulus intertinctus), and again under that of white 
and prominent papulae (strophulus albidus and strophulus candidus), 
which were usually evolved upon the loins, buttocks and thighs. 
This papular inflammation was habitually increased during the night. 
The pruritus frequently awoke and prevented the child from sleeping. 
The application of cold water or a little saliva to the papulae always 
seemed to appease the itchiness. For a long time the child had 
nothing but its mother's milk, upon which it thrived amain. The 
symptoms of the gastro-intestinal inflammation disappeared with those 
of the affection of the skin. At the period of teething, the strophulus 
recurred afresh, but without any marked derangement of the digestive 
organs. At the age of two years the infant became affected with 
laryngitis, and six months later with bronchitis, from both of which 
attacks, actively treated by the application of leeches, it recovered 
completely. 



Vocab. Cnesmos, Prurigo, Pruritus, Scubies Papuliformis. 

648. Prurigo is characterized by an eruption of papulae, nearly of 
the same colour as the skin, and accompanied with pruritus of the 
most intense description. The papulae, larger than those of lichen, 
after having been torn by the nails, are usually replaced by small 
black and circular scabs ; it happens more, rarely that in decaying 
naturally they leave minute yellowish stains behind them upon the 
skin. 

649. Prurigo is usually evolved either at once or successively 
upon several regions of the body; it is very seldom, indeed, that it 
attacks no more than one. 

650. Prurigo presents three principal varieties : 

1st. The eruption in one case is proclaimed by a troublesome feel- 
ing of itchiness over the shoulders, upper part of the breast, lumbar 
region, outer surfaces of the arms and thighs, &c. When the parts 
so affected are examined with care, numbers of papulae are perceived, 
soft to the touch, and broader than those of lichen, from which they 

(a) See also Underwood. Am. edition, p. 121. 

' Ita mulli sunt infantes quibus ad singulas dentitionis periodus irritatio lichenes 
exterius protrudit. (Lorry. De morb. Cutan., p. 245.) 
2 Russel. CEconom. natur. in morb. Gland., p. 42. 
» Nosol. meth., torn. i. p. 139. 
* Willan. Art. Strophulus. 



228 



PAPULA. 



also differ in preserving the natural colour of the skin, the greater 
number, indeed, only show symptoms of inflammation under the influ- 
ence ol external irritation. These papula- are attended with no 
prickling sensations, but simply with a violent and incessant sense of 
itchiness. They occasionally project in so slight a degree, that they 
ippear to be situated rather in the substance than on the surface of 
the skin. In this form of the disease, the pruritus is more especially 
complained of by patients when they first lie down, or after they have 
been in bed some time ; it is then so violent as completely to rob 
them of all chance of repose. The itching may also be excited or 
exasperated by the contact or friction of the clothes, and by any cause 
that tends to heat the body, such as meals, exercise, &c. The pru- 
ritus intermits occasionally for three or four hours at a time, and now 
and then is scarcely felt when the patient's attention is very deeply 
engaged. This variety is entitled prurigo mitis by Willan. 

Small, thin, circular incrustations, the size of a pin's head, and of 
a brownish or black colour, which often look wrinkled in the circum- 
ference, are always to be seen between the pruriginous papula?. 
These minute scabs, which are detached before long, are formed by 
the drying up of a little blood that has exuded from the summits of 
the papulae lacerated by the nails. A number of scratches, the cause 
of which is evident, and of stains of a brownish-yellow colour, due 
to the fading of papulae, may also almost invariably be distinguished. 
The papulae in prurigo mitis are successively evolved ; and the dis- 
ease, unless attacked by appropriate treatment, may continue for 
several months. 

2d. Prurigo in another instance presents itself with a character of 
greater severity and obstinacy, when it has been distinguished by the 
epithet formicans by Willan. The papulae, in this variety, broader 
and less apparent than in prurigo mitis, are attended by an incessant 
and insupportable pruritus, which is generally remarked to be intense 
in the same proportion as they appear flatter. They are usually scat- 
tered over the entire surface of the body, the face, the feet and the 
palms of the hands excepted ; but they are especially numerous upon 
the nape of the neck, the lumbar region and outer parts of the thighs. 
In the evening, and particularly towards three or four o'clock in the 
morning, the pruritus is increased, and the patient, if he has been 
asleep, is then promptly awakened. The hands are involuntarily 
carried to the parts covered with papula 1 , and a multitude of distress- 
ing sensations are then superadded to the one of pruritus. Some 
patients feel as if a host of insects were burrowing under the skin, 
others as if they were devoured by pismires, a circumstance which 
the epithet of Willan, formicans, is intended to recall. Others again 
feel as if the skin were pierced with red-hot needles. Patients then 
scratch themselves as if under the influence of rage or despair, and 
never cease from tearing their skin with their nails, brushes, combs, 
or any thing they can lay their hands on. The feeling of pruritus, 
increasing continually, is attended with an impatience and hurry of 
manner difficult to describe. The patients leap out of bed to walk 
about quite naked ; the muscles of the upper and lower extremities 
seem in a state of constant and universal contraction, feel hard, and 
show distinctly and strongly through the skin ; when the patients 
attempt to describe their sufferings, the phrases they make use of are 
heat of blood, burning fires, maddening itchiness, &c. &c. 

The apices, and indeed the whole of the papula?, are before long 
torn off by the nails. The skin appears covered with small, thin, and 
black-looking crusts, as in prurigo mitis. These incrustations are 
much more distinct than the papulae that remain intact ; these, having 
the colour of the integuments generally, are often distinguished with 
difficulty, on account of their trifling size. 

3d. The papular eruption of porrigo is usually more considerable, 
and attended with severer symptoms among the aged than any other 
class of patients ; hence Willan has established a third variety of the 
disease, under the title of prurigo senilis. The skin consequently 
appears more rudely scratched in this form of the disease than in the 
former two ; it is also affected with a more copious desquamation. 
The pruritus is even more unbearable and incessant than in the prurigo 
formicans of children or adults, the external characters of the eruption, 
however, being precisely the same. 

651. The intensity and continuance of the pruritus do not always 
bear an exact relation to the numbers of papulae ; I have occasionally 



seen this symptom excessive, when but a very small number of papillae 
could be distinguished on the skin. 

Besides the papulae which characterize prurigo, other and accidental 
lesions are generally observed, which disappear as soon as the irrita- 
tion, which has caused them, ceases. Thus, when individuals attacked 
with prurigo neglect proper attention to cleanliness, pustules, vesi- 
cles and furuncles arise amid the papillae ; the skin also presents chaps 
of greater or less extent, and occasionally acquires a considerable 
degree of thickness, when the disease is of long standing, especially 
among the aged, or a furfuraceous desquamation takes place here and 
there from the trunk and extremities. 

Scabies and impetigo may accidentally complicate prurigo ; but it 
is a mistake to suppose with Willan and Bateman, that they may- 
appear as one of the terminations of this disease. Several patholo- 
gists have maintained, that the state of the skin in prurigo senilis was 
favourable to the production and propagation of pediculi. (Vide 
Vocab. sub. pediculi.) And Willan even supposed that he had dis- 
covered a peculiar insect in one case of the disease ; his description, 
however, of this insect is very imperfect. 

Independently of these affections of the skin, general prurigo may 
be complicated with constitutional symptoms. In prurigo formicans 
the eruption of the papulae is occasionally preceded by headache, 
general uneasiness, pain at the pit of the stomach, &c. On the other 
hand, when individuals affected with prurigo are attacked with any 
acute disease, the papular eruption declines and sometimes even dis- 
appears entirely, to recur when convalescence is established. 

652. Prurigo may continue a few weeks only, or it may last for 
several years. During the longer period, very evident remissions 
and exacerbations are commonly observed. Among women and 
children, whose skins are fine and delicate, prurigo frequently disap- 
pears without leaving any trace of its existence behind it ; but when 
it has affected the thick and dry integument of the aged, the epidermis 
is continually thrown off under the form of a mealy powder in the 
vicinity of the papulae, and the skin presents stains or spots of a 
yellowish-brown colour intermingled with scratches. 

653. The verge of the anus and scrotum in men, and the labia 
majora in women, are not only occasionally attacked with lichen and 
eczema, diseases essentially pruriginous, but these parts may be the 
seat of distinct papular eruptions belonging to prurigo. Such local 
varieties of prurigo, however, occur much more rarely than is gene- 
rally imagined ; true lichens, and chronic eczema, accompanied with 
excessive pruritus, have very often been referred to under the title of 
prurigo. 

1st. Prurigo podicis is characterized by true papula? similar to those 
of prurigo formicans. The skin of the verge of the anus and inner 
parts of the thighs, and buttocks, is rough, uneven, and beset with 
papula? of the same colour as the integument that surrounds them, 
and with a greater number of small blackish scabs, which cover the 
summit of the papula? that have been lacerated. These papula? may 
be fortuitously mingled with a number of vesicles or small pustules. 
The itching occasioned by prurigo podicis is unbearable, especially 
during the night. Patients do not often forget themselves in sleep 
until they have scratched themselves with a kind of fury. This local 
variety of prurigo is always a long and obstinate disease. After con- 
tinuing for some months, the symptoms occasionally seem to remit, but 
they become more violent than ever before long, from some irregu- 
larity in diet, &c. Women arrived at the critical period of life are 
particularly subject to this species of prurigo, and to lichens of the 
same parts. When the prurigo has been long left to itself, the skin, 
in a state of incessant irritation, becomes rough, squamous, and of a 
yellowish-brown colour. Lichen and eczema impetiginodes occasion- 
ally follow the papular eruption of this variety of prurigo. 

2d. Prurigo scroti may exist alone or complicated with the prurigo 
podicis. It is characterized by papula? developed upon the scrotum, 
and at times even on the penis. When the papula? are torn with the 
nails they become extremely painful. Prurigo pudendi muliebris is 
likewise characterized by pruriginous papula? evolved on the mons 
veneris and labia majora. The mucous membrane of the vulva occa- 
sionally presents, at the same time, a multitude of small solid ele- 
vations which render its surface rough and uneven ; in this case there 
is frequently a true inflammation of the vulva and vagina, accompa- 



PRURIGO. 



229 



nied with intertrigo. Lorry 1 has given a picture as faithful as it is 
animated of the symptoms and sufferings produced by prurigo and 
lichen of the genital organs. " Morbus ille adultos ut plurimum et 
primum pubertatis fiorem agressosadoritur, eosque qui, caste viventes, 
urgenti tainem impetu ad venerem ferrentur ; mulieres etiam, sed ma- 
turius adoritur. Ejus ortus primo mitior est, et pruritu totus con- 
tinetur. At pruritui ill i turn in maribus, turn in faeminis jungitur 
ardor in venerem inexplebilis. Mores et praecepta repugnant, coercet 
virtus vivax, at manus indocilis ad has partes fertur, scalpendoque 
malum irritatur, et animus ipse in partem operis venit cum artuum 
tremore et palpitatione. Sedatur vulgo per plurimas horas malum, 
tuncque omnia tranquilla apparent, at recrudescit per paroxysmos, 
noctu potissirnum afficiens. Saevit autem eo vehementius, quo aut 
familiariter magis aut proximus cum faeminis mares, aut cum maribus 
faeminae vixerint. Nee minores accepit vires a vino, piperatis, spirit- 
uosis, acribus alimentis, potu coff'ea?, oleosorum spirituosorum, ita ut 
noverim viros qui nunquam similibus pruritibus, nisi una ex hisce 
causis accesserit, quas edocti experientia vitabant sedulius. Progre- 
diente malo partes ad aspectum maculosae, maculis flavis vix supra 
cutem extantibus distinctae sunt ; scrotum omnino rugosum est, ut et 
labia pudendorum in faeminis, et tempore paroxysmi prorsus retractum. 
Erectio penis et libidinis ardens cupido mentem incendunt. Partes 
illaa non eruptione lichenibus simili afficiuntur, sed epidermis rugosa 
olet, et alluitur liquore unctuoso, non lintea maculante, non digitis 
adhaerente, sed ad sensum lubrico. Increscente malo pruritus enormes 
fiunt, per paroxysmos et summe violentos, et frequentur redivivos, ita 
ut nee pudor, nee reverentia regum a scalpendo divertant, et saepe 
per intervalla etiam paroxysmorum puncturae acerrimae acubus inflam- 
inatis per cutem transactis morsu similes, in clamorura adigunt : hinc 
partes illae rhagadibus atque fissuris manu factis undique hiant. Ardor 
semper in est, et ad quemvis levissimum incessum exhalat humor 
olentissimus, fervente interea. cestro venereo." 

3d. Prurigo plantaris. M. Alibert has given an instance of a man, 
50 years of age, but vigorous in constitution, who was suddenly at- 
tacked with a violent sense of itching in the sole of his foot, which 
soon acquired such a degree of intensity that even in the street and 
in company he was compelled to take off his shoe and scratch the 
part violently till the pruritus was in some sort appeased. A second 
case of a similar description is quoted by the same author; but in 
neither of the instances is there any mention of papulae as the cause 
of the morbid symptoms, and as violent itching of the sole of the foot 
may be occasioned by various diseases, the species of prurigo under 
consideration is inadmissible until it shall have been confirmed by 
cases much more complete in their details than those we possess. 

654. The anatomical inquiries that have been made into the seat 
and nature of prurigo by Alibert and Mouronval have no actual 
bearing but upon concomitant affections. One of Alibert's patients 
had died of a suppression of urine and pneumonia ; the other pre- 
sented numerous morbid appearances in the three great splanchnic 
cavities. In a third case we are informed that the papulae had shrunk, 
death having been occasioned by a gastro-intestinal inflammation and 
an affection of the brain. 

655. Causes. — Prurigo attacks infants, and the aged especially. It 
is more common among the poor than the rich, and occurs more 
frequently among men than women. The disease occasionally appears 
owing to a residence in low and damp situations, and particularly to 
a want of proper attention to cleanliness. Other causes have been 
surmised, the influence of which is more questionable, such as in- 
different food, the abuse of spirituous liquors, salted and highly 
spiced meats, defective or irregular menstruation, vexation of mind, 
fatigue of body, &c, &c. It has also been observed that prurigo 
mitis generally invaded in the spring or beginning of summer, like 
lichen simplex, to which this disease, indeed, approximates, whilst 
pruri go formicans made its attacks at all seasons indifferently. 

656. Diagnosis. — Itching or pruritus in a greater or less degree is 
a symptom common to almost all the inflammatory affections of the 
skin, particularly to urticaria, scabies, eczema, strophulus and lichen. 
Although this sensation has a peculiar character in prurigo, still it 
cannot be assumed as a pathognomonic symptom of the affection. 



58 



Lorry. De morbis cutaneis, 4to. p. 449. 



The true character of the disease lies in its presenting an eruption of 
irregularly disseminated papulae, distinguished by their colour, which 
is similar to that of the surrounding skin, from the papulae of lichen 
and strophulus. 

When the papulae of prurigo have been destroyed by the nails, the 
true nature of the eruption is made out with great difficulty, the little 
scabs of this affection differing but very little from those of lichen 
simplex and scabies ; in the neighbourhood of the papulae that have 
suffered, however, others that have escaped untouched may very 
commonly be discovered, and these proclaim the peculiar nature of 
the eruption. Prurigo is a papular, scabies a vesicular disease. In 
prurigo the papulae present the colour of the integuments at large ; in 
scabies the vesicles are transparent on the apices. The summits of 
the papulae of prurigo when torn are covered by thin black crusts of 
dried blood ; the vesicles of scabies when they have suffered in the 
same way are frequently succeeded by small thin and yellowish- 
coloured scabs. Scabies is readily transmissible from person to per- 
son ; prurigo is not at all contagious. The pruritus of scabies is by 
no means a painful sensation ; in prurigo it is sharp and burning, 
and patients labouring under it tear themselves with a kind of cruelty. 
Prurigo commonly appears on the shoulders, back, neck, loins, chest 
and limbs in the direction of their extension, very rarely between the 
fingers, occasionally on the face, and even on the scalp ; scabies 
again occurs between the fingers, in the axillae, popliteal regions, 
bends of the arms, and surface of the abdomen. The pruritus of 
scabies is constant, that of prurigo comes on in paroxysms of greater 
severity. Prurigo occasionally gets well spontaneously ; scabies never 
terminates in this way, but it is much more under the influence of 
therapeutic agency than prurigo. 

It may happen, indeed, that prurigo is complicated with scabies. 
Among the solid papulae of the former the acuminated vesicles of 
the latter are then distinguished without difficulty. Lichen and the 
various other inflammatory affections of the skin may in like manner 
attack individuals labouring under prurigo. Such complicated cases 
of course require great discrimination in deducing accurate diagnoses. 

Local prurigo cannot well be confounded with scabies ; but it is 
more difficult to distinguish it from several other affections, which are 
themselves accompanied with pruritus of greater or less intensity. 
1st. Ascarides in the rectum, hemorrhoidal tumours, slight inflam- 
mation or irritation of the great intestines, are all occasional causes of 
violent itching of the verge of the anus. These complaints differ 
from prurigo podicis by the absence of papulae, and the presence of 
other manifest lesions which form no part of this eruptive disease. 
2d. The pruritus caused by pediculi pubis, by eczema impetiginodes 
scroti, &c, need never be confounded with that which depends upon 
prurigo of these regions : the papulae characteristic of the latter 
malady will always prevent mistake ; a proper examination of the 
parts interested, indeed, will constantly enable the practitioner to 
ascertain whether any violent sensation of pruritus complained of 
about the anus, scrotum, vulva, &c, depends on the development 
of the papulae of prurigo, or is due to another form of inflammation 
than the papular affecting these parts, to the presence of ascarides in 
the rectum, &c. 

We had an out-patient at the Hopital de la Charite, twenty-four 
years of age, in the ninth month of her pregnancy, who for a month 
had suffered from intolerable pruritus of the genital organs, accompa- 
nied, and apparently produced by a cluster of varicose veins upon the 
left greater labium, as there were no symptoms of any inflammatory 
affection of the parts implicated. The pruritus was completely re- 
moved by a single bleeding. Willan has quoted several analogous 
cases. 

657. Prog?iosis. — Prurigo in children is not generally a very obsti- 
nate disease, but it is apt to recur repeatedly. Prurigo senilis is a 
much more serious affection, and often resists the best directed treat- 
ment. Tormented by the continual and at times excessive pruritus, 
patients tear themselves cruelly with their nails ; but to the momentary 
relief thus procured, their enemy speedily returns in such burning and 
unbearable intensity, that they are frequently driven to acts of despair. 
The prurigo podicis, and prurigo picdendi muliebris are commonly very 
rebellious. 

I have several times seen prurigo, with or without pediculi, appear 



230 



PAPULA. 



as n kind of crisis after measles, or some other more serious disease. 
Among the aged, tiring in misery, it frequently coincides with pulmo- 
itarrb, without, however, appearing to have any influence on 
the progress or duration of this infirmity. 

atment. — The simple or slightly sulphureous bath is of all 
il remedies, that which proves constantly most beneficial in 
I prurigo. By this means alone, we very commonly succeed in 
speedily subduing the prurigo which is induced by filth and wretched- 
The baths ought to be taken tepid or cold ; at too high a tem- 
re they are injurious ; at any degree under tepid they are very 
serviceable in prurigo ?nitis and prurigo senilis. They ought to be 
taken regularly every day, and the patient must greatly protract the 
period of his remaining in the water, even though this should appear 
to be followed by some temporary increase in the symptoms. Patients 
seem occasionally to experience more marked relief, by soaking for 
an hour every day in a bath of some emollient decoction, as of bran. 
The same means are further useful in preventing relapses of this dis- 
ease. After the simple or emollient bath has been used for some time, 
if the eruption still continues, the alkaline bath, such as that of 
Plombieres, or the soap bath frequently produces the best effects. 
These baths leave no unpleasant odour after their use, like those of 
sulphureous waters, which are, however, extremely efficacious in many 
i ises, especially among the aged, and those individuals whose general 
health has suffered from bad or insufficient food. When sulphureous 
baths appear to increase the irritation of the skin, their action may be 
diminished by lessening the dose of the sulphuret of potash employed 
in making them, by adding a quantity of gelatin, or employing the 
sulphur and the simple bath alternately. This plan of treatment 
succeeds almost invariably in children affected with prurigo mitis. 

Sea- water baths, tepid or cold, are employed under the same cir- 
cumstances as sulphureous baths. Several cures have also been accom- 
plished by means of sulphureous fumigations; the irritation they are apt 
to excite in the skin, however, frequently compels us to abandon their 
regular employment, or to combine them with the occasional use of the 
simple water, vapour, or emollient bath. The sulphureous bath is 
preferable to any other in the cases of children. 

When prurigo is of long standing, or otherwise, when the skin has 
become rough and thickened, it is sometimes advisable to try the 
watery-vapour bath from time to time; in general, however, this form 
of bath is found detrimental to young and plethoric subjects, to chil- 
dren, and especially to the aged. It has been known to cause syncope, 
which, though not dangerous, perhaps, is still sufficiently distressing to 
the patient. 

It is very seldom that any good is done by the application of the 
ointments of sulphur or of any of the mercurial preparations, or by 
lotions of sublimate and lime water, except in those cases that are 
complicated with scabies. 

The pruritus has occasionally seemed to be mitigated by anointing 
the parts affected with an ointment of hellebore, and of the hydrochlo- 
rate of ammonia. 

Mercurial washes may be tried with advantage in some cases of 
prurigo formicans, especially when complicated with pediculi. In 
other instances by merely washing the parts affected with plain cold 
or tepid water, or with very weak vinegar and water, the greatest 
relief is procured. 

659. Of all the general measures employed in the treatment of 
prurigo, blood-letting, and diluents, such as whey, weak veal broth, 
thin gruel, decoction of dog's tooth grass, lemonade, &c, are indis- 
putably the most potent. Bleeding is almost always indicated in 
youthful and plethoric subjects, and when the disease is attended with 
distressing insomnia, even in the aged. In females labouring under 
prurigo, if the catamenia are suppressed, the return of the discharge 
must be solicited by the application of leeches to the external parts, 
&c. When the disease invades during pregnancy, should any symp- 
tom of plethora be apparent, bleeding must still be had recourse to. 

Those persons who have indulged in highly-seasoned food and 
spirituous liquors, must be restricted for some time to simple vegetable 
diet, and put upon the use of asses' or goat's milk. 

660. Some writers recommend the exhibition of an emetic, and a 
purge on the invasion of prurigo; others advise decoctions of the 
burr-dock and patentia, infusions of wild endive, fumitory chamo- 



mile flowers, &c, or the defecated expressed juice of these plants; 
and others assure us that they have derived the best effects from the 
exhibition of sulphur alone. Calomel is also prescribed, combined 
with the use of the neutral salts, and other more active purgatives. 
External applications have appeared to me so generally advan- 
tageous, that, except in some modified cases, depending on peculiari- 
ties of constitution, I recommend the treatment to be confined entirely 
to these. 

661. The varieties of local prurigo themselves present several 
peculiar indications : 1st. Prurigo podicis is in general difficult of 
cure. When it is severe, it requires imperatively the employment 
of local bleeding, and even in cases of less intensity, this measure 
is constantly followed by the most marked temporary amelioration of 
the symptoms. Emollient cool or cold poultices, hip-baths, supposi- 
tories of cacao butter, opiate lavements, compresses dipped in cold 
water, are all useful in allaying pruritus. After a due perseverance 
in these measures, and occasionally even from the first, in individuals 
whose skin is rather irritable, the best effects are derived from gela- 
tino-sulphureous douches. The application of a small quantity of the 
unguentum nitratis hydrargyri reduced, and of a weak acetic acid 
wash, is also frequently prescribed with advantage ; these means, 
however, will do harm rather than good, if the integuments around 
the anus chance to be excoriated, or in a very irritable state. 

2d. The same treatment is applicable in cases of prurigo scroti, 
which has now been recommended in prurigo podicis. Washes 
consisting of solutions of sublimate in lime-water, and the mercurial 
liniments recommended by Willan, are generally less useful than 
gelatino-sulphureous fomentations, douches and baths. 

3d. The treatment of prurigo pudendi muliebris should be begun 
by a bleeding from the foot, if the state of the constitution seem to 
warrant the practice, by the repeated application of leeches to the 
vulva, by fomentations and douches of cold water, mixed with the 
juices of emollient and narcotic plants. Gelatino-sulphureous douches 
are never to be employed in the earlier stages of the disease ; they 
would but increase the inflammation of the external parts and vagina, 
which almost always accompanies this variety of prurigo, (a) 



(a) Professional advice is more frequently asked for in prurigo or 
pruritus pudendi than for any other variety of porrigo. It is most 
common during pregnancy and disappears in general after childbirth. 
Dr. Dewees (Diseases of Females) regarded this disease as aphtha of 
the inner surface of the genital parts ; an opinion adopted in its full 
extent by Rigby (System of Midwifery), and Churchill (Diseases of 
Females). Dr. C. D. Meigs tells us, on the other hand, in his additions 
to his translation of the treatise of Colombat de l'Isere on the Diseases 
and Special Hygiene of Females, that he has not perceived, upon ex- 
amination, this aphthous condition of the mucous surface. Dr. Ash- 
well (Practical Treatise on Diseases of Females) takes a more 
extended view of the pathology of prurigo pudendi, in pointing out 
its connection with some diseases of the uterus and its appendages, 
as indeed Blundel had done before him, and also of affections of the 
urinary bladder and its meatus. Dr. Ashwell has, " on some occa- 
sions, admitted patients into the ward for some supposed affection of 
the vulva, which has turned out to be pruritus from disease of the 
bladder." 

The treatment will of course vary with the general health and state 
of the uterine system. After suitable purging with laxatives, the use 
of sedatives sometimes allays the irritation. Of the local remedies, 
the one most thought of in this country, and more successful, perhaps, 
than any one other, is borax (sub-borate of soda) in solution of water 
and alcohol applied freely and frequently to the parts affected. Dr. 
Meigs (op. cit.) says that he has rarely had occasion to order any thing 
more than the following formula, viz : 
K- Sodse borat. §ss; 

Morphse sulphat. gr. vi ; 
Aq. rosse destillat. Sviii. 
M. Ft. solutio. 

He directs the person to apply it thrice a day to the affected parts, 
by means of a bit of sponge or a piece of linen, taking the precaution 
first to wash the surfaces with tepid water and soap, and to dry them 
before applying the lotion. 



PRURIGO. 



231 



Patients should be cautioned against the use of a seat and bed that 
are too soft, as these excite and keep up a great degree of heat around 
the affected parts. During the paroxysms, which almost always occur 
through the night, patients occasionally succeed in allaying the pruri- 
tus that devours them, by applying, without intermission, a succession 
of cloths wrung out of cold water, to the external organs. Fumiga- 
tions of sulphur or of cinnibar have also been occasionally prescribed 
with success in very rebellious pruriginous eruptions of the margin of 
the anus and genital organs. I have, further, oftener than once had 
recourse to arsenical preparations with advantage in affections of the 
same description, (a) 

Historical Notices and particular Cases. 

662. It was probably prurigo senilis to which Hippocrates alluded 
when among the diseases affecting the aged, he mentions an itchy 
state of the whole body. 1 

The definition which Dietrich 2 has given of cnesmos, after Galen, is 
. obscure, and applicable to several other pruriginous diseases (lichen, 
urticaria, strophulus). The definition of Mercurialius, 3 although more 
precise, still presents us with as many of the characters of lichen as 
of those that belong to prurigo. Hafenreffer 4 subsequently proposed 
to distinguish pruritus into general and local. But it must still be 

I have found the borax solution to cure some cases, and that 
of the chloride of lime or of soda others. Hydrocyanic acid in 
adequate dilution as a wash, has been highly extolled in this dis- 
ease, or as in the following lotion: B- Liq. potass. f3ij ; Acid, hy- 
drocyan. dilut. f3i ; Emuls. amygd. amer. fSviii. — M. Iodine is 
used both topically and generally. Penciling the affected parts^with 
a weak solution of nitrate of silver, (2 grs. to the ounce of water and 
2 minims of nitric acid,) is sometimes beneficial. 

The relief given by lotions of vinegar or of vinegar and water 
would suggest the use of diluted lemon juice in prurigo pudendi, 
even if we did not know that this latter has entirely carried off 
prurigo scroti. 

In this latter affection the interposition of a fold of linen or muslin, 
as the skirt of the shirt between the sides of the scrotum and the 
• thighs, will often materially abate and sometimes prevent the trouble- 
some itching, — by diminishing the heat of the parts. 

(a) Mr. Wilson introduces the subjoined formulas " recommended 
by French dermatologists, and quoted by M. Gibert." 
" B- Hydrate of lime, 3ij ; 
Subcarbonate of soda ; 
Laudanum aa 3ss ; 
Lard, 3j. M. 

" Anti-pruriginous ointment recommended by Alibert: — 
B Laudanum ; 

Sublimed sulphur aa 3ss ; 
Oxide of zinc, 3j ; 
Oil of almonds, Ij ; 
Lard, 3iij. M. 

" Ointment employed successfully by Biett for an obstinate prurigo 
of the hands : — 

B- Cinnabar ; 

Laudanum aa 3ij ; 
Sublimed sulphur, Sss ; 
Lard, 3v. M. 

" Ointment for local prurigo : — 

B Muriate of ammonia, 3j ; 

Powder of white hellebore, gss ; 
Lard, giij. M." 

1 Aphorismi. Sect. iii. aph. 31.— Epidem. lib. v. 

2 Iatraeum Hippocraticum. In-4. Ulm., 1661. 

* Oportet tamen ante alia adnotare, quod omnes illi affectus quibus jungitur pru- 
ritus, ditferentes sunt ab hoc pruritu ; quia in illis vel tumor, vel exulceratio, vel 
excoriatio aliqua apparet, in pruritu nihil horum. Videntur carnes parum mutatae, 
asperiores quidem aliquo pacto, sed sine tumore insigni, exulceratione et excoria- 
tione. Praeterea in aliis aflectibus, qui junctum habent pruritum, a cute semper 
emanat aliqua sanies : in pruritu nihil emanat, nisi, ut ait Avicenna, qusedam corpora 
furfuracea, atque neque hasc emanant, nisi cutis unguibus delinietur. (Mercuriali. 
De morbis cutaneis, lib. ii. cap. 3, p. 62.) 

* Hafenreffer. De cutis aflectibus, lib. i. cap. 14. 



allowed that the true character of prurigo, to wit, the existence of 
pruriginous papula; of the same colour as the skin, was first pointed 
out by Willan, 5 whose labours are given by Bateman in a condensed 
shape, in his Synopsis. The subsequent observations of Alibert, 6 of 
Chamberet, 7 and of Mouronval, 8 as well as those published by Som- 
mer and Lcescher on prurigo senilis, 9 deserve to be particularly con- 
sulted. It is much to be regretted that pathological writers have so 
often employed the vague terms bouton, spot, eruption, rash, &c, to 
indicate a host of other cutaneous affections, as well as the one that 
now particularly engages our attention ; great pains, too, have been 
taken to signalize the characters that distinguish prurigo from scabies, 
whilst little has been said on the difference between prurigo and 
lichen, a papular disease, with which it has many more points in com- 
mon. Many cases entitled prurigo by M. Mouronval, even appear to 
me to be true lichens, particularly the fifth, that is quoted in his essay, 
in which he says that "the spots (boutons) were red and prominent, 
or arranged in clusters, so as to form irregularly rounded patches. " 
A few cases of prurigo may be found detailed in different periodical 
publications ; 10 and a very remarkable one occurs in Mr. Wilkinson's 
work, 11 who found the patient seated naked on his bed, and tearing 
his skin with a comb. 

Case CV. — Eruption of furuncles and prurigo, after a severe illness. 
G. Cuny, aged sixty-five, of vigorous constitution, but apparently 
living in filth and wretchedness. About seven years ago he was 
attacked with a putrid fever, for which he became, at four different 
times, a patient in the Hopital de la Pitie, having had relapses as 
often, and never getting completely convalescent. Immediately after 
this attack he suffered from an eruption of boils, which appeared on 
almost every part of his body, during a period of four months. No 
sooner had the boils disappeared than the patient became affected 
with the cutaneous eruption under which he now labours ; the dis- 
ease, consequently, dates at least six years back. 

At the time of its appearance he neither suffered from fever nor 
from disturbance in any of the functions. A number of small spots 
(boutons) were thrown out simultaneously over the whole of his body, 
even upon the hairy scalp and eyelids. The eyes also at length shared 
in the irritation, which did not then spare the palms of the hands and 
soles of the feet. Ever since its appearance this eruption has not 
ceased to torment the patient with a feeling of general heat, a sensa- 
tion of burning, and a pruritus which lasts for hours, and even for 
nights, and obliges him to tear his skin with his nails, which he has 
been careful not to cut s-ince the commencement of his malady. The 
nails of his thumbs are, in fact, nearly half an inch long, those of the 
fingers somewhat shorter. When the pruritus becomes excessive, he 
relieves himself by digging these claws into the substance of his skin. 
Unable any longer to contend with the torments he endured, Cuny 
presented himself for admission into the Hopital de la Charite. On 
the 20th of June, 1827, he was in the following state: — 

The skin is filthy and looks generally red ; over every part of the 
surface are perceived crusts of dried blood, yellowish stains, and 
small papulae ; it is, further, furrowed and marked with scratches in 
all directions. A few untouched papula; occur on the back, and tops 
of the shoulders; these are of the size of small pins' heads, little dif- 
ferent in colour from that of the skin, and affected with a violent 
itchiness. On the same parts, the small of the back, flanks, chest 
and arms, traces occur of a still greater number of papulae, which the 
patient has torn with his nails, and whose summits are covered with a 

5 Willan. Description and treatment of cutaneous diseases. Art. Prurigo, 4to. 
London, 1798. 

6 Alibert. Quelques considerations sur le prurigo formicans. (Nouvelle biblioth. 
medic, mai, 1825.) 

1 De Chamberet. Diss, sur le prurigo, 4to. Paris, 1808. 

8 Mouronval. Recherches et observations sur le prurigo, in-4. Paris, 1808. 

9 Sommer. De aflectibus pruriginosis senum. Altdorf, 1727. Lcescher. De pru- 
ritu senili. Wittenberg, 1728. 

10 Revue medicale, Juin, 1830, p. 353 (heredite). Archives generates de medecine, 
t. xvi. p. 291 (prurigo gueri par le vin de Colchique). Journ. hebdom., t. vii. p. 428. 
Revue medicale, t. ii. p. 454 (prurigo gueri par l'acide prussique). Revue medicale, 
Fervier, 1829; Juillet, 1830 (prurit de la vulve). Gazette des hopitaux, p. 352 (pru- 
rigo du pudendum traite par le sous-carbonate de potasse). Lond. Med. Gazette, v. 
xi. p. 34. Forestus, under the title of pruritus ani (Obs. lib. xxii. obs. ii.), and of 
pruritus auris (Obs. et curat. medicin.,lib. xi. Schol), describes, but in a vague man- 
ner, pruriginous affections of these parts. 

" Wilkinson's Remarks on Cutaneous Diseases, 8vo. London, 1832. 



232 



PAPULA. 



little crust of coagulated blood, of different shades of black according 
to its age, and nearly a line in diameter. The finger passed over the 
remains of the papulae detects a hardness in the skin of the points 
■fleeted. The base of several of the headless papulae is red, and 
around some of them a furfuraceous desquamation appears to be 
oroing on ; this is the case more especially about the lower parts of the 
loins. On the shoulders, upper parts of the back and arras, a number 
of slight scabs, of small extent and irregular shapes, are perceived, 
which in some places assume the appearance of a furfuraceous desqua- 
mation. The scabs are yellowish, or of a dirty gray colour ; the skin 
under them is moist, and they appear to be formed by the desiccation 
of fluids effused from some accidental vesicles. On the front of the 
chest and shoulders a number of small tubercular indurations are per- 
ceived, round or irregular in shape, projecting slightly above the level 
of the skin, of a rosy red colour, and from one to two or three lines in 
diameter on the surface. These give the patient no uneasiness. 

Amidst these various alterations, the numerous scratches which the 
patient had inflicted on himself, were easily recognized by the linear 
sanguineous incrustations which cover such injuries. Several pediculi 
were likewise discovered on the surface. 

The skin on the parts of the body which have not been mentioned 
was merely hard and dry, and seemed to have lost its natural pliancy ; 
its colour was made up of a mixture of different shades of red, violet 
and pale yellow, blending one with another. The principal functions 
seemed to be performed with perfect regularity. (The cool and tepid 
bath ; decoction of dog's-tooth grass for drink ; the three-quarters hos- 
pital allowance). June 24th. — The patient has taken the tepid bath 
twice, with the effect of cleansing his skin and freeing it from sangui- 
nolent scabs and furfurae, so that it now appears covered with minute 
dots, and small excoriated lines, the effects of scratching and tearing 
the papulae. The small tuberculated indurations still continue. The 
sanguinolent scabs of the lower part of the back and loins are suc- 
ceeded by red points, scarcely perceptible, around which the cuticle 
appears raised in a furfuraceous ring to the extent of a line ; these are 
so numerous that they run into each other, and the desquamation over 
the regions mentioned, is nearly general. 26th. — Perseverance in the 
use of the bath has caused the furfuraceous desquamation to disappear, 
so that the skin of the back and loins now looks healthy. 29th. — 
(V. S. B. ad Jviij ; ointment of black hellebore.) 30th. — The bleed- 
ing has appeased the pruritus and smarting notably. July 7th. — The 
skin has now regained nearly its natural appearance ; it is only rough- 
ish, dry, and of a deep brown tint — characters which are common in 
the aged, especially among those who, like Cuny, have laboured hard 
all their lives. He was dismissed completely cured on the above 
day. 

The patient has since presented himself at the baths of La Charite 
for the sake of cleanliness. He has suffered no return of his infirmity. 
Case CVI. — Prurigo pudendi. — Madame C * * *, twenty-six years 
of age, was attacked with this disease in the month of February, 1823. 
This patient's catamenia had never been regular, and although a wife 
for several years she had not become pregnant. On the upper and 
inner parts of the thighs, near the greater labia, and upon these parts 
themselves, were detected a number of distinct papulae nearly of the 
same colour as the skin upon which they were evolved. The tops 
of several other papulae were covered with small blackish, flattened 
and very adherent crusts. The skin of the private parts also bore 
traces of several scratches. The external passages were red and 
inflamed, and there was some discharge from the vagina. During 
the day the parts affected were the seat of an incessant pruritus, 
which grew more severe in the course of the evening, completely 
interrupted sleep, and, exasperated by the endeavour of the patient to 
appease it by scratching, only gave place to a painful orgasm, which 
lasted through a great part of the night. Leeches were applied re- 
peatedly to the vulva; the patient was bled from the foot; and the 
hip-bath, tepid, and with the addition of a narcotic infusion, was 
taken every day; a large blister was subsequently applied to the 
lumbar region ; but at the end of two months and a half, during which 
this plan ot treatment was pursued, a merely temporary amelioration 
was all that had been obtained. I now consulted with M. Dupuytren, 
and it was agreed to try the effect of the gelatino-sulphureous douche. 
After the first few days, this application had indeed a wonderful influ- 



ence in allaying the irritation. The patient at once recovered her 
tranquillity and her sleep ; and after using the remedy twenty-five 
times at the temperature of 25° R., for ten or fifteen minutes each 
time, she obtained a complete cure, as well of the papular affection 
as of the leucorrhoea which it had occasioned. The menstrual func- 
tion did not become more regular after this; Madame C. did not fall 
pregnant ; but three years have now elapsed since she recovered her 
health without any recurrence of the prurigo. 

Case CVII. — Prurigo of the scrotum and anus. — Verset, sixty years 
of age, was admitted a patient at the fourth Dispensary, June the 26th, 
1825. Ever since October, 1824, this patient had laboured under a 
prurigo of the scrotum, upper and anterior parts of the thighs, and 
margin of the anus, against which he had employed various remedies 
in vain. June 27th. — On the parts mentioned a number of volumi- 
nous papulae, having the same colour as the skin, which was not 
inflamed, were very conspicuous. A much larger number, however, 
had had their heads removed by the nails of the patient, who found 
it impossible to refrain from scratching every instant. The papula; 
in this condition were covered with a small black crust. Although 
continually tormented by the pruritus, and tasting only broken and 
unrefreshing slumbers, Verset's general health did not appear to have 
suffered. I prescribed fomentations of the sulphureous mineral water 
of Bareges, with two ounces of gelatin dissolved in each pint of the 
fluid. This prescription was followed by great relief: after it had 
been continued four or five days, the papulae appeared shrunk, and 
the patient enjoyed tranquil and uninterrupted sleep, which he had 
not known for eight months. (Same fomentations ; tartaric acid 
drink.) July 4th. — The patient continues better; he has used some 
of the fomentation by way of lavement, and the itchiness he had felt 
in the rectum was alleviated by this means. The scrotum is the only 
part upon which papulae can still be traced ; by the 4th these had 
vanished; the pruritus was complained of less and less; and by con- 
tinuing the same measures, applying fifteen leeches to the verge of 
the anus, and taking the tepid-bath twice, the prurigo was completely 
cured on the 8th of October, 1825. 



PAPULAR INFLAMMATIONS ARTIFICIALLY EXCITED. 

663. Vesicular and pustular forms of inflammation are much more 
frequently and readily produced by artificial excitement than papulae. 
I shall, however, give an account of one case in which a papular 
eruption was produced by the contact of fulminating quicksilver. 
Mr. North has given several instances in which an eruption was ex- 
cited by the internal use of the cubebs pepper, which, in some respects, 
presented the characters of lichen, but in many more those of roseola 
and urticaria. 1 

Case CVIII. — Papular eruption produced by fulminating mercury. 
Guillemot, aged thirty-six, was attacked a fortnight ago with a disease 
on the skin, which he designated by the universal title of tetter (dartre). 
On the 1st of January, 1834, he commenced working in a manufactory 
of detonating caps for guns, pistols, &c. The principal ingredient in 
these articles is fulminating mercury, and the air of the manufactory 
is so much loaded with this substance in fine powder, that fresh 
workmen are always troubled with repeated fits of sneezing for two 
or three days after they enter on the business there carried on. Guil- 
lemot soon began to complain of a violent sensation of itching in the 
face ; this was followed the next day by an eruption, which continued 
up to the time of his entering the hopital de la Charite, but disap- 
peared entirely within eight-and-forty hours after his reception. 

On the 3d of March, Guillemot again presented himself at La 
Charite, having ceased from his work the preceding evening. Upon 
the skin of the forehead, and back of the neck particularly, there 
was an eruption of small red points, rather crowded together, promi- 
nent, rough, containing no fluid, and fading but little under the pres- 
sure of the finger. The skin in the spaces between these papula 
was healthy, and the eruption was attended with a considerable 
degree of pruritus. A few spots, perfectly similar to those described, 
were also discovered on the penis. The patient's teeth were black 

1 Arch. gen. de medecine, Juill., 1832. 



LEPRA. 



233 



and loose, and the gums ulcerated ; there was no fever, the appetite 
was good, and the patient slept well. The patient was put upon the 
use of the nitric acid, and in two days the eruption began to fade ; 
by the fourth day it had totally disappeared. ( The tepid bath.) The 
patient again complained of itching on the fifth day ; but nothing 
beyond some yellowish stains could be discovered on the forehead. 
On the eighth day the patient went out well. 



VIII.— SQUAMA. SQUAMOUS INFLAMMATIONS. 

Vocab. Squarnse, Scale. 

664. It is the distinguishing character of the squamous inflamma- 
tions to appear as red elevations, spots, or blotches, upon which 
squama, in other words, lamina? of the cuticle, altered in various 
degrees, are formed, thrown off, and incessantly renewed. 

665. The number of squamous inflammations reckoned is six: 
Lepra, Psoriasis, Pityriasis, Pellagra, Acrodynia, and Scaly Syphilis. 
I shall treat of pellagra and acrodynia when speaking of the cuta- 
neous diseases peculiar to certain countries ; and the history of squa- 
mous syphilis will form part of that of the venereal disease in general. 
I have, further, separated from the group of pityriasis, two varieties 
of cutaneous affection described by Willan under the heads pityriasis 
versicolor, and pityriasis nigra. These I denominate chloasma, and 
melema, as I hold that they belong essentially to the class of pig- 
mentary affections. 

Mr. Plumbe and Dr. Duffin have proposed to unite the description 
of lepra to that of psoriasis. To place the distinguishing characters 
of these two diseases in greater relief, I have continued to describe 
them separately, although I still acknowledge the striking analogy 
that exists between their various symptoms. Inflammation of the 
reticular tissue and papillae is the first and main feature of squamous 
affections. The squama? are a secondary phenomenon to which 
Willan attached too much importance when he assimilated ichthyosis 
to this class of diseases. 

666. In an anatomical point of view, the analogy of the squamous 
inflammations to the exanthemata is indisputable. In both classes of 
disease there is sanguineous injection followed by desquamation. In 
the squamous forms of inflammation, however, the two phenomena 
continue to co-exist, frequently during a very considerable length of 
time, whilst in the exanthemata, the redness and desquamation suc- 
ceed each other, and usually occur but once. Nevertheless, when 
any of the exanthemata, erythema, for example, passes into the chronic 
state, it assumes almost the wdiole of the appearances characteristic 
of squamous inflammation. 

667. Two squamous inflammatory affections, lepra and psoriasis, 
make their appearance in the shape of small, hard, prominent, and 
papular-looking elevations, the tops of which soon become covered 
with squamee of a dull white colour. These elevations unite, and then 
change into scaly patches of various forms and dimensions, which 
may either be in small numbers and limited to a single region of the 
body, or occur disseminated over the whole of its surface. In the 
latter case, the desquamation is frequently so copious that the bed 
and clothes of the patient become filled with dry and whitish-looking 
scales. 

The dermis beneath the scaly patches is found red and inflamed, 
and inveterate squamous affections are always accompanied with 
chapping and a morbid increase of thickness in the skin. 

Squamous inflammations occasionally remained confined to the 
points which they have first invaded, or they quit these to show them- 
selves on others. They sometimes cause itching, tingling and an 
unpleasant sensation of heat, phenomena all of which are constantly 
increased by such causes as tend to raise the external temperature of 
the body. These sensations are usually very violent in pityriasis. 
The insensible perspiration appears occasionally to be diminished in 
the places occupied by the squama?. 
59 



668. The various forms of squamous inflammation frequently com- 
plicate each other, — a new proof of their analogy. They are rarely 
combined with any other form of cutaneous affection. 

669. Squamous diseases are much more common among the lower 
classes of society than among the higher. These diseases are ob- 
served at all seasons of the year, although they are more apt to make 
their attacks in the autumn and spring. Women seem more subject 
to them than men. No one of them is contagious ; but numerous 
instances prove that they are hereditary. 

670. It is necessary to distinguish the squamous inflammations pro- 
perly so called, from the natural epidermic exfoliations that take place 
from the skin of new-born infants, 1 and of the aged, phenomena which 
will be mentioned by and by. 

The squamous are not liable to be confounded with any of the 
other forms of cutaneous disease, when their elementary appearances 
have undergone no change. It is true, indeed, that squamae are 
observed in the second period of the exanthemata, and of some papu- 
lar and vesicular diseases, particularly chronic eczema, and lichen 
agrius ; but besides the fact, that a few vesicles or papulae may almost 
uniformly be detected in the vicinity of these squamous surfaces, 
which proclaim the nature of the existing inflammation, there are 
such differences in the whole appearance of these various diseases 
that it is impossible to mistake the one for the other. To conclude, 
the squamous phlegmasia? cannot be confounded with ichthyosis in 
which the dermis is unaffected with any degree of redness, and the 
seat of no morbid sensation. 

When treating of lepra, psoriasis and pityriasis, I shall take care 
to point out the particular features that distinguish these diseases 
severally. 

671. The squamous inflammations commonly require several months 
and sometimes several years of treatment for their cure. They are 
the more obstinate as they occupy a larger extent of surface, and as 
they are of longer standing. 

672. With regard to treatment, few of the phlegmasia? have so 
many points of resemblance as the squamous inflammations ; to be 
satisfied of this it is enough to glance from the treatment of lepra to 
that of psoriasis. 



Vocab. Alp/tos, Lepra, Leuce, Me/as, Dartre furfuracee arrondie. 

673. The word lepra, which was long used to signify almost the 
whole of the chronic diseases of the skin when they had attained a 
high degree of severity, is now employed in a limited and more 
determinate sense to designate a chronic inflammation of the integu- 
ments, characterized by scaly patches of different dimensions, of a 
round or orbicular shape, depressed in the centre, surrounded by a 
red and prominent circle, and either disseminated over the surface of 
the skin or united into one or more patches of larger size and more 
irregular shape. 

674. Symptoms. — Lepra is occasionally seen confined to the elbows 
and knees. Its orbicular patches generally make their first appear- 
ance on the extremities, and usually on the parts below the knees 
and elbows. In the majority of instances it is developed on both 
legs or both arms at the same time. It is then apt' to extend by the 
successive formation of new scaly patches along the arms and thighs 
to the breast and shoulders, and to the lumbar and lateral regions of 
the abdomen. The patches are often more numerous and prominent 
on the lower part of the belly than elsewhere. The disease rarely 
extends to the hands or hairy scalp. The patches that do occur on 
the head are generally of small size. A few are occasionally seen 
around the outer angles of the orbits, from whence they spread" alons* 
the eyebrows to the forehead and temples. The patches are every- 
where apt to coalesce by their corresponding edges, but the originally 
orbicular form of the parts composing these aggregate patches is 
still proclaimed by the arcs of circles which are seen in their circum- 
ference. 

1 Billard. Mai des Enf. nouveau-nes, p. 32, 8vo. Paris, 1828. 



234 



SQUAMiE. 



The lepra vulgaris of Willan, the dartre furfurack arrondie 
of Alibert, invades in the shape of small solid elevations, around 
which numbers of other reddish-coloured, prominent spots, about a 
line in diameter, of a circular form and firm consistency are evolved. 
It was undoubtedly this papular appearance which led Willan to 
imagine that lepra was owing to an induration of the papillae of the 
skin. 

The summit of these elevations, the appearance of which is fre- 
quently successive, smooth in the earlier stages of their existence, 
become covered some few days after their formation with a small 
epidermic scale, white, semi-transparent, smooth and polished. This 
minute spangle-like scale is detached before long, and its fall is 
announced by a feeling of tingling or pruritus. The small space of 
skin which it covered is now found red and is rough to the touch. 
In the centre of the inner surface of the scale which is thrown off, a 
minute eminence may be perceived, less consistent than the other 
parts and which appears to have been lodged in a slight depression 
of the skin ; it is even observed to be tinged with blood when vio- 
lence has been employed in removing the scale. 

These small scaly spots, after having thus shed their covering once, 
enlarge in rather a rapid manner, until they measure an inch and even 
more in diameter, but always preserving a circular shape. They are 
speedily again covered with squama?, which are dry, glistening, some- 
what opalescent, tough, and of a pearl-gray or pale yellow tint. 
They are bounded by a rosy, or purplish and slightly elevated margin, 
so that the centre of each patch appears somewhat depressed. The 
squamae, which almost always adhere very firmly to the skin, are by 
no means evenly and regularly spread over the surface of the leprous 
patches, which are never seen covered by a single scale. The 
squamae are superposed, especially in the circumference of the 
patches, and become thicker and thicker so as to form prominent 
layers. The exposed parts of the squamae often acquire a whitish 
tinge ; they are detached partially and irregularly. After their fall 
the small orbicular surfaces of the skin which they had covered, look 
red and shining, and rise above the level of the healthy parts which 
surround them. If the leprous patches are recent, the corion does 
not present lines in correspondence with those of the cuticle ; but 
impressions of this kind are observed on the patches of older standing. 
In the latter case, indeed, they occasionally present a furrowed ap- 
pearance, from an increase in the naturally superficial wrinkles of 
the skin, which are found in correspondence with smaller slight pro- 
jecting lines situated on the inner surface of the squamae. 

After being freed from scales naturally, or by art, the surface of 
leprous patches is speedily covered by a fresh formation of squamae, 
so that in the course of a few months or several years the parts 
affected may have presented a greater or smaller number of successive 
desquamations. 

The spontaneous or artificial cure of the orbicular patches of lepra 
begins in the centre, and extends towards the circumference. After 
the detachment of the squamae from the patches, the skin, when they 
are not renewed, first acquires a grayish tint with a shade of yellow; 
at a later period the ring which bounds the patches is narrowed pro- 
gressively from within outwards, the circle breaks at length in one 
or more places, and the spot subsequently disappears entirely. 

Upon some regions and in particular individuals, the squamous 
patches of lepra remain of inconsiderable size, never exceeding a few 
lines in diameter; they also increase very slowly and are but little 
prominent, rarely run into one another, are developed almost exclu- 
sively on the extremities, and differ from the patches of lepra vulgaris 
by the whiteness and small size of the squamae that are formed. This 
constitutes the variety entitled lepra alphoides by Willan. It is more 
commonly observed among children than adults or the aged, and is 
not easily distinguished from psoriasis guttata. Further, the scaly and 
orbicular patches of lepra may present a particular appearance, pro- 
duced by the confluence of the primary spots or scaly rounds. They 
then extend over large surfaces, and are often symmetrically disposed 
on the two sides of the body. 

I have, moreover, observed lepra under another form, that, namely, 
of arcs of circles a few lines in diameter, red, prominent, devoid of 
scales and bounding surfaces of various extent, occasionally as much 
as five or six inches across, the skin of which had either a yellowish 



cast, or appeared perfectly healthy. This variety, in its progress 
at least, has the most striking analogy with the centrifugal palmar 
psoriasis. Although most commonly encountered on the trunk, I 
have met with this variety of lepra exclusively on the lower part of 
one forearm and hand, on the anterior and posterior aspects of which 
it formed a kind of irregularly circular wreath. 

When lepra is long neglected, or when it extends to the fingers, 
the disease may at length reach the matrices of the nails. These 
appendages then become thick, rough, opaque, of a dirty yellow 
colour, and crooked at their ends, whilst their roots are thickened, 
and look as if they were formed of many distinct and superposed 
layers. 

Lepra is very seldom seen exclusively on the hairy scalp. When 
it is, the squamae are commonly yellow and furfuraceous ; they have 
none of the glistening micacious appearance which they present on 
the knees and elbows. 

When the number of squamous patches is not very considerable, and 
they are not highly inflamed, lepra is attended with no morbid sensa- 
tion, unless it be some slight degree of itching when the temperature 
of the surface is increased by exercise and the warmth of a bed. This 
sensation, according to Mr. Plumbe, is caused by the detachment of 
the circumference of the squamae, which is affected by the swelling 
of the areola surrounding the patches. It is certain that sensations 
of tingling and pruritus are no longer perceived by patients labouring 
under lepra, when no new scales are formed beneath those that 
already exist, and that the disease is then tending to recovery. 

When the patches of lepra are inflamed and extensively diffused 
over the surface of the body, they may be attended with pain and a 
feeling of tension in the skin of the extremities. The inflammation 
has been seen running to such a height, that it impeded the motions 
of the joints, and obliged patients to keep their beds, every move- 
ment of the body producing deep chaps and a very singular crackling 
noise. 

The influence of lepra does not seem to extend beyond the parts 
of the skin which are immediately attacked ; the disease appears to 
be essentially local. If several authors could be named who, in 
describing this affection as symptomatic, have specified different other 
morbid phenomena, especially an alteration of the voice, it is owing 
to their having confounded lepra with the Greek elephantiasis, and 
regarded two diseases every way distinct as varieties of the same 
affection. 

676. Observations on Structure. — The whole of the tissues which 
enter into the formation of the skin, do not appear to be alike affected 
in lepra. It has been conjectured that the vessels secreting the epi- 
dermis labour under a chronic irritation, the effect of which is to 
render the production of this substance more copious than natural ; 
but as this hypothesis offers no explanation of the orbicular form of 
the patches, some pathologists have supposed that the superficial 
vessels of the skin were disposed in small concentric circles ; others 
have maintained that the circular arrangement of the squamae was a 
natural consequence of their development under the form of a round 
elevation, the inflammation in spreading still retaining its primary 
form. 

I have ascertained that the papillae are more largely developed on 
the leprous patches than on the healthy skin. 

677. Causes. — Lepra is common to both sexes, and occurs at all 
ages ; I have not myself met with the disease in infants at the breast, 
but I have had frequent occasion to see it after the period of the first 
dentition. Mr. Wilson assures us, that it is observed more frequently 
at the present day in England than it used to be formerly; but it is 
very possible that the disease was long misunderstood or imperfectly 
described under other names. Heberden in particular was probably 
mistaken when he said, that lepra was very rare in England, — "de 
vero scorbuto et lepra nihil habeo quod dicam, nam alter rarissimus 
est in urbibus, altera in Anglia pene ignota," unless, indeed, by lepra 
he intended to refer to elephantiasis, a suspicion which seems to 
acquire confirmation from the fact that several French practitioners, 
entertaining confused notions of the nature of lepra, forgetting the 
characters which had been anciently assigned to the disease, and 
confounding it with elephantiasis, (the lepra of the middle ages,) 
have also said, that lepra was only seen in some of the southern 



LEPRA. 



235 



departments of France, whilst it is certain that in the hospitals of La 
Charite, St. Louis and Les Enfans Maladies, a considerable number 
of individuals are every year seen labouring under this form of 
squamous inflammation, which I have also encountered in all classes 
of society. Almost all that has appeared of late in France on the 
origin, propagation and disappearance of lepra in different quarters 
of the globe, has been advanced upon the strength of statements 
borrowed from writers who have confounded lepra with Greek or 
Arabian elephantiasis, or with other diseases not less distinct, (a) 

The causes of lepra are for the most part very obscure, or altogether 
inappreciable. The disease is not contagious ; patients labouring 
under it are not kept isolated in our hospitals, and husband and wife 
continue to cohabit without the one infecting the other. Like seve- 
ral other diseases of the skin, whose term of duration is much shorter 
(roseola, urticaria, &c)., lepra appears to be occasionally produced by 
the abuse, and even by the simple use of stimulating food and spirit- 
uous liquors. Bateman was acquainted with an individual in whom 
spiced food and a small quantity of spirits never failed to produce 
the disease. In the same way, it has been known to follow the 
ingestion of different poisonous substances, the salts of copper, for 
instance, and the abuse of acids. It has now and then appeared to 
be induced by the habitual use of game, salted and highly-seasoned 
food, fish, shell fish,&c, or to be engendered by the united influence 
of affliction and poverty. Willan was of opinion that lepra was 
principally caused by exposure to cold and moisture, and by the 
action of certain dry and powdery substances upon the skin: but 
Bateman has remarked, with justice, that bakers, and persons em- 
ployed in dusty workshops are rarely affected with this disease, 
whilst it is frequently observed among females, and those classes of 
society in which personal cleanliness is an object of the most par- 
ticular attention. In some cases, lepra has been seen occurring after 
violent and long-continued exercise. Many instances of hereditary 
lepra have been recorded. To recapitulate, it is impossible not to 
perceive that much obscurity still remains in regard to the number 
and nature of the causes capable of producing this disease. 

678. Diagnosis. — The diagnosis of lepra, even at the present day, 
remains one of the most important points of its history, on account of 
the confusion at which I have hinted ; and yet it is indisputably one 
of the diseases of the skin whose characters are the most remarkable. 
In many particulars it differs from all the chronic inflammatory affec- 
tions of the skin, even from those that show themselves like it under 
the squamous form. In psoriasis the epidermis is, indeed, as in lepra, 
more or less rough, scaly in a greater or less degree ; but the form of 
the squamous patches is much less regular, their edges are less raised, 
inflamed in a minor degree, and their contour is by no means so pre- 

(a) Dr. Green {A Practical Compendium of tfie Diseases of the Skin, 
&c.,) in confirmation of the opinion of Mr. J. Wilson in the text, says : 
— " Few are aware how very commonly scaly leprosy prevails in 
London ; those who are affected with it, and indeed with any cutane- 
ous affection, generally concealing the circumstance even from their 
most intimate friends, as if there were something disgraceful attached 
to this class of complaints. Individuals in every class of society are, 
however, subject to most of these, and to lepra in particular. The 
disease I find one of every-day occurrence, and by no means so 
intractable as I used at first to believe it, or as is supposed. Most 
slight cases will get well readily under the use of the sulphur fumi- 
gations, assisted by very gentle medicines ; others require greater 
perseverance, and the administration of medicines of a more active 
kind, among the number of which I believe the preparations of 
arsenic to deserve the preference. I never had but three cases of 
leprosy, which, by their obstinacy disheartened both myself and 
patients ; one was that of a gentleman who took the sulphur fume 
bath upwards of a hundred times, without deriving much or any 
permanent good from it. Another gentleman, after a trial to the same 
extent of this means, and a similar result, went to India, and I heard 
no more of him. The third is a medical gentleman, who has had the 
disease from puberty, and is now fifty years of age. He too has 
taken more than a hundred fumigations, though very irregularly, and 
considers himself incurable of the disease in question ; otherwise he 
is in fair health." 



cisely circular as that of the patches of lepra. Lastly, in inveterate 
psoriasis, the skin beneath the scaly patches is frequently traversed by 
deep fissures, and is in general much more sensitive and irritable than 
in lepra. Still there exists one variety of psoriasis, the psor. guttata, 
which has so many and such great analogies to lepra, that it consti- 
tutes, as it were, a form of disease intermediate between this affection 
and the other varieties of psoriasis. The scaly patches of psoriasis 
guttata are in fact isolated and distinct like those of lepra, but they 
are smaller in size, being rarely more than two or three lines in 
diameter, and their circumference is less regular and less prominent. 

In some inveterate cases of lepra, even when the orbicular patches 
are blended together by their corresponding edges, it is still possible 
to distinguish the disease from certain psoriasis ; with a little atten- 
tion, a few halves or quarters of circles may be distinguished pro- 
jecting from the circumference, or in the midst of the agglomerated 
patches. 

Certain circumscribed lichens which get well from the centre to- 
wards the circumference of the patches are also to be carefully dis- 
tinguished from lepra, the arcs of whose patches, always redder, more 
prominent, and more regularly defined on their convex edges, never 
exhibit true papula? on their surface. 

Syphilitic tubercles of a flattened form and arranged exactly side by 
side, so as to form perfect circles in the centre of which the skin is 
occasionally healthy, might be taken at the first glance for large rings 
of lepra vulgaris on the way to recovery ; but mistake becomes im- 
possible when it is seen that the squamae, when any occur on the 
tubercles, do not form a continuous circle ; they are thin hard lamellae, 
always of smaller size than the induration on whose summit they are 
fixed. 

The dryness and roughness of the skin, so remarkable in lepra, are 
not perceived in squamous syphilis, the thin and grayish squamae of 
which, when they are old, crown small copper-coloured elevations, 
and are almost as soft to the touch and as pliant as the other parts of 
the skin. Further, the blotches that occur after a syphilitic infection 
usually grow pale and get well under the influence of mercurial medi- 
cines ; their disappearance, moreover, is attended with this peculiarity, 
that they generally begin to heal off from the circumference, whilst 
the orbicular patches of lepra recover from the centre towards the 
circumference. 

Psoriasis and pityriasis of the hairy scalp present disseminated furfu- 
raceous squamae, not scaly patches with regularly circumscribed edges. 
It might be thought difficult to confound the squamae of lepra with the 
crusts formed by the desiccation of the fluids excreted from surfaces 
affected with vesicular and pustular inflammations : yet Willan ob- 
serves that lepra has occasionally been mistaken for impetigo Jigurata 
vel annularis, or rather for the scaly state of the skin consecutive to 
the fall of their incrustations. 

Lepra has been confounded with ichthyosis by Plenck and Chia- 
rugi. After the middle ages the title of lepra was often given to two dis- 
eases as different as possible from the one we are more immediately 
engaged in describing, — Greek elephantiasis and Arabian elephan- 
tiasis. 

Leprous patches that have been freed from squamae by the action 
of baths, lotions and unguents, are more difficult of distinction ; it is, 
however, generally sufficient to question the patients narrowly, to dis- 
cover that the circular red patches, healed up or not in their centres, 
and the red rings and half rings, that appear upon the skin, were 
originally covered with squamae ; besides they speedily again become 
crusted with scales when left to themselves. 

679. Prognosis. — Among the aged, lepra is almost always incu- 
rable, or at least is so rarely cured completely that it is often advisable 
not to persevere too long in endeavours to obtain such a consumma- 
tion. The disease seldom gets well spontaneously ; it almost always 
proves very rebellious to every kind of treatment ; the patches often 
follow each other in succession on one region, whilst they disappear 
on another. The hereditary forms of the disease are the most obsti- 
nate of any. The disease never degenerates into cancer, as has been 
affirmed by several authors. 

680. Treatment. — An infinite number of remedial measures have 
been proposed in reference to lepra. These means are observed to 
act much more powerfully in summer than at any other season. I have 



236 



SQUAM.E. 



seen a certain number of cases of lepra, in which the eruption made 
its appearance during the autumn, to vanish spontaneously with the 
following spring. 

Individuals whose constitution has been severely tried or broken, 
as well as those who show symptoms of plethora, require to undergo 
Mime preparation, directed with a view to bringing the system into a 
state more favourable to the success of the treatment : it may be com- 
menced at once when the habit of the patient presents no peculiar 
indication. 

1st. External remedies. — When lepra is of recent date, and extends 
over a large surface of the body, when the patches are affected with 
a painful pruritus, and the motions of the joints are impeded, the 
disease will be aggravated by sea bathing, by frictions or lotions with 
the preparations of sulphur, kc, which have been far too indiscrimi- 
nately recommended in the treatment of diseases of the skin : blood- 
letting, on the contrary, and anointing the parts affected with cream, 
fresh butter, or sweet lard, give speedy relief. The vapour-bath, and 
the emollient or gelatinous bath may be employed as a principal or 
accessory means. The simple vapour-bath, occasionally proves suffi- 
cient of itself to cure recent lepra. 

When the squamous patches are but very slightly inflamed, or of 
old standing, recourse is usually had to topical applications of a more 
or less exciting kind ; before using these, however, it is always proper 
to cleanse the skin by means of fomentations, the tepid-bath, and 
gentle frictions, in case the scales adhere very firmly or lie in very 
thick layers. The use of stimulating washes, such as those composed 
of a mixture of spirits and water, or a solution of the sulphuret of 
potash, favours the removal of the scales, and often gives a favourable 
tendency to the progress of the patches. When the squamae are 
detached, a little of the white pitch, tar, or weak nitrate of mercury 
ointment, may be rubbed over the affected parts, before the patient 
retires to rest for the night : next morning the skin must be washed 
with tepid water, or a weak saponaceous solution. By means of these 
topical applications, continued for several months, we occasionally 
succeed in restoring its natural texture to the skin, even after a course 
of internal medicines had been tried and failed. I have, however, 
obtained a still greater number of cures by the inunction of an oint- 
ment of the white precipitate, a drachm of white precipitate to an ounce 
of hog's lard ; a drachm or even a drachm and a half of this mixture 
may be rubbed in every day without any risk of exciting salivation ; 
this is the external application I am in the habit of prescribing in the 
greater number of cases of lepra. 

Sulphureous water baths and fomentations are often successfully 
employed under similar circumstances. The waters of Bareges, Cau- 
terets, Bagn6res, Bagnoles, Enghien, &c, in France, and those of 
Bath, Harrowgate, Leamington, Crofton, &c, in England, are fre- 
quently recommended. The sulphur vapour-bath generally fails to do 
any good, although its virtues have been often extolled ; a certain 
number of complete cures have nevertheless been obtained by this 
means. The acid vapour-bath, the natural or artificial sea-water-bath, 
the alkaline bath, and the waters of Plombieres have been employed 
with greater success. The sea- water-bath, especially, is much recom- 
mended in England, and it occasionally produces so much excitement 
of the skin, that it is found necessary to dilute the sea with river water. 
The simple vapour bath, commonly recommended with the view of 
freeing the skin from squama;, is frequently found to modify the state 
of the surface advantageously. The tepid-bath is also effectual in 
removing squama 3 and in keeping the skin clean. 

When leprous patches are few in number, and of very old standing, 
they arc sometimes successfully treated by the repeated application 
of small blisters, and by the use of superficial escharotics, such as 
dilute muriatic acid, or the acid nitrate of mercury. 1 Some incon- 
clusive trials have been made of the acetate and phosphate of mercury, 
and of the sulphate and deutoxide of antimony, in lepra ; more evi- 
dently good effects have followed the application of the iodide of 
sulphur, in the proportion of twelve grains to the ounce of lard. It is 
frequently only after numerous trials, that the application best suited 

1 Instead of applying caustics directly to the affected parts, I have been assured, in 
conversation with a gentleman whose name is unknown to me, that if the nitrate of 
silver be applied circularly around the leprous spots, they very speedily disappear.— 



to the particular case can be ascertained. My own practice is to begin 
with the white precipitate ointment, or with "that of the prolo-chloride 
of mercury, unless in those cases where the disease is of very long 
standing, when I try the iodide of sulphur in preference. 

2d. Internal remedies.' — The decoction of dulcamara in the propor- 
tion of half, and then a whole ounce, and even of two ounces to the 
pint of water, has been recommended by many practitioners, and more 
particularly by Dr. Crichlon, as very efficacious in lepra. I have 
prescribed it several times with success ; but I have seen this medi- 
cine, when given in somewhat large doses, produce vertigo, without 
in every instance, appearing to exert any very sensible influence on 
this squamous inflammation of the skin. The extract of dulcamara 
is much less energetic in its action than the decoction. The dulcamara 
may succeed in the slighter cases of lepra, affecting young and health- 
ily constituted individuals. I am in the habit of using "the white 
precipitate ointment externally, at the same time that the dulcamara 
is taken internally. 

Cases of lepra, which had resisted every other medicinal means 
attempted, have been cured in the course of six weeks, by the exhi- 
bition of purgatives, combined with the tepid or vapour-bath. Calo- 
mel combined with jalap or rhubarb, so as to produce one or two 
liquid evacuations daily, appears to be the form of purgative best 
adapted to these peculiar cases; when taken alone, calomel is apt to 
be absorbed into the system, and to cause ptyalism. In some cases 
of obstinate lepra, and in robust individuals, I have had recourse 
to purgatives of a more active description. 

The tincture of cantharides, administered internally in some muci- 
laginous drink, in doses gradually increased from five to ten, fifteen, 
twenty or thirty drops, occasionally causes the rapid disappearance of 
lepra, especially when the disease is of limited extent, and not very 
severe in its character. This medicine has been carried the length 
of sixty and even eighty drops, due regard being had to the state of 
the digestive organs ; such doses of course require to be very prudently 
administered ; but of all the energetic and dangerous remedies that 
have been used in the treatment of lepra, the tincture of cantharides 
is, perhaps, that which has the most remarkable influence on the dis- 
ease. The great objection to its employment is its liability to excite 
inflammation in the digestive organs and urinary passages, especially 
among females, which necessitates the immediate suspension, and 
occasionally even the entire abandonment of the medicine. 

When lepra is of long standing and extensive, and has been fruit- 
lessly treated in a variety of ways, we must then either be content to 
pursue palliative measures, regulate the diet, &c, or else resort to 
arsenical preparations, as the state of the general health, and the 
knowledge we possess of the diseases the patient has already laboured 
under, may incline us. As lepra, however, exerts no evident ill 
effects on the constitution, and the inconvenience it occasions being 
either extremely trifling or very endurable, it will probably be found 
advisable in the majority of instances to confine the treatment to that 
which is merely palliative, unless the patient positively insists on 
some more active system being followed. In the latter case, the use 
of Fowler's arsenical solution may be begun in doses of four or five 
drops daily, and the quantity gradually increased to fifteen drops, to 
be taken at four different times in the course of the four-and-twenty 
hours, and continued for several months. Some practitioners have 
not scrupled to carry this medicine the length of fifty and sixty drops 
daily. I have already quoted several cases, from the works of Girdle- 
stone, Willan, Bateman, Plumbe, and others, which demonstrate the 
excellent effects of this medicine in lepra. (§ 188.) I have myself 
obtained similar good effects in many cases; but I have often, also, 
in spite of all my care to graduate the doses of the medicine, seen it 
excite great disturbance in the functions of digestion; it therefore 
requires to be administered with the greatest caution ; and if, after 
being taken for a few days, patients begin to complain of a feeling of 
tension, of stiffness and puffing in the face, and of heat and prickling 
in the throat, these phenomena, even when unaccompanied with 
evident derangement of the functions of the stomach, proclaim that 
the medicine has been given in too large doses, and warn us that 
these must be diminished. If, in addition, the tongue become red on 
its tip and edges, if thirst be complained of, the features look slightly 
erythematous, and the secretion of saliva be augmented, the further 



LEPRA. 



237 



use of the arsenical solution must be immediately suspended. Lastly, 
the medicine must be entirely abandoned if such symptoms as nausea, 
vomiting and vertigo, accompanied with cough and pain in the epigas- 
trium, supervene. All these unpleasant phenomena usually subside 
upon the mere suspension of the arsenical solution, without our being 
obliged to combat them by blood-letting, which may, however, be- 
come necessary. The less active arsenical solutions of Valangin, 
Pearson and Lefevre, and the arsenical pills of the Edinburgh pharma- 
copoeia, have the same advantages and inconveniences as the com- 
mon Fowler's solution, and require the same watching and the same 
reserve in their administration. 

The pertinacity of lepra, its resistance to the most active remedial 
means, and the hope of substituting for these other medicines more 
certain in their effects or less dangerous at least in their action, have 
given rise to an infinity of experiments, the results of which I shall 
now endeavour to recapitulate. 

Tar, in the dose of eight, ten or twelve grains and more, and tere- 
binthinate pills, in doses of fifteen, twenty-four and thirty-six grains, 
have been tried in lepra, with very various and very uncertain results. 

The sulphuret, and other preparations of antimony, have occasion- 
ally appeared to produce an improvement in the state of the skin, 
but never any remarkable cure of this disease. 

The advantages of mercurial medicines have been exaggerated, 
particularly by Wilson. A watery or spirituous solution of the sub- 
limate in minute doses, is of all these preparations that whose efficacy 
is the least subject to dispute. Calomel, in purgative doses, as has 
already been said, is often useful in lepra vulgaris ; but it so readily 
excites salivation, that its action requires to be narrowly watched. 

The decoction of daphne mezereum, employed by Pearson in several 
cases of lepra, frequently produces a temporary improvement, never a 
complete cure ; its effects, however, are more apparent than those of 
sarsaparilla. The daphne mezereum may excite vomiting, hyperca- 
tharsis, and inflammation of the stomach and pharynx. The medicine 
is less energetic under the form of a syrup ; some practitioners are in 
the habit of prescribing it in combination with arsenical preparations. 

The liquor potassce of the Berlin pharmacopoeia in doses of from 
twenty to thirty drops ; the watery extract of white hellebore in doses 
of from two to four grains ; various preparations of the ranunculi, of 
the rhus radicans, and rhus toxicodendron, have occasionally proved 
of signal advantage in lepra, when the disease was extensive, and 
attended with high inflammation, but unaccompanied with notable 
derangement among the digestive functions. The effects of such 
medicines, of course, require to be carefully watched. 

Experiments, made subsequently to those of Dr. Lettsom, are far 
from confirming the benefits he believed he had derived from the 
decoction of the bark of the ulmus pyramidalis , a medicine of a much 
less formidable character than any of those just signalized. Much 
still remains to be done in regard to the treatment of lepra. A quiet 
and regular life, a diet of white meats, fresh vegetables, ripe and 
watery fruits, milk, &c, assist the action of tha different medicines I 
have mentioned, all of which we are often obliged to try, one after 
another, in a disease so obstinate in its characters, (a) 

(a) Plumbe lays great and deserved stress on the dependence of 
lepra on constitutional causes ; but as urgent are some, at least, of his 
predecessors in saying that this origin and connection have been 
much overlooked. Alibert I might cite, among others, as pointing 
out expressly, in some of his cases, the occurrence of the disease after 
strong mental emotions, and particularly fear and anxiety. This 
author gives the history of a patient at the St. Louis Hospital, who 
unexpectedly saw his former master, a member of the Parliament of 
Paris, dragged to the scaffold, during the horrors of the Revolution ; 
and who was so terrified at the sight, that a furfuraceous eruption 
broke out suddenly on the whole cutaneous surface. This affec- 
tion assumed the true character of lepra, or, as Alibert termed it, 
dartre furfurace'e. In another case, described by him, the disease 
originated from depression of spirits, caused by the imprisonment of a 
friend, and increased afterwards by a loss of the situation which he him- 
self held. Biett also assigns mental affections as one of the most 
common causes. 

The class of persons, says Plumbe, who appear to be most subject 
60 



Historical Notices and particular Cases. 

681. The word lepra is nowhere well defined in the collection of 
the Hippocratic writings. 1 It, however, occurs in a less vague accep- 

to lepra, are those minds that are anxiously occupied by the cares of 
business or study, or who are accustomed to bodily exertion beyond 
what their strength enables them to bear. He is too exclusive in his 
opinion, that lepra is always caused by debility either direct or indi- 
rect, and requires uniformly nutritive and stimulating diet. In his 
general proposition, however, w r e can all join, viz., that attention to 
the general health, and the invigoration of the constitution, are the 
chief means by which the cure is brought about. 

As respects a more specific cause in certain venereal indulgences, 
the observations of Plumbe merit serious attention. " If any fact 
were necessary," he tells us, " in addition to those I have adduced, 
that debility of circulation and system were the causes of lepra, I 
might allege that in young men, as confessed to me often, the practice 
of masturbation has been followed, and that to a very great extent, 
in the very worst cases which have come under my notice." He 
adds " the lepers of whom we read, therefore, as excommunicated 
from their species, and remarkable for their disgusting salaciousness, 
have been probably the victims of the vice alluded to — the effect has 
been mistaken for the cause." 

On the score of treatment of lepra, little essentially new can be 
added to the conditions and details so well laid down in the text. A 
preference is indicated by M. Rayer for the iodide of sulphur among 
the external remedies. It is the favourite one of M. Biett in several 
diseases of the skin, including lepra. The proportion of the iodide 
may be increased from 12 to 30 grains to the ounce of lard. M. 
Biett has also used with marked success, the iodide of ammonium in 
the proportion of Bs to 3s with li of adeps ; the weaker ointment 
being used when the disease is recent, and the stronger wdien it is 
chronic. As the iodide is decomposed by exposure to the air, the 
ointment should be kept in stopped bottles. For details, as to the 
mode of employing this preparation and on the treatment generally of 
lepra and psoriasis, illustrated by cases, the reader is referred to an 
instructive paper by Dr. Pennock in the American Journal of the 
Medical Sciences, vol. xv. M. Gibert speaks favourably of the oint- 
ments of anthracokali and foligokali, two new medicines of whose 
use mention has been more fully made in a note at pp. 201-2 of this 
work. 

" M. Lemery, of St. Louis, has lately recalled the attention of prac- 
titioners to an old, but valuable application, in leprous affections — 
namely tar. Finding, however, that this remedy was objectionable 
on account of its colour and odour, he had recourse to one of the 
products of tar, concrete naphthaline, which afforded him the most suc- 
cessful results. The preparation which he employs is an ointment, 
composed of 

Naphthaline two to four parts. 
Lard thirty parts. 
M. 
This he applies to the diseased skin, on folds of linen, night and 
morning. The ointment is highly stimulating, and has a powerful 
smell, which quickly passes away. By means of the naphthaline oint- 
ment, M. Lemery succeeded in curing eight patients out of fourteen, 
in from five weeks to three months." 

Dr. A. T. Thomson {Commentaries on Diseases of the Skin), Wilson 
states that he has found no combination of mercury equal to that with 
iodine, in the treatment of lepra. " The biniodide, in doses of a 
sixth to a fourth of a grain, seems to exert almost a specific influence 
upon the morbid state of the skin ; and when given at the same time 
as the iodide of arsenic, and aided by blood-letting, it has rarely failed 
in rapidly and permanently curing the most inveterate cases* of the 
disease. As the acrimony of the preparation has sometimes greatH 
disturbed the alimentary canal, I have usually combined it, either 
with opium or conium, and I have always carefully avoided pushing 
it to ptyalism. Candour obliges me to admit, that as I have usually 
prescribed the biniodide in conjunction with the iodide of arsenic, it 

1 De affectibus. Interp. Van der Linden, torn. 11, p. 182.— Prorrhet. t. 1 1, pp. 521 
et 522. 



•238 



SQUAMAE. 



talion in (lie Isagoge, which is ascribed to Galen. 1 The defini- 
tion of Paulus ^Egineta is more precise. 2 Subsequently, the title 

is difficult to say what share the mercurial had in the cures ; and, in 

is where idiosyncrasy prevented me from employing arsenicals in 
any form, 1 have "seen the beneficial properties of the biniodide very 
obviously displayed." 

The preparation of arsenic, which is preferred by Dr. Thomson, is 
the iodide in a dose at first of a tenth of a grain ; but in no instance 
to be increased beyond the third of a grain. Heat of the mouth and 
fauces, and anxiety at the praecordia with pain at the epigastrium or 
griping, will indicate a necessity for reducing the dose ; and if nausea, 
cough or salivation supervenes, it should be left off altogether. Iodide 
of arsenic is incompatible with cinchonia in any form. 

Donovan's solution, the triple' compound of iodine, arsenic and 
mercury, has been given with success in lepra, ptyriasis and psori- 
asis. The commonly prescribed dose of half a drachm, is larger 
than it will be prudent to begin with, in most cases. I prefer the 
dose of five drops, gradually increased to twenty, twice a day; 
in some cases even this latter cannot be reached without the patient 
suffering from nausea and gastric distress. Dr. Graves has, however, 
administered it to the extent of half a drachm four times a day, for 
two months with but two interruptions ; and Sir Henry Marsh carried 
it, in the case of a boy twelve years of age, to the extent of half an ounce 
daily, in divided doses, which only produced very small insalivation. 

Mr. Erichsen's remarks (Med. Gazette, 1843) on the employment of 
arsenic in squamous affections of the skin are so clear, and clinically 
valuable, that I have no hesitation in repeating them on the present 
occasion. 

" Useful, however, as arsenic may be in many diseases of the skin, 
it is in the treatment of the squamous affections, more particularly of 
long-standing cases of lepra and of inveterate psoriasis, that it is 
incontestably of the greatest service. For it is by no means rare to 
meet with cases of these diseases, which, obstinately resisting, perhaps 
for years, milder methods of treatment, will, in the course of a few 
weeks, yield to the judicious employment of the preparations of this 
metal, the utility of which in this class of affections is so fully esta- 
blished by most dermatologists, that it is almost needless to insist upon 
it. It was, indeed, the success that attended the employment of 
arsenic in the squamous diseases that first led to its introduction into 
practice as a most valuable remedy in other affections of the skin. 
But, notwithstanding its utility in this class of diseases (the squamous), 
it is not admissible in every stage of their progress, nor indeed is it 
required in the great majority of these cases ; far from it ; it is only in 
very extensive and obstinately rebellious forms of these complaints, or 
when the patient is suffering some very positive inconvenience from the 
disease, that we should be justified in administering it, and then only 
in the absence of those circumstances that have already been pointed 
out as contra-indicating the administration of arsenic in other affections. 

" With regard to the stage of lepra and psoriasis in which the pre- 
parations of this metal may be administered, it should be laid down 
as a rule that they should not be given until the disease had assumed 
a decidedly chronic, inactive character. So long, indeed, as there is 
any inflammatory redness, heat, or irritation about the patches, they 
should never, under any circumstances, be employed, as the stimulus 
of the arsenic would almost infallibly augment the severity of the 
disease ; besides, during the earlier periods of the complaint, we 
should probably be able to effect a cure by other and less heroic 
measures. It is only, then, in very long standing cases of an exten- 
sive and indolent squamous disease, in which all other means of 
treatment that are likely to benefit have been employed without 
success, that these remedies should be given. And even then, as 
Rayer justly remarks, as these diseases frequently exert no evident 
ill effects on the constitution, the inconvenience they occasion being 
but very trifling, it will be advisable to confine the treatment to a 
palliative one, unless the patient positively insist on some active 
measures being adopted, when we should not hesitate to have recourse 

1 Isagoge, p. 94. 

2 " Antf* per profunrlitatem corporum autem depascitur, orbiculatiori modo, et 
squamas piscium squarnis similes dimiuit." He even adds the characters which dis- 
tinguish it from psoriasis : " ^a autem magis in superficie hoeret et varie- figurata est" 
(lib. v. cap. 2, de lepra et psora). 



lepra was given to every disease of the skin, distinguished by a 
hideous and disgusting appearance, and particularly to the Greek 
elephantiasis. Willan was the first who restored to the term ils 
original meaning ; he has also given good figures, and a very accu- 
rate description of the disease which the word was originally used to 
designate. 3 Bateman has faithfully copied Willan's account of the 
disease in his Synopsis. Dr. Falconer 4 has inlcuded impetigo in his 
account of lepra. The remarks of Levacher Lafeutrie 5 appear to 
bear upon a complication of lepra with pellagra. Rcemer and Car- 
minati have published observations in favour of lizard and viper 
broths (§114). Gales, Clarke, and Willan quote several cases of 
lepra, cured by sulphur fumigations (§ 128). Carrere, Crichlon, 
Razon, and Bertrand-Lagresie have extolled the dulcamara (§202). 
Girdlestone, Willan, Bateman, Duffin, 6 and many others, have par- 
ticularly recommended arsenical preparations (§ 188). Various cases 
and observations have been published in different periodical works, 7 
and in the dissertations of Bonorden, and of Meckel. 8 Alibert has 
treated of lepra, in his large work, under the title of dartre squam- 
meuse orbiculee. 

Case CIX. — Lepra; blood-letting, baths and purgatives. D * * *, 
aged twenty-one, sprung of healthy parents, had laboured under lepra 
for two months, when he came to consult me on the 3d of May, 
1826. The disease had begun in the shape of small circular scaly 

to the employment of the arsenicals, due attention being paid to the 
temperament of the individual, and to the state of his digestive organs. 

" In the majority of cases of lepra or psoriasis, Fowler's solution 
will, I think, be found the most useful preparation of arsenic that we 
can employ. The liquor of the hydriodate of arsenic and mercury 
has been very successfully exhibited in cases of this description, as 
has also the iodide of arsenic, either alone, or, if the disease be of a 
syphilitic nature, in combination with the biniodide of mercury and 
extract of conium. Instances illustrative of the value of these prepa- 
rations have been adduced in a former part of this paper. The 
' Asiatic pills' were strongly recommended, and, according to Caze- 
nave and Schedel, employed by Biett with advantage, in cases of 
psoriasis inveterata : they are, however, open to the objection of 
being less manageable than the other preparations of arsenic. 

" When these remedies are about to exercise a beneficial influence 
in cases of lepra and psoriasis, it will be observed that an increased 
action appears to take place in the diseased cutis, which becomes 
red, inflamed, and irritable ; the scaly patches then appear to heal up, 
either from the centre or the circumference, according to the nature 
of the affection, whether it be lepra or psoriasis, and eventually fall 
off, leaving the subjacent skin red, smooth, shining, and covered by 
thin epidermic exfoliations, which may usually be readily cleared off 
by stimulating topical applications, such as the ointments of tar,' or of 
the nitrate or the biniodide of mercury ; after which nothing but a 
red stain will be left in the site of the squamous patch. And this 
will soon disappear if the remedies be persevered in, which they 
should always be, until this blotch is entirely and effectually removed; 
for, until this be accomplished, the disease will be very liable to 
return : indeed, it is from a want of due attention to this very import- 
ant circumstance, that the arsenical preparations have been so often 
accused of affecting merely temporary cures. We must not be content 
with removing the scales merely, which are secondary phenomena, 
but we must get rid of the primary lesion, that peculiar inflammatory 
or congested state of the blood-vessels of the cutis, which, by giving 
rise to an increased and morbid secretion of the epidermis, is the 
proximate cause of the scaly diseases." 

Mr. Plumbe states, that dulcamara has unfortunately failed in his 
hands, and Mr. Phillips' testimony is scarcely more favourable. 

3 On cutaneous disorders, 4to. Art. Lepra. 

4 An account of the lepra greecorum. (Memoirs of the Medic. Society of London, 
vol. iii-p. 369.) 

5 Observations d'une affection licheneuse de la peau tres frequente dans la cam- 
pagne de Milan. (Mem. de la soc. medic, d'emulation, annee vi. p. 282.) 

6 Duffin (L. W.). Of squamous disorders. (Edinb. Med. and Surg. Journal, 
January, 1826.) 

' Journal hebdomadaire, t. iv. p. 299 ; t. vii. p. 434 ; t. viii. p. 44.— Lancelte med., 
1831, t. v. p. 9, p. 42.— Lond. Med. Gazette, t. iii. p. 487 ; t. viii. p. 30. 

? Bonorden. De lepra squamosa. Halas, 1795. — Meckel. De lepra squamosa. 
Halas, 1795. 






LEPRA. 



239 



patches on the knee and elbow, and subsequently spread to other 
parts of the body. 

May 3d. — The patches on the knee, eleven in number, were gene- 
rally circular in shape, and from six to nine lines in diameter; their 
centres were depressed, covered with thick, hirsute squamae, and in- 
tersected with fine linear fissures ; their circumferences were in strong 
relief with the neighbouring skin. On the leg and thigh a number 
of squamous patches, circular like the former, but of smaller size, 
and with centres less depressed, and edges less raised, were con- 
spicuous ; these patches, in a word, bore the strongest resemblance 
to those of psoriasis guttata. Interspersed among the squamous 
patches, several small, solid elevations, the size of a millet-seed, 
were perceived, the summits of some of which were red ; those of 
others were covered with a small white scale, whilst others were 
transformed into squamous patches, so that the successive stages of 
the disease could be readily traced. On the upper extremities, the 
same gradations in the progress of the patches were conspicuous ; 
those first formed on the elbows being the largest. On the trunk, 
the patches were few in number, and only occurred on the lumbar 
region. The patches on the extremities were the seat of a very 
violent pruritus, when the heat of the surface happened to be in- 
creased by any accidental circumstance. In other respects, D * * * 
was in perfect health. I bled him from the arm to the extent of six 
ounces, and he took a tepid-bath every other day. The bleeding was 
followed by a great abatement of the pruritus ; and several of the most 
recently-formed patches became pale, and shrunk in appearance. The 
venesection was repeated after the lapse of a fortnight, and the baths 
were continued ; I afterwards recommended leeches to be several times 
applied in the vicinity of the patches that looked most inflamed. In 
this way I brought about a great diminution in the number and dimen- 
sions of the patches, which, for the most part, were now changed into 
true rings, the integument in their centre having become perfectly 
healthy. Several doses of purgative medicine were prescribed, as a 
final measure, at considerable intervals from each other, and the cure 
was complete after three months and a half of treatment. 

Case CX. — Lepra of the knees and elbows ; blisters and escharotics. 
F. B., aged twenty-eight, in other respects healthy, presented him- 
self at the Bureau Central with a number of well-characterized leprous 
patches on the olecranal regions of the right and left arms, as well as 
on both knees, a single one on the right foot, and two of small size on 
the cartilage of the right ear. The disease was of four months' standing, 
and the patches were scarcely at all inflamed. Within the space of 
eighteen days, six small flying blisters, the size of the patches upon 
the olecranal regions, were applied to their surface. The patches of 
the knee and ear were cauterized with the hydrochloric acid, and this 
measure had to be repeated many times on several of them. The 
acid acted so deeply that it left the mark of two circular cicatrices 
which still proclaim the forms and dimensions of the patches. 

Case CXI. — Lepra of the scalp ; white precipitate salve. J. V * * *, 
aged twenty-three, entered the La Charite Hospital on the 17th 
October, 1833. This young woman was fat and ruddy, and in gene- 
ral good health. In the course of the previous month of May, a 
number of solid elevations suddenly made their appearance on the 
scalp. These soon became covered with thin, dry scales, without 
causing pruritus or smarting. Suffering little inconvenience from this 
affection, the patient at first tried no means to get rid of it; more 
lately, however, she had made use of a tisan of saponaria, bathed the 
parts affected with salt and water, and applied a blister to her neck, 
but without deriving any benefit from the treatment. 

On entering the hospital, the surface of the scalp presented a great 
number of circular squamous patches varying from half an inch to an 
inch in diameter, distinctly circumscribed, and of a yellowish colour. 
These were covered by an agglomeration of small scales, which ap- 
peared to be attached to the scalp by one of their extremities, and to 
lie one over the other. The squamae did not adhere at all firmly, a 
little rubbing detached them readily ; the integument underthem was 
rosy and dry ; on several other places large papular-looking eleva- 
tions were perceived ; the hair had fallen off from some of the patches 
over others it was finer and thinner than on other parts of the head. 
On the integument in front of the left car, two patches occurred ; one 
of them, the size of a shilling, was covered around its circumference 



with fine dry white squamae, whilst its centre was without them, but 
dry, red, and discoloured. There was no discharge from any part of 
the affected skin. The patient complained from time to time of a 
slight degree of smarting in the affected parts. The whole of the 
rest of the body was free from all trace of any similar affection. The 
patient was directed to rub a drachm of the white precipitate oint- 
ment over the surface of the scalp daily, the hair having been pre- 
viously clipped short. By this means the squamae were all removed 
in the course of three or four days ; and those that were formed afresh 
were white and fine, and only apparent around the circumference of 
the patches. October 22d. — Four drops of the tincture of cantha- 
ricles were now prescribed in a mucilaginous mixture. 24th. — Head- 
ache, for which bleeding was deemed necessary ; five drops of the 
tinct. cantharid. 25th. — Symptoms of inflammation in the vein 
which had been opened ; twenty-five leeches, and a poultice to the 
part ; the arm to be twice put into a tepid bath. 26th. — The same 
number of leeches as before, applied to the bend of the arm, gave re- 
lief. The tinct. canthar. had been continued in doses of five drops 
daily, but the patient now complaining of pain and scalding in making 
water, the further use of the medicine was suspended. The lepra 
continued to advance nevertheless towards recovery. Squamae were 
now only formed here and there, and the colour of the patches was 
getting daily less and less vivid. A few tepid baths, and the renewed 
application of the white precipitate salve completed the cure, so that 
the patient left the hospital on the 10th of December, quite re- 
covered, (a) 

(a) Cases of lepra vulgaris — Sulphur vapour bath, bleeding, and 
Fowler's solution. 

" A lady, aged twenty-five, came to consult me in the beginning of 
April, 1832, on account of leprosy, under which she had laboured for the 
last seven years. When she applied to me, the disease was not con- 
fined to any particular region, but extended over the whole of the 
body, with the exception of the hands, feet, and face. The head 
had been shaved regularly once a fortnight during the last three years, 
for the convenience of making applications to the spots. The 
squamous patches, on the body and limbs, varied in size from that of 
a crown piece to that of a sixpence ; they were all of a very regular 
round shape, though some of them had run together indifferent places, 
and formed broad continuous patches. The edges of the several 
patches were of a more vivid red, and appeared more raised than 
their centres, which, for the most part, were covered with thin scales, 
constantly falling off, but as constantly reproduced. Several of the 
spots, however, were declining, and presented nearly the same pale 
colour as the skin at large ; the red raised edges which surrounded 
these, formed simple rings, enclosing patches of apparently healthy 
integument. Other spots again were on the increase, and appeared 
as small red elevations, covered with a thin shining scale of similar 
dimensions. The patient informed me that this process of decline in 
one part, and of increase in another, had been constantly going on 
for rather more than the last seven years. 

" The patient was otherwise in good health, complaining of nothing 
except a proneness to occasional headache. She had made trial of all 
the usual remedial means prescribed in cases of scaly leprosy without 
success, with the single exception of the sulphur fume baths ; and it 
was with the view of trying the effect of these that I was now con- 
sulted. 

" This patient began by taking three vapour baths, in order to free 
the surface in some degree from the thick covering of scales spread 
over it, and a few doses of aperient medicine as preparatory measures. 
The sulphur fume baths were only commenced on the 17th of April, 
one being taken every other day. But the disease was still in too 
active a state to be benefited by this treatment ; in a week, the patient 
was literally of a uniform and bright scarlet red colour, and very 
many new spots were brought out, to which her attention was directed. 
She therefore ceased to take the baths till the 30th, when she again 
commenced them. By this time, the general redness had disappeared, 
but the leprous spots were much in the same state as before. May 
10th. — The new spots had not maintained the character of the former 
ones, not having gone on gradually extending, and many of them 
having even receded entirely. The baths were now taken daily ; but 



240 



SQUAMA. 



PSORIASIS. 
Vocab. Dartre, Psoriasis, Scull, Itch [Dry Scaly Tetter, Arc.]. 

682. Psoriasis is a chronic inflammation of the skin, limited to a 
single region of the body, or occupying almost its entire surface, ap- 
pearing primarily under the form of solid elevations, which change 

up to the 20th of May, so little progress has been made in the cure, 
that I bled the patient to fourteen ounces. The blood was natural, 
but firm in texture. 

" 30th. — A great improvement had taken place since the bleeding, 
many of the spots having disappeared, and left red rings, some of 
which were broken through in different places, the skin in the gaps 
presenting its natural appearance. June 9th. — Improved, though not 
to so great an extent as during the interval up to last report. Few 
entire red patches remained, but the old rings had undergone little 
variation. To these, with a camel's hair pencil, the patient was 
directed to apply a little diluted aromatic vinegar every night, and she 
commenced taking four drops of the arsenical solution, morning and 
evening, in a cup of barley-water. 19th. — The patient began to com- 
plain of a troublesome itchiness of the skin, which very usually occurs 
in consequence of the excitement occasioned by the heat of the bath 
and the effects of the sulphur ; this, however, did not deter her from 
continuing the fumigation till the 24th, when the pruritus was so 
much increased, that they were discontinued for a few days. Having 
suffered from pains and uneasy sensations in the stomach and bowels 
also, the arsenical medicine, which had been increased to ten drops 
twice a day, was likewise left off for a time. 

" July 3d. — The patient, being now free from pain in the abdomen, 
and the pruritus of skin having subsided, resumed the fumigations, 
together with the medicine. At this date she was greatly better. 
13th. — The skin had become much darkened and hardened, from the 
effects of the sulphur. This state I knew to be the herald of the pro- 
cess of peeling or desquamation which always follows the continued 
use of the sulphur fume bath, and from which I anticipated the best 
effects in this case ; I therefore advised the sulphur bath to be dis- 
continued for six weeks ; and to facilitate the peeling of the skin, I 
recommended a few water baths, and now and then a vapour bath, 
to be taken, whilst the arsenical solution was steadily persevered in, 
so long as no unpleasant constitutional symptoms supervened. 

" I did not see this lady again until the end of September, when the 
whole of the leprous spots had disappeared, except two or three on 
the abdomen. To these she was advised to apply the aromatic 
vinegar as before, and still to await the result of the treatment, as 
desquamation of the cuticle had not yet come to an end. 

" This lady visited me again in the April of 1833, with a return of 
her complaint, but of very trifling extent, showing itself only on the 
body, and consisting in all of not more than a dozen spots. She was 
so much convinced that the bleeding had exerted a beneficial in- 
fluence in the treatment of the year before, that she had had herself 
bled before visiting me, with the intention of resuming the sulphur 
fume baths. Eighteen of these, on this occasion, removed every 
trace of the disease. 

" This lady informed me that she had gone on peeling during the 
greater part of the winter, and had lost all vestiges of her complaint, 
till, on the return of spring, when, as just stated, it showed a disposi- 
tion to recur. 

" Since this trifling attack the patient has remained quite well. On 
this latter occasion, no medicine whatever was taken. 

" Case 2.— Very nearly at the same time (April, 1832) as the last 
patient, a lady from Ireland consulted me on the same form of squa- 
mous disease— leprosy, and it was an odd coincidence, that this lady, 
on comparing notes with the one whose case has been just detailed, 
found that they had both been assailed with the disease about the 
same period, and were so similarly affected, that the account of the 
symptoms in the one proved to be a correct detail of those in the 
other. It is not very usual for lepra to appear on the hairy scalp, but 
this latter patient, like the former, was so attacked, and had been in 
the habit of having her head shaved for three or four years, every ten 



into squamous patches of different sizes, not depressed in the centre, 
and of which the edges are irregular and but slightly raised. 

683. Four principal varieties of psoriasis are reckoned; these are: 
1st. Psoriasis discreta (guttata, Willan). In this variety numbers of 
small, distinct elevations, and squamous patches, occur, from two to 
four lines in diameter, irregularly circumscribed, and of a form and 
appearance very analogous to that which results when the body is 
sprinkled with water and the fluid lies in large drops upon its sur- 
face; such, indeed, appears to have been the origin of the epithet 
employed by Willan, to distinguish this variety. 

Each of the squamous patches is announced by a small solid, red 
elevation, the size of a pin's head, the summit of which soon gets 
covered with a minute dry scale of a dull white colour. These 
patches are irregularly rounded, slightly prominent, especially to- 
wards their centre, and separated from each other by considerable 
intervals of healthy skin. When the patches are freed from their 
investing squamae, the corion appears red and irritable, and if the 

days, or once a fortnight, for the convenience of making applications 
of different kinds to it. The only difference in the cases was that this 
second patient was twenty-nine years of age, very prone to what she 
described as feverish heats, and to headaches, and was further of a 
very constipated habit. The numerous spots and patches were in all 
particulars alike in both patients, who were both of strong make, and 
in the enjoyment of fair average health. The first lady took the sul- 
phur fume bath fifty-one times, between the 17th of April and the 
13th of July, before the complaint disappeared, and she had a slight 
return of it the following year. The latter lady had forty-seven fumi- 
gations administered, between the 20th of April and the 23d of June, 
when it was judged unnecessary to continue them longer. After the 
process of peeling was completed, this lady found herself quite well, 
and has had no return of her malady up to the present time. 

" She was bled, and took medicines similar to those prescribed in 
the first case, with the addition of an aperient draught most mornings, 
when she first commenced the use of the fume bath ; aperient medi- 
cine, indeed, was required from time to time, throughout the whole 
course of the treatment. 

" The arsenical solution, given with the usual precautions, has long 
and justly held a high reputation in most countries, for its influence 
over lepra. I am anxious, from my own experience, to attest its 
beneficial powers in this disease. It is not improbable but that both 
of the cases detailed would have recovered under the use of the sul- 
phur fumes, without the addition of so powerful a medicine as arsenic ; 
and, indeed, I have known many cases that have been of short 
standing recover without any assistance from other means, even with- 
out the use of bleeding. But in cases of longer standing, I have 
reason to conclude that both of these adjuncts are advisable, and tend 
greatly to abridge and facilitate a cure. Leprous patients perspire 
readily and abundantly whilst in the fumigating bath ; in psoriasis, 
another scaly disease, I have found them to perspire less freely, and 
still less in general pityriasis, when the scales are much thinner, for 
the most part smaller, and much more continuous. 

" I have selected these two cases of lepra on account of their long 
standing, and because I think they tend to show the powerful reme- 
dial influence possessed by the sulphur fume bath, in this peculiar 
and generally intractable disease. These cases I also consider as 
fair specimens of the utility of conjoining internal medicines with the 
fumigatory method ; for although the latter has been upheld as ade- 
quate to cure lepra by itself, and I have known many instances of the 
fact, yet when we have a disease of an acknowledged rebellious cha- 
racter to contend with, it seems to me well to meet it with the Avhole 
of the corrective powers we possess." 1 — Green on Diseases of the 
Skin, pp. 152-3. 

1 Dr. Bardsley, in his "Hospital Facts," abstains from detail relative to the medi- 
cines given when putting to the test the efficacy of fumigations in the cutaneous dis- 
eases. 

Of the value of his preparatory treatment there can be no doubt, and although he 
speaks and his tables show so favourably in regard to the merits of the fumigatory 
method of treatment, I have reason either to doubt the excellence of the construction 
of the apparatus employed, or to judge unfavourably of the way in which the fumiga- 
tions were administered, from the results as shown in the tables. Dr. Bardsley's 
other statements relative to the fumigatory method deserve the particular considera- 
tion of the profession. 



PSORIASIS. 



241 



whole have been thus cleansed, the disease appears in the shape of 
rounded spots, from two to four lines across, slightly prominent and 
of a brownish-fed colour. These patches occasionally get well, like 
those of lepra, from the centre towards the circumference ; in this 
case the middle of the patches presents an accidental depression, and 
acquires a slightly yellow tint ; in proportion as the cure advances, these 
patches become transformed into segments or small arcs of circles, and 
after it is accomplished, the skin still presents small stains of a grayish 
brown, or yellowish cast, in those points that had been possessed by 
the eruption. 

Psoriasis discreta is seldom accompanied with much pruritus, even 
when the body is heated by exercise or any other accidental cause. 

The patches of this variety of psoriasis may be confined to the hairy- 
scalp, face, trunk, or extremities, or be disseminated over the whole 
of these regions, appearing either at once upon all of them, or upon 
each in succession. Almost always very irregularly disseminated, 
the patches appear crowded in one situation, and very thinly sown 
in another ; on the extremities they are always observed to be more 
numerous in the line of extension than in that of flexion. Psoriasis 
discreta makes its attacks most commonly in the spring and autumn, 
and occasionally disappears spontaneously during summer; it has 
been known to appear and disappear in this manner for several years 
in succession. In children it is more quickly evolved than among 
adults. 

2d. Psoriasis confluens {diffusa, Willan). Instead of being sepa- 
rate and distinct, it much more frequently happens that the primary 
papulae of psoriasis are evolved so close together that the squamous 
patches which succeed them meet and blend by their corresponding 
edges. As may be imagined, the patches in this instance are of very 
various sizes and forms. As in psoriasis discreta, each of the smaller 
patches which goes to the composition of the larger clusters, begins 
in the form of a solid papulardooking eminence, on the top of which 
a dry scale of a dull-white colour is soon formed. The patches in- 
crease in size, become confluent, and compose at length an irregular 
squamous surface, upon which, however, the original spots may often 
be distinguished. These large patches are sometimes irregularly- 
intersected by red lines, and here and there show angular portions of 
integument which are free from squama?. 

Psoriasis is more constantly confluent on the limbs than on the 
trunk ; and the patches characteristic of this form of the disease fre- 
quently disappear on one district at the same time that the eruption 
which gives rise to them makes its appearance on another. 

The arrangement of the eruption of psoriasis in small distinct circu- 
lar spots, or in broad confluent patches, is no evidence of diversity in 
the nature of the disease ; it is frequently seen in the shape of psoriasis 
discreta on the body, whilst it has the character of psoriasis confluens 
on the limbs. 

Patients labouring under confluent psoriasis of recent date, com- 
plain of a considerable degree of pain and pruritus in the affected 
parts, which is always increased by the warmth of bed, the vicinity 
of a fire, and any other cause that tends to stimulate, or raise the 
temperature of the surface. 

Psoriasis confluens of the forearms and legs is occasionally seen 
forming a kind of irregular band, and sometimes, but more rarely, a 
sort of case which includes the affected limb through its entire length. 
In this instance, instead of the usual micaceous squama? of psoriasis 
we occasionally only distinguish an agglomeration of minute furfu- 
raceous scales, the colour of which approaches that of the flour of 
mustard. When the squama?, in such cases, have been got rid of by 
baths, vapour douches, &c, the surface they covered appears smooth, 
shining, and highly inflamed. (a) 

(a) Psoriasis infantilis, a term applied by Willan to psoriasis diffusa, 
as it is seen in the infant, is thus described by Plumbe. 

" The psoriasis of infants is entitled to a separate consideration 
from the foregoing, on a very important account. There is no ques- 
tion that it has often been mistaken for the consequence of venereal 
taint on the part of the parents of the child who is the subject of it, 
and has been, therefore, the means of inflicting much injury and unde- 
served distress. Dr. Willan, after alluding to" one or two unimportant 
points, in which he states the venereal affection of the skin of infants 
61 



3d. Whether this squamous inflammation have appeared under the 
form of small distinct patches (psoriasis discreta), or of confluent 

to differ from that under consideration, advises ' practitioners not to 
be too hasty in judging from mere inspection, and never to decide till 
they are justified by collateral circumstances.' It is seen in infants 
from birth up to three years of age. 

" From a very minute and lengthened inquiry into the history of 
many cases of this disease, I am irresistibly led to the conclusion that 
it has no connection with any form of venereal disease, except indi- 
rectly, i. e., when syphilitic affection may have combined with other 
causes in reducing the strength of the mother, or otherwise depriving 
the child of healthy sustenance. A generally healthy performance of 
the different animal functions, which is often found compatible with 
constitutional syphilitic disease, is not seen in the cases of infants 
affected with psoriasis. It is found to occur, moreover, where the 
parents on neither side can be liable to suspicion. 

" Like the psoriasis and lepra of adults, it may continue long after 
its direct exciting cause has ceased to exist ; and when taking place 
on the skin of unhealthy and poorly nourished children, it frequently 
continues when a better constitutional condition has been produced. 
From this circumstance, and the unyielding nature of the disease, it 
has no doubt sometimes happened that the suspicion alluded to has 
arisen, where, at the commencement of the eruption, it would not 
have been entertained ; and the treatment which has been adopted 
under these circumstances has been improper and injurious. In an 
institution to which I have the honour of belonging, cases without 
number have come under my notice, where poverty of circumstances 
existed on the part of the parents in a most extreme degree, evidently 
operating as the cause of the disease, when from a change to better 
living, consequent on the parents obtaining employment, the disease 
has speedily disappeared. Many such cases have been considered 
and treated as venereal without benefit ; but, on the contrary, with 
aggravation of all the symptoms. 

" With respect to the class of society among which infants are chiefly 
affected with this disease, it may be safely asserted, that it is almost un- 
known among the rich or affluent, or even those whose circumstances 
bear them uniformly above the reach of want. It may sometimes 
occur from bad feeding or neglect, but it is generally the concomitant 
of poverty, and for the most part only seen in the cellars and confined 
apartments of the poor and unhappy, where privation of nourishing 
food and impurity of atmosphere unite their depressing powers. 

" When the disease first comes under our notice among the poor, it 
is characterized by red patches of inflammation on the cheeks, chin, 
forehead, nates, abdomen, &c. On the face some of the patches arc 
small and irregular, others large, and assuming somewhat of a circular 
form. Some are covered with a horny scale, which is glossy and 
smooth to the touch, but which in a few days cracks and exhibits 
fissures of greater or less length and depth. Some are occupied by 
portions of scales of morbid cuticle rapidly detaching themselves, 
while others are forming beneath, which take the same course. The 
eyes sometimes partake of the inflammation, and generally the mucous 
membrane of the nose becomes inflamed and thickened, leading to 
snuffling, difficulty of respiration, and some fluid discharge. 

" In the more aggravated cases, the bottoms of the fissures emit a 
bloody discharge, if situated in the neighbourhood of joints, but not 
otherwise ; and if no great emaciation may have existed at first, the 
irritation and pain belonging to the disease make it soon apparent, 
and it generally increases with rapidity till death takes place. 

" The most irritable and painful spot which the disease is found to 
occupy is about the nates or between the legs ; the perineum, labia?, 
scrotum, &c, also, are not unfrequently the seats of much abrasion 
and tenderness, apparently produced by the stimulating properties of 
the urine. 

" It seldom happens that if the excretions be examined, a very dis- 
ordered state of the alimentary canal with the secretions of the liver 
be not discovered, which may have been either concerned as an 
original cause, or impeding the restoration of health and strength. 
Hence small doses of the hydr. c. creta, with the occasional use of a 
brisker purgative, are necessary. Tepid bathing, to the extent of 
liberating all the hard scales which may have been formed, and allay- 



242 



SQUAMA. 



masses (psoriasis i , when it lias existed during many months, 

. especially when it can be traced to a hereditary 
taint, or attacks individuals of shattered constitution, the disease 
■ >rse and worse, the skin becomes hard, thickened, tense and 
inelastic, yielding uneasily to the motions of the limbs, and appearing 
to undergo a kind of hypertrophy ; the primary patches of the disease 
are no longer distinguishable, but the integument is covered with 
hard, dry, and thick white scales; numerous chaps of various depths 
soon follow, furrowing the surface in all directions, but especially in 
those of the natural folds of the skin (psoriasis inveterata Willan, agria 
of the ancient writers) ; and in those rare cases in which the trunk 
and extremities are involved in one common incrustation, the disease 
assumes a hideous appearance, and the surface of the body has been 
compared by some pathologists to the rugged bark of an aged tree. 
This circumstance has even led M. Alibert to designate this last and 
inveterate stage of the disease, under the name of dartre squammeuse 
lichenoide. The squamae at this stage frequently rise in strong relief 
from the skin, exceeding by from a quarter to half a line the level of 
the neighbouring healthy parts. They are also then produced in 
such abundance, that quantities may always be gathered from the 
beds, and shaken from the clothes of patients. These squama? are 
occasionally a full line in thickness. It is in the vicinity of the 
articulations, that chaps or cracks occur most commonly ; these get 
deeper and deeper, bleed when motion is attempted, and often pour 
out a glutinous fluid that dries up into linear incrustations. Further, 
the parts affected are frequently the seat of a burning pruritus, espe- 
cially during the night. To conclude, considerable superficial excoria- 
tions have been seen to form upon the. back, buttocks and lower 
limbs, when these parts were the seat of this disease, which caused 
the patients much and extreme suffering. 

4th. Under the title of psoriasis gyrata, Willan has described a 
squamous vermiform eruption, characterized by squamous bands, 
spirally twisted or arranged longitudinally, and traversed by nume- 
rous superficial lines, corresponding evidently to the natural folds or 
wrinkles of the skin. These bands, however disposed, are affected 
with a very slight f'urfuraceous desquamation. I have met with but 
two cases of this variety, in neither of which could I observe any 
thing like papulae, or round squamous patches, analogous to those of 
psoriasis discreta. This eruption is seldom attended with purritus, 
even when the temperature of the surface is increased by exercise or 
any other cause. 

684. Psoriasis may continue from a few months to several years ; 
it is always of long duration when the patches are numerous and it 
can be traced hereditarily. 

685. Independently of the remarkable varieties presented by this 
disease, which have now been described, it still offers several addi- 
tional peculiarities according to the regions of the body it attacks. 

1st. Psoriasis seldom appears primarily upon the hairy scalp. It 
there usually occurs in the distinct form ; the squamee are always 
yellower and more pulverulent then when they are produced from 
the trunk. The confluent form of the disease is still rarer here. I 
have, however, seen it covering almost the whole surface of the 
hairy scalp, and extending to the forehead, in a line parallel with that 
of the implantation of the hair, under the form of a prominent band, 
an inch in breadth, whose surface was covered with rough squama? of 
a dull white colour, and whose lower edge was red and much raised 
above the level of the healthy skin. The inflammation of psoriasis 
frequently attacks the bulbs of the hair, which is then detached from 
the points affected. 

2d. Psoriasis frequently attacks the face, at the same time that it 
appears on other regions of the body; the eruption, however, may be 
entirely confined to the countenance. The patches that characterize 
the disease in this situation are red and furfuraceous, and the squama? 
are usually very light and thin. The subcutaneous cellular tissue 
becomes tumefied when the disease is of long standing and has 
assumed the characters of the variety designated inveterata. On the 

— ■ — . » 

ing the general irritation of the skin ; frequent ablutions with warm 
water of the more irritable parts, change to a purer atmosphere, and 
more efficient nourishment, have been "in most cases adequate to the 
cure, when assisted by internal remedies of this nature." 



eyelids it is announced, as indeed it is everywhere else, by the forma- 
tion of papula 1 , which usually appear about the angles of the eyes; the 
eyelids soon become stiff, tense and chapped ; and in children the 
eruption is occasionally followed by the loss of the cilia; and hairs of 
the eyebrows. Several other scaly affections of the eyelids, as well 
as the disease which, following Willan, I formerly described under 
the name of psoriasis of the lips, now appear to me to belong to the 
group of pityriases, among which they will be found discussed. 

3d. Psoriasis of the trunk rarely occurs alone; the disease almost 
invariably affects the extremities at the same time. When inveterate, 
its squama? are commonly thinner and smaller than those observed in 
psoriasis of the extremities, especially when the knees and elbows are 
the parts affected. 

4th. Psoriasis of the scrotum is a rare disease ; when it does occur 
it generally becomes inveterate, and is attended with excessive pru- 
ritus, and most painful chaps. I have met with a case of psoriasis 
discreta, in which the patches were disposed in a line parallel with 
the raphe. The circular spots of psoriasis discreta occurring on the 
scrotum and verge of the anus in children, have been known to be 
mistaken for syphilitic tubercles, from which they differ in their mode 
of formation, which is that of squamous papula?, in the more deci- 
dedly scaly look of their surface, and generally by the almost uniform 
existence at the same time of scaly patches upon the belly and thighs. 

5th. Psoriasis of the prepuce is also of very rare occurrence, almost 
always becomes inveterate, and is attended with thickening of the skin, 
and painful and bleeding chaps, which are occasionally accompanied 
by some degree of swelling in the lymphatic glands of the groin. This 
form of psoriasis, usually very obstinate among adults, has occasionally 
required the operation for phymosis for its removal. It is of great con- 
sequence not to confound the squamous patches by which psoriasis of 
the prepuce begins with a syphilitic eruption occurring on the same part. 

686. I have, lastly, to make particular mention of three varieties of 
psoriasis of the hands : 

1st. Psoriasis palmaris may be distinct or confluent ; in either case 
the disease begins with broader elevations than those of the other 
varieties: they are reddish in colour and the seat of a considerable 
degree of heat and itchiness ; pressed upon strongly, or pinched, they 
become painful ; and if rather numerous, the patient is compelled to 
give up every kind of manual labour. In the confluent species, the 
palm of the hand swells generally, and becomes of a uniform violet- 
red colour. The feeling of heat which was complained of at first, 
becomes gradually less distressing, and ceases at length, in a great 
measure, whilst the painful pruritus that accompanied it, becomes 
much less troublesome ; during this time the cuticle that surrounds 
the elevations grows considerably thicker, acquires a yellowish colour 
like the skin of the heel, dries up and becomes friable, and at last of 
a dead white on the summits of the patches. At this period, the 
altered and cracked epidermis covering the elevations is detached, 
either spontaneously or by the nails of the patient, and leaves a new 
epidermis through which the corion shines. The epidermis in the 
vicinity of the diseased parts also undergoes modifications: it becomes 
considerably thicker than usual, and of a dirty yellow hue; it dries 
and looks mealy on the surface, and finally exfoliates irregularly, at 
first in the neighbourhood of the older patches, and then in that of 
the joints and natural folds of the skin of the hand. The desqua- 
mation in this case is always irregular, and is very different in ap- 
pearance from that which happens in the variety next to be described 
— the psoriasis palmaris centrifuga: like it, however, and perhaps 
even more constantly, it is attended with linear fissures, which pene- 
trate to the quick in the course of the lines of the palm, and with a 
still greater number of clefts that extend less deeply, and do not even 
reach the corion. 

2d. Psoriasis palmaris centrifuga. This variety begins in the palm 
of the hand by a solid elevation whose summit is covered with a small 
white and dry epidermic scale ; this spot is then surrounded by a red- 
dish ring upon which the epidermis dries and is thrown off circularly. 
Around this first circle a second is before long formed, upon which a 
similar process of desquamation takes place, and these circles may 
appear one after the other, becoming more and more eccentric, until 
the whole palm of the hand is implicated, and squamous patches even 
appear on the palmar aspects of the fingers. The diseased parts are 



PSORIASIS. 



243 



affected with a very troublesome pruritus, which is increased whenever 
the hand is exposed to any elevation of temperature, or even when 
the fingers are moved for any length of time. When patients yield 
to the impulse to scratch the parts affected, the skin assumes a violet- 
hue, and at a later stage presents numerous cracks that pursue the 
course of the lines habitually observed in the palm. The surfaces 
between two of these crevices are covered with very hard and thick 
squamae, and the whole palm is stiff and dry. This form of psoriasis 
has been principally observed among washerwomen and others, whose 
hands are habitually exposed to the contact of alkaline leys, or among 
coppersmiths, silversmiths and tinsmiths, the palms of whose bands are 
irritated by repeated pressure, combined with the contact of different 
metallic substances. Psoriasis palmaris usually grows worse in winter, 
and often gets well in summer. After recovery, the skin remains for 
some time smooth and of a dusky-red colour. It seldom happens that 
the disease does not recur several times after getting well, when those 
affected do not give up the craft they may be exercising at the time, 
and which has been recognized as its occasional cause at least. 

3d. There is a variety of psoriasis diffusa which is developed on the 
backs of the hands and is known under the name of grocer's itch, 
because frequently seen among persons exercising this trade, although 
it also attacks bakers, laundresses, and even individuals of the better 
classes of society. The eruption begins in the shape of two or three 
squamous elevations, which spread to such a degree as at length to 
cover the whole dorsum of the hand. The integuments are. before 
long seamed with numbers of dry and painful chaps; these occur 
especially over the wrist joint and the articulations between the meta- 
carpal bones and first phalanges of the fingers. This variety of 
psoriasis is distinguished from the confluent and chronic lichen of the 
backs of the hands by the circumstance of the latter being always 
preceded by a considerable eruption of small papulae. It is also im- 
portant to distinguish this true psoriasis from the squamous inflam- 
mations artificially excited, to which individuals exercising certain 
callings are subject. When one of these varieties, or any other form 
of psoriasis extends to the whole back of the hand, the matrix of the 
nails is occasionally attacked with chronic inflammation, in which 
case the nails themselves become thickened, bent, cracked and at 
length detached ; they are in due time succeeded by others, but these 
are liable to be affected in the same way. Psoriasis plantaris is a 
rarer disease than psoriasis palmaris, and less uniformly attended with 
chapping of the skin. 

4th. With regard to psoriasis of the inferior extremities I have only 
to remark, that the disease is very apt to become inveterate. The legs 
then appear furnished with a general adventitious squamous envelop, 
which does, indeed, bear some resemblance to the lichenous covering 
of trees with which it has been compared. 

687. Psoriasis rarely appears complicated with other inflammatory 
affections of the skin, if we except lepra. It has, however, been seen 
especially among children, occurring with characters of the greatest 
inveteracy along with eczema impetiginodes. Amidst the thin squama? 
that cover the diseased patches, vesicles and particularly purulent 
points are then perceived. At a later period, these surfaces may 
become excoriated, and form thin, lamellar, yellowish-coloured scabs 
like those of the eczema. It occasionally happens, especially when 
children are attacked with the disease during the period of teething, 
that, on the first invasion, or during the course of psoriasis, a certain 
degree of derangement is apparent in the functions of the digestive 
organs. It was this circumstance, undoubtedly, that led Willan and 
Bateman to speak of epigastric pains, lassitude, headache and various 
other symptoms as precursors of psoriasis, which ate, in fact, rarely 
observed in connection with the disease unless when developed under 
the circumstances indicated. 

688. Causes. — Next to eczema and lichen, psoriasis is one of the 
most common of the chronic affections of the skin. Of all the variety 
of forms assumed by the disease, that which I have designated psoriasis 
discreta is the most common ; in a given number of cases this will be 
found in the proportion of three-fifths to the whole. Psoriasis shows 
itself principally among adults, between the ages of twenty-five and 
thirty years ; women of a nervous and sanguine temperament are 
particularly obnoxious to its attacks. Of all the chronic and non- 
contagious affections of the skin, psoriasis is that the hereditary nature 



of which is most satisfactorily ascertained. The seasons have a very 
marked influence on the production of this disease ; it is usually 
developed in the beginning of the spring or autumn. The influence 
of different trades or professions appears limited to a few local varieties. 
To conclude, irritation of every kind, direct or indirect, applied to 
the skin, may prove the occasional cause of psoriasis ; the disease has, 
in fact, been seen succeeding repeated attacks of lichen, prurigo, 
different other diseases of the skin, and the application of a common 
blister. 

689. Diagnosis. — Psoriasis can only be confounded with three dis- 
eases, which like it affect the squamous form, namely lepra, pityriasis 
and scaly syphilis. There exists, indeed, between lepra and psoriasis 
a very great similarity. The resemblance of psoriasis discreta to lepra 
is more particularly striking. Both of these affections of the skin 
commence as solid papular-looking elevations, both soon assume the 
shape of circular scaly patches, and these in the same patient fre- 
quently present the appearances characteristic of psoriasis discreta on 
the trunk, and those distinctive of lepra on the knees and elbows. 

Some recent writers have consequently maintained that lepra and 
psoriasis w r ere nothing more than two varieties of the same disease. 
There are, however, certain characters which distinguish these two 
eruptions, or, if it must be so, these two degrees of the same form of 
inflammation, from each other. The patches of psoriasis discreta, for 
instance, are never so broad as those of lepra, neither are their edges 
raised, nor their centres depressed like those of the latter ; in psoriasis, 
too, the squama? adhere more firmly and are less abundantly produced 
than those of lepra. The differences between lepra and psoriasis 
diffusa are still more marked. The patches of the latter are irregular 
and not depressed in their centres, those of the former are exactly 
circular, and even when several leprous spots are blended together, 
their originally circular shapes continue to be proclaimed by the arcs 
of circles presented on their circumference. 

Psoriasis is distinguished from syphilitic scaly patches (psoriasis 
syphilitica, Willan), by the coppery or livid hue of the latter, which 
is deeper towards their centre than their circumference ; they are also 
without true squama?, being covered by a transparent epidermic layer, 
which is usually detached circularly, exposing a smooth and shining 
surface of a coppery-yellow, bounded by an epidermic edge. Syphi- 
litic blotches, further, are not accompanied with any pruritus, and 
are generally complicated with evident venereal affections of the 
pharynx or conjunctiva, with nodes, nocturnal pains, &c, and get 
speedily w r ell under the influence of mercurial medicines carefully 
administered. Lastly, these blotches disappear from the circumfer- 
ence towards their centre, a character which of itself distinguishes 
them sufficiently from the squamous patches of lepra and some of the 
varieties of psoriasis. 

Psoriasis discreta of the hairy-scalp differs from pityriasis of the 
same part, by appearing under the form of patches which, beneath the 
squama?, always present a red central point that rises above the level of 
the skin generally. 

690. The varieties of psoriasis designated by Willan diffusa and 
inveterata commonly prove very obstinate diseases, more so even than 
lepra. Psoriasis discreta vel guttata, in a general way, is less rebel- 
lious than the confluens vel diffusa, which in its turn is less intractable 
than the inveterata; this last variety, indeed, is often absolutely 
incurable. When psoriasis discreta begins to get well, the amend- 
ment is announced by the sinking of the patches, and takes place at 
first in one or several points of a particular district, from which it 
spreads to the other regions affected. When the varieties diffusa and 
inveterata end in recovery, the chaps of the skin disappear, the 
inflammation of the corion diminishes gradually, the altered epidermis 
is replaced by one of less thickness, less dry and inclined to crack, 
and after many successive desquamations, the dermis in the points 
affected becomes covered with a cuticle similar to that of the healthy 
integument. 

691. Treatment. — The medical treatment and dietetic plan pur- 
sued in psoriasis ought to be based on the same principles as those 
that guide us in lepra ; the curative means only require to be modified 
according to the more or less highly inflamed condition of the integu- 
ments. When psoriasis discreta is recent, and an adult is its subject, 
the disease must be attacked by one or two venesections. I am in 



244 



SQUAMJE. 



cssion of a sufficient number of facts to show that this measure is 
ble, and the same conclusion has. been come to by 
many other practitioners. Plain baths, or better still, narcotic and 
emollient temperate baths, which lessen the irritation of the skin and 
the pruritus with which it is constantly accompanied, are to be em- 
ployed at the same time and subsequently. The douche and vapour- 
hath are also frequently found of service in the cases of adults. By 
using these alternately with sulphureous-water baths, confluent pso- 
riasis, accompanied with no great degree of inflammation, are fre- 
quently got rid of in the course of three or four months. When 
confluent psoriasis is of old standing, a modification of the skin may 
often be advantageously attained by anointing it with an ointment 
of the tartrate of antimony ; the same practice has even been found 
serviceable in some cases of the inveterate disease, although in these 
the alteration of the skin is so deep that" the affection is generally 
incurable, at least among the aged. Inveterate psoriasis is always 
improved by the use of the emollient and narcotic bath, as well as of 
the vapour-hath and douche. Among the aged, attacked with in- 
veterate psoriasis, whose skin is thickened and indurated in different 
parts of the body, the treatment must be limited to such palliative 
measures. The same plan also appears to me better than any other 
when the subject of the disease is a member of the labouring class of 
the community, who would certainly have a relapse as soon as he 
was thrown upon his old occupations and habits. Such patients, 
labouring under inveterate psoriasis, have been seen, who derived 
no benefit whatever from taking the vapour-douche and bath more 
than one hundred and fifty times, or having undergone the most 
energetic internal treatment, from which, indeed, unpleasant symp- 
toms of different degrees of severity resulted. 

In the treatment of psoriasis diffusa and discreta the exhibition 
every day for some months, of half an ounce of Epsom salts, or two 
drachms of subcarbonate of potash, or a few grains of calomel in 
combination with the resin of jalap, so as to procure several alvine 
evacuations, has been favourably recommended, patients at the same 
time making use of the tepid-bath ; the purgative medicine, however, 
is immediately to be suspended should unequivocal symptoms of 
gastro-intestinal disturbance at any time make their appearance. 
This plan seems more particularly available in psoriasis of the face 
and hairy scalp. 

The deuto-chloride of mercury, in the dose of one-fourth of a grain, 
and the sulphurated sulphite of soda in the quantity of a scruple, 
daily, have also appeared to accomplish some cures of psoriasis. 
The tincture of cantharides is another medicine which has been tried 
in the different species of psoriasis, particularly the inveterata, with 
some success ; the dose has been carried gradually from five to sixty 
drops every day, when no appreciable disturbance in the digestive, 
respiratory or urinary organs supervened. The medicine is often 
continued for three or four months before any favourable change 
takes place in the state of the skin. One or other of the common 
arsenical solutions has also been strongly recommended in this obsti- 
nate form of disease. Arsenic of course requires great care in its 
exhibition ; its effects must be closely watched, and it is advisable to 
give up its use for a few days every now and then. It is undeniable 
that by means of these active medicines several of the varieties of 
psoriasis, even the most inveterate, have been cured ; but it is no 
less certain that the majority of the cures thus accomplished have 
been but temporary, relapses having occurred the following spring or 
autumn ; that such relapses are more especially frequent among the 
labouring classes of the community, and lastly, that the greater number 
of cases of psoriasis inveterata treated by such means have been in 
nowise amended, although the medicines were continued for five or 
six months. I am therefore of opinion that it is in general inexpe- 
dient to put patients affected with psoriasis inveterata upon an arsenical 
course, in the faint hope of deriving a mere temporary improvement, 
with the fear before our eyes of inducing some obstinate derangement 
of the digestive organs, or of permanently injuring the general con- 
stitution. (a) 



(a) I shall, in a subsequent page, introduce cases to show the efficacy 
of the arsenical treatment, but it must be conceded that there are 
good grounds for the author's cautionary remarks on this point. The 



In a word, then, psoriasis discreta and diffusa can be successfully 
attacked by measures less dangerous than those just mentioned, by 
the vapour bath, ointment of white precipitate, &c, &c. ; and to me 
a palliative plan of treatment appears the only one available in cases 
of inveterate psoriasis, especially when its subjects are individuals 
belonging to the labouring classes of society. 

692. The local varieties of psoriasis offer the same curative indica- 
tions as the general disease. Fomentations, baths, cataplasms, emol- 
lient and narcotic unguents are all useful when the skin is red and 
painful. In psoriasis palmaris simple baths and fomentations, the 
vapour douche, and calomel ointment are habitually employed. 
When the disease has arisen from, or seems to be kept up by any 
evident outward cause, the first indication of course is to make this 
unavailing. 

Historical Notices and particular Cases. 

693. The Greek physicians, under the title of psora, evidently in- 
dicated two different diseases. That which they designated ^ a l\xoit ( 
or ulcerous psora, appears to correspond with the pustular inflamma- 
tion described in this work under the name of impetigo ; the other, 
which they entitled simply psora or leprous psora (4wf<x u^oSti) was 
probably the squamous disease we have just been engaged in de- 
scribing. Galen 1 makes use of the word psoriasis to signify a squa- 
mous state of the eyelids and scrotum ; but his description appears 
equally applicable to pityriasis, lichen, and other diseases affecting 
these parts as to the malady now denominated psoriasis. Neverthe- 
less it is on the strength of this passage that Willan has felt himself 
authorized to collect,"under the common title of psoriasis, every non- 
contagious squamous inflammation different from lepra and pityriasis. 
The word psora does not occur in the writings of Celsus ; this author, 
however, has clearly pointed out the characters of the leprous psora 
of the Greeks, or psoriasis, in his definition of the second species of 
impetigo. 2 Willan conceives that the Arabian writers refer to pso- 
riasis under the name of usagero, a word which is rendered by the 
Latin translators serpedo or serpigo and impetigo. 3 Psoriasis was sub- 
sequently mentioned rather than described by Mercuriali, Hafenreffer, 
Plater, and others under the name of psora and scabies sicca, titles also 
given to lichen. The disease was spoken of by Manardus,Fernelius, 
Sennertus, Willis, &c, under the title of impetigo. The following 
passage of Sennertus appears peculiarly applicable to psoriasis diffusa : 
" cognoscitur morbus quod cutis dura, sicca, aspera et quasi squa- 
mosa redditur ; adest pruritus ; et malum in dies latius sepit, et ab 
initio exiguo sese late diffundit." 4 Several English writers might be 
referred to who have described psoriasis under the names of scaly 
tetter and dry scall. Willan was the first who gave a full and accu- 

following case, related by Mr. Erichsen, {Med. Gaz., 1843), conveys 
wholesome admonition. 

" In illustration of the bad effects that may result from the injudi- 
cious use of the preparations of arsenic, I may mention that I have at 
present under my observation a young lady, of a highly nervous tem- 
perament, but otherwise perfectly healthy, and without any hereditary 
disposition to disease, who, whilst suffering from an attack of psoriasis 
of the legs some years ago, was advised to take Fowler's solution, 
which she did in the hope of speedily getting rid of, to a delicate 
female, a disgusting affection, to such an extent, without the know- 
ledge, however, of the medical attendants, that she brought on exten- 
sive derangement of the stomach, which was followed by a violent 
neuralgic attack, together with, at a subsequent period, a distressing 
train of hysterical symptoms, which have terminated in a state of 
dementia, that, having now existed for nearly four years, may almost 
be looked upon as incurable." 

1 Galeni Opera. De oculo, cap. 7, def. med. 

2 "Alierum genus pejus est, simile papulce fere, sed asperius rubicundiusqoe 
figuras varias habens ; squarnulae ex summa cute decidunt," &c. — (Celsus, de medi- 
cina, lib. v. sect, xxviii.) 

3 Serpedo est asperitas quas in superficie accidit cutis et ad nigredinem declinat, 
aliquando ad ruborem. Petiginis autem chronica? etdiuturnac in qua non excorialur 
cutis, signa sunt, quod in profunda est membri, et squamulaa ab ea tolluniur rotunda; 
quales piscium vidernus squamas. — (Haly Abbas. Theor. lib. viii. cap. 16.) 

* Sennert. Med. Pract., t. i. 3o de impetigine. 



PSORIASIS. 



245 



rate account of the disease under the title adopted in this place. 
Bateman and Gomez have followed him without modification in their 
several works. The still more recent observations of Mr. Plumbe 
tend to show the identity of psoriasis and lepra, and those of Dr. 
Duffin go more particularly to prove the inflammatory nature of these 
two diseases. Some French pathologists have referred to psoriasis 
vaguely under the name of dartre seche. Alibert has described the 
disease in its severest form (the psoriasis inveterate.) under the title of 
dartre squammeuse lichenoide, and has given several cases of the 
varieties discreta and diffusa under the common name of dartre fur- 
furacee. 

Some observers, in opposition to the opinion generally entertained, 
believe that psoriasis may sometimes be transmitted by contagion, 1 
but the facts quoted in support of this opinion are any thing but con- 
clusive. 

Cases of the different varieties of this disease, and remarks on their 
treatment, occur in many of our periodicals. 2 

Case CXII. — Psoriasis discreta of the axillce; the gelatino- sulphu- 
reous douche. Madame D * * * was attacked in the beginning of 
March, 1826, with psoriasis guttata of the axilla?, a disease from 
which she had already suffered much two years previously, and 
which had only yielded to the long-continued use of sulphureous 
baths and purgatives. When I was consulted, there existed under 
the right axillae three oval patches of considerable size, and two or 
three small elevations as large as millet-seeds. The patches were 
red, not scaly; their edges were not raised, nor their centre depressed 
like those of lepra; they had nothing of a coppery nor livid tint like 
syphilitic blotches. They were further very itchy, and the patient 
scratched them when asleep or only half awake, by which the pru- 
ritus was subsequently greatly increased, and the patches next day 
made to look more highly inflamed. The pressure of the corsets 
also irritated them during the day; they had never discharged. In 
the left axillae there were five patches of a similar description, two 
others situated on the olecranon were covered with white squama? of 
considerable thickness. I recommended the sulphureous bath and 
douche from a watering pot at the temperature of 28° Reaum. Twenty 
baths for a quarter of an hour, and fifteen douches continued for ten 
minutes each time, restored this lady to perfect health. 

Case CXIII. — Psoriasis discreta of the scalp ; blood-letting and pur- 
gatives. Alphonse * * * was affected two years ago with a dry scall 
of the eyebrows, which got well by being anointed with grease and 
washed frequently with Eau de Cologne. Within the last year a simi- 
lar disease had made its appearance on the scalp, and durinp - the last 
three months had spread rapidly. March 20th, 1826. — The right 
frontal region, the ears and the scalp are exclusively affected with 
psoriasis discreta, four patches of which, covered with squama?, not 
prominent, and of the form and size of a shilling, exist on the right 
side of the forehead. The squamae are pulverulent, and have a slight 
yellowish tint ; the skin under them is red, and the margins of the 
patches blend with the healthy integuments. There are also a few 
patches on the concha of the ear, and a great many more of a small 
size, circular shape, and covered with minute furfuraceous and yel- 
lowish-coloured squamae, are discovered on the surface of the hairy 
scalp, more particularly on the right side near the angle of junction 
between the frontal and temporal bones. Many of these patches are 
confluent, and not very regularly circular. They are only affected 
with pruritus when the head is accidentally heated, and have not 
caused the loss of the hair. The rest of the body is unaffected with 
any similar patches, but a few solid elevations, already squamous on 
the summits, are visible on the arms. The whole of the principal 
functions are performed with regularity. (V. S. ad Vjxii ; an ounce of 
Epsom salts, with intervals of two days, repeated sixteen times ; lotions 
with water nearly cold, night and morning.) The cure was complete 
towards the end of May, 1826. 

Case CXIV. — Psoriasis discreta of the limbs ; diffusa of the trunk. 

' Gazette Medic, 1832, p. 110.-- -Bull, ties sc. med. de Ferussac, t. xvii. p. 44. 

1 Journ. Hebd., premiere serie, p. 258 (psor. inveterata cured by the solut. of Fow- 
ler).— Jonm. Hebd., t. iv. pp. 74-77; t. vii. p. 432; t. viii. p. 108.— Revue medic. Juin, 
1830, p. 341 (employment of the chloruret of sulphur). — Lond. Med. Gazette (employ- 
ment of nitrate of silver).— Lancette Francaise, t. v. p. 42.— Journ. des hopitau.x, p. 
349.— Journ. complem. des sc. mod., t. xxxix. p. 45; t. xliii. p. 71.— Lond. Med. Gaz., 
v. xi. p. 278. 

62 



J. D. le T * * *, seven years of age, was attacked with psoriasis in 
the month of June, 1826. A number of small elevations appeared 
on the arms and hands, but soon vanished again. Towards the end 
of August, of the same year, several of the papular elevations of pso- 
riasis appeared on different regions of the body. (Baths, anti-scor- 
butic syrup.) This child was brought to me on the 4th of September, 
1826. Two very broad squamous patches exist on the back of the 
trunk; one superiorly, between the shoulders, is entirely covered with 
squama? ; the second, inferiorly, and stretching almost completely 
across the lumbar region, is less thickly beset with squama?, and pre- 
sents indications, here and there, of healthy skin. On the shoulders 
and back of the neck, a few smaller patches also occurred ; these 
were from three lines to half an inch in diameter, prominent, and 
covered in the centre with partially detached epidermic lamella?. 
Under these squama? the skin was dry, and presented a red colour 
which disappeared with pressure. Near the large lumbar patch 
several smaller ones were observed. The anterior part of the chest 
was almost entirely occupied with large squamous patches, between 
which appeared numbers of small islets of healthy skin. These 
patches, like the rest, were covered with dry, epidermic lamina?, 
rough to the touch ; the corion beneath which was also of a red 
colour, which disappeared on pressure. A considerable number of 
patches of psoriasis discreta existed on the surface of the abdomen, 
divided by a broad but irregular squamous band which extended 
from the ensiform cartilage to the pubes. On the limbs various 
patches, of different sizes, and sundry papular-looking solid eleva- 
tions, one or two lines in diameter, and slightly prominent, were 
distinguished. The patches were circular, red at their base, and 
covered on their summits with minute squama?, which were not long 
of being detached. After their fall, the epidermis occasionally formed 
a little circle of a dull white colour around the place they had occu- 
pied, in the centre of which a red and prominent point was perceived. 
Various other compound patches, of very irregular shapes, were formed 
by the union of two or more of the papula? or squamous rounds. 
Lastly, a few small patches, not more than from five to six lines in diame- 
ter, of a circular shape, and covered over with minute squama?, of a 
white colour, and adherent or easily detached, were observed. Upon 
the face, and especially the forehead and parts about the outer ends of 
the eyebrows, there were a number of the papular elevations and squamae 
of psoriasis discreta. (Eight leeches to the band of healthy skin, between 
the two dorsal patches, emollient and narcotic temperate baths ; the dilu- 
ted sulphuric acid.) On the 14th of September the good effects of the 
treatment prescribed were apparent in the cessation of an adventitious 
sero-purulent secretion which was going on from several of the patches, 
and by a slight degree of sinking in several of them. (Leeches and 
baths as before.) On the 21st the acid was renewed, and four leeches 
were applied under the ears, and seven to the region of the navel ; 
the cutaneous inflammation was yielding gradually. 20th. — The skin 
is now in a great measure free from squama?, and appears stained 
here and there of a reddish brown ; no new squamous elevations 
were formed. (Temperate narcotic bath; three drachms of Epsom 
salts in the morning ; fasting every other day.) October 8th. — There 
are now no visible traces of the squamous inflammation ; the skin, 
however, still presents some reddish stains, on the surface of which 
the epithelium is smooth and shining. 

Case CXX. — Psoriasis discreta. Lepra. A young washerwoman, 
aged eighteen, was attacked without assignable cause with psoriasis 
discreta, in the beginning of the year 1826. The disease first ap- 
peared on the elbow and anterior aspect of the right forearm, next 
upon the opposite arm, and lastly on both of the inferior extremities and 
trunk. May 10th, 1826. — At this time there were observed upon the 
skin, 1st. A number of solid elevations, the size of millet seeds, red 
at their base, and covered on their summit with a minute scale of a 
dull white colour: 2d. Several papula? which have been torn with 
the nails, and are covered with little brown-coloured scabs, the size 
of pins' heads, and exactly similar to those of prurigo : 3d. Various 
patches from three to four lines in diameter, flattened and red, and 
dry on the surface, which is covered with minute squama?. When 
the squama? are detached, the patches present a red-coloured central 
point similar to that they exhibited at their origin ; the tint of this 
point in some of them is so deep that it approaches a violet. Other 



246 



SQUAMiE. 



patches are of much burger dimensions than those, and are of an irre- 
gular round or oral form; their edges, raised above the level of the 
surrounding integuments, are of a very deep red; the tint gradually 
diminishes in intensity from the circumference of the different patches, 
towards the centre, winch looks slightly depressed, and of a rose colour, 
so that these patches resemble in every respect those of lepra. Several 
patches of a still larger size are extremely irregular in their outline, and 
evidently formed by the fusion of two or more into one. On the surface 
of these compound patches, a great many superficial furrows, similar 
to, hut more conspicuous than, those naturally presented by the epi- 
dermis, are observed. The squama; are very small, and very thin. 
The integument in the intervals between the patches is of singular 
whiteness and delicacy. The inflamed parts are affected with a pru- 
ritus, and sense of heat, of considerable intensity, which are always 
increased after meals, and during the night. The whole of the inter- 
nal organs, particularly those of the digestive functions, appear to be 
perfectly healthy; the catamenia are regular, (V. S. B. ad 3xii. Two 
drachms of sidph. soda; in veal broth ; plain bath every other day at 
27° R.) May 18th. — The patches are less inflamed; the aperient 
does not distress the patient, and is ordered to be continued. 26th. — 
The papular elevations are much fallen ; several of the squamous 
patches have vanished entirely, and others present two very remark- 
able appearances, being here reduced to complete rings, within which 
the skin looks healthy though somewhat sallow, there, to mere arcs 
of circles. The same plan of treatment was continued, and the cure 
was accomplished within six weeks. 

Case CXVI. — Psoriasis palmaris; blisters. A. B., aged forty-two, 
labouring under palmar psoriasis confined to the right hand. Various 
measures which had been recommended, failed to do much good, 
probably, from not having been regularly employed. Two flying- 
blisters applied to the palm of the hand were followed by the detach- 
ment of the altered epidermis, and the formation of one that was 
smooth and permanent. 

Case CXVII. — Psoriasis discreta of the limbs, diffusa of the elbows : 
calomel ointment. — Fr. Chastel had been affected with psoriasis of the 
elbows, since the end of July, 1832. On the 14th of January, 1833, 
the disease had extended considerably along the dorsal aspect of the 
arms and forearms, these regions being occupied by two large patches, 
irregular in their outline, raised above the general level, furrowed by 
a great many linear chaps, and covered with squamae of a dull-white 
colour, which could be readily rubbed off with the finger, when the 
red and prominent corion beneath was exposed. Patches of a similar 
description occurred on the lumbar region. On the outer surface of 
the thigh and knee, and on both of the forearms, the disease presented 
itself in a simple form, the patches being small, isolated, circular, 
and covered with dry white squama?. The patient made no com- 
plaint of pruritus, or smarting, and the principal functions were regu- 
lar. He was put upon the decoction of dulcamara, ordered to rub in 
the calomel ointment, and to take the plain bath. By the 20th of 
January, the good effects of this treatment were already very appa- 
rent ; the squamae were, indeed, still reproduced, but they were not 
so copious, not so white, and the corion under them, which at first 
was very red and prominent, now presented a pale rose tint. Half a 
pound of ointment containing one ounce of calomel had been rubbed 
in, and no symptom of ptyalism was manifested. The same treat- 
ment was continued to the 1st of February, when the only appear- 
ances of disease remaining were a few papular-looking eminences 
as large as pins' heads. The ointment was now discontinued in 
order that the effects of the dulcamara might be the better studied. 
The decoction was prepared with two ounces of the herb to each pint 
of water. After the lapse of a week this medicine seemed to have 
done no good ; on the contrary, squama? began to be reproduced in 
several places. A recurrence to the calomel ointment speedily 
brought about a notable improvement, which by the end of the month 
was stdl more evident. The dulcamara was given up and a gum- 
lemonade substituted for it ; the plain water-bath was continued the 
whole time. The patient went on favourably; the skin, with the 
exception ot a very small patch on the elbow, being quite free from 
disease. The vapour-bath was ordered in lieu of the simple water- 
baths hitherto used ; and on the 10th of March the places mentioned 
were touched with the nitrate of silver. The eschars produced were 



detached on the 19th, leaving the skin they had covered smooth and 
of a vivid red; this tint soon disappeared, and on the 1st of April the 
integument had recovered its natural colour. The patient was dis- 
missed on the 8th of the month, well, having been forty-four days 
under treatment, during which time there had been expended in the 
way of inunction nearly five pounds of lard, containing ten ounces 
and six drachms of calomel, neither the salivary glands, the mucous 
membrane of the mouth, nor the gums having shown any symptom 
of irritation. 

Case CXVIII. — -General Psoriasis. Desquamation from the parts 
covered with hair. 1 — James Shooter, twenty-nine years of age, entered 
St. Bartholomew's Hospital on the 14th of July, 1828, affected wiih 
rheumatism of the joints and a cutaneous disease. The patient had 
been affected eighteen years previously with a red or scaly eruption 
upon the thorax, which after two years w r as either cured or disap- 
peared of itself. Seven years afterwards, another eruption of the 
same kind, but perhaps of less severity, made its appearance, and has 
continued since then to the present time. The scalp is entirely 
covered with minute whitish squama?, which are readily detached by 
rubbing the hair or scratching the integument. This part is not red, 
but is very hard and immovable under the finger, and feels stiff" and 
unyielding to the patient. The forehead is occupied by several 
patches of a reddish-brown colour, which project slightly above the 
general level. Several other patches occur which are covered with 
squamae ; these are readily detached and the subjacent skin is red ; on 
looking narrowly into this region, it is seen to be covered with quan- 
tities of fine white squamae. The face presents the same morbid 
appearances as the forehead ; the skin is hard, thickened and stiff; the 
difficulty experienced by the patient in speaking, from this state of 
the integuments, is very perceptible. The ears and surfaces behind 
them are even more affected than the rest of the head ; the squama' 
are larger and more confluent, if the expression may be used, and 
the skin is redder here than elsewhere. The neck and breast, how- 
ever, of all the regions are those that are most deeply affected ; the 
skin, besides being covered with many squamae, is extremely red, 
rough, chapped and very stiff'. In moving these parts the patient 
complains of a very unpleasant sensation produced by the dryness and 
stiffness of the integuments. The other parts of the body present 
the same morbid alteration in various, generally inferior, degrees of 
intensity. On the backs of the fingers a number of small isolated and 
perfectly circular squamous asperities, traversed in the centre by a hair, 
are perceived. The skin thus beset is extremely rough to the touch, 
and feels like a file. The asperities only occur in situations furnished 
with hair, that is to say, in the middle of the dorsal aspect of the first 
and second phalanges. By detaching them from the skin by means 
of a pin, the projections are found to be owing to an agglomeration 
of squamae, looking like minute grains, within the epidermic pro- 
longation that surrounds each hair. The patient had often plucked 
out the hairs thus surrounded, but the asperities always grew again 
with the hair. The roots of the hairs of the arms presented the same 
appearance, but in a very superior degree. A blister was applied to 
the surfaces thus affected, but failed to excite vesication. The patient 
was bled several times, and to a large amount ; he only appeared to 
derive signal relief from the first venesection, (a) 



(a) Psoriasis inveterata. Arsenical treatment successful. — " Sarah 
Partons, aetat. twenty, of lymphatico-sanguine temperament, being 
stout, rather pale, with gray eyes and light brown hair, came under 
my care on the 12th January, for psoriasis of the legs, arms, knees, 
and elbows, of thirteen years' standing. Her father and brother 
(who are now under my care) labour under the same disease. 
There are a number of patches of psoriasis, varying from the size of 
a sixpence to that of a crown piece, about both legs and arms, and 
a few on the back. Immediately below the left knee there is one as 
large as the palm of the hand, and the points of both elbows, but 
more particularly the left one, are covered by thick scaly incrusta- 
tions, extending some way down the posterior aspect of the forearm. 
The diseased patches were in a very indolent condition, there being 
no inflamed areola about them, and being unattended by any tingling 

' Comraunicaled by Mr. Tarral. 



PITYRIASIS. 



247 



or itching. The general health was good, and there were no dys- 
peptic symptoms of any kind. As the disease was of such long 
standing it had heen subjected to a great variety of treatment, and 
she had been a patient at two of the metropolitan hospitals, at one for 
a period of eight months, without receiving any benefit. I therefore, 
as she was very anxious for a cure, determined to try at once the effect 
of arsenic, and accordingly ordered her two and a half minims of the 
solution of the arsenite of potassa twice a day ; the biniodide of 
mercury ointment diluted with three pints of ung. cetacei,to be rubbed 
into the diseased patches night and morning. The quantity of the 
solution of the arsenite of potassa was gradually increased until the 
27th, when she was taking seven and a half minims three times a day. 
By this time the diseased patches on the arms, and some of those on 
the legs, had been cleared of their scales; the affected skin was, how- 
ever, redder than natural, and rapidly covered itself with scales of 
epidermis if the use of the ointment was interrupted. On the 28th 
some constitutional derangement, as headache, lassitude, pain in the 
eyes, and thirst, came on : the solution was accordingly discontinued. 
On the 4th February it was resumed in doses of five minims three 
times a day, which quantity was continued without any disturbance, 
either local or constitutional, until the 10th March, when, as the dis- 
ease appeared to be entirely cured, with the exception of a red stain 
as it were, of the skin in the site of the affected patches, the dose of 
the solution was diminished to three minims, which quantity was 
continued, in order to prevent a relapse, until the end of the month. 
The ointment of the biniodide of mercury had been persevered in 
during the whole of this time, its strength having been increased to 
equal parts of the ointment of the pharmacopoeia and of spermaceti 
cerate." Mr. Erichsen— (Med. Gaz., 1843.) 

Psoriasis of the neck and back : chronic rheumatism. Cure of both 
diseases by liquor of hydriodate of mercury and arsenic. — " Lawrence 
Keane, eetat. forty-six, an old sailor, of a sallow complexion, with dark 
hair and eyes, placed himself under my care on the 17th January 
last, for psoriasis of the posterior part of the neck and back, under 
which he had been labouring for the last four years. He states 
that, having been shipwrecked about twenty-four years ago, he was 
attacked with acute rheumatism, since which time he has never been 
free from pains in his limbs. I ordered him twenty minims of the 
solution of the hydriodate of arsenic and mercury three times a day, 
and a lotion of the bichloride of mercury to wash the affected parts 
with. On the 28th he had the dose of the solution increased to thirty- 
minims, and on the 15th of February he was perfectly cured of the 
disease of the skin, the rheumatic pains, from which he said he had 
not been free for twenty-four years, having ceased entirely for some 
time past. Since this date I have several times seen him, and he 
continues perfectly well in every respect." — Ibid. 

Psoriasis inveterata with eczema impetiginodes cured by the sulphur 
vapour bath.— 11 The subject was a gentleman about forty years of 
age, who from his boyhood has been afflicted with a most inveterate 
cutaneous disease, but from which he is sometimes quite free. His 
parents were not known to have had any skin disease, and he has no 
clue to enable him to account for its origin. When this gentleman 
was first subjected to the employment of the bath, he was unable to 
walk; his legs, from the toes to the middle of the thighs, were 
incased in a thick scab, with long deep fissures, from which issued 
an abundant ichorous discharge. The thighs above this were studded 
with impetiginous pustules, the sacrum, gluteus muscles, and part 
of the lumbar region, were likewise covered with scab containing 
deep cracks. The arms and axilla on one side were covered with 
large patches of scab, all discharging the same kind of fluid. He was 
obliged to move with great caution, lest he should extend these cracks, 
or occasion fresh ones, which were always attended with much pain 
and inflammation. He had been in the habit of taking and persever- 
ing in the use of medicine, but was not aware that he derived much 
benefit from it. 

"He was directed to take three emollient vapour baths, and after- 
wards to persevere daily in the use of the sulphureous fumigating 
bath, and to take occasionally opening medicine. After the third 
fumigation, the amendment was evident, and he expressed himself 
much more comfortable in his feelings ; he continued them for a fort- 
night with regular progressive improvement. At the expiration of a 



PITYRIASIS. 



Vocab. Dandriff, Pityriasis, Forrlgo. 



694. Pityriasis is a chronic and non-contagious inflammatory affec- 
tion of the skin, characterized by the evolution of red points and more 
frequently of red spots or patches from which a mealy or fohaceous de- 
squamation soon commences and continues till the disease is either 
cured or gets well spontaneously. 

This affection may make its appearance within a short space of 
time upon almost every part of the body in succession, (general pity- 
riasis,) or remain confined to any one region in particular (local pity- 
riasis)-. . 

695. Symptoms.— General pityriasis is one of the least frequent and 
most obstinate of the diseases of the skin ; it almost always invades 
without precursory symptoms ; patients complain, in those regions 
that are about to become affected, and most commonly in the extre- 
mities, of a violent feeling of itchiness, or rather of a painful and tan- 
talizing prickling sensation, which seems to have its seat under the 
skin, between it and the flesh. If the part thus affected be examined, 
and it chance to be without hair, a number of very superficial erythe- 
matous blotches are perceived. The heat of the surrounding integu- 
ment is almost uniformly increased, the subcutaneous cellular tissue is 
swollen, sometimes painful when pressed upon, and the soft parts 
generally seem to suffer from distension. It may be difficult to de- 
monstrate this primary redness when the scalp is the part affected ; 
but the phenomenon is always abundantly evident on other regions of 
the body when looked for early enough. Within a few days the 
blush diminishes in intensity and soon disappears entirely ; the epi- 
dermis then cracks, becomes less adherent, and a process of desqua- 
mation commences which varies in its characters according to the 
nature of the surface affected. On the outer surfaces of the legs and 
arms the cuticle is thrown off in foliaceous lanielke, which continue 
to adhere for some time, in one case by their centre, in another by 
either of their extremities, so as to appear floating, as it were, on the 
surface of the skin. These lamellae, formed by the cuticle nowise 

month, the arms and axilla were well, and the scab on the legs was 
now only in patches, the left leg being much the best. There now 
came on a fresh accession of disease, showing itself in pustules with 
yellow heads a little above each inner ankle ; higher up there were 
numerous small vesicles containing clear lymph ; some other parts of 
the legs still, however, went on improving, and the fumigations were 
continued ; this accession was not of long continuance, but scabbed 
over, healing underneath. He now complained of heat and itching 
in the face, particularly about the chin ; he had slight feverish symp- 
toms, for which he was directed a dose of the submur. hyd. and some 
saline medicine : he became relieved : achores made their appearance 
and gradually spread over the lower jaw, containing yellowish matter, 
forming scabs, with surrounding inflammation. To this part he 
pretty constantly applied flannels wrung out of hot water, and covered 
it with a bread and water poultice at night : there was no cracking of 
these parts, but much watery discharge. 

"He had used the fumigations daily six weeks ; he now complained 
of stiffness, itching, and redness in the left groin. On examination, 
the inguinal glands were enlarged, hard, and painful to the touch ; as 
the swelling of the glands subsided, the redness increased, and he 
had intertrigo, which became very troublesome to him. A space the 
size of a large dollar next made its appearance on the right clavicle, 
near the humerus, of a bright threatening aspect, and a smaller spot 
of the same appearance showed itself on the left clavicle, both itching 
very much, and with moist exudation; these spots in forty-eight 
hours became joined by an inflamed line about an inch broad, hang- 
ing, as it were, like a necklace : round the larger spots there came 
many small-sized pustules with yellowish matter in them ; these did 
not extend ; the large spot gradually became whiter in the middle, 
extending to the edges, disappearing slowly, leaving a shining, 
smooth red surface, which, with the connecting line, gradually went 
awav : of the intertrigo he was not quite well when business called 
him into the country. The legs, back, and arms were quite well : 
the gentleman used the bath seven weeks." — Ibid. 



ia 



SQUAMA. 



thickened, vary from about tlirce to eight lines in diameter. Those 
parts of the skin from which they have been recently detached or from 
which they have beta removed by the action of the nails, the rubbing 
of tlic clothes, kc., are usually of a rose colour; further, when pa- 
tients have \ ielded to the impulse to scratch, occasioned by the violent 
pruritus which accompanies the disease, the parts of the skin which 
have recently shed their cuticle pour out a serous, yellowish-coloured 
fluid, similar to that observed in the moist eczemas, and occasionally 
so abundant as completely to soak the linen or other clothing with 
which the parts affected happen to be covered. When this adventi- 
tious circumstance occurs to such an extent, it is apt to render the 
diagnosis of pityriasis obscure. 

Pityriasis is generally less severe on the insides of the limbs, and 
the desquamation then always consists of smaller laminae of the 
cuticle ; it is often, indeed, pulverulent. Behind the ears, about the 
clavicular fossa?, the axillae, bends of the arms, wrists, navel, pre- 
puce, groins and insteps, the inflamed skin has something of the look 
of intertrigo, that is to say, it is rough, moist, and slightly chapped in 
the direction of the natural folds of the skin which are powdery on 
their edges. On the anterior part of the breast and belly the desqua- 
mation always occurs in much smaller lamella? than on the posterior 
surfaces of the trunk. On the regions of the olecrana and patellae, 
and especially on the palms of the hands and soles of the feet, where 
the cuticle is naturally thicker, the exfoliation takes place in broader 
and thicker lamina? than elsewhere ; on the face and hairy scalp, on 
the contrary, it is almost uniformly powdery in its appearance. 

Pityriasis is accompanied with violent pruritus, especially of those 
parts where the eruption is recent, and of those where it is accident- 
ally exasperated ; the symptom then gains such a degree of intensity 
that the sleep is disturbed, and is only changed into a sensation of the 
most distressing kind by the efforts of the patient to allay it by 
scratching ; the satisfaction, however, the enjoyment experienced by 
yielding to the impulse, is described by patients as surpassing every 
other they have known. After the state of excitement or exaltation 
thus induced, has passed away, patients experience smarting sensa- 
tions of considerable violence, and fall into a kind of dozing state 
which is frequently followed by sleep. 

As to the principal functions, they are not in general very remark- 
ably disturbed ; yet it does occasionally happen that patients, labouring 
under extensive pityriasis, present functional disorders of the digestive 
organs. I have seen all the symptoms of chronic inflammation of the 
mucous membrane of the stomach and bowels under such circum- 
stances, and remember one case in which the severe suffering occa- 
sioned by acute pityriasis extended to the whole surface of the body, 
and the repeated serous evacuations that took place from the bowels 
even proved fatal. Amenorrhoea is occasionally observed to precede or 
to follow an attack of pityriasis. I have never observed any thing like 
a true febrile paroxysm except in those cases in which the eruption 
broke out over almost the whole surface of the body at once, or at 
those times when the disease seemed to increase in severity, or other- 
wise, when an inflammatory affection of the intestines was superadded 
to the pre-existing malady. 

The continuance of the symptoms of general pityriasis, and their 
mode of succession and increment, are subject to numerous shades of 
individual variety. The disease is frequently seen arising in situations 
where it never before appeared, at the same time that it is vanishing 
upon others where it had appeared fixed for a great length of time. 
The very appearance of the disease, indeed, is modified by these same 
circumstances : powdery or scaly, as in slight ichthyosis, upon those 
points where the inflammation is declining but still lingers in a trifling 
degree, of a vivid red and moist upon those where the inflammation 
has been accidentally increased, whilst in those places where desqua- 
mation is no longer going on, the skin has a white and slightly 
yellowish tint. 

The cellular membrane is more or less tumefied in those places 
where the inflammation possesses some acuteness, and in the lower 
extremities even when there is little apparent redness under the 
squama?. When the disease extends to the greater portion of the sur- 
face, patients can generally gather a considerable quantity of squama? 
from their beds every day. Lastly, when parts provided with hair are 
attacked, the disease causes its partial fall. 



G96. I have already mentioned the principal varieties of appear- 
ance presented by pityriasis occurring on different regions of the body. 
The better to expose the characters of the local varieties of this disease, 
however, I here add a few particulars connected with each : — 

1st. Pityriasis capitis is, of all these varieties, the most frequent and 
that which has been longest known ; it has, however, been often con- 
founded with the desquamations consequent on psoriasis, lichen, and 
eczema, and with those which take place without inflammation from 
the scalp in some individuals. 

Individuals attacked with pityriasis capitis suffer habitually from a 
considerable itching of the scalp, especially on the first attack of the 
disease, and at the period of subsequent exacerbations ; they are then 
led to scratch or rub the head with different degrees of force, when a 
whitish powder is detached, consisting of minute epidermic squama?. 
The secretion of these goes on continually, and a quantity may at all 
times be detached by rubbing with the hand, or the action of a brush. 
By separating the hair in different places, numbers of small, red, 
irregular, and very superficial patches may be discovered under the 
squama?, disseminated over the surface of the scalp. The skin on these 
points is shining, dry, and rough to the touch. The red patches, it is 
to be observed, are only very distinct in those places where desqua- 
mation has but recently been established ; after having been long 
affected, instead of being red, the scalp becomes, on the contrary, of a 
rather dull white in the places affected. 

It rarely happens that the inflammation reaches a very high degree 
of intensity in this variety of pityriasis. I have, however, met with 
some patients who complained of a feeling of stiffness and tension, of 
burning heat and insupportable pruritus in the hairy scalp. When this 
is the case, besides the ordinary attendant epidermic desquamation, 
there is almost always an exudation of a thin but glutinous fluid, 
similar to that secreted by surfaces affected with eczema. This matter 
agglutinates the hair and squama? into masses, and when the disease 
continues in this state for a month or two, the head looks as if it were 
covered with a gray or whitish cap, composed of the hair and an 
abundance of squama? matted together, the superficial layers of which, 
drier and more friable than those that are deeper, have the greatest 
resemblance in point of colour to the mineral named asbestos (teigne 
amiantacee, Alibert). When an attempt is made to isolate the parti- 
cular hairs, they are found buried as it were and lost amid scaly 
masses ; and if, by means of pretty strong pulling, a few locks be 
separated from the mass, they are so strongly agglutinated, and so 
much mixed up with squama?, that they still form stiff bundles only 
to be divided into others of smaller dimensions : the individual hairs 
can only be separated from each other with extreme difficulty. When 
the hair is clipped off pretty close to the scalp, after having been 
softened by means of poultices and fomentations, the skin is found of 
a rather vivid red on numerous points. The hair is only found de- 
tached from a spot here and there : baldness forms no feature in this 
disease, in which pediculi are also much more rarely encountered than 
in favus. 

Whether pityriasis capitis consists of a mere furfuraceous desqua- 
mation, or of the abestous cap that has been described, it may in 
either case extend to the eyelids, and occasion the fall of the eye- 
lashes. In young children the disease is most commonly seen on the 
upper part of the forehead and temples ; in the aged it frequently 
extends to the eyebrows, and when severe, almost uniformly spreads 
to the face and different other regions of the body. Pityriasis capitis 
is a disease that always lasts long ; it may exist for months and even 
for years. It is known to be approaching amendment when the secre- 
tion of furfura? becomes less copious, and when the serous exudation, 
when it has taken place, no longer goes on. A new, smooth and 
shining epidermis is formed when the recovery is complete. 

697. Pityriasis palpebrarum may also exist alone, and independ- 
ently of any anterior manifestation of the disease on another region. 
The only peculiarity presented by this variety is the frequency with 
which it causes the fall of some of the eyelashes, and the propagation 
of the inflammation upon the conjunctiva, it differs, and may be dis- 
tinguished from psoriasis developed on the same parts, by the erythe- 
matous look of its patches and flimsiness of its squama?, which contrast 
strongly with the papular elevations that announce the development, 
and the thick squama? that afterwards characterize psoriasis. 



PITYRIASIS. 



249 



698. Pityriasis labrum, is a variety that has hitherto been con- 
founded with psoriasis, a disease, however, from which it differs in 
being evolved on the lips and surrounding skin, not as papular ele- 
vations, followed by thick squamae, but under the semblance of 
minute red stains, to which succeed a general redness and a continual 
desquamation of the epithelium of the lips, and occasionally of the 
cuticle of the neighbouring skin. The desquamation goes on in the 
shape of little thin and transparent lamina?, very similar to portions of 
the healthy epidermis dried, or of the epidermis whose inner surface 
has imbibed a little serum previous to its desiccation. The lips, in 
this state, are affected with heat and tension : the epithelium gets 
yellow and thickened, it then cracks, and falls off in laminae of con- 
siderable size. It frequently happens that these continue to adhere 
for some time by their centre, when their edges are loose and already 
dry, so that a new epidermis is formed under the one about to be 
detached before it falls; this new cuticle then grows yellow, cracks, 
peels off, and falls in its turn, to be succeeded by another which 
undergoes the same changes and shares the same fate. This is 
always a long continuing and obstinate affection ; every now and 
then it gets worse than usual, when the lips look swollen and of the 
brightest red. It is very different from that transient inflammation to 
which the lips are subject, attended with chapping and the detach- 
ment of the epithelium, which is induced by exposure to cold, or 
happens as a consequence of different acute diseases ; this slight affec- 
tion soon passes, whilst true pityriasis is always a lengthy and trouble- 
some disease. The causes of pityriasis labrum. are frequently obscure ; 
I have observed it in two individuals, great talkers, who had a trick 
of always biting their lips. 

699. Pityriasis palmaris and plantaris are varieties which have 
hitherto been confounded with psoriasis affecting the palms and soles. 
The two diseases, however, may be distinguished by the following 
circumstances : Psoriasis begins in the shape of papular-looking ele- 
vations, the summits of which are soon afterwards covered with dry 
squamae of a dull white colour ; pityriasis, on the contrary, commences 
as small red spots or stains, irregular in their outline, which spread, 
and before long acquire a yellowish hue, probably in consequence of 
a slight exudation from the corion, which thickens the epidermis, by 
penetrating its inner surface. The epidermis then dries, cracks, and 
is constantly peeling off in foliaceous lamellae ; this exfoliation may 
extend to the fingers, and even take place under the nails, which are 
then occasionally detached. The skin almost always appears bathed 
in perspiration around the diseased points, which, on the contrary, are 
uniformly dry. I once attended a patient in whom this squamous 
affection appeared in the soles of the feet, a year after having attacked 
the palms of the hands. The heel and anterior part of the sole of the 
foot were painful when the erect posture was assumed, and during the 
act of walking. 

700. I have observed the inside of the mouth affected with chronic 
inflammation and habitual desquamation of the epithelium, especially 
about the base of the tongue, without any antecedent or concomitant 
affection of the pharynx, stomach or lungs, — pityriasis oris. This 
state continued during five or six years with but brief intermissions, 
the principal functions being all the while performed with great regu- 
larity. At the time a desquamation of this kind was going on, one 
patient complained of heat, and often of painful sensations, difficult to 
define, in the interior of the mouth. In a woman who was similarly 
situated, almost the whole of the mucous membrane of the mouth was 
habitually of a grayish-white colour, and when the epithelium was 
thrown off from the tongue, its surface presented several patches of a 
bright red colour, which continued until the investing membrane was 
either formed anew, or again rendered thick and opaque. 

701. The prepuce in the male and labia majora in the female are 
also occasionally the seat of superficial chronic inflammations which 
cause exfoliations of the epithelium, and an increase in the secretion 
of the follicular fluids; several of these affections in their course, their 
principal phenomena, and their rebellious character bear a singular 
affinity to pityriasis. 

702. Causes. — General pityriasis is happily a disease of rare occur- 
rence ; I have observed it more frequently among women than men ; 
patients are commonly altogether at a loss for any cause to which 
they can assign their disease. The causes of local pityriasis are also, 

63 



for the most part, very obscure. It appears occasionally to be excited 
among men by the action of the razor on the chin. The repeated 
action of a rough comb or hard brush may possibly conduce to its 
development on the hairy scalp. 

703. Diagnosis.— The natural exfoliation which frequently takes 
place from the skin of the infant, a few days after its birth, is of too 
short a duration, and appears under circumstances too particular to 
be confounded with pityriasis. The scurf of the scalp, often observed 
at the period of birth, is formed by a hard, yellow, and friable matter 
deposited on the anterior and upper part of the head, and bears a 
much stronger resemblance to an incrustation than to an exfoliation 
of the epidermis. This scurf, indeed, continues without any appear- 
ance of desquamation for many months, unless it be got rid of by the 
aid of fomentations or other applications that soften and permit it to 
be removed ; it no more consists, in fact, of the epidermis, altered 
and dried, than the scurf which is sometimes observed on the scalp 
of elderly individuals negligent of personal cleanliness. 

The skin of the scalp and of the extremities in some adults, and 
especially in some aged persons, is occasionally affected with an habi- 
tual exfoliation of the epidermis, which differs essentially from pityri- 
asis by being attended with neither redness, heat, nor any other mor- 
bid sensation. Certain desquamations of the epidermis, also, which 
follow acute diseases, differ essentially from pityriasis in their origin 
and transient nature. The desquamation, or rather the exfoliation 
of the cuticle that happens in pityriasis, differs in its character from 
that formation of squamae which takes place in all the varieties of 
psoriasis, inasmuch as the cuticle, in the latter disease, is thickened, 
dry, rough and of a dull white colour. But the feature that distin- 
I gu'ishes these two diseases from each other, more than any other, is 
j the circumstance of the red patches of psoriasis always rising above 
the level of the general integument, whilst those of pityriasis are not 
at all prominent. Further, when the inflammation runs very high in 
I pityriasis, the skin, especially when scratched, is very apt to pour 
' out an abundant serous secretion, whilst in psoriasis it always con- 
tinues dry. Lastly, in acute pityriasis the subcutaneous cellular tissue 
is often swollen and painful over a large extent of surface, a circum- 
stance which never happens in psoriasis discreta, and which, in 
psoriasis inveterata, is only observed to occur in limited spaces. The 
heat and pruritus that accompany pityriasis are, moreover, much more 
troublesome than the same phenomena in psoriasis; and pityriasis, 
when general, is much more frequently complicated with symptoms 
of constitutional disturbance and derangement of the digestive func- 
tions than psoriasis. 

When pityriasis is compared with lepra the same points of differ- 
ence are detected, with two distinguishing features in addition; the 
circular form of the patches of lepra, and their mode of recovery from 
the centre towards the circumference. The detachment of the cuticle 
in ichthyosis is not preceded by redness or morbid sensations of the 
skin. The desquamation that follows chronic lichen and eczema is 
preceded by the evolution of papulae and vesicles. I shall by and by 
have occasion to contrast pityriasis with acrodynia and with pellagra, 
but I must here pause to expose the characters that distinguish it 
from chloasma (pityriasis versicolor, Willan), and from melasma 
(pityriasis nigra, Willan), diseases which I have felt called upon to 
transfer to another order, that, namely, of the adventitious pigmentary 
discolorations. In the first place, the most striking feature in the 
two diseases, last mentioned, is undoubtedly the change of colour 
presented by the skin ; further, if some degreee of desquamation does 
take place at one period in the progress of these diseases, an habitual 
and abundant exfoliation of the cuticle forms no point in their history. 
Neither is there any of that serous exudation which I have men- 
tioned when speaking of acute pityriasis ; lastly, the ease with which 
chloasma is cured, and the deplorable resistance of pityriasis, in almost 
every instance, to remedial measures of every kind, show an essential 
difference in the nature of these two diseases. As to melasma (pity- 
riasis nigtv, Willan), when desquamation has once taken place, it 
seldom happens that this phenomenon and the other symptoms of the 
disease return with any intensity, or prove of any duration (Vide 
Chloasma, Melasma). 

704. Prognosis. — General pityriasis is one of the most obstinate 
diseases of the skin. When the inflammation extends to the lining 



250 



SQUAM.E. 



membrane of the internal passages, it always proves, like that affecting 
the outer integument, very rebellious ; m one case I have even seen 
it end fatally. The whole of the local varieties of pityriasis, particu- 
larly that of the lips, are constantly very difficult of cure, and are 
subject to frequent returns. 

705. Treatment. — When, in general pityriasis, the exfoliation from 
the epidermis is great, and when the skin looks vividly red and pours 
out an abundant serous secretion from various places, when the sub- 
jacent cellular membrane is swollen and the heat of the surface is 
increased, blood-letting, combined with the temperate mucilaginous 
bath, the antiphlogistic regimen and diluents, seldom fails to give 
considerable relief, at least for a season, a circumstance, however, 
which should not induce the neglect of this, the most important of 
these measures, when the patient appears able to stand it. The 
inflammatory affections of the bronchi, bowels and genital organs 
which occasionally make their appearance in the course of pityriasis, 
and especially at the periods of its paroxysms, are also relieved by 
the detraction of blood ; but they do not yield with the same readi- 
ness to this practice as the inflammation which is induced in these 
parts by external and appreciable causes. It would therefore be 
wrong to attempt to cut short these inflammations by the severest 
antiphlogistic means and repeated blood-letting. After a first or a 
second bleeding, which may have been very decidedly beneficial, a 
third generally appears to have no influence in modifying the disease : 
it is even seen occasionally to return with all its original violence a 
few days after a freest use of the lancet. Another circumstance 
which ought to be noted is that the blood is often buffy in this dis- 
ease, and continues so, unmodified by repeated venesections, during 
its whole course. 

In acute general pityriasis, opium is often employed with advantage 
to procure sleep and lull the pruritus and heat of skin so much com- 
plained of; this is also one of the best medicines we possess for com- 
bating the obstinate diarrhoea that occasionally comes on in the course 
of the disease. Purgatives and the preparations of arsenic cannot be 
prescribed with the same propriety in this as in the generality of the 
squamous inflammations, pityriasis being much more frequently asso- 
ciated with gastro-intestinal disturbance than any one of them, and 
this is a slate which these medicines are apt to induce, and one which 
they would certainly aggravate did it already exist. Simple baths, 
emollient topical applications, and the vapour-bath prove more gene- 
rally useful than the sulphureous or alkaline bath, both of which are 
contra-indicated when the skin is of a vivid red and the subjacent 
cellular substance is painful and swollen. When the skin, however, 
scarcely looks coloured under the epidermic lamella?, the vapour-bath 
and douche may be administered with advantage. But it is with 
general pityriasis as with almost the whole of the chronic diseases of 
the skin that are independent of appreciable causes, — a solid and 
enduring cure is only to be obtained by a general change of the con- 
stitution, brought about by dietetic means long and regularly pursued, 
effected naturally by the progress of years and the modifications 
undergone by the organization, or accidentally induced by some 
intervening disease, such as measles, scarlatina, &c. 

The local varieties of pityriasis frequently prove very rebellious 
also ; yet that of the hairy scalp of infants at the breast occasionally 
gets well spontaneously or by mere attention to cleanliness, after 
several months continuance. The variety of pityriasis capitis wdiich 
attacks adults and the aged, and is characterized by a simple powdery 
exfoliation of the epidermis and pruritus, without serous discharge 
and matting of the hair, only requires attention to cleanliness, and 
the application from time to time of some soothing unguent. The 
severer variety, however, which occasionally occurs along with gene- 
ral pityriasis, but which may also exist alone, and is denominated 
teigne. amiantacfe by French writers, requires more active treatment. 
After having softened the mass of dried exudation, hair and squama?, 
by means of poultices, vapour-baths, &c, the hair must be clipped 
off as near to the skin as possible with scissors curved on the flat. 
The vapour-douche must then be continued, and may be alternated 
with alkaline lotions; purgative medicines should next be cautiously 
tried ; and whenever symptoms of excitement appear, when the scalp 
becomes of a bright rose colour in several places, and appears moist- 
ened with a serous exudation, leeches should be applied behind the 



ears. In a case of pityriasis of the lips, I have detailed the routine 
of treatment usually pursued. The white precipitate ointment and 
vapour-douche are the means which have generally appeared to me 
most efficient in curing pityriasis of the palms and soles. Pityriasis 
of the mouth, nipple and genital organs have as yet been too little 
studied to admit of any thing like a satisfactory view being given 
of the value of therapeutic means in regard to them, (a) 

Historical JYotices and particular Cases. 

706. The Greek physicians have rather hinted at than described 
pityriasis. Galen 1 entitles those persons jtuv^ains, furfurosi, auibus 
asidue furfures in capite gignuntur. Alexander Trallianus, and Paulus 
iEgineta* tell us thafpityriasis consists of slight or furfuraceous exfo- 
liations of the epidermis. Several of the translators of the Greek 
writers have Latinized the word pityriasis ; others have rendered it by 
porrigo, and have thus committed an error which they might have 
avoided by translating pityriasis by furfures, capitis farrea nubes as 
Quintus Serenus Sammonicus had already done. Celsus, in truth, 
having under the title of porrigo comprehended several diseases fre- 
quently evolved on the hairy scalp, which were described at a later 
period under the common name of tinea, the word porrigo from this time 
forward occurs with two different meanings attached to it ; by some, 
such as Lorry and Jos. Frank, it is used to indicate the pityriasis of 
the Greeks: "Desquamatio epidermis nullo prffivio aut praesenti 
evidenti cutis vitio originem debens, relicta abnormi pellis subjacentis 
conditio Porrigo dicitur" (J. Frank) ; a definition in which various 
epidermic exfoliations, independent of an inflammatory cause, are 
evidently included ; whilst others, Willan, Bateman, &c, have used 
the word porrigo, in the acceptation of Celsus, to designate the dis- 
eases very commonly entitled tinea, and which are but varieties of 
impetigo, favus, &c, induced by peculiarity of situation. The alvarati 
of Avicenna appears to correspond to the pityriasis of the Greeks : — 
" Est, modus excorticationis levis accidentis capiti propter corrup- 
tionem accidentem in complexione proprie cum impressione in super- 
ficie cutis." 3 Alibert has given a representation of pityriasis under 
the title of dartre furfuracee volante. Willan, as I have already had 
occasion to mention, has described under the names of pityriasis ver- 
sicolor, and pityriasis nigra, two alterations of the pigmentary body 
which I have detached from this group. Jos. Frank, in his descrip- 
tion of porrigo, has included the pityriasis palmaris, scrotalis, and 
diffusa of Willan. Other writers have described, under the name of 
jntyriasis or porrigo, the furfuraceous desquamation consequent on 
lichen of the face, &c. These various meanings attached to the word 
pityriasis have caused no small amount of confusion in the writings of 
authors otherwise commendable. 

There is a case detailed by Marcellus Donatus, 4 and quoted by 
Schenckius, which appears to be one of general pityriasis. The case 
published by Hoepffner 5 also appears to me to correspond to this dis- 
ease ; and yet the changes undergone by the skin on different parts of 
the body in this case bore a different appearance from those commonly 
observed in pityriasis ; thick and yellow-coloured incrustations, for 
example, are stated to have occurred in some places, and in others 
red and excoriated patches, sprinkled over with reddish points, appear- 
ances very similar, therefore, to what are seen in impetiginous eczema. 
Forestus 6 and Mercurialus 7 have treated at considerable length on 
pityriasis or porrigo. Roederer 8 has published a dissertation upon 

(a) In the chronic stages of pityriasis, the treatment will differ but 
little from that recommended in psoriasis ; and the various remedies 
recommended in the latter, may be had recourse to in the present 
disease. My favourite wash of the fluid chloride of soda, will be 
found one of the best topical applications. 

' Galeni. Comment, iii. in lib. vi. Epid. 

2 Alexander, lib. i. cap. 5. — Pauli ^Eginetae, lib. iii. cap. 3. 

3 Avicen., lib. iv. Fen. 7, Tr. 2, cap. 24. 

< Marcel. Donatus, lib. i. cap. 3. Hist. Med. Mirabilis. 

6 Hoepffner. Disq. de herpetis furfuracei universalis maligni casu memorabili, 
8vo. Berolini, 1815. 

6 Forestus, lib. viii. obs. 12-13. 

i Mercuriali. De morb. cutis, cap. 7, de porrigine, p. 31. 

8 Roederer. Diss, de porrigine. Gcett., 1262. 



PITYRIASIS. 



251 



this subject which I have had no opportunity of consulting. Several 
observations on pityriasis are to be found in different periodical pub- 
lications. 1 

Case CXIX. — General pityriasis; complications. Martha Mullot 
entered the Hopital St. Antoine. January 19th, 1828, on account of 
rheumatism confined to the joints of the right foot, and while there 
was attacked with a squamous inflammation of the skin. The cata- 
menia had disappeared in the 48th year of the patient's age, without 
any unpleasant symptom. In the course of the month of February the 
skin of the face was observed to be the seat of a number of small red 
spots or stains, which speedily became covered with minute squamae, 
and the affection spread so rapidly that within a few days it had in- 
volved a very large portion of the trunk. The disease began in the 
points corresponding to the follicular eminences, as very small solid 
red elevations, the bases of which were surrounded by a narrow rosy 
circle ; the skin of the parts affected acquired, in this way, a general 
rosy tint. These elevations were soon covered on their summits with 
a very small, thin, and whitish scale, which was readily detached. 
Some redness remained even in those parts where the eruption was of 
oldest standing, and there the heat of the surface was sensibly increased; 
generally, however, it was almost entirely concealed by furfural of a 
dull white hue, which in several places even formed a layer of some 
thickness, the external surface of which was detached in the form of 
powder. The arms at the same time, became affected in a similar 
way, especially on their outer aspects, where the squamae were from 
four to five lines in diameter, much larger than those of the back, and 
of a more regularly rounded figure. The scalp, also, and those parts 
of the face which had escaped in the first instance, were affected, by 
and by, with an eruption of red spots which were succeeded by 
squamae. The backs of the hands, and those parts upon which the 
body rested, when laid horizontally on the back, the usual posture of 
the patient, became covered with squamae of great comparative thick- 
ness, under which the skin was of a more vivid red than on any other 
point. On the knees the appearance of the eruption was nearly simi- 
lar, only the squamae were even thicker ; they also projected slightly, 
and the portions of the integuments they covered were of a still more 
fiery tint than elsewhere. Several months afterwards the desquama- 
tion extended to the points of the fingers, the exfoliation taking place 
there in large flaps, the whole cuticular covering of the pulps being 
thrown off in a single piece ; under the nails there remained for a very 
long time a substance of a yellowish-white colour, which by scraping 
was detached in the form of furfurae. The different appearances that 
have now been detailed continued without remarkable change till the 
month of December, when the cold, rather than the medical treatment, 
seemed to produce some slight improvement. The squamae and hair, 
however, became matted together by means of a glutinous exudation, 
and acquired a glistening appearance like asbestos. The hair, when 
parted in different places, snowed the surface of the scalp of a vivid 
red colour, and beset with a multitude of minute orifices whence the 
serous agglutinating fluid was discharged. The patient, since the 
commencement of the disease, has had repeated attacks of profuse 
leucorrhcea, of colic and bronchitis. 

Mild diluents and blood-letting caused some diminution in the red- 
ness of the skin and pruritus, with which it was affected ; but these 
phenomena re-appeared within a few days in their original intensity. 
The salt-water-bath, repeated six times only, seemed but to cause a 
greater degree of irritation, a more vivid tint, and increased heat of 
the surface. The tincture of cantharides, in doses of no more than 
three drops, continued for three or four days successively, occasioned 
so profuse a diarrhoea, attended with tormina to such a "degree, with- 
out appearing at all to influence the disease of the skin, that antiphlo- 
gistics were immediately resorted to anew, and these seemed to do 
some o-ood. Gelatinous baths were now prescribed, but without 
effect ; one of the regions was touched with the nitrate of silver, but 
this application did no good. Arsenic was tried, as a last resource, 
and the solution of arseniate of soda was prescribed in doses of ten 
drops, gradually increased to half a drachm ; but after the third dose 
of the latter amount the patient complained so violently of pains in 
the bowels, and showed so many symptoms of gastro-enteritis that 
this medicine was abandoned also. The cold of the month of De- 

1 Journ. Hebdom., t. vii. p. 459.— Revue Medicale, Juio, 1830, p. 317. 



cember was the only thing that seemed to do any good ; the disease 
has since remained unmitigated, and will probably continue so inde- 
finitely. Tk * * *= 
CaseCXX.— General pityriasis. Chronic enteritis. Madame D , 
aged sixty-one, of good constitution, born of healthy parents, and her- 
self the mother of six lively children, was always very regular until 
the age of forty-eight, when the catamenia disappeared entirely. Two 
years afterwards the patient had first a violent pain in the left knee, 
and within two days perceived a vivid redness, attended with extreme 
itchiness in her left groin, from the skin of which the cuticle soon 
began to crack and be thrown off. This disease of the integuments 
spread rapidly, and ended by implicating the whole body except the 
palms of the hands and soles of the feet. In this state the disease 
continued for six years; it then improved, and ultimately got well 
under the use of the warm-bath and diluents. Within a year, how- 
ever, the patient had a relapse. Bathing and leeching did no good 
now, and Madame D * * * entered La Charite, March 3d, 1834, 
labouring under general pityriasis, which had already continued for 
upwards of three years. At this time the lower extremities were 
hard and swollen, pitting under the pressure of the finger. They 
were covered, principally on their outer aspects, with largish squamae, 
which were readily removed by simple friction. The parts of the 
skin that had been freed in this way, looked red, and a plentiful 
serous exudation, similar to that of eczema, began to be poured out. 
On the arms, the same state obtained, the squamae being very large 
on the outer aspects of the limbs. On the abdomen, desquamation 
in a less degree was going on, the squamae being furfuraceous ; 
on the loins, however, they were as large as on the extremities. 
The forehead was the part of the face most severely affected ; the 
ears were also covered with squamae, and quite moist from the 
abundant serous secretion. The patient suffered greatly from a feel- 
ing of heat in the whole surface of the skin, and of a pruritus that 
occasionally became excessive ; she then scratched herself severely, 
deriving the utmost enjoyment from the operation, after which the 
skin became extremely red, and poured forth an abundance of the 
serous fluid. 

This patient had, in addition, long suffered from diarrhoea ; her 
colour was pale and sallow; in other respects she was well. Simple 
bathing, the vapour and sulphur bath, the nitric acid, decoction of 
dulcamara, blisters, and blood-letting, both general and local, modi- 
fied the state of the skin in some slight degree : the desquamation 
became less abundant ; but when the patient was discharged on the 
8th of May, she was still suffering from diarrhoea, which neither regi- 
men nor opiates had been able to check, and on the whole the disease 
of the skin remained much in the same state as it was when she 
entered. 

Case CXXI. — General pityriasis ; diarrhcea ; subcutaneous ab- 
scesses: death. Marie Paul, aged twenty-two, had long been subject to 
a tetter, which every now and then assumed the acute type, and prin- 
cipally affected the parts behind the ears and the bends of the arms. 
Some time in the month of July 1831, the patient had to contend with 
serious moral afflictions, and shortly afterwards she observed that the 
whole surface of her body had become red, and was affected with a 
desquamation incessantly renewed. The digestive functions were 
disordered at the same time, and the patient felt generally unwell. 
On entering the Hopital de la Charite on the 27th September, 1831, 
almost every part of the surface was found affected with pityriasis ; the 
face is entirely covered with the eruption ; but around the ears and 
eyelids, which have lost their ciliae, and are inflamed on their edges, 
the skin is red and moist, and the disease there presents the cha- 
racters of acute eczema, without a trace of desquamation ; from the 
cheeks, on the contrary, the epidermis is detached in flaps of extreme 
thinness, and of different sizes, exposing a smooth and slightly moist 
surface. The skin of the neck only looks cracked transversely in 
different places. On the arms, breast, belly, thighs and legs, a nearly 
similar state of affairs obtains : the epidermis is incessantly falling off 
in irregular shreds, which are transparent and rather soft, from being 
moistened with the serous exudation that is everywhere poured forth 
from the red diseased surfaces underneath. When the body of the 
patient is handled for some little time the fingers become moist and 
clammy. 



262 



SQUAMiE. 



To these cutaneous affections are superadded pain of the epigas- 
trium ; quick and compressible pulse ; tongue red at the point, loaded 
in the centre ; diarrhoea ; insomnia, or disturbed sleep ; want of real 
appetite ; loaded and scanty urine. (Rice-water toith gum/or drink ; 
gummy potion, with half an ounce of syrup of poppies ; beeftea and 
milk ; tiz leeches to each side of the nec/c ; emollient cataplasms ; bath 
!!.i The patient was so weak that she could not continue in 
the bath for any length of time. The skin generally is red and moist ; 
the desquamation goes on ; the febrile symptoms increase in severity ; 
the epigastrium is more painful. {Eight leeches to the epigastrium; 
mucilaginous drink; demi-lavement.) 28th. — Matters going on still 
more unfavourably ; the patient was ordered to lose four ounces of 
blood from the arm ; but little, however, could be obtained. 30th. — 
A second attempt to bleed the patient was not more successful than 
the first, on account of the small size of the veins. Oct. 1st. — A 
number of small superficial abscesses were discovered, several of 
which we're seated in the substance of the skin, whilst others, of 
somewhat larger size, extended into the subcutaneous cellular tissue, 
and presented an evident fluctuation. Some of them were opened, 
others, by reason of the opposition of the patient, were left to them- 
selves. The patient exhales a fetid odour, which becomes more power- 
ful every day, so that the nurses now approach her with great reluctance. 
Her slate gets more deplorable every hour ; the diarrhoea continues ; 
she is greatly emaciated ; the beat of the heart is rapid and feeble ; 
the respiration quick and short, &c. She died on the night of the 
5th. On opening the body ulcers, and other alterations characteristic 
of chronic inflammation of the intestines, were discovered. 

707. I here subjoin two cases from the Philosophical Transactions, 
in which the general and habitual desquamation to which the skin 
became subject, was preceded by fever, and oilier serious symptoms, 
after which appeared a general eruption of red spots. These cases 
differ from those I have just detailed in the circumstance of the gene- 
ral desquamation being renewed after a fresh febrile attack, without 
any new eruption. In ordinary pityriasis, as we have seen, the 
desquamation goes on incessantly, and is not got rid of but with great 
difficulty. These cases of desquamation, however, differ from those 
that take place consecutively to exanthematous fevers, in having been 
habitual and frequently repeated. There is another case, similar to 
these two in its circumstances, detailed in the Ephimerides Nature 
Curiosorum, 1 and a fourth has been related by Mr. Newell, 2 which 
got well under the use of the Cheltenham waters continued for several 
seasons. I am anxious to direct attention to these cases, which pre- 
sent such remarkable discrepancies from those of common pityriasis. 
They appear to form a kind of transition link between this disease 
and the eruptive fevers. Cases of this kind are not yet sufficiently 
numerous to allow of their being thrown together into a particular 
group ; but I have given several a place here with a view to their 
perhaps being made the basis of an arrangement that will one day 
become more precise. 

Case CXXII. — Case of general desquamation of the cuticle, par- 
ticularly of that of the hands. 3 Mr. W. Wright, about fifty years of 
age, was first seized about ten years ago with a singular kind of fever 
which has returned many times since, even twice in the course of the 
same year, attended with the same symptoms and circumstances 
appearing generally to be brought on by obstructed perspiration, in 
consequence of catching cold. Besides the common febrile symp- 
toms upon the invasion of the disease, his skin itches universally, 
more especially at the joints, and the itching is followed by many 
little red spots with a small degree of swelling ; soon after his fingers 
become very stiff, hard, and painful at the ends, and at the roots of 
his nails. In 24 hours, or thereabouts, the cuticle begins to separate 
from the cutis, and in 10 or 12 days this separation is general, from 
head to foot, when he has many times turned the cuticle off from the 
wrists to the fingers' ends, completely like gloves ; and in the same 
manner also to the ends of his toes ; after which his nails shoot gra- 
dually from their roots, at first attended with exquisite pain, which 
abates as the separation of the cuticle advances, and the nails are 

de'nJST ACad ' Nat ' ° Ur " DeC - 5 ' an - 5 ' l686 ' P - 396 - (Abcedens P° st mor bum epi- 
* Lond. Med. Gaz., vol. iii. p. 576. 
5 Latham, in Phil. Trans, vol. 60, p. 451. 



generally thrown off by new ones in about six months. The cuticle 
rises in the palms and soles like blisters, but has no fluid under it; 
and when it comes off, it leaves the subjacent skin very visible for a 
few days. Sometimes, upon catching cold, before he has been quite 
free from feverish symptoms, he has had a second separation of the 
cuticle from the cutis ; but then it is so thin as to appear only like 
scurf, which demonstrates the quick renewal of this part. 

Case CXXIII. — Repeated attacks of general desquamation of the 
cuticle.* Mr. A. B., aged thirty-five, enjoyed good health till about 
his thirty-fifth year ; his business, as a miller, and maker of French 
barley, exposes him to a great heat and clouds of dust. On the first 
cold caught, after entering on this employment, a fever attacked him, 
and this has returned once, and sometimes twice, a year, chiefly in 
the autumn, attended with a loosening and detachment of the cuticle. 
The disorder begins with violent fever, attended with pains in the 
head, back, and limbs, retching, and vomiting, the skin being dry, 
the tongue furred, the thirst urgent, bowels constipated, and urine 
high-coloured. The whole surface of the body then, usually, but 
not invariably, became yellow ; it afterwards became florid, having 
the appearance of a rash ; on which he felt a great uneasiness for 
several days, with a numbness and tingling all over him, when the 
urine began to deposit a thick sediment. About the beginning of 
the third week from the first attack, the cuticle appeared elevated in 
many places, and in eight or nine days afterwards it became so loose 
as to admit of being easily removed in large flakes. The cuticle of 
the hands, from the wrists to the fingers' ends, came off whole like 
a glove. The patient was never disposed to sweat, and when this 
was attempted to be forced he grew worse ; nor was he much at ease 
till his urine deposited a sediment, after which he felt but little in- 
convenience but from the rigidity of his skin. The nails were not 
detached, as in the preceding case. 

Case CXXIV.— Pityriasis of the lips. M. D * * *, aged thirty-six, 
has suffered for the last fifteen years with a pityriasis of the lips ; the 
disease is confined to the coloured parts, and has never spread either 
to the skin without, or to the lining membrane of the mouth within. 
The epithelium becomes hard and dry, cracks, and is detached in 
small shreds, so that in the course of four or five days it is completely 
renewed over the surfaces affected. Whilst the desquamation is going 
on, the lips are stiff, and the patient keeps moistening them with his 
tongue. The affection is most troublesome in winter, when it is more 
constantly attended with chaps than at other seasons. M. D * * * is 
in the habit of talking much, and with his voice pitched high ; he, 
himself, attributes his malady to a practice he has long indulged in of 
biting his lips ; he also suffers from a kind of tic before each renewal 
of the desquamation. He has, from the beginning, tried a host of 
remedies against his distemper — common cerate, cucumber ointment, 
the pommade de Regent, 5 and even that of Frere Come; 6 the latter 
only inflamed the lips and made them very painful. Some time after- 
wards, the lunar caustic was tried ; and the parts affected were sub- 
sequently touched with a muriatic, acid liniment, which irritated them 
anew, in a very distressing manner. M. D * * * also tried lotions of 
the natural sulphureous waters of Bareges, but all proved futile, and 
the patient returned to the use of simple cerate, his lips remaining 
subject to an habitual desquamation. A great variety of internal 
medicines were also tried, without any one of them appearing to 
exert the slightest influence on the progress of the disease. These 
details M. D * * * gave me when he consulted me in the winter of 
1823. I recommended him to keep his lips anointed for a fortnight 
with an ointment of the acetate of lead ; this application, which seemed 
at first to make the desquamation less frequent, and less extensive, 
failed at length, like every thing else, in giving relief. I then desired 
the patient to apply three or four leeches, repeatedly at intervals, to 
the inner surface of the lips ; but he showed a repugnance to this 
measure, and I did not recommend any other. M. D * * * has never 
suffered from an attack either of psoriasis, or of any chronic inflam- 
mation of the skin of a different nature, on any of the other regions 
of the body. 

* B. Gooch, in Phil. Trans, vol. 59, p. 281. 

5 A mercurial salve. 

6 An arsenical peparation. — Tr. 



LUPUS. 



253 



SQUAMOUS INFLAM51AT10NS ARTIFICIALLY EXCITED. 

708. Squamous inflammations, arising under the influence of acci- 
dental excitement, differ from those we have just been engaged in 
considering, in their natural tendency towards recovery when not kept 
up by the constant action of the cause which has produced them. 

709. The irritation caused by an indifferent razor occasionally 
produces a degree of redness in the skin, followed by desquamation, 
which has been classed with the pityriases. This trifling complaint 
disappears entirely when the skin is no longer subjected to irritation. 

710. A squamous inflammation is frequently observed on the backs 
of the hands of grocers, and those persons who handle alkalies, spices 
and other stimulating substances ; the skin looks red, slightly puffed, 
and squamous, and is commonly traversed by dry and painful chaps, 
more especially across the joints between the metatarsal bones and 
phalanges, and between the carpus and bones of the forearm. This 
affection is speedily cured by a change of occupation, or by keeping 
the hands for a time from the action of irritants. Eruptions of the 
same kind are occasionally observed among bricklayers, masons, 
engravers, &c. 

711. Washerwomen are also frequently attacked with a squamous 
inflammation of the hands, and lower parts of the arms, excited by 
the prolonged immersion of these parts in water, and especially in 
alkaline leys. The parts become habitually red, and covered with 
a hard, dry and brittle epidermis, which falls off and is renewed 
incessantly. Those individuals whose hands are still more constantly 
kept plunged among irritating fluids, above all dyers, are subject to 
redness and swelling of the hands, with numerous deep fissures of 
the epidermis, which is always coming off in shreds. These chaps 
are frequently seen impregnated with colouring matter which cannot 
be got rid of by washing ; they also frequently penetrate to the quick, 
and the pain and swelling they occasion, attended with stiffening and 
impediment to the motions of the hand, are often extremely trouble- 
some. These latter varieties of squamous inflammation disappear 
like the others by a simple removal of the cause to which they are 
due ; they get well much more slowly, however ; the skin being 
swollen, and as it were hypertrophied in its entire thickness, so that 
it has lost its natural pliancy. The state of chronic inflammation of 
the integument seems also to be kept up in part by the irritation of 
the numerous chaps with which it is affected. 

712. The nature of the whole of these accidental inflammations of 
the skin is to be distinguished by their causes, which patients almost 
always mention. They also differ from diseases of the same class 
induced by a morbid internal cause, in their mode of appearance ; 
they are, in fact, simple diffuse chronic inflammatory affections of the 
skin, whilst lepra and psoriasis begin as papular elevations, and pity- 
riasis as small red spots or stains upon the surface of the healthy skin. 
Further, lepra and psoriasis are evolved by the growth and multipli- 
cation of circumscribed patches, whilst the accidental squamous inflam- 
mations extend generally and irregularly. Lastly, these affections 
differ from pityriasis in this: — that they commonly cause more stiff- 
ness and chapping of the skin, and are occasionally attended with 
accidental vesicles and pustules. 



IX.— TUBERCULA. TUBERCULAR INFLAMMATIONS. 

Vocab. Tubercula. 

713. The tubercular inflammations are characterized at their height 
by the occurrence of tubercles, or small solid, circumscribed, indu- 
rated, and enduring tumours, which, after continuing for some months, 
often for several years, almost uniformly end by becoming changed 
in their nature, and falling into a state of ulceration. 

714. The number of tubercular inflammations reckoned is six: 
64 



lupus, cutaneous scrofula, cancer, Greek elephantiasis, tubercular 
syphilis, and accidental and artificially excited tubercles. Some 
pathologists are of opinion that lupus and cutaneous cancer do not 
always begin as tubercles ; they have not, however, given any exact 
account of the forms under which they suppose that these two dis- 
eases may begin. I think it almost unnecessary to observe that this 
group of diseases is very different from that which Willan and Bate- 
man have designated under the name of tubercles, which includes 
alterations of the most dissimilar description, such as carbuncle, 
warts, rosacea, elephantiasis, furuncle and lupus. 

715. Tubercles, whatever their nature, are occasionally solitary, 
but much more frequently numerous. They begin in the shape of 
flattened elevations, larger and harder than papulae, and frequently of 
the same colour as the healthy skin that surrounds them ; or they first 
appear as spots of a reddish colour. Tubercular affections are almost 
always chronic in their character ; they may continue stationary for 
many months, and even for several years ; but when accidentally irri- 
tated, tubercles are apt to increase in size, and to undergo different 
alterations. At a later period they soften or are destroyed by an 
ulcerative process, becoming covered with scabs when the sore is 
exposed to the air. These changes have distinct characters peculiar 
to each of the tubercular diseases. In relation to their origin, nature, 
appearance, progress and termination, the tubercles of lupus, scrofula, 
cancer, Greek elephantiasis and syphilis, have, in reality, nothing in 
common save their form ; and although much more restricted than 
that of Willan, this group is only to be regarded as an artificial means 
of facilitating the diagnosis of these diseases. 

716. The tubercular diseases at their acme, are in general easily 
distinguished from all other affections of the skin. Tubercles alone 
constitute small solid organized tumours, having a tendency to ulcera- 
tion. The smaller dimensions of papulae, and their essentially pruri- 
ginous character prevent them from being confounded with tubercles. 
As to tumours, properly so called, they are distinguished from tuber- 
cles in having no disposition to softening or ulceration, and in neither 
being preceded nor accompanied by any other symptoms of inflamma- 
tion. When tubercles are partially or wholly destroyed, the sores and 
scabs which succeed present particular characters which are sufficient 
not only to separate these diseases from others of a different class, 
but even to distinguish each of them individually. In each particular 
case, after having discovered the existence of tubercles, we ought to 
ascertain whether they are primitive, or are consecutive to some other 
elementary form of disease, as also, whether they are natural or have 
been artificially excited. Tubercular diseases are always very serious 
in their tendency, and extremely difficult of cure. 

717. In the body of this work I have intentionally omitted any 
account of several exotic diseases which show themselves in a tuber- 
cular form ; in the attached vocabulary, however, some notice will 
be found taken of them. (Vide Frambcesia, Radesyge.) 



Vocab. Lupus, Noli me tangere. 

718. Lupus is a chronic cutaneous inflammation which usually ap- 
pears in the shape of external tubercles of different sizes, singly or in 
clusters, of a livid colour and indolent character, followed either by 
ichorous and phagedsenic ulcers, whieh become covered with brown- 
ish, and usually very adherent, scabs — lupus exedens ; or by extensive 
changes in the structure of the skin, but without preliminary or con- 
secutive ulceration — lupus non exedens. This disease may be confined 
to the face, and even to one of its parts, or may attack at once, or in 
succession, several regions of the body. The two varieties, which 
have been indicated, are very distinct in their external appearance, 
and to a certain extent in their mode of treatment, (a) 



(a) The following paragraphs indicate the view which M. Biett 
takes of lupus. " This disease has been described under the name 
of dartre rongeante, by Alibert, who has divided it into three varie- 
ties, based on the causes which produce them : 1st. Dartre rongeante 
idiopathique ; 2d. Dartre rongeante scrophuleuse ; 3d. Dartre rongeante 






TUBERCULA. 



- ,,, Lu, , or noli m, is commonly developed on 

•„,. .,!,,, ()1 . tjp f the nose, li makes its appearance as a small external 
tubercle of a dusky-red colour, and hard consistency, whose progress 
s usualh tardy. It sometimes commences as a chronic inflammation 
,f the mucous membrane of the nasal fossa', with redness and swelling 
if the nose in general ; a thin scab or crust then forms at the opening 
if the nostrils ; this is removed, and a second and thicker one succeeds 
it— an ulcer has in fact been formed, and soon extends to the alae of 
the nose. Under other circumstances a livid or purple tint, and some 
swelling of the end of the nose, are the first symptoms of the disease 
observed. The redness increases, a superficial sore is formed, which 
becomes covered with a scab, and the ulcer extends in depth. It often 
happens, too, that one of the alee of the nose swells, grows painful and 
>t a purplish hue ; a slight ulcer then forms and becomes covered with 
.1 little scab ; this the patient commonly picks off, when it is replaced 
with a thicker one, under which the ulcerative process continues to 
go on, the scab being found to increase in thickness every time it is 
renewed; the patient scarcely makes any complaint ; the skin, and 
■regionally the cartilage, are silently destroyed, and an ulcer of a 
bad character, from which a foetid sero-purulent discharge is poured 
>ut, is at length discovered, as if by accident, established under 
he scab. , . 

The nose is occasionally red on the superficies only, and this in a 
very equal and regular manner; sometimes instead of being of its 
ordinary size and shape, the nose becomes pointed, sharp, and taper- 
ing, the nostrils tending continually to close. The cartilage at the 
angle which unites its two lateral halves superiorly, seems then to 
project, and presents a red tint that is even perceptible through the 
soft parts. 

The ravages committed by this disease vary extremely; almost the 
whole of the nose disappears in one instance, and the point only 
sutlers a little in another, in which case it often looks as if a piece 
had been removed with a cutting instrument. When such ulcers 
have been arrested and healed up, new tubercles occasionally form 
on or near the cicatrices, and the parts which had been spared origi- 
nally may be entirely destroyed by a renewal of the ulcerative process ; 
even the whole nose and septum may vanish before its destructive 
influence. The ulceration may prove rapid or slow in its progress: 
sometimes after existing for several years, a small portion only of the 
nose is lost ; in other instances, happily of rarer occurrence, the 
whole of the member is destroyed in from fifteen to twenty days 

lupus vorax). Sometimes, if the disease is interfered with, it seems 
to acquire new energy: the point of the nose assumes a livid red 
colour, which, though it may seem to disappear, returns within two 
or three days; incrustations, which are attended with acute pain, 
and grow very thick in the course of a few days, form in the interior 
of the nasal fossa 1 , whence a puriform fluid distils, and the point of 
the nose is then rapidly destroyed. The disease seems every now and 
then to be advancing towards recovery, when the part that was almost 

venirUnne ; this last evidently belongs to the syphilitic complaints, 
and the author himself describes it under that head. 

" Lupus is a disease which sometimes commences with spots of a 
violet red colour, but most generally with livid, indolent tubercles, 
and is above all characterized by its tendency to destroy the surround- 
ing parts and subjacent tissues, under the form of ill-conditioned, 
ichorous ulcers, which become covered with very adherent brownish 
scales, which, on falling off, discover that the disease has continued its 
ravages. 

" Lupus presents many differences, not only in its seat, the rapidity 
of its progress, and the extent of the destruction it produces, but also 
in the mode in which these ravages are committed, and in the form 
of the. ulceration. Thus, sometimes it confines its attacks to the 
surface, sometimes it successfully invades the subjacent parts; at 
others, again, it is accompanied with a real hypertrophy of the skin ; 
hence ML Biett has divided it into three varieties: 1st. That which 
destroys the surface ; 2d. That which destroys the subjacent parts; 
3d. When it is accompanied with hypertrophy. This division is 
wholly practical, and much facilitates the study and description of 
the disease."— Cazenave and Schedel, Practical Synopsis of Cutane- 
ous Diseases — Philadelphia Translation. 



cicatrized, turns to a vivid red, is attacked anew with painful ulcera- 
tion, and is covered with a thick scab under which the destructive 
inflammation makes rapid progress. 

In lupus exedens of the skin of the nose, the mucous membrane of 
the nasal fossae is almost always affected with chronic inflammation, 
In some rare cases, altogether independent of a syphilitic cause, the 
septum is even destroyed before the outer surface of the nose is im- 
plicated. When the destruction commences in the skin, again, it 
extends to the pituitary membrane, spreads along the nasal fossa* , and 
is even occasionally reflected over the mucous membrane of the arch 
of the palate to the gums, which are then deeply furrowed. Besides 
the destruction, which is discovered when the scabs that have long 
concealed the mischief wrought by this disease are removed, it is 
very common to find the openings of the nostrils contracted in a 
greater or less degree by the thickening of the affected parts, or by 
the indurations consequent on the formation of cicatrices. 

2d. The tubercles of lupus exedens are occasionally evolved near 
the commissures of the lips. Thick incrustations cover the ulcers, 
and the patient cannot open his mouth without pain. After having 
destroyed a considerable extent of parts about the commissures, the 
ulcers'often extend to the movable substance of the lips, in which 
case, by the shrinking of the cicatrices when the disease gets well, 
the opening of the mouth is apt to be considerably diminished. 

3d. The lower eyelid is occasionally attacked with lupus exedens, 
and the ulceration generally spreads to the skin of the cheeks and to 
the conjunctiva palpebralis. The eyeball in this case imperfectly 
protected, inflames, the conjunctiva thickens, the cornea loses its 
transparency, and by and by becomes so dim that total blindness 
follows. If the eyelids are not entirely destroyed, the sores in heal- 
ing cause their eversion ; the eyes then appear of twice their usual 
size, a circumstance which, added to the vivid red of the conjunctiva, 
produces hideous deformity. 

4th. It sometimes happens that one or more tubercles are evolved 1 
on the face, which, after continuing long stationary, increase suddenly 
in number as well as in size. The skin in the spaces between them 
swells and becomes (edematous in appearance, the tubercles then 
unite by their bases, and the whole mass falls into a state of irregu- 
lar ulceration of bad character. The sore is covered with a blackish- 
looking and very adherent scab, and spreads by degree to the neigh- 
bouring parts. Lupus exedens, in this way, frequently attacks almost 
the whole of the face. When the ulcerative process stops, cicatriza- 
tion takes place in the form of irregular white bands, which stretch 
from the parts where the mischief began to those in the vicinity, and 
are very similar in their appearance to the cicatrices that result from 
extensive burns. 

5th. Lupus exedens occurs with symptoms of still greater severity. 
Whilst it is advancing among parts still untouched, it returns and 
attacks the cicatrices, whether of old or recent date, which have re- 
sulted from its previous existence. These disappear very rapidly, 
and fresh tubercles, developed like a hard, rough, and swollen band 
around them and the ulcers that exist, become open before long and 
add to the havoc going on. In the course of a few months the dis- 
ease may thus ravage not only the greater part of the face but a large 
extent of the surface of the neck. The nose is frequently implicated 
in the destruction, and when the scabs are detached, the alas or a por- 
tion of its end is found gone. When, by means properly directed, 
the progress of the disease is arrested, the skin, beset with numbers 
of small, red, and sallow tubercles, becomes covered with minute 
squamae, and white and firmer cicatrices ere long succeed upon the 
ulcerated points. When the ravages of lupus have been thus exten- 
sive, the face is seamed with irregular cicatrices, often of a dull 
white, but occasionally of a rosy red colour, tense, shining, pretty 
thick in some places, but so thin in others that they appear trans- 
parent and on the point of giving way. This latter character they 
present especially on those parts that have been oftener than once 
attacked. These cicatrices seem frequently to hold by their extremi- 
ties to two different tubercles, between which they stretch like lines 
of communication. They often appear covered on various points of 
their circumference with blackish incrustations, which, however, are 
commonly soon detached. 

6th. Lupus exedens rarely attacks the integuments of the chest, or 



LUPUS. 



255 



of the extremities; these regions are more frequently the seat of the 
lupus non exedens serpiginosus. 

7th. Lastly, in one variety of lupus exedens the ulcers are beset with 
small, soft, red and spongy-looking and very prominent tumours, 
which occasion much deformity. This variety is one of the most for- 
midable, but it occurs rarely. 

8th. Lupus exedens often continues for years, committing the most 
frightful ravages, without the general health appearing to suffer in 
any degree. Yet, when not only the skin but the cartilage of the nose 
is rapidly destroyed, some patients show unequivocal symptoms of 
chronic inflammation of the lining membrane of the stomach, intes- 
tines or bronchi, and several even sink under a species of slow fever 
accompanied with colliquative diarrhoea ; such a termination of lupus, 
however, so rarely happens, that when it does occur, it ought pro- 
bably to be ascribed to an accidental complication, rather than to the 
influence of the disease itself. 

720. Lupus non exedens. This variety occasionally presents itself 
as a single tubercle, of a yellowish-red colour, developed in the sub- 
stance of the skin, — lupus non exedens simplex. I have observed a 
solitary tubercle, possessing these characters, continue on one of the 
cheeks in several children for a number of years, and leave; at a sub- 
sequent period, a small cicatrice in the spot it had occupied. The 
disease, however, more commonly begins in the face, as an irregular 
cluster of little tubercles of a dingy red colour, and a flattened or len- 
ticular form, scarcely rising above the level of the skin. In some 
cases, they implicate a great portion of one or of both cheeks, of the fore- 
head, and even of thence in general. These tubercles do not ulce- 
rate on theirsummits ; and the sores that are occasionally encountered 
in th£ circumference of the clusters, are so rare that they must be 
held entirely accidental. The disease spreads by the formation of fresh 
tubercles, which spring up near those that already exist, and thus by 
degrees increase the area of the diseased surface — lupus non exedens 
serpiginosus. The skin and subjacent cellular substance often become 
affected with an indolent infiltration, and the diseased surfaces look 
puffy and enlarged. The yellowish-red colour of the tubercles dis- 
appears under the pressure of the finger. The patient does not expe- 
rience any pain ; but touching the parts causes uneasiness; and the 
diseased surfaces frequently become sensible after violent exercise, 
and indulgence in spirituous liquors. The tubercles begin to shrink 
in the centre of the group; the skin there grows red, shining, slightly 
furfuraceous, and subsequently assumes the look of such a cicatrice 
as is formed after a superficial burn ; it is, however, beset with points 
of a yellow coppery colour, due to the tubercles which, from shrinking 
themselves, or from the tumefaction of the neighbouring 'subjacent 
parts, are brought to the level of the skin. The clusters appear 
mingled with white points and bands, which are evidently cicatrices, 
owing to the disappearance of tubercles of another date, and which 
in vanishing have caused this singular alteration of the integuments. 
The tubercles of lupus non exedens are habitually affected with an 
epidermic desquamation, which is usually most remarkable around the 
circumference of the clusters where they are best defined. 

The features occasionally become very much enlarged in this dis- 
ease ; the cheeks, soft and flabby, or pasty, preserve to a certain 
degree the print of the finger, and look as if they were affected with 
the Arabian elephantiasis. The forehead and eyelids are puffed, and 
the eyes, covered with hypertrophied masses, seem sunk and hidden 
in the bottoms of the orbits ; the lips, too, are considerably swollen, 
and often form two enormous, flabby masses, which expose the mucous 
membrane of their inner surface turned outwards; the ears, in fine, 
occasionally participate in this general tumefaction of the face. The 
tubercles of lupus non exedens are rarely affected with ulceration ; 
such as does occur is accidental, very superficial, and covered with 
thin, laminated and but slightly adherent incrustations. This disease 
continues for an indefinite period ; whether left to itself or modified 
by the action of various therapeutic agents, the affected parts never 
regain their natural state completely ; the tumefaction of the skin and 
subcutaneous cellular tissue diminishes, the tubercles shrink and dis- 
appear, but the skin continues thin, shining, smooth to the touch, and 
seems to have lost something of its proper thickness. 

2d. Lupus non exedens occasionally appears on the extremities in 
one or more clusters of small flattened lenticular tubercles, of a 



yellow-red tint, changing subsequently into patches of an irregular 
circular shape, the areas of which are red, furfuraceous, often tra- 
versed by prominent bands, whose salient edges are evidently tuber- 
culated, and covered with firmer and thicker squamae. When this 
eruption is left to itself, fresh tubercles appear successively in the 
circumference of the primary clusters, and encroach more and more 
upon the healthy integument; in this way I have seen the disease 
extend over the whole of a limb, the arm, for instance, from the 
shoulder to the wrist. The extremity thus affected, became much 
larger than the one on the opposite side, and even acquired the 
dimensions which the same part presents in Arabian elephantiasis. 
The motions of the elbow-joint were executed with pain and diffi- 
culty; the extent of the disease was sharply defined towards the 
shoulder superiorly, and near the wrist inferiorly, by a tuberculated 
line covered with squamae. The skin of the arm and forearm, 
changed into a kind of indurated tissue of a paler colour than the 
healthy integument, was puckered or ridged with numbers of bands 
similar to those that follow burns, and sprinkled over with lenticular 
spots of a brown and dirty yellow, owing to tubercles that had shrunk 
or were buried in the substance of this tumid skin. The subcuta- 
neous cellular membrane was infiltrated, and in several places, pitted 
under pressure. At intervals, variously remote from each other, some- 
times under the influence of the deuto-ioduret of mercury exhibited 
internally, sometimes to all appearance spontaneously, the skin and 
cellular substance under it were attacked with a low kind of inflam- 
mation, attended with some swelling, heat and pain, but without any 
distinct external redness. A serous exudation then took place from 
a number of fine pores, or openings which were visible on the sur- 
face of almost the whole of the tubercles, and into which the point 
of a large pin might have been insinuated. This intervening inflam- 
mation was always followed by a diminution in the size of the extre- 
mity, and the dispersion of a certain number of tubercles. I have, 
however, seen this variety of lupus non exedens, disappearing about 
the shoulder, at the same time that the disease was making rapid 
advances around the elbow and forearm. 

3d. Lupus non exedens is occasionally evolved below the ear, and 
on the nucha, whence it extends in one instance towards the throat 
and shoulders, in another towards the occipital region, which it de- 
spoils completely of hair. 

721. Both of these varieties of lupus appear at first sight to be 
diseases entirely of a local nature. Those who are attacked with 
them are commonly in the enjoyment of pretty good health at the 
time ; females, indeed, occasionally complain of something like de- 
rangement in the periodical discharge, especially when the constitu- 
tion appears to have a scrofulous taint, and when the disease is of 
some extent; yet I have known several women who suffered from 
old and inveterate lupus in whom the catamenia had always been 
regular and pretty copious. 

Of all intercurrent diseases erysipelas is the one which is most fre- 
quently observed along with lupus. The occurrence of this inflam- 
mation is occasionally to be accounted a lucky accident, especially 
in the lupus non exedens serpiginosus, inasmuch as under its influence 
a certain number of tubercles are always dispersed, and the whole 
disease may even be brought to a fortunate conclusion. But it also 
happens now and then that an attack of erysipelas, even in effecting 
a desirable modification in the state of the diseased integuments, may 
be attended with nervous symptoms of such severity as to make its 
occurrence subject of deep regret. As to the diseases of the skin 
and other affections which existed previously to the development of 
lupus, the whole, with the exception of scrofula, perhaps, appear to 
be strangers to its cause. 

722. Causes. — Lupus is happily a disease rather of rare occurrence. 
It is most generally developed between the sixteenth and twenty-fifth 
year, and seldom shows itself after the age of forty. Scrofulous chil- 
dren are of all individuals those -who are most obnoxious to its attacks ; 
yet it undoubtedly occurs among the robust who have lived in the' 
habitual enjoyment of excellent health. The disease is frequently un- 
influenced by the arrival of puberty, and may recur in those who have 
suffered from it in their youth. It seems to be more common in the 
country than in towns ; and, perhaps, also to attack women more fre- 
quently than men. The. poor inhabitants of Haute-Auvergne who 






»56 



TUBERCULA. 



liyc on acrid food, such as old cheese, tainted meats, &c, and house 
with their cattle, are often attacked with it. The disease is not conta- 
gious, and is seldom seen among the better classes of society. Blows, 
See, under the influence of which it has seemed occasionally to 
be developed, can only be regarded as determining and occasional 
causes of the disease. 

Diagnosis. — Lupus is easily distinguished from rosacea, Greek 
elephantiasis, syphilitic affections, and the other forms of cutaneous 
disease that present tubercles, or ulcers covered with incrustations of 
varying thickness. Scrofula is peculiar to individuals of a strumous 
constitution ; the tubercles, sores, and affections of the bones and 
lymphatic glands that accompany it have peculiar characters. Further, 
scrofulous ulcers extend by the detachment of their edges from the 
subjacent tissues, and the formation of sinuses, in consequence of the 
softening and suppuration of lymphatic glands, of caries of the bones, 
&c. ; whilst the ulcers of lupus are the effect of a process that con- 
sumes the skin and neighbouring parts from without, inwards — from 
the surface towards the deeper structures. The red colour, the ery- 
thematous areola that surrounds the circumscribed indurations which 
succeed the pustules of rosacea, and these pustules themselves, which 
are generally met with in the neighbourhood of such indurations, are 
so many characters distinguishing this affection from the discoloured 
and indolent tubercles of lupus. In Greek elephantiasis the general 
tawny colour of the skin, the form and arrangement of the tubercles, 
which are nearly of the same tint, and present themselves as small 
knotty and unequal tumours, as well as the partial augmentations in 
size, succeeded by swellings that deform the face, are so many symp- 
toms foreign to lupus non exedens. Further, the tubercles of this variety 
of lupus are commonly arranged in circular groups, the limits of which 
are strongly marked and covered with squamae, which is not the case 
with Greek elephantiasis. With the slightest attention it seems im- 
possible to confound the circular clusters of lupus non exedens though 
covered with squamae, with the patches of lepra, the areas of which 
never show any thing like the cicatrice of a burn, nor the lenticular 
stains of a tawny yellow hue, produced by such tubercles as have 
shrunk, or such as are arising in their circumference (§ 674). The 
ulcers of Greek elephantiasis are always more superficial than those of 
lupus exedens, and show no tendency like them to attack the neigh- 
bouring healthy parts. Lastly, the tubercles of Greek elephantiasis 
are commonly disseminated over several points of the surface of the 
body, and are accompanied with many other symptoms that never 
occur in lupus. 

The crusts of impetigo, yellow, prominent, rugous, and often very 
slightly connected, especially on the face, are very different from the 
thick, brown and firmly adhering scabs of lupus exedens, which, more- 
over, terminates in ulceration and cicatrization, consequences never 
seen in impetigo. It is also of importance to distinguish lupus exedens 
from some cancerous and syphilitic affections of the skin. Cancerous 
tubercles, very hard and often painful, are evolved among subjects 
more or less advanced in life, on the nose, cheeks and lips, especially, 
and generally exist for some considerable time before they ulcerate ; 
lupus exedens, on the contrary, almost never appears in persons past 
the prime of life. , and its tubercles are unaccompanied with pain from the 
first. Phagedaenic cancer frequently commences in a solitary tubercle : 
in lupus exedens there are usually several, and in lupus non exedens 
there are almost uniformly a considerable number. Further, cancerous 
ulceration is often attended with considerable swelling of the soft 
parts, and the neighbouring vessels are dilated and varicose ; these 
sores are also made w T orse by the application of escharotics ; when the 
nose is the part affected, the bones also suffer and exhibit alterations 
characteristic of the disease. Lastly, cancerous sores discharge plenti- 
fully and are painful ; they are not covered with thick dry scabs like 
lupus. 

Syphilitic tubercles un-ulcerated, are more rounded, larger, and pro- 
minent in a greater degree, they are also of a more coppery red colour, 
without epidermic exfoliation, and have less tendency to ulcerate than 
those of lupus exedens, whose tubercles, flattened in their forms, and 
accompanied with a slight puffiness of the skin, are almost always 
covered with a small epidermic lamella ; they are arranged in clusters, 
the circumference of which is strongly defined, while the centre is 
erythematous, iurfuraceous, and traversed by lines or bands of a dull 



white colour. To conclude, syphilitic tubercles, as consecutive symp- 
toms of a venereal affection, are favourably modified by mercurial 
preparations, and commonly appear in individuals of a certain age, 
whilst lupus resists mercury in every form, and makes its attacks most 
generally among children and persons before the age of puberty. The 
ulcers that follow syphilitic tubercles are deep, and their edges are 
tumefied, of a coppery red tint and sharply cut ; whilst those of lupus 
exedens differ in their causes and in their mode of destroying parts. 
In lupus exedens of the nose, the skin is commonly first ulcerated, the 
cartilages and bones being only attacked consecutively, and often after 
a very long interval has elapsed from the beginning of the disease ; 
in syphilis, on the contrary, the bones are the structures that usually 
suffer first, and it is only after portions of them are affected with 
necrosis that the skin is perforated with ulcers. Lastly, tubercles and 
ulcers of syphilitic origin are almost always accompanied with symp- 
toms that distinctly tell of their nature, such as nocturnal pains in the 
bones, exostoses, iritis, and often with tubercles or sores of the mouth, 
pharynx, velum palati, &c. The solitary tubercles of lupus exedens 
of the cheeks have frequently been mistaken, during their stationary- 
period, for small sanguineous tumours or naevi; they differ from these, 
however, both in their structure and mode of formation, as well as in 
their tendency and termination. (Vide Tumour vascular, in Vocab.) 

724. Prognosis. — Lupus is always a very obstinate disease. Months 
and even years commonly elapse before it yields to any form of treat- 
ment. Lupus exedens is not generally subdued until a considerable 
extent of parts has been destroyed, and always leaves indelible and 
deformed cicatrices behind it. The disease proves so much the less 
troublesome, and its effects less deplorable, as we are called upon to 
treat it at an earlier period of its existence, and as its progress, has 
been slow. So long as the cicatrices remain soft, bluish, and con- 
vey to the finger something like a feeling of fluctuation, and so long as 
they are surrounded with tubercles of different sizes, there are grounds 
to apprehend a renewed attack of erosive inflammation, in which case 
the tubercles ulcerate, and the cicatrices already formed are not long 
of again becoming open. Puberty, and the establishment of the men- 
strual flux, which among women produce favourable changes in the 
greater number of chronic skin complaints, appear to have little influ- 
ence in modifying or mitigating the destructive character of lupus. 

725. Treatment. — The first indication in commencing the treatment 
of lupus is to endeavour to modify the general constitution by appro- 
priate remedies. The disease itself is at the same time to be combatted 
by such external and internal medicines as appear to exert a salutary 
influence on the development and progress of tubercles and the ulcera- 
tive process. When individuals of a flabby or evidently scrofulous 
habit are attacked with lupus, they may every morning take with ad- 
vantage a tablespoonful of a solution of the hydrochlorate of lime, 
made by dissolving a drachm of the salt in a pound of water; every 
eight days the dose may be increased by a spoonful, and the medicine 
may at last be carried to the length of ten or even twelve spoonfuls in 
the course of the day with propriety. This is a preferable medicine 
to the hydrochlorate of baryta, the activity of which sometimes gives 
grounds for apprehension. Chalybeate mineral waters and the artifi- 
cial preparations of iron may also be tried. I myself make frequent 
use of a powder composed of carbonate of iron, cinchona and cinna- 
mon. Others have recommended the carburet and sulphuret of iron. 
Sulphureous baths taken every day, for one or two months, the patient 
continuing immersed for several hours each time, are also powerful 
means of modifying flabby and scrofulous constitutions. Bitter medi- 
cines, such as the infusion of gentian, &c, and above all, the prepa- 
rations of iodine, are employed with the same views. Food of good 
quality, the moderate use of some generous wine, a residence in a 
dry and bracing air, are also powerful modifiers of constitutions of the 
above description. 

Each variety of lupus presents particular indications : 
1st. It is seldom that we are called in time to attempt the resolution 
of the primary tubercles of lupus exedens ; patients generally present 
themselves with ulcers more or less extensive. When any tubercles 
exist, they appear disseminated in the neighbourhood of some ulcer, 
which it is then of the last consequence to check in its destructive 
progress. This is generally effected by means of caustic applica- 
tions; — the animal oil of Dippel, the nitrate of silver, potassa fusa, 



LUPUS. 



257 



butter of antimony, super-nitrate of mercury, arsenical powders and 
pastes, and the actual cautery, have each had, and still have, their 
supporters. When the disease is very extensive, the cauterization 
ought to be at first confined to a single part, and extended success- 
ively to the whole of the affected surfaces. "When the ulcers are 
covered with scabs, these must previously be got rid of by means of 
softening poultices. In lupus exedens nasi, when this part is affected 
with an indolent enlargement, and its surface is of a purplish hue, 
and covered with an epidermic exfoliation, it is often advisable to 
carry a hair pencil, dipped in the animal oil of Dippel, gently but 
repeatedly over the whole extent of the diseased skin The nitrate 
of silver employed in solution, in a similar manner, has, however, 
generally appeared to me a preferable application. In the more 
serious cases, the nitrate of silver is very advantageously employed 
after the parts affected have been once or twice touched with the 
acid nitrate of mercury or the arsenical paste of Frere Come ; it is 
the most useful escharotic, indeed, whenever the object proposed is 
to cauterize superficially and with little pain. The acid nitrate of 
mercury may be applied not only to the ulcers of lupus exedens, but 
to the tubercles themselves, and to such of the cicatrices as remain 
bluish and soft, and threaten again to break open. When the end 
proposed is to produce an eschar of considerable depth, which is 
often necessary, the acid nitrate of mercury has indisputable advan- 
tages over the other active caustics that are often employed in the 
same intention, such as the potassa fusa and butter of antimony. A 
small dossil of lint is dipped in the solution, and applied to a portion 
of the diseased surface twelve or fifteen lines in diameter ; a little 
soft dry lint is then to be laid over the space cauterized ; this trifling 
operation is not performed without the infliction of severe pain. The 
surfaces destroyed in this way are at first of a greenish- white colour ; 
a yellowish and slightly adhering slough or scab is gradually formed 
afterwards, and the eschar is finally thrown off at the end of a week 
or a fortnight. Arsenical pastes can only be employed with safety as 
escharotics, by enforcing precautionary measures of the greatest strict- 
ness against their entrance into the nasal fossae. The use of the acid 
nitrate of mercury as an escharotic, has the same disadvantage as the 
arsenical paste, in occasionally causing a considerable degree of erysi- 
pelatous inflammation ; this consequence, however, is in general much 
less severe, and far more transient with the mercurial than with the 
arsenical preparation. 

In lupus of considerable extent affecting children, women, and 
subjects of irritable constitution, the ulcerated surfaces, freed from 
incrustations, may be dusted over with a thin layer of a powder 
composed of ninety-nine parts of calomel, and one of arsenious acid. 
This application is much employed by M. Dupuytren, according to 
whom it acts rather as a specific than as an escharotic. Should the 
affected parts be covered with an imperfect cicatrice, it is even advi- 
sable to destroy this, and to apply the powder four-and-twenty hours 
afterwards. Should there be any difficulty in getting the powder to 
adhere insufficient quantity, it may be mixed with a little gum- water 
or simple ointment and applied ; in this case, however, the dose of 
arsenious acid employed must be increased by one or two hundred 
parts. In every case we are to wait till the powder or unguent falls 
off of itself, which usually happens after the lapse of eight or ten days, 
and then renew the application until a complete cure takes place, 
which is occasionally accomplished within eight or ten weeks, that is 
to say after five or six applications of the remedy. When the ulcer- 
ated surface is of considerable extent, it is advisable to apply this 
compound powder to a space of about two inches square at a time, 
and only to cover the whole extent of parts affected by degrees. 
Lastly, when the ulcers of lupus are of very old standing, and 
extremely indolent, great benefit is occasionally derived from cover- 
ing them with a blister, before beginning the application of the 
powder or salve above mentioned. The advantages possessed by this 
powder over the arsenical paste in common use, (pdte arsinicale de 
frere Come,) are those of not exciting erysipelas in the tissues around 
the diseased structures to which it is applied and in cauterizing much 
less deeply, so that it may be used again and again without danger to 
the patient. The relative proportions of its component ingredients 
inay be changed by the cautious practitioner, according to the extent 
and circumstances of the case he has in hand ; but it seems important 
65 



that neither be omitted, inasmuch as both appear necessary to its 
action, without our being able to determine precisely the part which 
each of them plays in the general effect. 

726. The arsenical powder of frere Come 1 is a more energetic 
external remedy, which seems more particularly available in cases of 
old and obstinate ulcerated lupus, the ravages of which have been 
found uncontrollable by other less active applications. It is well to 
have recourse to this preparation at the very outset in lupus exedens 
of the cheeks. To prepare it for use a small quantity must be made 
sufficiently thin upon a piece of broken earthenware plate, and by 
means of a spatula spread upon a surface that ought not to exceed 
eight or ten lines in diameter. This application is almost always fol- 
lowed by some degree of erysipelas, which, when slight, may be left 
to itself; but when it proves severe, when the face becomes very 
much swollen, and the patient complains of violent headache, whilst 
the pulse is full and frequent, blood-letting must be practised, leeches 
attached behind the ears, emollient or laxative lavements thrown up, 
stimulating pediluvia employed, &c. ; the inflammation soon abates, 
and the only consequence of the application of the arsenical caustic 
that remains is a blackish and thick eschar which continues very- 
long adherent. These are all much more effectual modes of produc- 
ing eschars and arresting the current of diseased action in lupus than 
the use of the actual cautery, a remedy which in this complaint is 
nearly abandoned at the present day. In lupus exedens of the nose, 
indeed, it frequently aggravates the disease, causing the cartilages to 
swell and be absorbed ; it would appear to be rather more applicable 
in lupus of the cheeks. Whatever the form of cautery or caustic 
employed, when the eschars are detached, they seldom fail to expose 
an ulcerated surface of the best appearance beneath them ; a single 
application of the caustic, however, is generally insufficient to accom- 
plish a cure ; ten, fifteen, twenty, thirty or more, may be necessary 
in the course of several years, when the diseased surfaces are very 
extensive and of ancient date ; a cure, indeed, is seldom or never 
consummated but by perseverance and undeviating attention. Whilst 
this is going on, when the nose is the seat of the disease, it is neces- 
sary to guard against the contraction of the nostrils, which then fre- 
quently show a great tendency to close up. They must be enlarged, 
when they have shrunk in any considerable degree, with the knife or 
caustic, and kept from again shrinking during many months by means 
of tents of prepared sponge. 

727. During the treatment, patients should avoid exposure to ex- 
cessive heat or to rigorous cold. By want of attention to this simple 
precaution, cicatrices that appeared sound have frequently been seen 
to open out afresh. When the disease is accompanied with any evi- 
dent functional disturbance, this must be remedied by appropriate 
means. When amenorrhcea complicates it, the return of the cata- 
menia must be solicited, and the appearance of this discharge kept 
up by every means at our disposal ; when it cannot be brought back, 
a few leeches should be vicariously applied to the external parts, 
when symptoms of general uneasiness, or pains in the head, &c, seem 
to indicate the periods of its natural flow. 

728. Lupus non exedens is a more obstinate disease, if possible, 
than the one we have just been engaged in describing ; in the hope 
of effecting the resolution of the tubercles which characterize it, the 
most powerful medicines of every description have been pushed to 
the uttermost. The tisan of Feltz, 2 Pearson's solution of arseniate of 
soda, in doses, increased from a scruple to a drachm daily ; Fowler's 
solution of the arseniate of potash even in hazardous doses ; arsenic, 
in a word, in every form, has appeared to exert but a very slight 
influence on the evolution and progress of the tubercles of this variety 
of lupus. The animal oil of Dippel has been tried, but with results 
too diversified to enable us to have any reliance on its powers. 

The deuto-iodide of mercury, in doses gradually increased from 
one-fourteenth or one-tenth to one-fifth of a grain daily, is the only 
one of all the internal medicines that I have tried, which has appeared 
to me to exert an indubitable influence upon the progress of the 
tubercles of lupus non exedens. After continuing this medicine for 
a month or two, the parts covered with tubercles frequently become 
painful, and after a kind of local or intestine inflammation, attended 

1 White oxide of arsenic, cinnabar, and animal charcoal. — Tr. 

2 A decoction of crude antimony, sarsaparilla, and fish glue. — Tr. 






TUBERCULA. 



with vague and irregular symptoms of general febrile disturbance, 
the tubercles begin to shrink, and many of them disappear entirely. 
Alter continuing the use of the deuto-iodide of mercury for two or 
three months, patients should leave it off for some short time, and 
thus to its influence repeatedly. Besides the undoubted action 
i by this preparation on such tubercles as already exist, its 
influence on the general constitution in preventing completely the 
formation of fresh tubercles, is not less remarkable. Nevertheless, 
despite my utmost care in the exhibition of the medicine, and all the 
watching I could give its action, I have occasionally had to contend 
with symptoms of inflammation in the large intestines which com- 
pelled me immediately to suspend its use, if, indeed, I was not ob- 
liged to abandon it altogether, (a) 

External applications have been administered with some success in 
this form of lupus. In the foremost rank of remedies of this class 
must be placed the inunction, over the districts occupied by tuber- 
cles, of the ioduret of sulphur ointment (K. Iodid. sulphur, gr. xviii; 
Adipis suil. 3i), of an ointment of the proto-ioduret of mercury (K. 
Proto-iodid. hydrarg. gr. xxx; Adipis Si), and of the deuto-iodid. of 
mercury (R. Deuto-iodid. hydrarg. gr. xviii; Adipis li). Under the 
influence of one or other of these unguents, rubbed on the affected 
parts, the skin becomes hot and red, and the tubercles frequently 
shrink and disappear entirely. Yet cases do occur in which these 
applications produce little or no amendment, if they do not perchance 
excite unpleasant erysipelas of the face. 

729. The occurrence of this inflammation as a consequence of the 
internal use, or external application of these preparations, however, 
frequently appears to have a beneficial ulterior effect, not only on the 
part in which it is developed, if this chance to be beset with tuber- 
cles, but, further, on the clusters at some distance from the seat of 
this new affection. This circumstance was presented to my notice 
in a very recent instance in the Hopital de la Charit6 : A young 
woman labouring under lupus non exedens of the cheeks, forehead, 
and left arm, was attacked with erysipelas of the face, and during the 
continuance of this kind of exanthematous fever, the skin of the arm 
underwent as evident an improvement as that of the cheeks. 

730. In the hope of preventing the extension of the tubercular 
clusters of lupus, I have isolated them by an incision, as well as by a 
deep application of caustic; but in vain; fresh tubercles appeared 
beyond the artificial boundary I had traced. The destruction of the 
clusters by caustic, or their extirpation with the knife, would be at- 
tended with no good effects in the greater number of cases: to 
cure this variety of lupus completely it were necessary to eradicate 
the unknown cause under the influence of which its tubercles are 
evolved ; and it is probable that the only means by which this can be 
in any way accomplished consists in the exhibition of those medicines 
which pervade the whole system, and alter it deeply. 

Historical Notices and particular Cases. 

731. Hippocrates mentions eating or gnawing herpes, 'epiietes 
iaOw/tttoi 1 and eating ulcers Oftia. 2 Celsus has amalgamated the ac- 
count of these two forms of disease, in his description of thenoma, 3 
in which the striking and essential features of lupus may be recog- 
nised. From this time the denominations, herpes esthiomenes ;* herpes 
exedens; 5 herpes ulcerosus f and dartre rongeante, 7 eating tetter and 

(a) The benefits promised in the text from the use of the iodide of 
mercury, may, with still stronger probability, be procured by the 
iodide of mercury and arsenic, (Donovan's solution) — Dr. Dunglison 
(JVew Remedies, 4th ed.), among others, speaks favourably of this pre- 
paration, employed both internally and externally. 

' Hippocrates. Pracdictorura, lib. ii, ed. Foes, in-fol. Francofurti, 1621, p. 98. 
2 (hconom. Hippocr. art. fl, 5 -«. v 

n,P„n, e rl S «n,;, Lib ' V-de Theriomate: H >'psum ulcus neque (actum, neque medica- 
re ruKuodLr," 8 .' tantU r m ° VetUr • • atq * ,e U qU ° qUe ma,um ser P"> fit 1 ue ex 
usque " , 'a corpus VST" ^ V ° Cant ' qUia celeritw Ser P endo > Penetr.ndoq«« 

* Forestus. Observ. chirurg., lib. ii. obs. v. p. 42. 

* F. Joel. Oper. chirurg. de ulceribus, p 221 

6 Amatus Lusitanus. Curat, med., cent. ii. curat. xxxvii. p. 185. 
I Alibert. Precis theonque et pratique sur les maladies de la peau. 



phagedenic ulcer have been in very general use among medical 
authorities. The translators of the Arabian writers introduced the 
titles formica corrosiva," and formica ambulativa ; by which they 
rendered the Arabic word, that appears to correspond to the esthi- 
omenous or eating herpes of the Greeks. The term lupus, introduced 
into our modern momenclature, by Willan and Bateman, had already 
been applied by several writers of the middle ages to designate aii 
eating ulcer; 9 in the same sense, therefore, as the term herpes exedens 
was employed of old. The disease which we have described under 
the name of Lupus, has further been confusedly spoken of under that 
of papula J era, 10 although the disease mentioned by Celsus under this 
title is evidently lichen agrius. Lupus has also been described under 
the head of noli me tangere, 11 a designation which has likewise been 
applied to cancer; and Delpech, 12 under the name of lupus of the 
fingers, has given the details of an ulcerous disease attended with 
extreme pain, to relieve which he was even compelled to divide the 
ulnar nerve. Alibert first described lupus under the title of dartre 
rongeante, but has more recently designated the disease under the 
denomination of esthiomene. Messrs. Cazenave and Schedel, who 
have taken great pains to expose the characters of this disease, have, 
like myself, adopted Willan's name, lupus, which has the advantage 
at least of not designating as phagedenic or eating the whole of the 
varieties of this disease, one of which does not even cause ulcera- 
tion of the skin. M. Bachelet de Lindry 13 was certainly to blame 
when he united, under the title of dartre rongeante, the details of 
cancerous sores, and of ulcerated syphilitic tubercles of the skin. 
M. Arnal has mentioned a lupus exedens of the septum nasi, and arch 
of the palate. 14 The remarks of M. Biett, 15 and of M. Paillard, 16 on 
the use of the ointment of the deuto-ioduret of mercury, may be con- 
sulted with advantage. The observations of M. Lugol 17 on the 
employment of iodine in cutaneous phagedcenic scrofula ; and those of 
M. Lemasson 13 on the exhibition of opium and iodine in combina- 
tion, will also be read with profit. To conclude on the subject of 
escharotics, the dissertations of M. Guillermineau on the nitrate of 
silver, 4to., Paris, 1824, of Mr. Godart on the acid nitrate of mer- 
cury, 4to., Paris, 1826, and the essay of M. Patrix on the art of 
applying the arsenical paste, 8vo., Paris, 1817; as well as an account 
of several cases of lupus treated by caustic applications, in the Jour- 
nal Hebdomadaire, 19 will be found to give a large amount of informa- 
tion. The case related by M. Brillouet, 20 under the title of dartre 
rongeante, is evidently one of impetiginous eczema. 

Case CXXV. — Lupus non exedens serpiginosus ; deuto-ioduret of 
mercury ; erysipelas; bitters ; improvement. HeleneH * * *, aged nine- 
teen, of fair complexion, was received into the Hopital de la Charite, in 
December, 1832, labouring under lupus, which had appeared, when 
she was but three years old, upon the upper part of the left arm, and 
extended from thence, in spite of various applications, as far as the 
wrist. To this extent of surface the disease continued limited during 
twelve years. At the age of fifteen, however, when the catamenia 
first made their appearance, the disease, besides increasing in severity 
on the arm, began to attack other regions, — the cheeks, chin, upper 
part of the right buttock, and neighbourhood of the left knee. All 
the remedial measures again enforced, proved as unavailing as ever 
against the progress of the disease. 

On the entrance of the patient into the hospital, the whole of the 
left arm, from about three finger-breadths below the thick of the 
shoulder to the wrist, was one mass of disease ; it was bounded above 
and below by a distinct rank of tubercles, several lines in breadth, 

8 Avicenna, fen. iii. lib. iv. Tract, i. cap. vi. — Fen. iv. Tract, iii. cap. i- — Zacutus 
Lusitanus. Prax. hist.," lib. i. obs. 66. 

9 Th. Bonet. Oper. chirurg., t. ii. lib. vi. De affectibus externis, sec. iv. p. 305. 

10 Haffenreffer (Sam.). De cutis affectibus, lib. i. cap. xv. p. 161. 

" Cooper (Samuel). Dictionary of Practical Surgery, 8vo. London, 1829. Art. 
Noli me tangere. 

■ 2 Gazette des hopitaux, 1832, p. 458. 

13 Diss, sur la dartre rongeante, in-8. Paris, 1803. 

14 Journal Hebd., deuxieme serie, t. vi. p. 29.; ibid., p. 137 ; t. viii. p. 437. 

15 Rec. period, de la soc. de med. de Paris, t. lvii. p. 187. 

16 Journ. Hebd., deuxieme serie, t. viii. p. 99. 
" Journ. Hebd., U iv. p. 76. 

18 Nouvelle Biblioth. med., 1826. 

,9 Troisieme Essai sur l'emploi de 1'iode dans les maladies scrofuleuses, in-8. 
Paris, 1831, p. 61. 
20 Journ. Hebd., t. iv. deuxieme serie, p. 117. 



LUPUS. 



259 



and presenting a sharp and well-defined edge towards the healthy 
skin, and was higher here than on the inside, towards the diseased 
surface, where it was flattened, and covered with whitish or yellowish 
squama?. Seen from a certain distance the disease had very much 
the appearance of a large cicatrice produced by a burn ; but more 
narrowly inspected, the whole surface was found beset with hard, 
flattened, and, in general, but slightly prominent tubercles, of a dusky 
red colour, and varying in size from that of a large pin's head to that 
of a pea. The greater number of these tubercles, which were more 
prominent than the generality, were without squamae ; the remainder 
were scaly on their surface, and disseminated over the limb, more 
especially in the line of extension. The squamae were thin, easily 
detached, and broader in the circumference than in the centre of the 
tubercles, around which they formed an irregular indented circle. 
Besides these squamae, quantities of flimsy lamellae, bran-like in 
appearance, were seen at the bottoms of the furrows which intersected 
the whole of the diseased surface. The skin in the spaces between 
the tubercles was of a pale rose, or slightly violet hue. An irregular 
whitish cicatrice extended between the arm and forearm, impeding 
the ready extension of the elbow-joint. The bursa that lies over the 
olecranon was distended with fluid. 

Both cheeks were almost completely covered with a pretty regularly 
circular patch of lupus, the circumference being formed by a well- 
defined raised ring of flattened, yellowish tubercles, and its middle, 
of a rose colour generally, but mottled with white, naked in some 
places, in others covered with flimsy epidermic scales. Under the 
chin and on the forehead there were two small clusters of not more 
than three or four tubercles each, covered with thin squamae. 

The patient was at first put upon a course of bitters, combined with 
the exhibition of one-twenty-fourth of a grain of the deuto-iodide of 
mercury daily, whilst the clusters on the cheeks were regularly rubbed 
with an ointment of the ioduret of sulphur. The dose of the deuto- 
ioduret was gradually increased till the tenth of a grain was taken at 
a time. The iodide of sulphur was continued in frictions externally ; 
the patient took a few simple and then several sulphureous baths 
(March, 1833). Towards the end of April the squamae which covered 
several of the tubercles of the arm were detached, and not reproduced. 
The tubercles looked shrunk, but those that bounded the disease 
interiorly and that were the largest, did not appear to have undergone 
any modification. About this time, however, a kind of excitement 
seemed to take possession of the forearm, which became swollen, 
painful and generally shining on the surface. The tubercles which 
on the entrance of the patient were of a dull red or pale rose colour, 
enlarged, got more sensitive, and anon were affected with a serous 
exudation to such an amount that the patient was obliged to change 
the linen dressing that was now applied several times a day. A 
minute orifice could be perceived by close inspection on the summit 
of several of them, and when those that were swollen and of an oval 
shape were pricked with a needle, a globule of transparent, yellowish 
serum could be expressed from them. At a later period these tuber- 
cles declined in size, became less sensitive, shrunk to the level of 
the surrounding skin, faded generally in depth of colour, and ended 
by disappearing completely. The skin of this part, however, did not 
recover its natural pliancy. The patches of the face underwent no 
remarkable change. During the month of May the internal medicine 
was continued ; the external application was suspended, and gelati- 
nous were substituted for sulphureous baths. The state of the disease 
was everywhere stationary. During the course of June, the deuto- 
iodide of mercury was carried to the length of one-eighth of a grain 
daily, and for five or six days consecutively the sulphur ointment was 
rubbed upon the affected parts. On the 15th general uneasiness was 
complained of, and the patient was attacked with vomiting of bilious 
stuff". There was no fever. These symptoms I ascribed to the deuto- 
iodide, and ordered it to be suspended for five days ; the common 
effervescing draught checked the sickness. The medicine was not 
resumed before the 12th of July, when it was again prescribed in the 
dose of one-twelfth of a grain. Vomiting supervened for the second 
time, and was now accompanied with fever. Leeches were applied 
to the epigastrium, and the patient was confined to low diet. The 
unpleasant symptoms soon ceased. 

August. — The deuto-iodide was resumed and continued to the 



15th, when it was suspended, and decoction of bark and gentian, 
with carbonate of iron, prescribed in its stead. The same medicines 
were continued during the whole month of September. The disease 
seemed nearly stationary. October 5th.— Uneasiness, retching. 6th. — 
An erysipelatous point appeared on the face (mercurial inunction). 
7th.— It extended to the forehead (V. S. B. ad gxii); fever in the 
evening rather severe ; some delirium during the night; the diseased 
arm became hot, and slightly swelled ; the erysipelas spread to the 
scalp. 9th. — Incessant delirium ; decubitus on the back ; pupils di- 
lated ; no answer to questions ; diminished sensibility of skin ; pros- 
tration ; difficult deglutition; breathing deep; skin hot; pulse 110 
per minute. (Venesection in the morning ; forty leeches in the evening 
to the mastoid processes ; ol. ricini.) 12th. — Continuance of the cere- 
bral symptoms; coma; the erysipelas fading. (01. Croton, gtts. 2. 
Whey with cream of tartar ; blisters to the clusters of the cheeks.) 

13th. — The comatose state continues ; pulse weak and frequent. 
(Ice constantly to the head.) 14th. — The ice continued ; a purgative 
glyster brought away a copious and foetid evacuation from the bowels ; 
the comatose state ceased ; the face was desquamating rapidly The 
remarkable point in the history of this erysipelatous fever is this: that 
many of the tubercles of the forearm and arm shrunk away. The 
bold lines, too, that bounded the disease above and below, disap- 
peared almost completely. This favourable change, however, was 
purchased with a severe illness, and a subsequent attack of melan- 
cholic delirium, in which the patient fancied her life, and that of her 
relations, were threatened, &c, and which was not dissipated for 
many months after her return to her family. She left the hospital on 
the 1st of November, 1833. 

Case CXXVI. — Lupus exedens of the left ala nasi. P. F. C, aged 
thirty-one, entered the Hopital de la Charite the 3d of April, 1833. 
Except an habitual cough depending on a chronic bronchial affec- 
tion, this man had always enjoyed good health until he became locally 
affected with lupus around the nostrils, about eighteen months ago. 
At this time, without known or suspected cause, a spot (bouton) of 
considerable magnitude, and of a deep red colour, probably a tuber- 
cle, appeared on the furrow corresponding with the upper edge of the 
cartilage which forms the left ala of the nose, with no other symp- 
toms than a slight feeling of tension and itchiness, that led the patient 
to scratch the part ; this caused it to ulcerate ; it became covered 
with a yellowish scab, by picking which, the progress of the disease 
seemed to be accelerated. Other tubercles made their appearance in 
the neighbourhood of the spot first formed ; but these did not ulcerate. 
The skin upon which they were evolved was of a deep-red colour, 
and covered with squamae. C * * * had entered himself a patient of 
the Hopital St. Louis in March, 1832, six months after the appearance 
of the disease. There the sore was cauterized ; vapour-baths were 
administered ; the parts affected were anointed with an ointment of 
the deuto-ioduret of mercury ; an infusion of hops and chalybeate 
medicines were prescribed. Various other medicines were subse- 
quently tried, among them the syrup of Cuisinier. 1 Having got 
considerably better he left the hospital. 

When C * * * entered La Charite, the anterior and outer part of the 
left ala nasi, near its junction with the cartilage of the septum, was 
destroyed; the part in this situation presenting a semicircular notch, 
irregular in its outline, of a sallow-red colour, and partially covered 
with laminated yellowish-gray scabs, which adhered pretty firmly, and 
clung more especially to the inner surface of the remaining portion of 
the ala nasi. Externally the skin was of a deep-red, and covered also 
with small, half-raised squamae. The right ala nasi was in the same 
condition, especially in three different places, corresponding to so 
many small tubercular elevations. The patient only complained of a 
little smarting in the affected parts from time to time. There was no 
unpleasant odour, and no discharge. The patient was at this time 
labouring under one of his habitual attacks of bronchitis, which was 
acute in its character, but was successfully treated by rest, mild dilu- 
ents and purgatives. 

After washing the nose with decoction of althea, the diseased struc- 
tures were touched with the nitrate of silver in substance, on the 20th 
of May. On the 23d, after bathing anew with decoction of althea, 

4 A comp. syrup of sarsaparilla, senna, &c— 7V. 



260 



TUBERCULA. 



and applying an emollient cataplasm to remove the incrustations which 
had been but imperfectly got rid of before, the parts affected were 
touched in the morning with the acid nitrate of mercury. This caused 
pain, which lasted till mid-day. The eschar was not detached 
till the 27th, after a vapour-bath. The sore appeared covered with 
small nipple-like projections, and was of a bright-red colour. Fresh 
laminated scabs soon covered the ulcerated surface; they were thin- 
ner than at first, and the vapour-bath, which the patient took every 
day, caused them speedily to fall. June 5th. — Sulphureous baths and 
an infusion of hops were prescribed ; the latter was replaced by the 
decoction of sarsaparilla. On the 10th the deuto-ioduret of mer- 
cury was ordered in the dose of one-tenth of a grain. Under the 
influence of these various measures the squama? and scabs were repro- 
duced with less rapidity, and the small tubercles of the right ala nasi 
faded. 

20th. — The diseased surfaces were again touched with the acid 
nitrate of mercury, but without any improvement following : the dis- 
ease was stationary. The deuto-ioduret on the 25th was carried the 
length of one-eighth of a grain, and continued at this dose to the 14th 
of July, when the patient requested his discharge, and left the house 
imperfectly relieved. 

Case CXXVII. — Lupus exedens of the nose. M. C. Boulard, a 
sempstress, aged twenty-three, became my patient in the Hopital de 
la Charite, the 17th of September, 1833. This girl is in the habitual 
enjoyment of good health ; she lives in an airy situation, and has 
abundance of wholesome food. It is now about three years since a 
scab formed in the inside of the right nostril, without remarkable local 
phenomena, and when she felt herself in perfect general health. This 
scab always returned when the patient picked it off with her nail. 
The part then became chapped, pouring out a kind of sanies which 
concreted into scabs; the chap extended slowly but evidently, and a 
lenticular tubercle made its appearance on the anterior part of the 
lobe of the nose. The patient now took various tisans without ad- 
vantage. The application of a plaster, finally, which was kept open 
for several weeks, caused much pain, and swelling of the nose and 
face ; a fortnight afterwards the end of the nose sloughed off. 

When Boulard entered the Hopital de la Charit6, the one-half of 
the right ala nasi was completely destroyed, so that the septum could 
be readily seen ; and a second sore, developed in the median line on 
the point of the nose, had rendered it bifid. The soft parts that 
ought to have formed the point of the nose were gone, and the lower 
part of the cartilage of the septum was eroded. In the angles of the 
sore small scabs of a yellowish-brown colour, were observed restino- 
on moist surfaces of a pale rose tint, and mammillated on their surface! 
The skin of the nose to the distance of five or six lines from the ulcer 
was of a deep red, swelled, and covered with squama;, for the most 
part of a light gray colour, thin and dry. The transition from the 
diseased to the sound integument was rapid, and marked by a distinct 
line, above which, however, a few epidermic furfura? were still con- 
spicuous. The principal functions were regular ; the appetite good ; 
only the catamenia, which had appeared four days too soon, were 
less copious than wont. 

The patient was at first directed to take an infusion of hops, a tonic 
powder, (li. Ferri subcarb. 3; pulv. cinchon. gr. xxx ; pulv. cort. 
cinnamon, gr. xii,) and to use the sulphureous bath every day. Emol- 
lient poultices were further applied to the nose to facilitate the removal 
of the scabs and squama?. 

Sept. 20th. — Application of the acidulous proto-nitrate of mercury 
especially to the angles of the sore. The pain excited by this was 
severe, and some degree of swelling followed. In three days the 
eschar had fallen, and the parts were again cauterized ; the pain on 
tins occasion was less than at first ; no great improvement was per- 
ceptible. \ et the redness of the nose had declined, and the squama? 
were formed less rapidly than heretofore. The medicines were con- 
on!l i ,w c f atamema which should have appeared between the 
20th and 21st of October failed, and the patient complained of lassi- 
tude, general uneasiness and headache 

u T ?i! r ? d T ^ eryS r lat0US blush showed itself u P° n the nose, 
and by next day had spread to the cheeks ; the inflammation did no! 



appear very active; headache, tongue foul, thirst (diluents; mustard 
foot-bath, venesection, low diet). 4th.— The erysipelas has extended 
to the whole of the face ; general symptoms as before ; the blood ab- 
stracted is not buffy. The scabs in the right nostril are so thick that 
they obstruct the passage considerably. 6th. — The erysipelas ceased 
to spread, the febrile symptoms became moderate. 7th and following 
days, the erysipelas was resolved, and desquamation took place from 
the whole of the parts which had been inflamed. The lupus was now 
found to have undergone a remarkable change. The redness about 
the ulcer had disappeared ; the skin of the nose was smooth and 
white, the eroded parts were dry and covered with scabs of extreme 
tenuity. (Sulphureous bath.) 

Towards the end of November the catamenia again failed to make 
their appearance, and the lupus which had hitherto worn a favourable 
aspect began to ulcerate afresh. (Renewed application of the caustic 
solution ; lotions with a tvash of sulphuret of potash.) The lupus 
again looked better; but the patient became indisposed with febrile 
symptoms, which lasted to the 15th of November, when the appli- 
cation of fifteen leeches to the external organs put a period to the 
accidents, during the continuance of which a perforation had been 
made through the septum narium. The sulphureous baths were 
again tried, and repeated applications made of the nitrate of silver. 
The patient quitted the hospital some time afterwards, not sensibly 
better than when she entered. 

Case CXXVIII. — Lupus exedens of the chin, cheeks and lips, in a 
person of scrofulous habit. A young shepherd, eighteen years of age, 
was received into the Hopital St. Antoine, in 1828, labouring under 
a tubercular affection of the chin. In his youth he had suffered from 
crusta lactea (eczema impetiginodes) of the scalp. At the age of nine 
the lymphatic glands of the neck enlarged considerably, and several 
of them formed abscesses and burst, leaving indelible cicatrices under 
the angles of the jaw. 

The tubercles of the chin were of a violet-red colour, considerable 
size, slightly conical shape and ulcerated on the summit. The ulcera- 
tive process soon spread over the whole of the chin, without pene- 
trating deeply among the subjacent tissues. The sore was concealed 
beneath enormous scabs, nearly an inch in thickness, rising above the 
level of the skin, and surrounded with a red, and, as it were, erysipela- 
tous blush. The lips, cheeks and nose became rapidly the seat of new 
tubercles and ulcers ; the upper lip was particularly red and swollen. 
The eyes were inflamed and slightly sensible to the light; there was a 
large pterygium on the right eye ; the conjunctiva of the left was red 
and inflamed; the lower eyelids of both sides were somewhat everted ; 
the nostrils poured out a plentiful discharge of thick mucus, which 
dried up under the form of crusts. On the right cheek there w r ere three 
tubercles in a state of suppuration on their summits ; the left cheek and 
malar region were possessed by a broad but not very deep ulcer. 

This patient continued under treatment for nearly a year ; bitter 
medicines internally, and sulphureous baths externally, were employed; 
the powder of calomel and arsenious acid were applied repeatedly; but 
despite of all that could be done, new tubercles continued to be deve- 
loped and to fall into a state of ulceration. 

Case CXXIX. — Lupus of the nose in a scrofulous subject. Diogue, 
aged thirty-six, had menstruated at eighteen, and continued to do so 
irregularly ever since. At the age of fourteen a spot (bouton), probably 
a tubercle, made its appearance on the lobe of the nose, and continued 
in the same state for about a year, when it ulcerated and w T as followed 
by several others. This woman then went into an hospital where she 
took various medicines — infusion of hops, baths, and the elixir of 
Peyrilhe, and the ulcer cicatrized, but only after the destruction of the 
right ala of the nose, and with the contraction of the opening into the 
nostril of the same side. Two years afterwards the disease recurred, 
and Diogue became a patient in the same hospital. Under similar 
treatment, continued for two months, she recovered a second time ; 
but, probably, in consequence of her indocility or her negligence, the 
right nostril was wholly obliterated, and all that remained of the left 
one was a hole, scarcely perceptible, and only capable of admitting a 
thread. 



SCROFULA. 



261 



SCROFULA. 
Vocab. Scrofula, Struma. 

732. The title scrofula, as is well known, is given to a general and 
constitutional affection, usually proclaimed by glandular or articular 
enlargements, which are frequently followed by ulcers and fistulous 
sores. Occasionally, however, this disease appears on the surface of 
the body, when it is characterized by lesions peculiar to itself; tuber- 
cles of a livid red, which remain very long indolent and stationary, 
make their appearance on different regions of the skin ; these end at 
length by becoming softened and perforated, when they discharge a 
serous orpuriform fluid, which, exposed to the air, dries up under the 
form of crusts or scabs. 

733. The tubercular formations characteristic of cutaneous scrofula 
are the lesions which it is my object to treat of in this work ; not only 
because the skin is the element in which they appear, and because they 
have peculiar and distinguishing characters ; but, further, because it 
is often of the highest importance, in a therapeutical point of view, 
especially, to distinguish these from other tubercular diseases. It is 
therefore mainly with a view to prevent errors in diagnosis that I have 
determined to describe cutaneous and subcutaneous scrofula, and 
scrofulous ulcers in these situations. 

734. It would seem that cutaneous scrofulous tubercles may be 
developed on every region of the body ; but they are most frequently 
seen on the face, neck and upper extremities. They often appear in 
the vicinity of the scrofulous ulcers consecutive to glandular or indo- 
lent subcutaneous abscesses. I have also observed them succeed the 
bites of leeches in persons of scrofulous habit. They are seldom nu- 
merous, and more frequently isolated than in clusters. The isolated 
tubercles commence as small spots or stains of a livid red colour, and 
unaccompanied with heat, pain or itching. The finger applied to these 
spots detects something hard, like a grain of barley or small kernel 
imbedded in the substance of the skin. One or two months after its 
first appearance, the small spot, which has become gradually more and 
more prominent, acquires the tubercular character very decidedly. 
These tubercles are usually no larger than a pea, in some cases they 
equal a small olive in size. If they increase in size, at a subsequent 
period, it is only when they begin to soften. This softening, which 
is one of their principal characters, is accomplished with extreme 
slowness. It is already perceptible to the touch, before the surface 
and the circumference of the tubercles show any symptoms of excite- 
ment, and very long before they become open. The softening usually 
begins in several points, when the tubercles are of any size ; and each 
of these softened points occasionally bursts outwardly and very gene- 
rally at different times. The form of the tubercles is then irregular, 
they are uneven on the surface, full of depressions and elevations, 
and often present a small and recent perforation covered with a scab. 
Under other circumstances, whether in consequence of the softening, 
after having begun in the centres of the tubercles, extending from 
thence to their entire masses, whether, after having begun in several 
places, from ending in the formation of no more than a single abscess, 
the whole of their superficies becomes soft and fluctuating to the 
touch. Arrived at this stage, scrofulous tubercles may still remain 
stationary for a very long time: the skin, red and livid, is neither 
materially softened, nor perforated, and if the tubercle be now punc- 
tured, a few drops of a serous rather than of a purulent fluid escape. 
The opening continues for a very long while fistulous, and when it 
does cicatrize, be it naturally or after repeated applications of caustic, 
a small hard and irregular nucleus or kernel always, or almost always 
remains in the part affected. Matters are much the same when the 
tubercle is left to itself, and it bursts after an interval of one or more 
years ; the violet colour of the skin grows less intense, but the indu- 
ration does not give way in the same proportion. It very rarely 
happens that true ulcers succeed these little tumours. 

735. Cutaneous scrofulous tubercles may occur in clusters of larger 
or smaller extent. Under this form they occasionally appear on the 
outer aspect of the arm, forearm, back of the hand and fingers, coin- 
ciding for the most part with other evident strumous affections of the 
bones and conglobate glands. The form and dimensions of these 

66 



clusters are rather variable: generally they are not less than an inch, 
nor more than from two to three inches in diameter. The tubercles 
thus agglomerated stand out in relief from the skin ; they form mammil- 
lated or knubbly clusters, the violet-coloured surface of which, i- 
pretty firm in some points where the tubercles are not dissolved, soft 
and fluctuating in others where this has taken place, moist in (hose 
parts where the contents of the tubercles have made their way to the 
surface, and covered with lamellar scabs in those where the discharge 
has become hard and dry. When the constitution has suffered pro- 
foundly under the influence of scanty and unwholesome fare, and of 
the privations of every kind that attend upon extreme poverty, the 
tubercular patches sometimes put on a very peculiar appearance ; 
their surface to a very considerable extent, becomes soft, fungous, of 
a grayish white or ruddy violet colour, without any morbid increase 
of temperature and almost without pain, at the same time that it is 
habitually defiled by a yellowish, and sometimes sanguinolent, serous 
exudation. This variety of cutaneous scrofula is still slower in its 
progress and more rebellious to all remedial treatment than the 
preceding. 

736. Subcutaneous scrofulous tubercles are small circumscribed 
tumours, situated in the cellular substance, under common integu- 
ment, and developed not only in the vicinity of glandular enlarge- 
ments but in districts that are free from all other disease, and particu- 
larly on the upper extremities. These tubercles are flatter and less 
movable than enlarged lymphatic glands, and are distinguished at 
the outset by a small circumscribed lenticular hardness, situated 
under the skin, which is movable over them, and unaltered in its 
colour. They usually continue for a long time stationary in this their 
first stage; insensibly, however, and by very slow degrees, they increase 
in size, and at length attain the volume of a walnut or small egg. 

It is only at a considerably advanced period of their growth that 
the skin, which had hitherto preserved its natural mobility, becomes 
adherent to the centre of these subcutaneous scrofulous tubercles ; it 
is also in this point that at a still later period the skin acquires the 
peculiar livid red colour characteristic, among other things, of the 
affection which subsequently spreads to the base of the tumours. 

The tumours, firm at first under the finger, become soft at length, 
and if opened at this stage, a small quantity of greenish-coloured, 
serous fluid, thickened with whitish flocculi or curdy-looking matter, 
is evacuated. If left to themselves the skin over their centre com- 
monly gets thinner and thinner, and an opening, which is always 
of greater size than in cutaneous scrofulous tubercles, is finally esta- 
blished. The skin is then almost always loosened to the base of the 
tumour, and is at last destroyed to such an extent that it is no longer 
a fistulous opening which is presented to us, but an open ulcerated 
surface. When these tubercles burst spontaneously, their fistulous 
openings yield nothing but a little serum, and a few curdy fragments, 
a quantity of which always continue in the tumour and may be ex- 
pelled by a sufficient degree of pressure exerted on its base. When 
these tubercles arise near the edges of scrofulous sores, they are 
evolved and soften less tardily than under other circumstances. Their 
contents are also occasionally evacuated under the loosened edges of 
these ulcers. 

737. Scrofulous ulcers are consecutive to cutaneous and subcuta- 
neous tubercles ; to excoriated chilblains, and indolent abscesses ; to 
caries and white swelling, &c, occurring in strumous constitutions. 
They are more particularly frequent on the neck, and next on the 
extremities. They are in general of small extent ; yet they are occa- 
sionally observed to multiply astonishingly in some particular region 
of the body, and to destroy, for instance, the skin of the neck, and a 
considerable portion of that of the chest and shoulders. 

The isolated cutaneous tubercle seldom proves the primary caus? 
of true ulceration ; it frequently shrinks, and cicatrizes, after becom- 
ing softened. This kind of tubercle of a large size, however, does 
occasionally end in an ulcer, the dark red or livid, hard and indole;.': 
edges of which penetrate deeply into the skin. 

The edges of the ulcers consequent on cutaneous scrofulous tuber- 
cles collected into clusters, are of a brightish red, considerably swollen, 
not very painful, and apt to bleed on the slightest touch. Those of 
the ulcers that follow subcutaneous scrofulous affections, — tubercles, 
enlarged glands, indolent abscesses, caries, &c, present several peci • 






TUBERCULA. 



. : fay frequently form loose Haps, detached from the subja- 
cent tissues, doughy, and very commonly of a livid red colour, which 
indicate* very accurately on the exterior, the distance to which the 
lo isening extends internally. The bottoms of scrofulous ulcers of 
[in, consequent on agglomerated and confluent tuhercles, are 
pale and without granulations, but puffed and flabby. The 
rge from these ulcers is sanious rather than purulent, and, in 
, forms greenish and brownish incrustations, which are by and 
iched from the surfaces to which they adhered by a fresh secre- 
tion of the sanious fluid. The bottoms of these sores in other cases 
remain constantly bedewed with this peculiar secretion, and are very 
n, and of a yellowish-gray in different places. The lymphatic 
glands in the vicinity of such ulcers are frequently enlarged ; in the 
neck especially, they seem now and then to form a kind of case for 
the sore ; at other times, again, they appear as lumps lying at their 
bottom or clustered like a chain around their circumference. The 
open mouths of fistulous passages, which run towards softening tuber- 
cles or indolent abscesses in the vicinity, are frequently to be observed 
on the surface, or under the loose edges of these ulcers. When this 
is the case, and the fistula? are long and tortuous, the discharge is 
apt to remain, and occasion burrowing under the skin and the sur- 
rounding structures. It happens occasionally, also, though very rarely, 
that gangrenous eschars of a brownish-gray colour, are formed at the 
bottom of scrofulous ulcers. To conclude, in those cases in which 
the periosteum is exposed by the progress of scrofulous ulcers, this 
membrane swells and becomes covered with soft grayish-coloured 
fungous excrescences. 

The progress of scrofulous ulcers is, in general, extremely slow ; 
they frequently continue for years together without any material alter- 
ation in point of extent or otherwise. The ravages they commit, and 
deformities they occasion in some cases, although very extensive, are 
the work of so tardy a process, that their progressive amount is not 
perceived ; it is only discovered in the end. Scrofulous ulcers differ 
visibly in this particular from those characteristic of lupus exedens, 
and of the serpiginous or phagedenic syphilis. Some cases, how- 
ever, are on record, designated as scrofula (whether this disease were 
confounded with a lupus, or a syphilitic affection, or there existed an 
actual complication of one or other of these affections with true scro- 
fula, or whether they were scrofulous ulcers that had been accidentally 
irritated, it is difficult to say), in which the progress of the disease is 
reported as having been much more acute. 

738. Whether the cure of a scrofulous ulcer is accomplished spon- 
taneously or under the ministration of art, it always takes place with 
extreme slowness. The surface of the sore looks less pale, its edges 
not so hard, not so livid, and are less disposed to bleed ; it is then 
covered with granulations of a clearer rose colour, and the discharge 
becomes whiter and more consistent. The cicatrice that results long 
continues red, shining, easily torn, puffed and uneven. To this red 
colour of the scar, a bluish tint succeeds by slow degrees; its surface 
sinks, and its margins still puffed, often present irregular lumps in 
their course, a species of consecutive tubercles which are very long 
of disappearing. The skin frequently exhibits irregular bands which 
bear a great resemblance to the cicatrices of burns, and here and 
there numbers of whitish, rounded, and soft inequalities, produced 
by an excess of integument, and a lax state of the portions that have 
escaped alteration ; these having been long distended and lost their 
elasticity, recover it very slowly, and are puckered up by the newly- 
formed cicatrices as they shrink and gain solidity. It is not till after 
the lapse of several years that the cicatrices of scrofulous sores be- 
come white, and that these puckerings of the skin disappear. As to 
the newly-formed bands, like those that follow extensive burns, they 
are never absorbed entirely. 

739. Scrofulous ulcers are occasionally formed under, or in the 
neighbourhood of the nails (scrofula unguealis). Whether the pha- 
langes of the fingers have been primarily swelled, softened, and ulcer- 
ated, or not, these scrofulous sores are generally observed to com- 
mence in a swelling which attacks the skin in the neighbourhood, of 
the nails especially towards their roots. This swelling increases 
slowly and forms a puffy r i m of a livid red colour, which ulcerates and 
grows fungous at a subsequent period. The bone of the last phalange 
frequently enlarges ; the whole finger swells, and its extremity acquires 



the shape of a little club. The nail then becomes misshapen, looks 
black, grows soft, and is partially detached. In this state the extreme 
round of the pulp of the finger enlarges and forms a kind of fungous 
ring, in the centre of which the diseased and partially loosened nail is 
perceived. The nail is at length thrown off, and an irregular reddish, 
naked surface is left, from which misshapen horny productions are 
thrown out. These often take a faulty direction, and by their irri- 
tation tend to keep up inflammation in the surrounding parts. 

740. Individuals affected with scrofulous tubercles or ulcers, further 
almost invariably exhibit other morbid phenomena characteristic of 
the strumous constitution. The most common of these are enlarge- 
ments of the lymphatic glands, chronic inflammation of the eoVes of 
the eyelids, chilblains, sores, indolent abscesses, and white swellings 
of the structures about the joints, caries and tubercular affections of 
the bones, pulmonary and mesenteric tubercles, &c. Attention to 
these different symptoms may frequently be of service in doubtful 
cases, inasmuch as they lead us to the true nature of certain cuta- 
neous and subcutaneous tubercles, and of the ulcers which succeed 
them. 

741. Individuals wdio are the subjects of scrofulous affections are 
usually of fair complexion, with light or clear brown hair, large blue 
eyes, the pupils dilated, and the sclerotic coat of a bluish tinge ; the 
point, and especially the alee of the nose, and the upper lip are often 
thick and swollen ; the nose secretes habitually in excess ; the lips 
chap and become painful in winter ; the teeth are disposed to get in- 
crusted with tartar ; the jaws are large ; the cranium is often shaped 
like a calabash ; the chest is narrow, the thorax generally contracted, 
the belly large, and the articulations bulky. One or several of these 
characters are very commonly observable ; it is seldom that they all 
occur together. It is also to be observed that individuals with black 
hair and dark eyes, and who do not appear at all deficient in vigour 
of constitution, are occasionally seen the victims of scrofula, which 
appears then to be developed under the influence of the law of heredi- 
tary descent, or in consequence of insalubrious regimen. 

742. Diagnosis. — The diseases with which the tubercles and ulcers 
of scrofula may be most readily confounded are the tubercles and 
ulcers of lupus, syphilis, and cancer. But independently of the fact 
that cutaneous scrofula is almost always accompanied by other altera- 
tions proper to the general affection, and by unequivocal indications 
of the strumous constitution, the tardy progress of scrofulous tubercles, 
which become inflamed internally, and then cause perforations of the 
skin, the pale and fungous appearance of the ulcers, and their violet 
and frequently loosened edges, admit of no mistake in the diagnosis. 

743. Prognosis. — The development of a scrofulous tubercle or 
ulcer, however trifling its extent, is always a serious affair, for it is one 
of the manifestations of a constitutional disease, the cure of which is 
always effected with difficulty, which the progress of years may 
modify, but will rarely destroy completely, and which is frequently 
transmitted hereditarily, even when the principal characters of the 
affection have disappeared. In a particular case, the number, extent, 
and gravity of the concomitant lesions, when any exist, their cha- 
racter, and their development before or after the age of puberty, are 
so many circumstances, the due appreciation of which is of the highest 
importance in predicating with regard to the effects and final issue of 
the disease. 

744. Treatment. — The basis of the treatment of scrofula may be 
thus laid down: — The first and main object must be to accomplish 
some modification of the constitution by means of appropriate regi- 
men, habits, and exercises. Practitioners are generally agreed in 
recommending a warm climate and dry atmosphere, living in a 
healthy situation, exercise in the open air when the season and the 
weather permit, the use of the temperate or cold bath, dry frictions of 
the skin, &c. The diet requires particular attention. Good animal 
food : — beef or mutton, roasted or broiled ; bitter, or, as they are 
termed, anti-scorbutic vegetables, — endive, water-cress, &c. ; fresh 
eggs ; roast poultry or game ; fresh fish ; good beer, or generous 
wine, mixed with some sparkling slightly chalybeate water, appear to 
compose the aliment and drink most appropriate to the scrofulous 
diathesis. 

The action of certain therapeutic means have been found, when 
combined with these most indispensable and primary measures, to aid 






SCROFULA. 



263 



their action and to hasten the cure of scrofulous affections. In the 
first rank of these additional remedies must be placed sulphureous 
sea-water, and iodated baths. Sulphureous water baths may be 
readily prepared and administered at all seasons, and their action regu- 
lated with the greatest nicety. Besides the general curative effects 
of these baths, they are found to preserve children from colds and 
chilblains during the winter, whilst in summer they brace the frame 
against the enervating effects of the heat. The tub in which this bath 
is administered, requires to be thoroughly cleaned out several times 
a year at least. 

When sea-bathing is adopted as the principal curative means, 
patients, after having gone through the season, should be afterwards 
put into an alkaline bath at intervals, to cleanse the skin. 

The preparations of iodine, administered by way of bath and inter- 
nally, are often of singular efficacy in scrofulous complaints. Iodated 
baths, in which the iodine is held dissolved by means of the ioduret 
of potassium, act very advantageously locally, by their active princi- 
ples being brought into immediate contact with the tubercles and 
sores, as well as generally, by the absorption of these into the system. 
I occasionally direct the iodated and sulphureous water-bath to be 
taken alternately. Whilst the iodine is employed externally in baths, 
this medicine is commonly exhibited at the same time internally, 
being begun in doses of half a grain during the first fortnight ; three- 
quarters of a grain during the second, and a grain during the fourth. 
In every case the half of the dose is to be taken early in the morning ; 
the other half before dinner. 

745. The antiscorbutic syrup ' in doses of from half an ounce to 
a whole ounce ; the bitter tincture of gentian in doses of from two 
to three drachms ; the infusion of hops and other bitters, are also very 
commonly prescribed for scrofulous children. 

746. Other medicines, such as the hydrochlorate of baryta and of 
lime, the subcarbonate of soda, chalybeates, and mercurial prepara- 
tions, have also been all severally and particularly recommended in 
scrofulous cases. (a) 

747. The treatment of scrofulous tubercles and ulcers, by local 
means, although of less importance than that which is directed with 
a view to modify the constitution, is still deserving of very particular 
attention : the resolution and suppuration of the tubercles are accele- 
rated by rubbing them with an ointment either of the deuto-iodide of 
mercury, or of the iodide of sulphur. 

The ulcers are stimulated into better action by washing their surface 
with wine, a weak alkaline solution, or a sulphureous or iodated water, 
by dusting them over with citric acid, burnt alum, cream of tartar, 

(a) Preferably to simple iodine, in the treatment of scrofula, is its 
combination with an alkali or metal, as in the iodide of potassium and 
the iodides of iron and zinc. The dose of the former, for a young 
subject, will be from a quarter of a grain to a grain gradually increased 
to three grains in the twenty-four hours, in watery solution. The 
favourite preparation just now, is the iodide of iron in the form of 
liquor ferri iodidi ; as directed by the American Pharmacopoeia. Dose, 
ten to thirty or forty drops, according to the. age of the subject, twice 
a day in a little sugar and water. Biniodide of potassium and binio- 
dide of iron are, also, of late well spoken of in scrofula ; the former 
in a dose varying from half a grain to four, and even ten grains three 
times a day, according to the age of the patient. 

Cod-liver oil is also one of the new remedies — nearly enough to 
have more virtues than it really possesses. For further details of 
practice in scrofula, and pathological views of the disease, the reader 
is referred to Bell and Stokes's Lectures on the Practice of Physic, 
vol. ii. 

In subjects not very anaemic, and whose digestive system is not 
materially irritated, I can suppose that Donovan's solution given in 
small doses, watching carefully its operation, would be attended with 
resolutive and other good effects in scrofulous tubercles. 

The formulae of the stimulant, rubefacient and caustic solutions of 
iodine, recommended by M. Lugol for scrofulous ulcers, and of baths 
in the early stages of the disease, will be found in the different works 
on Materia Medica. 

1 A compound syrup of cochlearia araorica, bitter orange-peel, &c— Tr. 



calomel, &c, by covering them with poultices of sorrel, hemlock, sea- 
weed, and various other topical applications, charged with sulphur or 
iodine. Fungous growths and loose edges require to be removed with 
caustic or the knife, when there seems no prospect of a better action, 
or an adhesive inflammation ; a free passage for pus must be established, 
and fistulous passages laid open when they are discovered in the vicinity 
of ulcers ; bony sequestrae must be searched for, if suspected, and ex- 
tracted, if any be discovered, when the bones are affected, &c. To 
conclude, when by means of regimen, combined with internal and 
local treatment, the ulcers are brought into the condition of simple 
suppurating sores ; their surface must be touched from time to time 
with the nitrate of silver, or sulphate of copper; their edges approxi- 
mated by means of adhesive straps ; and every attention paid to secur- 
ing cicatrices that shall be as little unsightly, and cause as small an 
amount of deformity as possible. 

748. Scrofulous sores about the nails occasionally prove obstinate 
to all these measures of general and local treatment, especially when 
the chronic inflammation of the matrix of the nail is kept up by the 
production and presence of the irregular horny substances that have 
been mentioned. In the severest cases there are puffing and softening 
of the unguiferous phalange, and this state is followed by such inter- 
minable fistulae that some surgeons then recommend the amputation 
of the joint as the best and speediest way of getting rid of the evil; 
this last remedy, however, may generally be safely deferred indefi- 
nitely; the deformed nails that are thrown out being alone removed, 
and the progress of years confided in for bringing about the recovery 
of the part. 

Historical JVotices and particular Cases. 

749. The principal morbid changes produced by scrofula, such as 
glandular enlargements, swellings about the joints, caries of the bones, 
indolent abscesses, fistulous passages and ulcers, &c, were long ago 
described with much care and precision ; but it was in vain that trea- 
tises, ex professo 1 even, were searched in the hope of finding a good 
account of cutaneous scrofula in any of its forms, distinct and isolated, 
or in clusters, or even of scrofula unguealis. M. Alibert was the first 
who saw the propriety of forming the scrofulous affections of the skin 
into a distinct group. 

M. Lugol has detailed a very interesting case of tubercular cutane- 
ous scrofula in clusters, and several instances of scrofulous ulcers suc- 
cessfully treated by the preparations of iodine. Mr. Lemasson has 
published several facts in favour of the combined action of opium 
and iodine in the same class of complaints. 

In several recent works, scrofula unguealis is vaguely hinted at, or 
noticed, mixed up with other varieties of onychia. M. Delpech, 2 
however, perceived, and has stated his opinion broadly, that sponta- 
neous onychia might be owing to a scrofulous affection of the matrix 
of the nails. 

When any affection of the skin, other than the one I have described 
under the name of scrofula (acne, eczema, impetigo, &c.) occurs in 
an individual of strumous constitution, this condition of the system 
occasionally modifies the symptoms, and always influences the treat- 
ment of the eruption : these facts, however, do not authorize us in 
considering the accidental disease as a manifestation of scrofula. It 
is in this point of view that M. De Vering 3 appears to have pushed 
too far a consideration otherwise of the highest practical value. 

Case CXXX. — Ulcerated scrofula. Stationary tubercles of the 
cheeks, and backs of the hands. A girl, fourteen years of age, of a 
scrofulous habit, was brought to me for advice, May 10th, 1825. 
From the mother I learned that this girl had suffered, during the time 
of teething and subsequently, from sore eyes, which were long of 
getting well, and kernels under the chin. After her tenth year, 
several tubercles had also been evolved upon the face. When pre- 
sented to me, the right ala of the nose, which was red and swollen, 
was covered with a yellowish-white scab, and the cheek of the same 

2 Hufeland. Traite de la maladie scrofuleuse, traduit par Bousquet, 8vo. Paris, 
1821. 

3 Chirurgie Clinique, t. i. p. 374. 

< Vering. Maniere de guerir la maladie scrofuleuse, 8vo. Vienna, 1832.— § Des 
maladies cutances scrofuleuses. 



264 



TUBERCULA. 



side was occupied by three tubercles unulcerated, and a fourth whose 
centre was concealed by a thin brownish incrustation. A tubercle 
of the same description is seated on the left cheek. The skin of the 
cheeks in the vicinity of the ahe nasi is of a violet-red colour; the lips, 
especially the upper one, are swelled ; the right eye is injected, and the 
edges of the eyelids are slightly glutinous; the submaxillary glands 
are enlarged. ' A large indolent, Hat, violet-coloured unulcerated 
tubercle exists on the back of the right hand. The organs of the 
chief functions appear to be quite healthy. (Weak infusion of gen- 
tinn, and $\ of the compound syrup of coc/dearia daily.) These medi- 
cines were taken pretty regularly for eight months. Towards the end 
of the treatment two applications of the powder of calomel and arseni- 
ous acid (poudre de M. Dupuytren — vide § 725) brought about the 
cicatrization of the ulcer of the nose. The tubercles of the cheek 
and back of the hand had disappeared, but the skin still continued 
somewhat swollen, and of a violet colour, in the situations which 
they had occupied. 

Case CXXXI. — Scrofulous tubercles of the left forearm. — Justine 
Geoffroy, aged twenty-six, of scrofulous constitution, never having 
had any serious illness. When thirteen years old she had had a 
small abscess on the left forearm. Six years later, a pimple (bouton), 
which she likened to a large pea, appeared in the same place, but 
got well in the course of six months. Last winter the patient suffered 
from chilblains, and the disease reappeared in the old place. At one 
time the catamenia ceased, and the sore on the forearm by bleeding 
seemed to supply this discharge. There have always been, and 
there still remain, several enlarged glands under the lower jaw on 
the left side. 

April 5th, 1830. — On the dorsal aspect of the forearm, two inches 
above the wrist, numerous mammillary tubercles, isolated or disposed 
in clusters, and projecting above the level of the integuments, are 
perceived. Each cluster seems to rest upon a common basis, being 
separated from its neighbour by depressions or clefts, which are ulcer- 
ated in the points where they are narrowest. The surface of the 
tubercles is moistened with a purulent secretion, and in some places 
covered with a kind of bluish-coloured false membrane. The size 
of the mammillary eminences varies between that of the head of a pin 
and that of a large pea. Another cluster of tubercles, somewhat more 
numerous, occupying a larger space, and covered with indolent sores, 
is seen near the one above the wrist ; and several isolated tubercles 
are scattered over spaces which are separated from each other by 
cicatrices of a general red or livid colour, but presenting whitish 
points here and there. Several more tubercles, covered with a small 
scab, also occur disseminated in the neighbourhood of the principal 
alterations, but still separated from these by bands of healthy integu- 
ment. A few enlarged lymphatic glands are seen on the left side of 
the neck. The patient is in pretty good general health ; the cata- 
menia are regular. (Tonic regimen; compression of the tubercular 
masses.) April 12th. — The mammillated tubercles have shrunk under 
the effects of the compression, and here and there small scabs have 
been formed; a little yellowish pus is deposited between the masses. 
Next day the patient complained of having suffered great pain in the 
forearm, and a number of small irregular ulcers, a line or more in 
depth, w r ere found checkering the mammillary eminences, and giving 
them the appearance of excrescences. 

24th. — The compression appears to have increased the extent of 
several of the sores ; the parts were touched with the acid nitrate of 
mercury. May 5th. — Compression was renewed on the first of this 
month, and the tubercles, more and more shrunk, were now almost 
level with the skin. The sores were getting well. June 18th. — Up 
to this date the whole of the sores had been gradually healing up, 
and were now all skimmed over ; but on this day the patient com- 
plained of pain ; the arm became hot ; and the upper part of the 
cicatrice, which had continued of a purple colour, appeared beset 
with a number of pale yellow points, evidently consisting of purulent 
matter. These, next day, broke into small "round ulcers, between 
each of which the skin looked pasty and infiltrated ; many of them 
met by their edges on the day following, giving rise to broad irre- 
gular ulcers, with yellowish bottoms. Emollient cataplasms, and 
subsequently sulphur-baths were prescribed. The sores were all 
whole by the 18th of July, but small purulent points of the same 



description, and ending in the same way, still made their appearance 
from time to time. The patient was discharged on the 12th of No- 
vember, at her own request, not completely cured. 

Case CXXXII. — Cutaneous scrofula. Tubercles agglomerated. 1 
Caesar Mortreux, aged seventeen and a half, sprung of healthy parents, 
but born labouring under small-pox, which was in the family at the 
time of his birth, so feeble that till he was two years old, it was not 
supposed he could live. At this age the disease under which he 
now laboured made its appearance, and his general health seemed to 
improve. Scrofulous abscesses formed in the neck, buttock, thioh, 
leg and back of the left hand ; the sore that resulted in the last- 
named situation was much longer of healing than any of the others, 
and when this was nearly well, scrofula, in another guise, took pos- 
session of the backs of the fingers, from whence it spread successively 
to the wrist, forearm and arm. Within the last fifteen months the 
disease has made very rapid progress, particularly since the insertion 
of an issue into the arm in the spring. 

July 30th, 1828. — The skin on the dorsal aspect of the wrist was 
hard, hypertrophied, of a violet-red colour, and diminished in its 
sensibility; that of the back of the thumbs and remaining fingers pre- 
sented growths from a line and a half to two lines in length, separated 
by chaps in the skin, and bathed in a grayish-coloured pus. These 
growths were covered on their .tops with yellowish incrustations, 
which became soft when bathed, and were then readily detached, 
leaving the summits of the productions they covered of a delicate rose 
tint, and sensible to the action of the air. The matrices of the nails 
were deeply affected ; the nails were long and all turned away from 
the thumb side of the hand ; their dorsal surfaces were rough, and 
generally of a deep gray colour; those of the ring and little finger 
were entirely black. Patches of growths, of a similar description, 
two inches in diameter, existed on the dorsal aspect of the wrist 
joint; two on the inner surface of the forearm were of the dimensions 
respectively of a crowm-piece, and three or four more of rather less 
size appeared on the posterior surface of the same part. Around the 
elbow there was an assemblage of at least nine principal patches, of 
a round shape, and varying from one to two inches in diameter, in 
general confluent, but in some places leaving narrow intervals in 
wdiich the skin appeared to be in the normal state, though presenting 
here and there a few red pustules, which appeared to be the rudi- 
mentary forms of the disease; and, in fact, the whole of the patches 
did finally become blended together by the development of these 
pustules ; so that the elbow w T as at last surrounded by a diseased 
surface, five inches in length, by about four in breadth, very similar 
in its appearance to the patches which have been already described, 
although the growths in this situation were neither acuminated nor 
isolated by chaps of the corion. 

In addition to these diseased patches, a great number of small 
pustules were scattered over the forearm and arm. These pustules 
were generally of the size of pins' heads, though some of them 
were considerably larger; the latter, under the magnifying glass, 
appeared to be made up of two or three elementary pustules united. 
The patient informed us that the whole of the patches on the arm 
and forearm had been originally formed by the agglomeration and 
subsequent development of pustules still smaller and redder than 
those we were now examining. The patches of the fingers were the 
only ones whose mode of formation he could not recollect. 

The skin of the limb generally was hypertrophied, indurated, dry, 
and presented more or less of a violet hue, especially on the back of 
the wrist, where it was also less impressionable than in other parts. 
The whole of the diseased patches that have been mentioned were 
primary ; no one had ever healed, nor changed its place. Those on 
the fingers only had got well at one end whilst they were advancing 
on the other ; so that the parts on the dorsal aspects of the fingers 
which were now healthy had once been diseased like those that still 
continued so. The disease had only once appeared to receive a 
check ; it had even appeared tending to recovery : about the age of 
eleven, in the month of August, the growths shrunk, the suppuration 
became greatly lessened, and even ceased entirely for a time during 
the winter; but on the return of the fine weather the disease also 

1 Iconographie pathologique, in-fo). Paris, 1829, pi. 4. Obs. de M. Lugol. 



CANCER. 



265 



returned, and has since continued to advance uninterruptedly. The 
patient has never suffered from local pain, neither has his sleep been 
once disturbed in the last fifteen months during which this cutaneous 
scrofula with morbid growths (scrofule cutante vtgetante) has been 
spreading with alarming rapidity over the left arm. 

Besides the scrofulous cicatrices, of which mention has been made, 
Mortreux had prominent cheek bones, a thick nose and upper lip ; 
but his skin was bronzed and swarthy, his hair brown and thick, and 
he showed a generally strong and well-knit frame. The digestive 
organs were healthy, though the bowels were habitually confined. 

The disease was at first treated by iodine and iodide of potassium 
externally, and iodine internally. The external application was 
followed by pain and paroxysms of pruritus of the most violent 
description which were frequently renewed in the course of the day. 
This treatment, continued for six weeks, did little good, and it was 
then determined to treat the disease locally in four different ways : 
1st, with the iodated iodide of potassium in friction over the elbow ; 
2d, with the proto-iodide of mercury in friction over the fingers ; 3d, 
with the white oxide of arsenic in friction over the anterior aspect of 
the arm ; and 4th, with the acid nitrate of mercury as an escharotic, 
over the posterior surface of the limb. 

The inunction over the elbow was attended with extreme pain, and 
the most violent pruritus, and occasioned a very profuse secretion of 
pus. The growing pustules, however, shrank away. The more circum- 
scribed patches became covered with incrustations, and only secreted 
a little matter about the centres of the diseased surfaces, which also 
appeared on the way to recovery. The inunction over the fingers 
proved less efficacious ; nevertheless the diseased patches healed 
around their circumferences, and the neighbouring skin appeared to 
differ less from the standard condition. The application of the acid 
nitrate of mercury succeeded the best of all, especially in regard to a 
patch situated on the outer surface of the wrist, which had at first 
been rubbed with the proto-iodate of mercury, a plan of treatment 
under which it had at first improved rapidly, but soon became station- 
ary. This patch is now (Dec. 29, 1828) nearly healed, after five 
applications of the escharotic made in the course of nearly two months. 
The arsenical application seemed to do much good in the first instance, 
but the amendment did not make any progress. An additional dose 
of the white oxide of arsenic did not seem to give the medicine any 
new power over the disease ; and as this was a circumstance I had 
observed in a great number of cases, I ordered this part of the treat- 
ment to be given up, and frictions with the iodated iodide of potassium, 
which had been employed over the elbow w r ith progressive success, to 
be substituted in its stead. 

The watery solution of iodine was administered internally in gra- 
duated doses, until a grain of the medicine was taken daily. This 
quantity has been taken for a month. The other curative means em- 
ployed were baths for the arm, of a decoction of bark, and a decoction 
of bran, with the addition of sulphuret of potash ; three sulphureous 
baths were also taken through the week, and three ounces of the com- 
pound syrup, or wine of cochlearia, every morning, together with a 
pint of barley-water, made palatable with syrup of tartar, as drink 
during the day. Let us just observe, before concluding, that the most 
efficient of the local measures excited profuse suppuration. I have had 
occasion to witness this property of the iodine in a very great number 
of cases. The acid nitrate of mercury also causes a very copious puru- 
lent secretion, which makes its way through the eschars, causes them 
to fall off", and produces incrustations, which, as the diseased surfaces 
get well, are subsequently less and less frequently renewed. 

Case CXXXIII. — Scrofula unguealis. 1 A villager, aged twenty- 
four, who had suffered in his youth from indolent abscesses and other 
symptoms of scrofula, began to complain towards the end of the year 
1820, of pain and swelling in the great toe of the left foot, to which 
succeeded a sore, which at first surrounded the root of the nail, and 
then extended under it ; so that at length the nail became loose, and 
detached at all points, except its posterior edge. The nail itself was 
soft, filamentous, readily torn, and was turned back towards the dorsal 
aspect of the foot ; it seemed, like a foreign body in the midst of parts 
in a state of ulceration, to keep up their irritation: attempts had con- 



67 



1 Delpech. Clinique medicale de Montpellier, 4to., t. i. p. 367. 



sequently been often made to destroy it entirely by taking it away ; 
but it was speedily reproduced with the same defective structure a;; 
before. This state of affairs continued to January, 1822. The patient 
was received into the hospital Saint Eloi, at the same time as another 
patient, labouring under a syphilitic affection of the matrices of the 
nails. The appearances in these two cases were the same ; but the 
cause, and consequently the essential conditions in each were very 
different. The scrofulous patient had never run the risk of a venereal 
affection, &c. He was put upon a diet of animal food and wine, and 
took bitter and tonic medicines alternately with one of the alkalies : 
gentian, bark, oxide of iron, and carbonate of soda, were the article.': 
employed ; emollient cataplasms and local baths were at the same time 
prescribed. At a later period, baths, with a solution of the carbonate 
and even of the pure potash, were tried ; the baume vert de Mete,* 
a solution of the muriate of mercury, and then of the nitrate of silver, 
were one after the other used as transient stimuli. The patient con • 
tinued under treatment for nearly four months, but the effects of the 
system pursued were ultimately as favourable as those (hat followed 
in the case of syphilitic origin alluded to, under the influence of mer- 
curial preparations. The sore cicatrized, and the nail was reproduced 
with its pristine consistence, its colour, and nearly its shape. 



Vocab. Cancer, Noli me Tangere, <fa. 

750. Cancer of the skin is proclaimed by one or more tubercles, 
which, after an interval of time, greater or less in extent, become the 
seat of acute lancinating pains, and end in ulcers, the surfaces of 
which sprout in the form of fungi, or, otherwise, which deeply 
destroy the skin and neighbouring parts. These tubercles consist, 
in part at least, of scirrhous tisssue, or cerebriform matter, the pre- 
sence of one or other of which constitutes their distinguishing ans 
tomical character. 

Cancer of the skin shows itself under five principal forms. 1 st s 
cancer vulgaris, or common cancer; 2d, melanic cancer (anthracine) ; 
3d, leucoid cancer ; 4th, mollusciform cancer ; 5th, and lastly, m 
cous cancer (chimney-sweeper's cancer). 

751. Cancer vulgaris. The tubercles that characterize this variety 
may be isolated and solitary, or numerous, and either collected in 
clusters, or widely disseminated. They are most frequently evolved 
on the hairy scalp, face, lips, nose, margin of the anus, and about the 
genital organs. They vary from the size of a grape stone to that of 
an olive. They are hard and solid, and in their earlier stages do not 
differ from the surrounding skin in colour. They are occasionally 
observed to continue indolent for several years ; or, from the very 
date of their appearance, to be the seat of violent pruriginous sensa- 
tions, or of lancinating pains. Accidentally irritated, these tub 
enlarge, grow livid, and constantly occasion acute suffering, though 
they may have remained perfectly indolent up to this period ; their 
bases then widen, and extend more deeply ; chaps form on the sur- 
face, which, at times, pour out some yellowish and sanguinoleat 
serum ; under other circumstances, again, the cuticle covering the 
tubercles is detached from the corion, by the effusion under it of a 
serous fluid, and the exposed summits of the tubercles then become 
softened and ulcerated. 

752. The ulceration that succeeds, presents itself under three dis- 
tinct forms : 1st. The ulcer, of varying depth, exhibits a fungous 
and uneven surface, which, by exposure to the air, becomes hidden 
under a brownish incrustation ; its edges are hard and everted, and 
the surrounding skin is frequently traversed by small blue veins — the 
chancre-like cancerous ulcer. The pain of a lancinating kind is usualh 
very severe at this period, and is sometimes compared by patients to 
the passage of red-hot needles through the seat of the disease. Left 
to itself, the ulcerative process continues to advance among the neigh 
bouring parts. One-half, and more, of the face, has thus been seen 
destroyed by these eating or phagedenic cancers, which several patholo- 
gists have characterized by the title of noli me tangere. 2d. At othei 

2 A terebinlhinate liniment of the sub-acetate of copper. — 7>. 






TUBERCULA. 



times the surface of the excoriated tubercle becomes covered with 

I ill mammillated elevations, which give it very much the appearance 
of ,1 mulberry, a state in which the disease may long remain stationary. 
In thil case there are commonly several cutaneous and subcutaneous 
iua tubercles disseminated over the surface of the body. These 
ferry cancers occasionally attain the size of a walnut ; the fluid 
they secrete dries upon the surface in layers, which, by accumulating, 
form, at length, prominent scabs, occasionally a little twisted, which 
have been likened to, and entitled, horns. These scabs are detached 
by and by, and the tubercles are succeeded by chancre-like ulcers. 
3d. I nder still other circumstances, the growths that spring from the 

rface of the excoriated tubercles, are much more considerable than 
in the variety last described, and a tumour results, having a fungoid 
appearance, and secreting a sanious or sanguinolent fluid from its sur- 

e ; this constitutes \hz fungiform, or fungoid cancer of pathological 
writers. Where the morbid growth expands superiorly, whilst its 
neck retains the original dimensions of the ulcerated tubercle, the 
disease has been entitled pediculated cancer. This variety is in gene- 
ral less painful than the phagedaenic cancer. It is also almost always 
solitary. 4th. There is another mode, much more rare, indeed, in 
which I have seen cancerous tubercles terminate ; this is in gangrene. 
The woman in whom this occurred, laboured under a tumour of the 
right ovarium, cancer of the right breast, and cancerous tubercle 
above the left eyebrow. This tubercle, on a sudden, became very 
painful, assumed a deep-brownish or dusky-red colour, and losing all 
sensibility, it came entirely away with the diachylon plaster I had ap- 
plied to its surface. The tubercle thus detached, exhaled a distinctly 
gangrenous odour. The resulting sore suppurated kindly, and by and 
by healed up completely of itself. 

753. The tubercles of common cancer are frequently evolved in 
the subcutaneous cellular tissue, where they appear under the form of 
small movable tumours like grains of wheat, which is painful under 
pressure. These subcutaneous cancerous tubercles, which must not 
be confounded with the small tumours occasionally developed in the 
course of a nervous twig, sometimes continue stationary for an indefi- 
nite period ; at other times they increase until they equal an egg in 
size, when they usually become attached to the skin, in which a very 
remarkable vascular network is then frequently developed. By and 
by the integument inflames, softens, and gives way, and a fungous 
growth, after a certain lapse of time, very commonly makes its 
appearance from the bottom of the ulcer. 

754. The tubercles of common cancer have particular anatomical 
characters. If at their commencement they appear to consist of a 
mere thickening, with induration of the corion, the indurated parts, 

iter period, acquire a considerable resemblance to a mass of lard 
hus). When they are incised lengthwise, and their interior is 
examined under the magnifier, they are found principally to consist 
of a lardaceous tissue, traversed by whitish lines or bands, analogous 
in point of colour to the fibro-cartilages. After maceration, these 
tubercles, stripped of their cuticular covering, almost always present 
a mammillated surface. When they are softened in a slight degree, a 
whitish matter can be forced out of them by pressure. Besides the 
peculiar scirrhous tissue which has now been described, cerebriform 
matter is frequently met with in these small cancerous tumours. 

755. Melanic Cancer (Anthracine Jurine). Under this title have 
been described certain small tumours of a melanose appearance, 
which approximate those of an undoubted cancerous nature in the 
acute pain which accompanies them, in their tendency to ulceration, 
and in their disposition to grow again when they have been extir- 
pated. These small blackish and painful tumours would seem to be 
distinct in their nature from those of pure melanosis, which are most 
commonly indolent, and occasionally evolved in the corion, as well as 
in the subcutaneous cellular tissue. Yet if they bear affinity to can- 
cer in their symptoms, and in their tendencies, a lack of exact and 
often enough repeated anatomical inquiries, leaves us still in doubt 
whether or not they, hke certain cancerous tumours of the liver con- 
tarn a mixture ot scirrhous tissue or of encephaloid matter, with a 
portion of melamc substance; perhaps they constitute a mere variety 
of the melanose tumour. However this may be, these little tumours 
according to Jurine begin as minute black or bluish and usuX 
itchy spots, which take the form of tubercles slowly nd'subsequen ly 



acquire that of true tumours, the centres of which are generally more 
depressed than their circumference. 

The tubercles of this variety of cancer sometimes partially lose 
their original black colour ; their base acquires a bistery hue, and 
their centre something of an olive shade. They scarcely attain the 
size of a strawberry in some cases, before the integuments give way 
with acute and lancinating pains ; an ulcer, with fungous and ragged 
edges, is formed, which pours out a sanguinolent sanies habitually 
and at times bleeds profusely. Ulcers of this description are as 
inveterate as those of common cancer, and M. Alibert is of opinion 
that the species of tumour which occasions them is even more apt to 
be reproduced, when extirpated, than those of the other varieties of 
cancer. Repeatedly, and after cures that were believed to he com- 
plete, black points have been observed to appear in the neighbour- 
hood of the cicatrices, which were never long afterwards of spreading 
and becoming open ulcers. 

756. Messrs. Marjolin and Blandin, 1 under the name of melanic 
cancer, have described a subcutaneous tumour, consisting of a hard 
mass, which occupied almost the whole of the palmar surface of the 
right hand, and extended over a portion of its dorsal aspect; this 
tumour was irregularly rounded, lobulated, and traversed by a longi- 
tudinal furrow ; it was accompanied by pain of a lancinating kind 
and its centre, which was ulcerated, uneven and of a livid hue' 
poured out a fetid ichor. The hand was successfully amputated by 
M. Blandin. The tissue of which the tumour consisted was hard of 
a slate gray, or blackish tint, creaking under the scalpel, and under 
pressure yielding a fluid which stained linen like China-ink; the 
deep-seated veins of the palm were very much enlarged. 2 

Under the name of melanic sub-ungual cancer, M. Dubourg 3 has 
given the details of a spherical tumour, four inches and a half in 
circumference, of a blackish colour, mammillated on its surface, the 
seat of lancinating pains, and presenting here and there erosions, 
from which slight hemorrhage occasionally took place. The disease 
had commenced thirty years previously without evident cause: a 
small black line made its appearance under the nail of the little 
finger; this continued stationary for twenty-seven years; during 
the last three years only had it extended, and by degrees spread 
to the whole surface covered by the nail. At the end of a year 
the nail was detached, and was succeeded by black fungous ex- 
crescences, which increased rapidly in size, assumed a globular 
form, and exhaled a fetid smell. After amputation, the tumour was 
found very similar, in its colour and consistency, to a large softened 
truffle ; a larger quantity of fluid than of solid matter, entered into its 
composition. 4 

M. Lisfranc once removed a melanic cancer, the size of the fist, 
from the left cheek. The tumour, which was uneven on its surface, 
had been the seat of pretty severe lancinating pains ; it had grown 
very rapidly, and was accompanied with an enlargement of the sub- 
maxillary glands. The skin, in its vicinity, was of a violet colour. 5 
757. Before bringing this subject to a close, I think it right to state 
that if some pathologists, taking the character of the pain with which 
these melanic tumours are generally affected, their termination, in a 
very great number of cases, in a fungous ulcer of bad character, and 
their disposition to be reproduced after having been extirpated into 
account, have held themselves authorized to consider them as a 
variety of cancer ; others, on anatomical grounds, and insisting espe- 
cially on the fact of no scirrhous tissue, nor cerebriform matter having 
been demonstrated in their composition, have assigned them their 
place along with the melanoses. For my own part, it seems to me 
evident that certain soft and indolent melanic tumours ought to be 
separated entirely from cancer; but I think, on the other hand, that 
those which are attended with lancinating pains, which shoot again 

' Journ. Hebdom., t. iii. p. 459. 

« I have noticed this case with a view to show that melanic tumours are nearly 
akin to those of a decidedly cancerous nature, as regards the character of the pain 
that attends them, the appearance of the ulcers to which they give rise, and the hard- 
ness of their tissue. 

3 Journ. Hebd., t. vii. p. 73. 

* In its structure and softness, this tumour is assimilated with the melanoses, and 
in two or its phenomena (lancinating pains, and fungous growths), with cancer. 

Kevue med. t. ix. p. 189. As in cancer, lancinating pains and glandular swellings 
are observed in this case. 



CANCER. 



267 



after their extirpation, and which are of so firm a texture as to creak 
under the scalpel, have a very great analogy to cancer. 

758. Leucoid cancer. — I shall, by and by, give a case of this rare 
variety of cancer which differs from all the others in the milky-white 
colour of its tubercles. Of these, some are flat, depressed in their 
centres, and prominent in their edges, which are covered with vas- 
cular ramifications; others, again, are rounded, and vascular in the 
centre, whilst their circumference is of a milky-white colour melting 
gradually into that of the skin (Case CXXXVII). Under the mag- 
nifier, these tubercles appear to be formed by a kind of hypertrophy 
of the corion, with the infiltration of a milky fluid, and the accidental 
development of the minute blood-vessels of their centre or circum- 
ference. Like the preceding variety, this one appears to proclaim 
a cancerous diathesis, which is manifested at the same time in other 
organs. 

759. Globose cancer is characterized by small globular tumours, of 
a reddish or violet hue, bearing some resemblance in their external 
appearance to whortle or juniper berries. M. Alibert 1 has given the 
case of a woman, in whom a multitude of small tumours of this 
description made their appearance, some on the scalp, others clus- 
tered on the top of the right shoulder, others again scattered over the 
parietes of the abdomen, over the thighs, legs, and soles of the feet, 
all presenting the same appearance and possessing the same cha- 
racters. The patient died under a lingering and painful consumption. 
The tumours, when cut into, were hard, of a yellowish-white in their 
interior, and very like lard, both in colour and consistency ; some 
were black on the surface and ulcerated in the centre. To this case, 
two others, also related by M. Alibert, and one which I shall myself 
detail by and by, must be assimilated ; my case, however, differs from 
the rest in this, that the small globular tumours consisted of cerebri- 
form matter, of a pinkish-white, or milky hue {(Pun rose blanc ou 
laiteaux). This variety of cancer, in which the disease is developed 
in so singular a manner on the surface of the body, is always a very 
serious affection ; and although a patient labouring under it may now 
and then be found in the enjoyment of apparently good health, the 
external disease is certainly significant of a diathesis, which will 
silently but surely implicate some vital organ at a future time, and 
make the individual its victim at length. 

760. Mullusciform cancer. This variety is distinguished by tuber- 
cles flattened in their form, or slightly rounded at their centre, indo- 
lent in their nature, of the same colour as the skin, and of a size 
varying from that of a silver twopenny to that of a half-crown or a 
crown piece. Their surface presents wrinkles or furrows, which are 
circular and concentric on those of small and middling dimensions, 
and irregular on those of the largest size. The anatomical character 
of this variety is a thickening, often very considerable, of the corion, 
the tissue of which becomes hard and scirrhous in its consistence. I 
have observed this variety, which, in its external characters, bears 
great analogy to one species of molluscum, in a woman, whose body, 
after her death, was found to present several other alterations of a can- 
cerous nature (Case CXXXVI). 

761. Chimney-sweepers' cancer. Warty or chimney-sweepers' 1 can- 
cer has been observed to attack the skin of the lower part of the 
scrotum with especial frequency. It begins in the shape of a warty 
excrescence, which very commonly continues stationary for several 
months, and even for several years. After a lapse of time, of various 
extent, the excrescence pours out an ichorous fluid, which excoriates 
the surrounding skin, its centre ulcerates, and, although not deep, 
the sore very soon exhibits all the characters of cancer in the most 
unequivocal form. Its edges are hard, raised, sharp, as if cut with 
a pinking iron, and everted ; the surface of the sore has an unhealthy 
appearance ; it is covered here and there with fungous growths, and 
is affected with pain of a greater or less degree of severity. As the 
disease advances, the neighbouring parts become affected, and the 
whole scrotum may at last be implicated ; or the disease may extend 
along the perineum ; the proper coats of the testis are also occasion- 
ally affected ; the disease then usually extends to the body of this 
organ, creeps along the spermatic cord to the inguinal glands, and 
gains the abdominal viscera. When one of the testes is affected in 

' Nosologic Naturelle, 4lo., t. i. p. 548. 



this way, it becomes bulky, and very hard, and contracts strong 
adhesions to the diseased scrotum ; the ulcerative process soon gains 
its substance, and portions of it even slough out. In these cases, the 
fungous growths, which spring up so rapidly when the disease is 
confined to the scrotum, are but rarely observed. Both testicles are 
sometimes simultaneously affected in this way. In proportion as the 
disease extends its ravages, whether it has been left to itself or have 
recurred after one or more attempts to excise it, the constitution is 
insensibly deteriorated ; worn out by incessant suffering and want of 
sleep, the strength of the patient gives way ; he loses flesh rapidly ; 
the skin presents a peculiar leaden cast of colour, and is at the same 
time bedewed with profuse perspiration, wdiich exhales an ammoniacal 
odour, always to be recognized again after it has once been felt ; the 
fatal termination is very often preceded by an acute affection of one 
or other of the viscera. 

762. This species of cancer is only met with in individuals whose 
skin is habitually irritated by the contact of soot, whence its vulgar 
name of soot wort. It occurs most frequently on the lower part of 
the scrotum, where the irritation would seem to be most constant, 
from the confinement of the soot within the wrinkles of the skin. 
The disease has been observed on the wrist in a gardener who was 
in the habit of using soot largely every spring for the destruction of 
snails. It has also been several times seen on the face. Chimney- 
sweepers'' cancer is most frequently observed among persons between 
thirty and forty years of age, but as children are mostly employed in 
the business of sweeping chimneys, this occupation, as Mr. Earle has 
very well observed, is not the sole condition necessary to the deve- 
lopment of the disease : a peculiar susceptibility or predisposition is 
required in addition. Although the disease has been almost exclu- 
sively seen among chimney-sweepers and those who traffic in soot, it 
has been said that the smelters of certain metallic ores containing 
arsenic, are subject to a disease of the scrotum of a similar description. 

763. I subjoin a few remarks on cancer studied comparatively in 
its development and progress on different districts of the skin. 

1st. Cancer of the hairy scalp has been chiefly observed among 
the aged ; this region seems more subject to the globular form of the 
disease than any other. When the tubercles which characterize the 
affection have attained a certain size they are distinguished from 
steatomatous formations by the sharp lancinating pains with which 
they are affected, whilst steatomata are always indolent. 

Cancer vulgaris has also been seen upon the hairy scalp, ending 
in a phagedaenic ulcer, whose ravages extended even to the bones of 
the cranium. 

2d. Cancer of the skin of the nose frequently begins in the form 
of a tubercle (cancer vulgaris) developed on the lachrymal sac, or 
over the lobe, the ala, or root of the member. This tubercle is at 
first of the same colour as the skin ; a number of minute vascular 
ramifications then appear on its surface ; it next becomes red, in- 
flamed, ulcerated, and covered with a brownish and rather adherent 
incrustation ; when its surface escapes all accidental irritation, it 
sometimes continues stationary for several months and even for seve- 
ral years, the skin that surrounds it neither inflamed nor marked by 
the ramifications of dilated veins. This cancerous spot is frequently 
purely local, and independent of any other affection of the same kind, 
as I had an opportunity of ascertaining in the body of a woman, 
affected with a cancerous tetter, &c, of the left ala nasi, who died 
of accidental pneumonia. 

Cancer of the nose is often more rapid and destructive in its pro- 
gress, gnawing the cartilages and consuming the skin. Cancerous 
masses are also seen evolved underneath the skin, about the root of 
the nose, which is then observed to be traversed by varicose veins ; 
after producing external deformity in this way, these masses are very 
apt to extend to the nasal fossae, where they commit great havoc. 

3d. Cancer of the lips is proclaimed by a common or melanic tu- 
bercle, which is almost always evolved on the lower lip. When this 
tubercle becomes ulcerated, it pours out a small quantity of sharp 
ichor, which dries into a grayish or yellowish scab. So fono- as the 
ulcer implicates the skin only, it does not extend otherwise than 
superficially ; but when the mucous membrane of the lip is impli- 
cated, the sore extends rapidly, penetrates the cellular substance 
deeply, and destroys the muscles and all the other tissues of the face. 



268 



TUBERCULA. 



4th. Cancerous tubercles of the cheek, usually flatter, and more 
indolent than those of the lips, end in ulcers that show a particular 
disposition to spread superficially. The sore in this case is com- 
nionlv chapped on the edges, around which creep many varicose 
veins, and is covered with a yellow or grayish scab; it is only 
attended with shooting, and not very severe pains at distant inter- 
vals. I have also observed cancer of the cheek developed in the 
form of a fungus. 

&th. One or more small tubercles are often found in the skin of 
the mamma, when the gland is itself affected with cancer. These 
tubercles are commonly flat in their forms, and of a dull white or 
earthy colour — they resemble, in a word, the leucoid or mollusciform 
variety of cancer. 

6th. The cancerous tubercles of the extremities are almost always 
of a violet colour, and surrounded by varicose venous ramifications. 
They are particularly apt to occur in those parts of the skin which are 
morbidly altered ; in ncevi, for example. A woman was brought to me 
for advice, upon the calf of one of whose legs there was a cancerous 
fungus of the size of an apple. The patient assured me that this 
growth had been developed upon a blackish pigmentary ncevus, simi- 
lar to two others, the size of a bean respectively, whicb existed on 
the inner part of the thigh of the opposite side. This cancerous 
tumour was not surrounded by any varicose veins, and the patient, 
the mother of several children, was actually suckling one of two 
months' old. 

7th. Cancer of the palm of the hand and sole of the foot generally 
possesses the character of the melanic species. 

8th. The cancerous tubercle of the skin of the anus is commonly 
single, and situated on some point of the circumference of this pas- 
sage. It is very frequently accompanied with a chronic inflammation 
of the rectum. Of course, it is a matter of great importance on no 
occasion to confound tubercles of this character with hemorrhoidal 
tumours, or growths of syphilitic origin. 

9th. Cancer of the prepuce almost always commences as an in- 
dolent tubercle ; irritated by the sexual act, or the friction of the 
clothes, it enlarges, becomes painful, and terminates in a fungous 
ulcer, the surface of which secretes a fcetid and ichorous fluid. Can- 
cerous tubercles of the vulva are evolved, and ulcerate in the same 
manner. 

10th. Cancer of the glans penis sometimes begins as a warty ex- 
crescence, or fungous tubercle. It is frequently accompanied by 
enlargement of the lymphatic glands of the groin. 

764. Cancerous tubercles, and sores of a cancerous nature, are often 
accompanied with alterations of the same description, developed most 
commonly in the lymphatic and other glands, in the vicinity of the 
parts affected ; these lesions may be either primary or secondary. We 
almost always remark, moreover, in individuals labouring under old 
and inveterate cancer, deep traces of a constitutional affection, of a 
cachexia cancerosa, as it has been named ; the skin has an earthy or 
sallow complexion ; the patients are emaciated, &c. It must, never- 
theless, be confessed that these constitutional symptoms are in general 
rather rare among individuals attacked with cutaneous cancer, unless 
the disease, in consequence of the existence of a truly cancerous dia- 
thesis, is simultaneously developed in one or several of the viscera ; 
the implication of these organs necessarily causes considerable dis- 
turbance in the principal functions at once, and ultimately inevitable 
death, (a) 

(a) Into the detailed history of cancer, and an exposition of existing 
opinions of its origin, structure and progressive changes, it is not 
deemed necessary to enter in this place. Some additional light on 
the subject has been lent by the recent labours of Hodgskin, Carswell. 
Cruveilhier, Gluge, Muller and others. A good summary of the 
Anatomy, Physiology, Pathology, and Treatment of Cancer, by Dr. 
Walshe, will be found in an article in the Cyclopedia of Surgery, and 
subsequently brought out in a separate volume by Dr. J. Mason Warren, 
with additions. In the article "Cancer," in the Dictionnaire dc Mede- 
rmc el de Chdmrgie Pratiques, and in the Diction, de Medecine, and 
" Scirrhus" in the Cyclopedia of Practical Medicine, the reader will 
find abundant details arranged in a methodical manner. 

On the special divisions of cancer of the skin, treated of in the text, 



7G5. Causes. — Cancerous tubercles have been known to be formed 
in the substance of the skin, in consequence of local irritation; but in 
by far the greater number of cases, these little tumours have appeared 
slowly, and without any assignable cause. Cancerous tubercles are 
rarely met with before the age of puberty ; they even occur much more 
frequently between the fortieth and sixtieth years than at any other 
time, and in subjects of a bilious temperament, although even nu- 
merous instances of their development among the youthful, and per- 
sons in the flower of life, might be quoted. Cancer is occasionally 
a hereditary disease, and is often seen evolved under the influence 
of long-continued depressing moral causes. The disease is not con- 
tagious. 

766. Diagnosis. — The tubercles of lupus, of Greek elephantiasis 
and of certain forms of syphilis, are almost always indolent, and un- 
attended with suffering ; those of cancer, sooner or later, become the 
seat of severe lancinating pains. Cancerous tubercles differ in their 
appearance from warts; the cuticle is usually thickened, and cleft on 
the surface of these last, which are also almost always numerous and 
indolent, and never fall into a state of ulceration spontaneously. Those 
painful subcutaneous tubercles, which have been entitled neuromata, 
occasion, from their very commencement, pain of a much severer 
character than cancerous tubercles of the skin — pain which is like- 
wise propagated to a distance, in the direction of the nervous twigs 
upon which they happen to be developed. 

Dr. Walshe imparts little additional information from that given by 
M. Rayer, who is, by the way, largely quoted by Dr. W. The 
remarks of the latter on one of the varieties of cancer are not without 
interest. — I give them in the words of the author. 

" From the uncertainty referred to has arisen some difference of 
opinion respecting the true nature of the disease termed ' chimney- 
sweepers' cancer.' According to our views, this affection may, or 
may not, be cancerous, and, in the latter case, may be so either 
primarily or secondarily ; primarily, if it originate in true scirrhous 
infiltration or excrescence ; secondarily, if the ulcer produced by 
simple irritation become the seat of scirrhous or encephaloid forma- 
tion. Of the cancerous nature of the specimen, in which we dis- 
covered the following appearances immediately after excision, no 
doubt can be entertained. Four layers might be distinguished in the 
mass removed from the scrotum : 1, a stratum of firm laminar cellular 
membrane, presumed to be healthy ; 2, the deep layer of the morbid 
structure, consisting of an indurated substance as resisting as fibro- 
cartilage, creaking like that tissue when the point of a scalpel was 
rubbed along its divided surface, and possessing a linear arrangement 
— the fibres being perpendicular to the base ; 3, a stratum of much 
softer material, of yellowish-white colour, lobulated, and somewhat 
of a fungous aspect ; 4, a viscid coating of ichor, of a brownish-gray 
tint. These layers, more closely examined, presented the following 
characters. 1. With a common lens, a distinct partition of the cel- 
lular layer, by white opaque septa, enclosing yellowish and more 
transparent matter between them, was plainly discernible. Under a 
microscope of 150 powers, a particle of this putative normal tissue 
was found to consist of cells, some irregularly shaped, others pen- 
tagonal, and containing a distinct nucleus with nuclear corpuscles. 
A number of minute bodies, without internal cavity, (granules of 
Muller,) floated free ; in one part, an elongated mass, with exactly the 
appearance of the fibrous matter of carcinoma fasciculatum, presented 
itself; it had the transparent character of that product. 1 2. In the 
fibrous or linear part, caudate corpuscula, with or without nuclei and 
nuclear corpuscula, were abundantly seen. These were associated 
with cells of the description frequently referred to. 3. In this layer, 
a fibrillar stroma constituted a most remarkable feature. 4. In the 
ichor, we observed, in addition to nuclear cells, curved caudate cor- 
puscles." 

1 This shows distinctly that the germina of cancer (for here they probably extend 
much beyond the part examined, which almost presented the grosser characters of 
the disease), are occasionally left behind in tissue, which appears at the time of ope- 
ration to be perfectly healthy. A remark of the same kind has been made by Gluge : 
" It is not only," he says, "in the encephaloid tissue itself, of afTected organs, that its 
globules are found ; they are also to be discerned in parts apparently healthy ; for 
example, in portions of encephaloid lungs, which still retain the property of crepitat- 
ing."— (VInstitut., No. 191, Jan. 4, 1837.) 



CANCER. 



269 



The tubercles of melanic cancer differ from pure melanosis deve- 
loped in grains, by being accompanied with lancinating pains, which 
melanosis never is. Leucoid cancer has a characteristic appearance, 
which distinguishes it from every other disease. Mollusciform can- 
cer cannot well be distinguished from the disease called molluscum, 
unless where symptoms, or other alterations of an unequivocally can- 
cerous character, are observed at the same time. 

The ulcers of lupus, of Greek elephantiasis, and of syphilis, do not 
occasion pain of the same description as cancerous sores, and are, 
moreover, accompanied with various phenomena which contribute to 
distinguish them. In other and more simple cases, the diagnosis may 
even remain for some time uncertain. I once saw a small fungous 
sore, nearly six lines in breadth, and of a cancerous appearance, 
situated towards the outer angle of the eye, below the level of the 
under eyelid, which had existed for a month, having followed a spot 
that had become excoriated ; but the long continuance, and particular 
appearance of this sore, were solely owing to neglect of proper clean- 
liness, and to irritation kept up by the nails of the patient ; for I 
succeeded in healing it up in the course of a month, by means of 
emollient applications, and the use of the simple tepid bath. 

767. Prognosis. — It maybe stated, generally, that cancerous tuber- 
cles of the 'face, lips, and ala? nasi, are less serious affections than 
cancer of the glands ; when extirpated, the disease is also less apt to 
recur. Melanic tubercles, however, form a marked exception to this 
rule ; the disease in this form being particularly apt to be reproduced. 
Cancerous ulcers of the face, trunk, extremities, genital organs, &c, 
are beyond the reach of art when they have extended so far as to 
make it impossible to remove with the knife or caustic, the whole of 
the parts which the disease has implicated. When a very large num- 
ber of cancerous tubercles are developed in the skin, it may always 
be taken as evidence of the existence of a cancerous diathesis, which 
sooner or later will extend to the viscera, and prove inevitably fatal. 

768. Treatment. — When one, or a very small number only of 
cancerous tubercles have been evolved within a short time upon a 
particular district of the skin, we have of late been advised to attempt 
their resolution by means of local bleedings, of emollient or narcotic 
applications, and the administration of gentle laxatives. I have little 
confidence in this mode of treatment, the value of which has been 
singularly over-rated ; I have tried it several times, but without once 
obtaining the complete discussion of a cancerous tubercle ; forty 
leeches applied in the course of eight days around a tubercle recently 
evolved, failed to effect the slightest diminution in the size of this 
production ; in one case only did a cancerous tubercle of the nose 
shrink temporarily under the influence of the abstraction of blood ; in 
consequence of a cold it enlarged again, and the patient having died 
shortly afterwards of an acute disease, I was enabled to ascertain that 
the tubercle contained cerebriform matter. 

Dr. Recamier has given a case of cancerous tubercle in which 
cauterization and compression were employed with advantage. In 
the majority of instances, however, it is better, when the cancerous 
nature of a tubercle has been well established, to remove it with 
the knife at once. A multitude of cases show that tubercles of this 
description evolved in the skin of the cranium, of the face, and other 
regions of the body, may be extirpated with complete success. The 
existence of some lesion of the viscera or their membranes could 
alone contra-indicate such an operation. A multiplicity of tubercles 
need prove no obstacle to their removal, for they may all be taken 
away one after the other in a very short space of time, if no other 
symptom of a cancerous diathesis be present. When the wound 
which results from the extirpation of a cancerous tubercle cannot be 
healed by the first intention, I am of opinion that instead of dressing 
it simply, like a common suppurating wound, it is better to cauterize 
its surface with the acid nitrate of mercury, or even to cover it with 
the arsenical paste. Cancerous tubercles in a state of ulceration, in 
young or middle-aged subjects, may also be attacked with the scalpel, 
whenever it appears possible to remove the whole of the structures 
affected, and when the disease is not hereditary. After the operation, 
I should always recommend the use of caustic in these particular 
cases. And I have fancied that relapses were less frequent when, 
under such circumstances, a caustic issue was made in the arm or 
leg, either before or shortly after the operation. 
68 



769. When cancerof the skin, after having destroyed in succession 
this tissue, the subjacent cellular substance and the muscles, extends 
to the bones, to the cartilages, conglobate and conglomerate glands, 
or to the tissues in the vicinage of its primary seat, or when it occurs 
among the aged, or individuals who present marks of the cancerous 
diathesis, the disease can neither be successfully attacked by the knite 
nor by caustics. Nothing more can then be done, in fact, than to en- 
deavour to assuage the acute and incessant pain which the patient 
endures. The necessity of employing anodynes, in large doses, for a 
great length of time, and the no less evident necessity of sparing the 
digestive organs the paralysis of their powers, induced by the habitual 
use of opium, led me to recommend, in these desperate cases, tire 
application of small doses of the acetate of morphia to the surface of 
the sores, or of the corion at any point where it happened to have lost 
its cuticle : experience has satisfied me of the advantages of this mode 
of using the narcotic. 

770. Many different medicines, of various degrees of activity, have 
in their turn been spoken of as calculated to modify the cancerous dia- 
thesis, to favour the resolution of cancerous tubercles, or to heal up 
cancerous ulcers. Arsenic, in one or other of its forms, has been 
tried internally by Loder, Lentin, Selle, Tode, and others ; I have 
prescribed many of these myself, but in vain. I have also tried the 
preparations of hemlock, which have been lauded in this class of com- 
plaints, in doses of from one to two grains, for a year, in several cases 
of cancer of the skin and mammary glands; and, under the influence 
of this medicine, the disease appeared to me to advance more slowly 
than usual, and to be attended with less severe pain. I have tried 
the carbonate of iron in doses of half a drachm, a drachm, and even 
several drachms, for months together, without perceiving any good 
effect from the action of the medicine. Several experiments have 
been made with iodine ; and, as usual, with the effect of arousing 
hopes at first, which have not been subsequently realized. Rust 
assures us that he has succeeded in curing radically, several cancer- 
ous affections of the lips, with the decoction of Zittmann ; x were not 
these presumed cancers, syphilitic in their nature ? Graefe 2 has given 
a case of very extensive cancer of the face and palate, which was 
much improved by creosote. We should, therefore, feel encouraged 
to enter upon new, and even bold attempts, to check a disease, which 
it is difficult to conceive, must necessarily and under all circumstances, 
remain incurable ; the more especially when we remark the extraordi- 
nary success that has attended the introduction of several powerful 
medicines, in the treatment of certain syphilitic ulcers, the havoc com- 
mitted by which is neither less extensive, nor their consequences less 
deplorable, than those of cancer. When called to give our assistance 
to the aged, however, and to those whose constitutions, although, 
perhaps, not seriously affected by the disease, have been injured by 
severe abstinence, by long courses of active medicines, or the shock,, 
and after consequences, of a surgical operation-, it is always well to 
bear in mind the following passage of Celsus, which has been often 
quoted, both by physicians and surgeons of ripe experience : " Quidam. 
usi sunt medicamentis urentibus : quidam ferro adusserunt r quidam 
scalpello exciderunt ; neque ulli unquam medicina proficit — excisa 
(carcinomata) etiam post inductam cicatricem tamen reverterunt, et 
causam mortis attulerunt — sed imponendo tantum lenia medicamenta, 
quae quasi blandiantur, quominus ad ultimam senectutem perveniant, 
non prohibentur." (Celsus. De MedicinS, lib. v. sect, xviii.) 

Historical Notices and particular Cases, 

771. Hippocrates nowhere mentions cancer of the skin distinctly. 
Celsus 3 has left a most accurate account of the external characters of 
the disease. He has remarked on the great tendency of KapxiVwjua to 
relapse, after it has been extirpated by caustic or the knife. Paul of 

1 A comp. decoct, of sarsaparilla. — Tr. 

s Liltre\ Art. Cancer.- Diet, de Medecine, 8vo. Ed. 

3 Celsus. De medicina, lib. v. De carcinomate. "Id vilmm fit maxime in super! ■ 

oribus paitibus, circa faciem, nares, aures, labra, mammas foeminarum circa locu:u 

aliqua quasi puncta sentiuntur— circa eum inflatae vena* — interdum simili his est 
quae vocant xwivitipirit, aspredine quadam et magnitudine sua." Celsus has 
spoken particularly of the characters and treatment of cancer of the penis (lib. vi. 
sect, xviii. 3;) and the case he had in his eye, from one of the appearances he mea- 
tions, (incipit a nigritie,) would seem to have belonged to the melanic variety, 



270 



TUBERCULA. 



/Egina, in giving the characters of cancer, insists particularly upon 
. mptoma — " «egros maxime fatigans et perpetuo fcrc dolore aflli- 
llal'enrclfer 1 has given a good description of the cutaneous 
cancerous tubercle, and cancerous ulcer. Forestus, 2 under the title of 
noli me tungere, has detailed the symptoms of a tumour, probably can- 
cerous in its nature, situated on the right cheek, and extending to the 
and nasal fossae. According to Ledran 3 this title properly belongs 
to phagedenic cancers, regarded as incurable. I have already had 
occasion to state that lupus had been described under the same name. 
Partf speaks of a plump hussy of goodly presence (une garce potelh 
de bonne apparence), who simulated cancer of the skin by dabbing 
her breast with a sponge dipped in a mixture of milk and blood. 

Several varieties of cancer have of late been described in our medi- 
cal journals, and systems of surgery, with great accuracy. A number 
of cases of cancer of the face/ of fungiform cancer of the skin, cover- 
ing the calf of the leg, 6 groin, and forearm ; 7 of cancer vulgaris of the 
scrotum ; 8 of melanic cancer of the lips, 9 hands, finger, 10 face, &c. ;" 
and of globular cancer, 12 will all be read with interest. Chimney- 
sweepers' 1 cancer has only been observed and described in England. 13 
1 have mvself given the first account of the leucoid, of the mollusci- 
form and disseminated encephaloid forms of cancer. 

772. The local treatment of cancer has been a subject of much 
research. The effects and advantages of compression, which was so 
much recommended by Dr. Young, 14 have been studied with great 
care by Dr. Recamier. 15 Some practitioners of great eminence, with 
Dr. Al. Monro 16 at their head, condemn excision entirely. Others, 
and especially Hill, 17 on the contrary, rely on this means as one very 
often successful ; others, again, among whom Boyer deserves to be 
particularly mentioned, without rejecting an operation entirely, ac- 
knowledge the frequency of relapses, even in those cases which were, 
to all outward appearance, the most favourable for its performance. 
In another work 13 I have given an account of the greater number of 
the experiments which have been made with arsenic, administered 
internally and applied externally, in the treatment of cancer. 

Several medicines — hemlock, 19 belladonna, 20 carbonate of iron, 21 
iodine, 22 &c, have been held up as calculated to subdue the can- 
cerous diathesis, and to cure cancer. The whole of these remedies, 
as well as the curafamis, 23 which has been advised with similar views, 
I have tried a very considerable number of times, but always with 
results very little satisfactory. 

It were greatly to be wished that further experiments were under- 
taken under definite and well-determined circumstances, and that the 
results of these were faithfully detailed. 

i Hafenreffer. na*$oxtw aiA'Ai^ucvxov, lib. ii. cap. 7. 

2 Forest. Obs. chirurg., lib. ii. ob^. ix. 

3 Mem. sin- le cancer; sect, des cancers de la peau. (Mem.de l'Acad. roy. de 
chirurg., t. iii. p. 3.) 

* Pare. CEuvres in-fol., p. 1051 (l'imposture d'une belitresse feignant avoir un 
chancre en la tnamelle.) 

s Scarpa. Opuscoli di chirurgia, etc., vol. i. Pavia, 1825 (Memoire sur le squirrhe 
et le cancer). Exirait par Ollivier (d'Angers) : Archives gener. de med., t. xi. p. 276. 
6 Sabatier. Journ. Hebd., t. v. p. 321. 
1 Dubourg. Journ. Hebdomad., 2e serie, t. ii. p. 363. 
s Lisfranc. Archiv. gener. de med., t. xii. p. 521. 

9 Alibert. Nosol. meth., t. i. (Observations de Jurine.) 

10 Jadelot. Journ. Hebd., t. iii. p. 459.— Cruveilhier. Anat. Pathol, in-fol, 19e 
livraison. — Dubourg. Journ. Hebd., t. vii. p. 73. 

'i Dupuytren. Rev. med., mars 1829, p. 353.— Lisfranc. Rev. med., t. ix. p. 189. 
'- Alibert. Nosologic naturelle, art. Cancer. 

13 Pott's Works, vol. iii. — Simmons. Cases and Obs. on Lithotomy, in which are 
added obs. on chimney sweepers' cancer, in 8vo. Manchester, 1808. Earle. Medic. 
Chirurg. Transact., vol. xii. p. 297. 

14 S. Young. Inquiry into the nature of cancer, 8vo. London, 1805. 

15 Recamier. Recherches sur le traitement du cancer, 2 vol. 8vo. Paris, 1829. 
(Etude de la compression, de la cura famis, de Taction du nitrate acide de mercure 
et de quelques autres caustiques). 

'6 Monro (Alex.). Edinb. Medic. Essays, vol. ii. 

17 Hill. Edinb. Med. and Surgic. Journ., vol. vi. 

'8 Diction, de med. et de chirurg. prat., art. Arsenic, t. iii. p. 374, et suiv. 

19 Stork (A.). Libellusquodemonstraturcicutam.etc. Vienna?, 1760,8vo. Libellus 
ii. (praises the remedy). J. Andree. Obs. upon a treatise on the virtues of hemlock, 
in cases of cancers etc., 8vo. London, 1761, gives negative results. 

20 Lamberger. Lectio inaug. sistens ephemeridem persanati carcinomatis, 4io. 
Groningae, 1754. r 

« Carmichael. Essay on the effects of carbonate and other preparations of iron 
upon cancers, etc., 2d edit. 8vo. Dublin, 1809. 

-'-' Magendie. Formulaire, sixieme edit., 8vo. 1827. Art lode 

* Pouteau. CEuvres posthumes, t. i. Tissot Prix de l'Acad. de chirurgie. 



Case CXXXIV. — Cancerous tubercle of the lower lip. Ri>i)it>r,i! 
and cure. Anne Blasie, sixty-eight years of age, became a patient in 
the Hotel Dieu, Feb. 14, 1826, on account of a cancerous affection of 
the lips. The disease had appeared eleven months previously, as a 
small tubercle, on the inner surface of the lower lip. This tumour, 
by and by, became covered with a scab, which the patient removed 
by working at it with the point of her tongue. The patient leads a 
very active life, going to bed soon, and rising very early in the morn- 
ing. She had had herself bled a few days ago, and since then, thinks 
that the tumour of the lip has been less inflamed, and not so hard as 
before. The tubercle, at the date of her admission, is as large as an 
almond, hard and ulcerated on its upper part along (he edge of the lip, 
the mucous membrane of which is destroyed in two different places. 
Usually indolent, this tubercle is at times the seat of acute shooting 
pains, similar to what are caused by the slight prick of a needle. 

M. Sanson, surgeon of the Hotel-Dieu, removed the tubercle with 
a single stroke of the flat curved scissors. The semi-lunar wound 
that resulted, healed rapidly, so that the patient was dismissed on the 
4th of March, perfectly well, the lip presenting no deformity. 

Case CXXXV. — Cancerous tubercle — ulceration — complications — 
death. Madame * * *, sixty years of age, consulted me towards the 
end of the year 1824, on account of a chronic laryngo-tracheitic affec- 
tion, attended with loss of voice. Asses' milk, and a soothing plan 
of treatment, were recommended ; and she afterwards went into the 
country to try the effects of the method in restoring her voice. 

About the 15th of June of the year following (1825), she perceived 
a small tubercle, or wart, as she called it, on the prominent edge of 
the root of the nose. Another practitioner attempted to get rid of 
this wart by passing a ligature round its base on the 1st of July. 
This was not done without much difficulty, on account of the flat 
lenticular shape of the tubercle, which was of the same colour as the 
skin, with a black point in its centre, and nowise painful. The liga- 
ture at first caused little inconvenience, but at length, before the 
tubercle fell off, which happened on the 13th, great suffering. A 
sore, a little larger than a silver threepenny piece, surrounded by a 
great deal of inflammation, was left. 

On the 16th of July the patient returned to Paris, when I saw her 
again. At this time there was on the median line of the root of the 
nose, an ulcer half an inch in breadth, rounded and prominent, and 
presenting a singular mixture of whitish, livid, and blackish points, 
upon its surface ; this sore did not discharge, and formed the centre 
of an inflammatory circle, which spread to the lateral parts of the root 
of the nose. The appearance of this ulcer reminded me of that pre- 
sented by fungoid cancers, and I proposed calling M. Dupuytren into 
consultation. This eminent surgeon could hardly be persuaded that 
the sore we had before us could have been developed in a month. It 
was agreed to cover the swollen parts with emollient and anodyne 
cataplasms, and to apply five leeches every day to the base of the 
sore, causing the bites to bleed as plentifully as possible, by the use 
of tepid fomentations. Forty leeches were in this way successively 
applied to the base of the tumour in the course of eight days ; but no 
sensible abatement of the inflammation resulted. In consultation, a 
week afterwards, it was determined that nothing was to be expected 
from the antiphlogistic treatment : the swelling had rather increased 
than otherwise under it ; and, reflecting that the progress of cancerous 
sores is seldom so rapid as in this instance, and conceiving it possible 
that the obstinacy of the laryngeal affection, which still continued, 
might be owing to something specific, Madame * * * was put upon a 
course of the bichloride of mercury in solution, and decoction of 
sarsaparilla. These medicines, continued for two months, produced 
no good effect ; on the contrary, the ulcerated tumour was more 
rounded and prominent than before, chapped in several places, and 
scarcely secreted any thing. The general health of the patient, too, 
seemed to have suffered. She therefore returned to a tranquil mode 
of life, took asses' milk, &c. ; and I covered the ulcer with a little 
powder, composed of ninety-nine parts of calomel and one of pro- 
toxide of arsenic. This application produced the most singular abate- 
ment in the inflammation of the base of the tumour, and removed the 
disagreeable smell emitted by the sore. An operation being held 
inadmissible by the eminent surgeon consulted, and the patient herself 
having an unconquerable aversion to anything of the kind, I resolved 



CANCER. 



271 



on destroying the indolent fungus that rose from the surface of the 
ulcer, by means of the concentrated nitric acid. The patient felt no 
pain from the action of the acid, either at the time of the application 
or afterwards, so that on the following day I used the acid again, and 
more freely than at first. Neither did the patient, on this occasion, 
make any complaint at the time of using the acid ; but next day, she 
felt some deep pricking pains under the small tumour. Five days 
afterwards, (Sept. 28,) a portion of the tumour, like the half of a 
large walnut, sloughed out, and the surface of the sore was reduced 
to a level with its edges. By and by, recourse was again had to the 
compound powder of calomel and oxide of arsenic, with which the 
surface of the sore was dusted over ; and under this application, the 
neighbouring parts became much less inflamed, and the ulcer itself 
contracted, and even cicatrized over three-quarters of its whole extent. 
But while the cancerous sore improved, the chronic inflammation of 
the larynx and trachea extended to the bronchi, and even appeared in 
others of the mucous membranes ; so that the patient, long confined to 
spare diet, lost her strength rapidly, and died on the 5th of April, 1826. 

Case CXXXVI. — Mollusciform cancer. Cancerous formations in 
various parts of the body. M. S. Duboille, aged forty-Two, married, 
and a mother, had felt her health on the wane for the last three years 
and a half, having suffered from wandering pains of the abdomen, 
and the sensation of something like a tumour in the lower part of the 
left hypogastrium, a situation in which she felt rather severe lancina- 
ting pains from time to time. The right breast had begun to enlarge 
about a year ago, and was now hard, shrunk, and knotty, with a 
chain of enlarged lymphatic glands stretching from it, though it had 
never been very painful towards the axilla. In January, 1827, a 
number of tubercles made their appearance on different regions of the 
body, two of which soon became much larger than the rest, the one 
situated midway between the ribs and haunch bone of the right side; 
the other on the right scapular region. Many of the tubercles had 
precisely the appearance which is held characteristic of the non- 
contagious form of molluscum. The patient's skin was of a uniform 
pale straw colour. The belly was large, and the seat of deep lanci- 
nating pains. The evening after her entrance into the Hopital de la 
Charite, the patient had a violent attack of bleeding from the nose, 
which was only stopped by plugging the nostrils. The patient 
having taken out the plugs, the hemorrhage returned next day, and 
the apparatus had to be replaced, while a small quantity of blood was 
taken away from the arm. The patient died a few days afterwards. 

On inspecting the body of this woman, thirty-six hours after her 
death, the skin of the thorax was found beset by about ten small 
tubercles, scarcely rising above the general level, of a bluish cast in 
some instances, in others, of the same colour as the surrounding 
integuments ; the smaller of these tubercles did not extend deeper 
than the skin, so that the inner or adhering surface of this tissue pre- 
sented its ordinary appearance ; opposite the larger tubercles, how- 
ever, the texture of the skin was altered, indurated, and yellowish. 
The left mammary gland was healthy. On the posterior surface of 
the thorax, two tumours, of much larger size than any that have 
been mentioned, were observed. These were prominent, uneven, 
fungiform, and when cut into presented the following dispositions: 
The most external layer was yellowish, and in its general charac- 
ters, approached the organic alteration w T hich has been described 
under the name of scirrhus; the next layer consisted of the corion 
hypertrophied, but not otherwise changed. The skin of the abdo- 
men, held between the eye and the light, showed a number of small 
reddish or livid tubercles, nowhere prominent; and the integument 
of the left arm presented two tubercles, of the same colour as the skin. 
These morbid changes in their first stage, and as they occurred in the 
smaller tubercles, appeared to consist of circumscribed simple hyper- 
trophied patches of the corion ; in the larger tumour, however, the more 
superficial layers of the corion presented an uniform yellowish tint, 
and a semi-transparency analogous to what is observed in scirrhus. 

The right breast was hardly larger than that of the opposite side, 
but it was very hard, yellowish, and creaked under the scalpel, like 
a scirrhous mass. The colour here formed a striking contrast with the 
milky white of the left mammary gland. Running from the breast to 
the hollow of the axilla, there was a chain of lymphatic glands, red- 
dish in colour, and rather voluminous, but not otherwise altered. 



In the abdomen, the stomach exhibited a very remarkable morbid 
appearance. Its inner surface presented a great number of nipple- 
like eminences, analogous to the tubercles of the skin; they were in 
general of the size of a hazelnut, and, when cut across, showed that 
they consisted of four layers: the mucous coat, very much hypertro- 
phied externally, the sub-mucous cellular tissue indurated, the muscu- 
lar coat hypertrophied, and redder than natural, and the peritoneum, 
which was not sensibly changed. Three or four of these tubercles 
were ulcerated in their centre. The intestinal canal was healthy. 
The pancreas and liver were greasy. The spleen was hard, and in 
one part presented a mass either of cerebriform matter, or of dis- 
coloured fibrinous deposit. The left ovarium, the size of a turkey's 
egg, consisted in part of cerebriform matter, and in part of a serous 
cyst. No other morbid alterations sufficiently remarkable to enume- 
rate, were detected* 

Case CXXXVII. — Leucoid cancer. Cutaneous tubercles. Can- 
cerous alterations in a female aged seventeen. Marie Patureux, semp- 
stress, aged seventeen, of lymphatic temperament, had menstruated 
regularly for six months, when in the month of February, 1828, she 
began to feel lancinating pains in one of her thighs, and became 
aware of a tumour in this situation, nearly as large as a walnut. The 
application of twenty leeches relieved the pain for a time, but the 
tumour went on increasing in size ; the thigh swelled, walking became 
laborious, and the patient entered the Hopital de la Charite, where, 
besides the tumour on the thigh, another, occupying the umbilical 
region, was discovered. Rest was prescribed ; a soap plaster, and, 
by and by, the inunction of some mercurial ointment, combined with 
the methodic compression of the femoral tumour, were tried. After 
remaining in the. hospital a month, a number of small tumours, which 
I shall describe by and by, began to make their appearance on differ- 
ent parts of the body. She then left the house ; but on the 14th 
September, became a patient in the Hupital St. Antoine. The num- 
ber of tumours had now very much increased ; and, although three of 
these had acquired a considerable size before the patient became 
aware of their existence, to show us the mode in which they were 
generally evolved, she directed our attention to a number of small 
round bodies, about the size of large pins' heads, imbedded in the 
skin of the belly and thighs ; these were not made visible by any pro- 
jection above the level of the surface ; they were quite immovable, 
and not painful to pressure. As the tubercles advanced, however, 
they rose above the general level, and, assuming an oval shape, very 
commonly appeared surrounded with a large pale red areola. They 
were then mostly of the size of a shilling, or rather larger. Here and 
there several appeared irregularly clustered together. The greater 
number were pink in the centre, and of a dull white in the circum- 
ference. Those of oldest formation, however, presented a brownish 
hue in the middle, which, instead of being raised, was flattened, and 
even depressed. The brown tint seemed to inhere in the cuticle, 
which could be detached in small plates from several of the tubercles. 
Lastly, the majority of the tubercles were traversed by a number 
(commonly four or five) of small tortuous venous branches, which, 
in case the tumour were prominent, proceeded from the base, to unite 
in the centre, and which, in case it were flat, were distributed almost 
solely around its circumference. 

The tubercles were not accompanied with any pain : the surface 
of the right thigh was completely covered with them. They were 
also very numerous above the pubes ; an irregular band of them 
stretched from the right inguinal region to the anterior and superior 
spinous process of the left os ilium. The skin of the abdomen 
generally, and of the bosom, was also thickly beset. Besides the 
cutaneous tubercles, a large tumour could be felt deeply imbedded 
in the substance of the right thigh, which was much swelled, and 
nearly a third more in circumference than that of the opposite side. 
On the right arm there was another morbid growth, of a rounded 
form, an inch and a half in diameter, and pointed in its centre, which 
fluctuated, and was of a livid red, slightly squamous, and occasion- 
ally moistened with a little exudation. The abdomen, in fine, was 
hard and tense, and seemed distended under the navel by a bulky 
tumour. The patient scouted every hint at the possibility of this last 
tumour being induced by pregnancy, so obstinately, that we were at 
first misled in our estimate of its nature, when we presumed it might 






TUBERCULA. 



be similar to the others. By and by, however, the truth came out: 
the u'irl was pregnant, and the mistake committed might have been 
avoided by a recurrence to auscultation. 

The patient's general health was at first satisfactory; but she soon 
began to droop and lose flesh. The cancerous nature of the com- 
plaint under which she laboured being recognized, made us fear for 
the worst. Arsenical medicines were tried for some short time, but 
these appearing to cause heat in the throat, and pain in the bowels, 
were soon discontinued, and leeches applied to relieve these symp- 
toms. The patient became jaundiced at length, and was sinking 
fast, when, on the 11th of January, 1829, she was taken in labour, 
and died almost immediately after giving birth to a child, which lived 
but a few hours. 

Inspected twenty-four hours after death, the body of the patient 
presented the jaundiced colour observed during life. The cutaneous 
tubercles, when cut into, appeared, in many cases, to be formed of the 
corion hypertrophied, the prolongations of this structure into the sub- 
jacent cellular membrane being much more largely developed than 
they are in the normal state. Some of the tubercles presented large 
drops of blood effused into the substance of the corion ; others again 
were softened, and when squeezed between the fingers, a little puru- 
lent matter exuded from the cut surfaces. The tumour of the right 
arm consisted of a mass of cerebriform matter, softened, and tinged 
yellow like the skin. The subcutaneous cellular substance, which 
was very abundant, formed small white, hard and rounded masses, 
which creaked when cut into, under the several tubercles. The deep- 
seated tumour of the right thigh was composed of cerebriform matter, 
but very hard. The centre of the mass, as large as the fist, was tra- 
versed by the crural veins. Several small, hard, cancerous masses 
were detected in the upper part of the intestinal canal. The mesen- 
teric glands had also evidently undergone alteration. The liver was 
healthy. The ductus cysticus and ductus choledochus were alike dis- 
tended with bile ; the latter was compressed by the extremity of the 
pancreas in a scirrhous condition, and this had caused the jaundice. 
The aorta was surrounded by a cerebriform mass of considerable size. 
The other viscera did not appear to be changed. The foetus, appa- 
rently in the seventh or eighth month of its uterine existence, was 
quite free of all appearance of cancerous affection. 

Case CXXXVIII. — Encephaloid cancer of the scalp and pubic 
region; death. Tyron, aged twenty-five, the mother of several chil- 
dren, observed in the month of April, 1826, that a small tumour, the 
size of a mulberry, had grown on her head, having been preceded 
for several weeks by constant and pretty severe pain in the parietes of 
the cranium. Towards the month of August this woman consulted 
M. Ollivier d' Angers, who discovered four mammillated tumours of 
a like description on the scalp, one of which was extirpated ; but 
scarcely had the edges of the wound coalesced, when a new tumour 
sprang up, and speedily attained the size of a hazelnut. This tumour 
was uncovered with hair, of a pale-red colour, slightly flattened, hard 
and resisting, and the seat of acute intermitting pain. The other 
tumours were rather smaller, of a violet-red colour, hard, and also 
without any covering of hair ; the skin that was stretched over them 
was of a pallid or bluish-white colour. The tumours only became 
painful when they had acquired a certain size. Two more of the 
tumours were subsequently removed by M. Boyer, one of which was 
rapidly reproduced, and, at the time I saw the patient first, bore the 
most perfect resemblance to a raspberry. At this period the patient 
appeared to be labouring under a purely local affection. The prin- 
cipal functions were performed with perfect regularity, and Tyron had 
all the appearance of a person in good health. 

The indifferent success that had attended the two operations already 
performed, the repugnance of the patient to any further measure of 
the kind, and the obscure nature of the disease," led to the prescrip- 
tion of bleeding, and the use of simple emollients. Two of the 
tumours of the scalp became red and fungous, and a tumour of the 
same kind was evolved above the pubes. Symptoms of morbid 
alterations in the abdomen soon afterwards made their appearance. 
In the hypogastric region, a tumour, equal to the mass of the uterus 
in the fourth month of pregnancy, was discovered. There was no 
change in the state of the cervix uteri, however, to cause any suspi- 
cions of pregnancy ; besides, the catamenia continued regular, though 



scanty. This tumour was the seat of violent pain, and the patient 
became feverish and disturbed in her sleep. On the 8th of January 
all the symptoms of acute peritonitis were presented ; the patient was 
bled, put on low diet, ordered to have diluents, lavements, &c, but 
in vain ; she died on the 22d of January, 1827. 

The body was inspected by M. Ollivier, who communicated the 
appearances to me, and sent for my more particular examination the 
tumours of the scalp. Three of these were completely subcutaneous 
and as large as musket balls. The skin which covered them was 
naked, the hair bulbs having probably been atrophied under the 
effects of the compression they had undergone. The cellular sub- 
stance surrounding these tumours was healthy. When dissected out, 
their surface was lobulated, which made them look as if they con- 
sisted of a number of smaller parts. When cut into, they were found 
composed of cerebriform matter, in a state of crudity. Other two 
fungous and vascular-looking tumours, which were not covered with 
integument, were also formed of encephaloid matter, but very much 
injected and softened. The bone under these last tumours was 
healthy. Aqjong the hair of the pubes, a small red bleeding tumour, 
the size of a nut, also formed of encephaloid matter, was discovered. 
On either side of the umbilicus, a tumour of the same size and like 
composition, but less vascular, was found. The peritoneum, in a 
state of inflammation, contained about a pound and a half of a sero- 
purulent fluid. The lower or lesser pelvis was filled by a lobulated 
tumour, uneven on its surface, of a pale rose-colour, and as large as 
a child's head, lying betw r een the uterus and rectum, which were 
respectively pushed by it forwards and backwards. When cut into, 
this tumour presented all the characters of the encephaloid tissue ; 
several of the lobuli were softened, others were still in a state of 
crudity ; every part of it had the same smell as the substance of the 
brain. The centre of the tumour appeared to be occupied by the left 
ovary ; the broad ligament of the same part formed a very distinct 
band on the external surface of the tumour. Around this ovary, the 
morbid formation was clustered in the shape of lobular masses, most 
of which were of the size of hens' eggs. A lobulated encephaloid 
mass, as large as a hen's egg, was also found in the thorax, adhering 
to the right lung, which presented a peculiar structure: instead of 
being cleft transversely, as usual, it appeared divided longitudinally 
by a deep fissure. The head and spinal canal were not examined. 

773. Having felt called upon in the course of this work to describe 
subcutaneous tubercles of a syphilitic and of a scrofulous nature, I con- 
ceive it will be well to quote a case of painful subcutaneous tubercle. 1 

Case CXXXIX. — Painful subcutaneous tubercle. M. J. Roy or 
Fuque, aged forty-two, became a patient in the Hopital de Cochin, 
1st Oct., 1826, on account of the disease which Mr. W. Wood has 
denominated painful subcutaneous tubercle. The tumour in this case 
was situated in the posterior part of the thigh, was as large as a grape 
stone or a small pea, of an oval form, nowise adherent to the skin, 
and not only extremely painful when touched or pressed upon, but 
repeatedly during the course of the day, the seat of severe pain, 
which shot downwards from the thigh into the leg. The patient 
informed me that she had suffered for some time with severe darting 
pains in the seat of the tumour, before she discovered a small hard 
body, about the size of a large pin's head. It continued nearly sta- 
tionary for several years, and attended with the same symptoms; it 
had finally grown gradually till it had attained the dimensions stated, 
accompanied with paroxysms of pain, more and more frequent, and 
more and more severe. The patient has now from two to fifteen 
paroxysms daily, which last from a quarter of an hour to an hour, 
often with such intensity, that tears are forced from the patient, 
though she appears to p'ossess a great share of fortitude and much 
good sense. These paroxysms, which frequently came on sponta- 
neously, were certainly excited by the slightest touch, so that the 
patient is very careful how she either lies or sits down, and now 
submits to the examinations of medical men with great reluctance, as 
she never fails to suffer severely from their manipulations. Each 
paroxysm begins with tingling and severe shootings, and with a feel- 
ing of extreme heat in the tubercle and skin which covers it. An 
instant afterwards the pain extends down the whole of the back part 

' For a particular account of these tubercles, vide Descot. Diss, sur les affections 
locales des Nerfs, 8vo. Paris, 1825. 



ELEPHANTIASIS. 



273 



of the limb, from the tubercle to the heel, ending between the malle- 
olus internus and the inner and under edge of the os calcis, without 
any diminution of intensity, through the whole of this course ; if there 
were any difference, indeed, it was rather in the greater severity of 
the pain in the tubercle itself, the calf of the leg, and the inner side 
of the heel. The sole of the foot, and all the parts above the tubercle, 
have always been exempt from pain. In its extension, the pain did 
not seem to follow the course of any particular nerve ; it was general, 
and diffused over the posterior part of the limb. The anterior aspect 
of the thigh and leg was unaffected. Active exercise always made 
the paroxysms more severe. These were also more than commonly 
acute on the approach of the menstrual period, and when any great 
change occurred in the state of the atmosphere, especially when it 
became cold and moist. During the paroxysm, the pain was almost 
constantly of the shooting kind, or appeared to extend in rapid pulses 
from the tubercle to the heel. When the paroxysms were long and 
severe, the feeling of heat was not confined to the tubercle, but 
extended to the whole of the back part of the thigh ; although unac- 
companied with febrile symptoms, they always left the patient ex- 
hausted and enfeebled. Various remedies had been tried, but without 
doing any good. 

M. Guerbois extirpated the tumour next day, October 2d, exposing 
it by a longitudinal incision, raising it by means of a hook, and taking 
it away along with a small portion of lamellar tissue, by which it was 
surrounded. The wound scarcely bled, and its edges, being brought 
together with sticking-plaster, united by the first intention. From the 
moment of the operation no further paroxysm of pain was felt, and by 
the 6th of the month, the patient felt completely relieved from the tor- 
ture she had endured for eight years. 

On the day of the operation, M. Ollivier (d'Angers) and I examined 
the tumour particularly. It was of an oval form, of the weight of six 
grains, smooth, and of a very slightly bluish-white cast of colour, very 
similar to that of made starch, without any thing of the pearly lustre of 
cartilage. The texture of the tumour was hard and solid, like that of 
the fibro-cartilages, from which it differed, however, in being homo- 
geneous, in presenting no trace of fibres in any part ; neither could 
any vessel or nerve be detected in its composition, even with the 
assistance of the magnifier. The cellular substance in which the 
tumour was enveloped, was also searched in vain for even the 
smallest branch of an artery or nerve. The tumour was not developed 
in the course of any nervous twig; neither can it well be imagined 
that it lay in the neighbourhood of one of the posterior subcutaneous 
branches of the sciatic nerve, to the compression of which all the 
suffering endured by the patient might be attributed ; for the inter- 
mitting, extremely acute and lancinating character of the pain, could 
not be explained by this supposition. Looking at the bluish cast of 
the tumour, and all the circumstances attending its development, we 
were inclined to view it as a modification of scirrhus, rather than as 
simply cartilaginous. 

ELEPHANTIASIS, (fl) 

Vocab. Elephantiasis, Djtizam, Lepra Medii cei'i, Lepra Taurica, Mai rouge de 

Cayenne. 

774. Elephantiasis is a serious chronic disease, characterized exter- 
nally by shining and oily-looking dark patches, to which succeed 
irregular, slightly prominent, softish, and at first, red and livid tuber- 
cles, which by and by assume a dusky or bronze colour; these usually 
continue long indolent ; they may terminate in resolution or ulceration ; 
their most common seat is the face. They also often appear on the 
palatine arch ; but the nose and ears, swelled and hideously distorted, 
are the parts of all others which suffer most frequently. 

775. Symptoms. — Some writers inform us that Greek elephantiasis 

(a) It will be seen that M. Rayer restricts this term to the disease 
known as leprosy, the Greek leprosy of the middle ages. By many 
writers it is applied to the other form of leprosy, or the Arabian, the 
prominent or chief feature of which is a swelled leg, (Barbadoes leer). 
This disease is described in a subsequent part of this volume at § 
1331 et seq. 
69 



is usually preceded by a state of languor and depression both physical 
and moral. Robinson mentions this particularly as one of the most 
remarkable symptoms of the first period of the disease. The spots 
and tubercles which characterize the disease, when fairly formed, 
occasionally appear upon the skin, with acute febrile symptoms of 
some intensity — (development by fluxion, Th. Heberden). But the 
attack of the disease is more commonly gradual and slow (develop- 
ment by congestion, Th. Heberden). The evolution of the tubercles 
is sometimes preceded by a change of colour in the integuments, 
which in whites become sallow, bronzed, or of a hue which might be 
likened to that of the mulatto. In blacks, the spots are even deeper 
coloured than the skin ; in whites they are yellowish or reddish, and 
slightly raised above the general level of the surface. Irregularly dis- 
seminated, like the patches of psoriasis guttata, the spots of ele- 
phantiasis look as if they were full of oil (Adams), or covered with 
varnish. Occasionally they are quite insensible ; but more frequently, 
feeling is not quite absent in them, though they may still be com- 
pressed without pain. In the very first stage of their formation, they 
are now and then observed to be endowed with a greater degree of 
sensibility than the skin which surrounds them : by degrees this state, 
and the redness which has accompaned it, subside ; the flush being 
followed by a tan or bronze colour ; in every case, after having con- 
tinued stationary during a period, the duration of which varies con- 
siderably, the spots are succeeded by tubercles, some of which are 
truly cutaneous, whilst others are evidently developed in the cellular 
membrane which lies under the skin. 

The cutaneous tubercles of elephantiasis are small, soft, round, 
reddish, or livid tumours, the size of which varies between that of a 
pea, and that of an olive. They generally appear on every part of the 
face, on the nose and ears particularly, but are also, occasionally, 
though rarely, evolved on the legs only. When patients live under 
this infliction for a few years, the disease very commonly spreads to 
the whole body. The disease becomes even more and more marked. 
Of all the parts which are implicated, the face always bears the 
strongest traces of the havoc and deformity that characterize it. This 
seems to be generally puffed. The skin of the forehead, marked by 
numbers of deep transverse furrows, is beset with many tubercles, the 
superciliary ridges, swelled, and furrowed with oblique lines, are 
covered with nipple-like projections. The hair of the scalp, that of 
the eyebrows, and the cilia, are lost. The lips become thick and 
shining ; the chin and concha of the ear enlarge, and become thickly 
covered with livid tumours ; the lobe and alse of the nose are in 
general even more seriously altered than the other parts of the face ; 
the nostrils are irregularly dilated ; lastly, the cheeks are swollen, and 
the whole of the features, enlarged and distorted by the puffing of the 
subcutaneous cellular membrane, acquire a character of the most 
frightful deformity. Arrived at this stage, elephantiasis sometimes 
remains stationary ; and then the skin alone seems implicated ; the 
principal functions are performed with perfect regularity. 

The time which elapses between the appearance of the first tubercles 
and the development of those which succeed them, varies extremely ; 
in general, however, they are rapidly evolved ; they never acquire a 
very large size. At a subsequent period, commonly after several years, 
the greater number of these tubercles inflame, and are either resolved 
or suppurate. Ulceration is preceded by an acute inflammatory state, 
during which the tubercles, and the integuments surrounding them, 
become hot and red. The sanious pus of the tubercles which become 
softened, dries up speedily, and forms adhering, brown or blackish 
scabs, which rarely rise above the level of the skin. Sound cicatrices 
are occasionally formed under these scabs ; but this termination is 
extremely rare. 

776. When Greek elephantiasis appears before the age of puberty, 
the development of the beard, and of the hair upon the genital organs 
and axillae, is often checked. In some patients the axillae and pubes 
are covered as usual with hair, but the beard is wanting, or a few strag- 
gling hairs appear upon the throat in situations where no tubercles are 
evolved. In adults, the beard, and axillary and pubic coverings, and 
occasionally, but more rarely, that of the scalp, have also been observed 
to be lost. I have already said that the sensibility of the skin might be 
blunted or increased ; sometimes it is not at all changed. 

777. On the upper extremities the tubercles follow the same course 



274 



TUBERCULA. 



in their evolution : loss numerous in general than on the face, they 
appear more particularly on the outer and posterior aspects of the 
forearms. The hand is almost always swollen, but is rarely the seat 
of tubercles ; it is commonly of a livid tint, with less of the bronze 
cast than the other parts of the body. The same phenomena are 
observed to take place in reference to the lower extremities and feet. 
The space in the sole, included between the heel and heads of the 
metatarsal bones, fdled with swollen cellular membrane, causes the 
foot to appear quite flat. The tubercles of the buttocks are rather 
large ; those of the sole are flattened. Ulceration of the tubercles of 
the legs is always slow of healing ; the phalanges are occasionally 
stricken with sphacelus, especially when the disease, complicated with 
important lesions of internal organs, is tending to a fatal termination. 
The trunk of the body is seldom affected with tubercles. 

778. The mucous membrane of the mouth, the velum palati, uvula, 
amygdahe, pharynx, and nasal fossa?, very commonly also present 
tubercles, but less voluminous than those of the skin ; a longitudinal 
band of tubercles is frequently seen extending from the superior in- 
cisor teeth backwards along the roof of the mouth to the uvula. The 
lingual veins are occasionally observed to be varicose. An inflamed 
state of the pituitary membrane gives rise to the secretion of a sero- 
purulent fluid from the nostrils, to pain of the frontal sinuses, and 
finally to caries of the cartilages and turbinated bones of the nose. 
The voice becomes hoarse, nasal, and then is lost. The affections of 
the organ of hearing in elephantiasis do not extend beyond the exter- 
nal auricle. This part is enlarged, deformed, of a livid colour, and 
commonly beset with tubercles. The sense of smell, almost uni- 
formly deranged even from the commencement of the disease, is 
always destroyed entirely when it has attained a certain stage ; that is 
to say, when the pituitary membrane, covered with tubercles, ulcer- 
ates, and pours out a profusion of fetid secretion. The eyes, except 
the deformity caused by the loss of the cilia, are seldom affected either 
externally or internally. Although the arch of the palate and the lining 
membrane of the mouth are frequently thickly beset with small tuber- 
cles, developed in the mucous follicles of this tissue, the sense of taste 
generally remains intact. The pharynx at length, is usually covered 
with tubercles, but the oesophagus is seldom thus affected. When the 
patient has not been put upon a lengthened course of purgatives or 
arsenical preparations, the stomach and intestines commonly perform 
their functions satisfactorily. Yet in the bodies of those who have 
died while labouring under Greek elephantiasis, the follicles of Peyer 
have been found very much developed, as well as intestinal tubercles 
ulcerated, or on the point of becoming so, small cicatrices, and en- 
larged or tubercular mesenteric glands (Larrey). The liver and spleen 
have not been observed to be morbidly affected. In accordance with 
the affection of the voice during life, a thickened state of the mucous 
folds of the larynx, tubercles upon the chordae vocales, and occasionally 
ulcers which had destroyed the thyro-arytenoid ligaments, have been 
discovered after death. Neither is it uncommon to observe small 
ulcers of the mucous membrane of the trachea. The lungs have 
generally some crude or softened tubercles scattered through their 
substance. Three patients affected with elephantiasis, whose bodies 
I have examined, after their demise, presented this alteration of the 
lungs. Others, who have died at a less advanced stage of the disease, 
have shown unequivocal traces of pneumonia. The organs of circu- 
lation and of innervation present nothing peculiar, so long as the 
disease continues limited to the skin. 

Authors are not agreed in regard to the influence of Greek ele- 
phantiasis on the organs of generation. According to some, the dis- 
ease always arrests the evolution of these organs when it occurs before 
puberty; and when the attack occurs after this period, it causes them 
to fall into a state of atrophy (Adams). Pallas also informs us that 
the Tartars affected with elephantiasis show a distaste to sexual inter- 
course. All the patients I have had an opportunity of seeing myself, 
however, had the genital organs very well developed. On the other 
hand, none of them were tormented by the libido inexplebilis, men- 
tioned by some writers, particularly by Vidal and Joannis, as a frequent 
concomitant of elephantiasis. Niebuhr relates that a leper of the La- 
zaretto of Bagdad, a prey to the venereal appetite, succeeded in 
communicating his disease to a woman of the town, who was in 
consequence admitted into the Lazaretto to him. This patient was 



perhaps affected with lues venerea and syphilitic tubercles of the 
skin. (a) 

The organs of locomotion are remarkably enfeebled in elephantiasis, 
although this is not a constant symptom of the disease. If it has begun 
before puberty, the patient continuea weakly and gradually becomes 
deformed ; if, on the other hand, manhood has been attained before 
its invasion, and the subject be in other respects well constituted, the 
affection of the muscular system is only observed to come on by slow 
degrees, and follows the current of the disease. The lesions of the 
osseous system, described by some authors, and denied by others, are 
admitted on the strength of the solitary case related in the disserta- 
tion of Ruette. To sum up, Greek elephantiasis appears to affect 
especially the skin, the mouth, the nasal fossae, and the organs of the 
voice and of respiration. 

779. Robinson, who studied elephantiasis at Calcutta, reckons two 
species of the disease; one, the tubercular, the characters of which I 
have just detailed (775-778), the other distinguished by the occur- 
rence of broad tawny patches, of considerable extent, shriveled or 
wrinkled on the surface, insensible, attended with slight desquamation 
of the cuticle, and a peculiar deformity of the hands and the feet, 
and ending in extensive ulceration, which causes a loss of soft parts, 
greater or less in amount. This is the elephantiasis aneslhesiaca ;' 
the same disease described under the name of Baras, by Avicenna, 
and which has been observed by Winterbottom. Vidal tells us that 
he has seen individuals labouring under elephantiasis, whose sense of 
touch was blunted, not only in the extremities, but over almost the 
whole surface of the body, though they still suffered much from 
internal pain. 2 (b) 



(a) Mr. Peacock, (Edinb. Med. and Surg. Journ., 1840,) in his ac- 
count of the tubercular form of elephantiasis in the island of Ceylon, 
coincides with Ainslie, who describes the loss of power and wasting 
of the testicles as of invariable occurrence in the latter stages of the 
disease. In some cases these glands could scarcely be detected, and 
in the case of a young man, then 25 years of age, who had been 
attacked with the disease before he was 14, the signs of puberty had 
not developed themselves. Mr. Peacock admits, however, that 
where the disease has been of much shorter duration the sexual feel- 
ing was certainly not impaired. 

(b) The symptoms of the more aggravated form of elephantiasis are 
well described by Mr. Brett (On the Surgical Diseases of India). 
He calls the disease lepra tuberculata virulenta. — " An individual 
labouring under this complaint usually presents himself in the follow- 
ing condition: A general torpor seems to pervade his system, so that 
his sensations of pleasure and pain are considerably impaired. Instead 
of that excessive propensity to venery which they are generally sup- 
posed to possess, they have usually little or no inclination for such 

' From a priv. and aU6a.vofA.ai sento. 

2 On the subject of anesthesia in elephantiasis, the authors who have written on 
the lepra of the middle ages, must be consulted. The greater number of these 
recommend the skin to be pricked, to ascertain whether it besensible or not. Fernelius 
describes, as the first degree of elephantiasis, the case of a man fifty-one years of 
age, whose skin was marked with black or livid spots, sensu nullo aut obtuso prseditx ; 
and in his general description of the disease, he says of those who are affected: in his 
sensus torpescit. Pare tells us — " Veritablement je me suis souvent trouvea l'espreuve 
des ladres, et entre tous les signes dignes d'etre bien notez, cestuy-cy m'estoit com- 
mun, e'est que les ayant piquez d'une grosse et longue espingle au gros tendon qui 
s'attache au talon, et voyant qu'ils n'en sentoient rien, bien que j'eusse poussii 
1'aiguille fort avant, je conclus que veritablement ils sont ladres." — (Pare. CEuvres, 
liv. vii. chap, ii.) More modern writers have also particularly mentioned the dimi- 
nution of sensibility in the disease denominated elephantiasis. Cleyer notices the 
symptom in his account of the elephantiasis he observed at Java. According to 
Schilling, elephantiasis is distinguished by two principal characters: a change in the 
colour of the parts afTecied, and insensibility of the skin. Hahn, in speaking of a 
patient labouring under elephantiasis, whose skin, besides tubercles, was covered 
with white squamae, says — " Plena amis-flEs-ia est in cute senistri genu, quae non tantum, 
quatenus exstat, sed profundious pungi, inscio aegro, potest." 'Phis insensibility, he 
observes, was especially remarked over the old patches of the disease, which were of 
a dusky hue, and slightly prominent. Winterbottom divides the elephantiasis which 
he studied among the negroes on the west coast of Africa, into three species, or rather 
three degrees: — 1st. Demadyang, in which the skin is only discoloured and insensible: 
2d. Didyan (Juzam), in which there were ulceration and loss of the phalanges of the 
fingers and toes, swelling and ulceration of the lips and alas nasi. 3d. Baras, in 
which the same symptoms occur, but of greater intensity, with ulcerative deslruction 
of the throat and structures of the nose. Robinson describes a variety of aneslhesiac 
elephantiasis with discoloration of the skin, which he observed in the East Indies, 
and which Bateman conceives to be the Baras of the Arabian writers. Dr. Fuchs 
has given the details of two cases of elephaniiasis aneslhesiaca. 



ELEPHANTIASIS. 



275 



780. Anatomical Researches.— Elephantiasis is a disease which is 
very seldom seen in Europe, and opportunities of instituting inquiries 
into the morbid anatomy of the affection occur still more rarely. All 
the inquiries that have been instituted, however, tend to show that 
those who are the subjects of the disease, almost always fall victims to 
acute or chronic inflammatory affections of the organs of voice, of 
respiration, and of digestion. I shall, by and by, give the history of 
a case of elephantiasis, with the whole of the very accurate details of 
the post-mortem appearances. Vidal saw one patient affected with 
elephantiasis die of a pleurisy; a second succumbed, after having suf- 
fered extreme oppression in his breathing, which was preceded by 
the drying up of his ulcers ; a third was carried offby a putrid fever ; 
a woman sank under the sequelae of her confinement. 

781. Causes. — First observed in Egypt, then in Italy during the 
time of Pompey, elephantiasis subsequently extended, and has since 
been seen in the four quarters of the globe. It spread over the whole 
of Europe like an epidemic during the middle ages, especially about 
the period of the Crusades ; and at this time, houses destined for the 
reception, or rather for the confinement of lepers, were established in 
great numbers. 1 Since the commencement of the 17th century, this 

indulgence, though there are exceptions to this, where it exists in a 
diminished degree only. The pulse is slow, not small, but heavy, 
' as moving through mud.' There seems to be a sort of stagnation 
in the process of nutritive vitality. The bowels are generally consti- 
pated. The patient's face is bloated. His forehead, nose, lips, and 
ears become swollen ; his nostrils expand ; his eyes appear sunk and 
fiery, the tone of his voice is altered to a loud and nasal sound ; the 
skin, especially of the extremities, is harsh and scaly, resembling a 
case of ichthyosis. He is subject to profuse perspirations, especially 
when exposed to the sun ; these are confined to the trunk, not the 
slightest moisture permeating the surface of the scaly extremities. 
He is often distressed with thirst and a sensation of internal heat. 
The knees are stiff", and their motions contracted. The hairs gene- 
rally fall from the brows, the beard, the pubes, and axillae, &c, or 
they are seen stunted and dried up for want of moisture. His breath 
is fetid, and his perspiration rank and offensive. The blood drawn 
by venesection is very dark. A kind of dry gangrene pervades the 
fingers and toes, which are generally eaten away, and drop off at the 
first phalanges ; these sores then generally cicatrize over without any 
rete mucosum, and the next joint becomes invaded by a renewal of 
the ulcerative process. It is singular to observe that notwithstanding 
these extensive sores, they can wear hard shoes, which are seen satu- 
rated with thesanious ichor that exudes from these ulcerated surfaces. 
The disease progressively advances, eating through the ankles and 
wrists, and performing slow but certain and successive dismember- 
ments, every revolving year bearing some trophy of this tardy but 
gradual march of death, till at last the vitals become affected. During 
all this, a sleepy inertness overpowers his mind, and ' seems to benumb 
and almost annihilate every faculty, as well of the soul as of the body, 
leaving only sufficient sense and activity to crawl through the routine 
of existence.' In the last stages of the complaint, the flesh gapes 
with long sores, the mouth, nose, and brain become exposed to its 
ravages, and death at length terminates this loathsome existence. He 
is usually cut offby the supervention of diarrhoea. It is astonishing, 
however, to witness how long the victim lingers, from twelve to 
twenty years being no uncommon duration. During the greater part 
of this period he has a good and even voracious appetite, and moves 
about from village to village." — British and Foreign Med. Rev., pp. 
424-5, vol. xii. 

1 Between the lllh and 16th centuries, an immense number of hospitals for lepers 
were to be found in every country in Europe. The numbers of these houses, how- 
ever, have been over-rated, through a false interpretation of a passage of Math. 
Paris (Hist. Angl. ad ann. 1244. Ducange, Glossaire, Art. Lazaret). Still they must 
have been very common in certain provinces of France. Thus Henry IT., Duke of 
Normandy, caused a superb edifice, for the reception of lepers, (grancle maladrerie), 
to be erected near Caen, in the year 1160. This building is now a maison de deten- 
tion. We have also accounts of the maladrerics of Mondeville, Cagny, Argences, 
Troarn, Rupierre, Varavielle, Ranville, &c, so that it would appear there was no 
burgh or commune which had not its special maladrarium, misellarium, ladrarium, 
or hospital for lepers. (Delarue, Hist, de la Ville de Caen, 8vo. Caen, 1820.) Into 
these houses, individuals affected with ulcers and other chronic diseases of the skin, 
were also at length received. (Vide G. Horst. Obs. Med , lib. vii. obs. xviii.) P. 
Foreest. Obs. Chirurg., lib. iv. obs. vii. Riedlin. Linnas Medic, vol. iii., an. 1677. 



dreadful disease has disappeared from almost all the districts of our 
continent which it formerly ravaged; and Greek elephantiasis, at the 
present time, is a disease confined to the equatorial or inter-tropical 
regions of the globe. Much more common among the poor than the 
rich, it principally attacks those who are in indigence, and strangers 
after a residence of longer or shorter duration. The disease has been 
studied by Pococke in Asia Minor, by Prosper Alpinus, and Messrs. 
Desgenettes and Larrey in Egypt, by Bruce in Abyssinia, Marsden in 
Sumatra, Marshall in Ceylon, Robinson and Ainslie in India, and 
Bergeron in Cayenne. It has also been seen in the Antilles, in St. 
Domingo, Martinique, and New Orleans, on the west coast of Africa, 
and the islands that lie to the southeast of this continent, Bourbon, the 
Isle of France, Madagascar, &c. ; so that it seems demonstrated that 
a generally high temperature, joined to a humid and variable state of 
the atmosphere, is a condition extremely favourable to the develop- 
ment of elephantiasis. Nevertheless, it is well ascertained, that the 
disease prevailed in the year 1686, in the Faro Islands, 1 which lie to 
the southwest of Iceland, in the Northern Ocean, (a) Greek ele- 
phantiasis has also been seen in France among natives of the country : 
Vidal, Valentin, and Foddre, have observed it at Martignes and 
Vitrolles ; Delpech informs us that it is frequently seen at Roussillon, 
especially in the neighbourhood of Elsne. It is, however, still a 
question, whether the disease originated in these situations, or has not 
rather been, as all circumstances would lead us to believe, imported 
thither and continued hereditarily. The same uncertainty prevails in 
regard to the origin of the elephantiasis which occurs on the plains of 
Arragon. 

Other causes have been stated, the influence of which on the deve- 
lopment of Greek elephantiasis is less apparent. The stagnant waters 
of marshy districs, the moist heats of autumn, low and sheltered situa- 
tions, filthy habits, bad food, exposure to wet, &c, have one after 
another been set forth as adequate to produce the disease ; but the 
whole of these causes occur combined in places where Greek ele- 
phantiasis has never been seen. Though inadequate to excite the 
disease, however, they may unquestionably favour its development, 
and keep it up in certain districts. 

Areteeus, Galen, Schilling, Forest, &c, and in later times, Darwin 
and Cullen, have held that Greek elephantiasis was contagious. Had 
the disease truly this character in the olden times, when it prevailed 
epidemically in Europe ? The cases observed in India by Robinson 
and Ainslie (Medico-Chirurg. Trans., vol. x.), in Madeira by Adams 
and Heberden, the few I have myself seen in France, where I have 
observed West Indian Creoles living in the midst of large families 
without communicating the horrible malady to a single individual, 
and the concurring testimony of all observers, lead to the conclusion 
that Greek elephantiasis is never communicated by an individual 
affected, to an individual in health — that the disease, in a word, is 
not contagious. One of my pupils, M. Raisin, jun., has oftener than 
once, and for several days in succession, worn the clothes of a person af- 
fected with elephantiasis, without suffering the slightest inconvenience. 
Many facts prove that Europeans have contracted this disease during 
a residence in the East and West Indies. Women labouring under 
elephantiasis have produced children who have never suffered in the 
same way ; but the fact of the hereditary transmissibility of the dis- 
ease is one not less certainly ascertained. After the most careful 
study of the affection in the Lazaretto of Madeira, both Adams and 
Heberden are of opinion, that not only is the disease transmitted 
hereditarily, but that it occasionally descends through several suc- 
cessive generations. The researches of Dr. Ainslie in India tend to 
confirm the views of these excellent observers. M. Alibert tells us 
that he had met with two women who inherited elephantiasis from 
their parents. 

In the Lazaretto of Funchal, the majority of the individuals affected 
with Greek elephantiasis had not yet attained the age of puberty. 

(a) Greek elephantiasis or leprosy, is met with along the western coast 
of Norway. It is represented by Dr. Danielssen as hereditary, but 
not contagious. A similar disease has lately appeared in New Bruns- 
wick, and is described by Mr. Skene (Med. Gaz., 1844). 

* De Chamserue et Coquereau. Recherches sur l'utat actuel de la lepre en Europe, 
&c; Memoires de la Soc. Roy. de Med., t. v. p. 199. 






TUBERCULA. 



From the other documents examined by Adams, it would appear that 
in the course of B century, live hundred and twenty-six men, and 
only three hundred and seventy-three women had been received into 
thai establishment, a difference of nearly a third in favour of women. 
M. J. C. Snares, of Marseilles, informs us that, of a hundred indi- 
viduals attacked with Greek elephantiasis in the Brazils, ninety are 
of a sanguine or bilious-sanguine temperament. 

Diagnosis. — It is of importance to distinguish accurately be- 
tween Greek elephantiasis and Arabian elephantiasis, lepra and cer- 
tain syphilitic affections. 1 Arabian elephantiasis never commences 
primarily in the skin ; even when it follows a confluent lichenous 
eruption, or a chronic eczema ; these affections are evidently causes 
not elements of the disease. Arabian elephantiasis is observed at 
the present time in countries under every latitude ; Greek elephan- 
tiasis, on the contrary, is scarcely seen save among individuals who 
have lived in one or other of the inter-tropical European colonies, or 
who are natives of these regions, or who have inherited the disease 
from their parents. As to Greek leprosy (lepra vulgaris), charac- 
terized by rounded and pretty broad squamous patches, depressed in 
their centres, enclosed within a raised reddish circle, and scattered 
over the surface of the body, it has really nothing in common with 
elephantiasis save the distinctive epithet. 

783. Greek elephantiasis has been maintained to be a mere modi- 
fication of syphilis ; but elephantiasis, besides that it was described 
long before we have any mention of syphilis, has been observed in 
many instances when there could be no suspicion of venereal affec- 
tion, either of recent date or older standing. Further, the blotches 
and tubercles of syphilis have by no means the same appearance as 
the tuberculations of elephantiasis. Those of elephantiasis have a 
shining brownish tint, and oily look, and are attended with a general 
pumness, and occasionally with a great degree of insensibility of the 
skin in their vicinity. The tubercles of syphilis, again, are red or 
livid, hard, developed in the substance of the corion, clustered toge- 
ther, and almost always consecutive to venereal ulcers of the genital 
organs ; very different, therefore, from the soft, tawny, irregular tuber- 
cles, separated from each other by deep fissures, proper to Greek 
elephantiasis. Lastly, in those rare cases in which Greek elephan- 
tiasis is characterized, not by yellowish blotches and oily-looking 
tubercles, but by fungous and sanious sores, resting upon soft and 
flabby bases ; these are not less distinct from ulcers of syphilitic 
origin, for the most part so well marked by their indurated and 
sharply cut but irregular edges, and their grayish bottoms of variable 
depth. The tubercles of cutaneous cancer, or of lupus, cannot be 
confounded with those of elephantiasis. 

Neither of these is attended with the loss of the hair of the parts 
they affect, with the development of tubercles on the arch of the 
palate, or any material alteration of the voice ; they have, in addition, 
peculiar and very constant characters, extremely different from those 
of Greek elephantiasis. 

784. No one now thinks of simulating Greek elephantiasis, although 
this seems to have been done occasionally in former times. 2 The 
serious nature of the disease has been noted by every writer who has 
seen it since the time of Aretaeus. Despite the praises that have been 
lavished on certain medicines, almost all the well-marked and invete- 
rate cases of the disease are incurable. Those who are attacked with 
it before the age of puberty, commonly die between their twentieth 
and twenty-fifth year. Those who contract it later in life, may drag 
on a painful existence for some considerable time. Some have been 
seen presenting all the outward symptoms of the disease for more 
than twenty years, without any notable disturbance of the principal 
functions of the system. The fatal termination is almost always 
owing to the sequelae of inflammatory affections of the organs of the 
voiceand respiration, and of those of digestion. 

785. Treatment. — The treatment in Greek elephantiasis should be 
directed with a view to prevent the development of tubercles; to 
favour the cicatrization of sores ; to obtain the resolution of such 
spots and tubercles as exist, when any have been formed ; and to 

- When elephantiasis (lepra) reigned epidemically during the middle ages in 
Europe .hose who are suspected of being affected underwent an examination, the 
model of which may be found m Horstius, Fernelius, Pare,&c, and those pronounced 
lepers, were shut up m one of the houses appropriated for that purpose. 

* The case given by Pare deserves to be particularly referred to. Liv. xxiv. 
chap, vni. 



check the progress of chronic inflammation of the larynx, lungs, 
stomach and intestines, if it has already occurred, or to prevent it 
entirely, in case it has not yet made its appearance. To attain these 
ends, removal into a mild and temperate climate has been recom- 
mended, and many persons affected with elephantiasis, have quitted 
intertropical countries for the south of France and Italy, but in gene- 
ral without deriving any benefit from the change. The practitioners 
of the Antilles are in the habit of sending their patients to the island 
of Desiderada, remarkable for the mildness of its climate, and the 
excellence of its fruits, a twofold recommendation, which, it is pre- 
sumed, should tend to modify the constitution favourably, and to retard 
the natural course of the disease. Patients should pay the greatest 
attention to personal cleanliness, and change their linen frequently • 
they should take gentle exercise, and their spirits must be kept up by 
the constant presence of some devoted friend or attendant. 

Besides the morbid alterations of the skin, some patients exhibit 
unequivocal symptoms of chronic inflammation of the pharynx and 
stomach, of the larynx, trachea, and occasionally of the lungs. These 
ought to be put upon the use of mucilaginous drinks, with a diet 
consisting of milk, white meats, veal, chicken, or turtle broth, &c. 
As to the specific properties of the viper in this complaint, modern 
observers are mostly agreed in regarding them as fabulous, (a) Other 
patients affected with elephantiasis show no symptoms of any serious 
disorder of the larynx, trachea, lungs, or intestines. In the majority 
of these cases, I have preferred recommending bland diet, and a regu- 
lar plan of life, to prescribing a course of active medicines, often 
uncertain in their primary effects, and occasionally dangerous in their 
secondary or remote consequences. It cannot surely be a matter of 
indifference, whether or not individuals are put upon a course of can- 
tharides, of arsenic, of decoction of mezereon bark, &c, who, from 
all concurring testimony, are known commonly to die at an early age, 
of some inflammatory gastro-pulmonic affection. 

Heberden informs us that he cured a patient in five months, who 
had taken antimony and mercury fruitlessly for seven years. The 
medicine employed was a mixture of an ounce and a half of powdered 
cinchona bark, and half an ounce of powdered sassafras root, made 
into an electuary with simple syrup, of which the patient took a piece, 
the size of a nutmeg, twice a day. He, at the same time, rubbed his 
arms and legs, night and morning, with a mixture of an ounce of oil 
of tartar, two ounces of sal ammoniac, and eight ounces of brandy. 
Blisters were also applied between the shoulders. Several cases seem 
to prove the utility of the muriate of gold, administered in doses, 
gradually increased from the tenth to the fourth of a grain, during 
several months, by way of friction, under the tongue. These cases, 
however, it is much to be regretted, are still very far from satisfactory. 
Our Indian practitioners have spoken of the asclepias gigantea as a 
kind of specific. Playfair has published an interesting account of the 
therapeutic effects of this plant, in the first volume of the Transac- 
tions of the Medical Society of Calcutta ; and Robinson (Med. Chir. 
Trs. of Lond., first part), thinks that it may be useful in anesthesiac 
elephantiasis. Sarsaparilla and squill have also been recommended 
to attention. Turner and Vidal have seen tubercles resolved under 
the use of alkaline frictions. The tubercles and stains of the disease 
may be destroyed by the application of caustic when they are not nu- 
merous ; but it almost always happens that new tubercles are developed 
in other situations. The discussion of the tubercles of elephantiasis 
has also been attempted by means of the sulphur, the vapour, and the 
sea- water douche, ammoniacal frictions, &c. ; but the whole of these 
various remedies have been attended with very uncertain results. 
The baths recommended by some authors have been held useless by 

(a) M. Sigaud (Du Climat et des Maladies du Bresil, pp. 389-93) 
gives the details of the case of a Brazilian who, having suffered for 
more than four years from leprosy in its worst form, determined to try 
the effects of the bite of a rattlesnake. The wound was received be- 
tween the first joints of the little and ring fingers, at ten minutes before 
twelve (noon), and at half-past eleven the following morning, the man 
was dead, after great suffering. No autopsic examination was made, 
owing to the rapid decomposition and extreme fetor of the body. Ten 
hours after the bite, there was a great depression of the tubercles on 
the arms and face. 



ELEPHANTIASIS. 



27' 



others, as Walesius and M. Cassan. Robinson has advised the ap- 
plication of blisters to the insensible patches of elephantiasis anes- 
thesiaca. The bi-chloride of mercury internally, and mercurial fric- 
tions externally, have been employed in elephantiasis without success. 
The various preparations of arsenic have been particularly upheld, 
for their powers for bringing about the resolution of the tubercles of 
elephantiasis. But patients have frequently been found to droop and 
then to die, under the fever which these medicines are apt to light up. 
In two cases, which were watched by M. Raisin with particular atten- 
tion, the Asiatic pills, 1 taken regularly for a short season, had soon to 
be given up on account of the irritation of the gastro-intestinal mem- 
brane they occasioned, without benefiting a single symptom of the 
disease for which they were prescribed. 

The whole of these various and fruitless experiments but too 
forcibly remind us of the accuracy of the prognosis pronounced by 
Hollerius, — confirmata elephantiasis non curatur (de Morbis internis, 
p. 64, de elephantiasi). 

It is from the labours of the practitioners of the European colonies 
established in intertropical countries, that science looks for new light 
in regard to Greek elephantiasis and its treatment, (a) 

Historical Notices and particular Cases. 

786. No mention is made of the collection of Hippocratic writings 
of elephantiasis. Some interpreters, however, insist on the affection 
being there indicated under the name of the Phoenician disease. 2 The 
poet Lucretius, 3 forty years before the time of Celsus, 4 first speaks of 
elephantiasis, and he assigns Egypt as the country where it occurs. 
Celsus gives the principal characters of elephantiasis, and adds that 
the disease is scarcely known in Italy, but very common in certain 
other countries. Galen supplies us with several particular but imper- 
fect cases of elephantiasis, with a view to demonstrate the value of 
the flesh of the viper ; in another place he adds that the disease is 
common in Alexandria. 5 Aretaeus 6 has left a very accurate picture 
of the symptoms of elephantiasis. The sole objection, indeed, that 
can be raised to this description of the disease, which is much more 
detailed than that of Galen and Celsus, must be made on the score 
of certain forced comparisons and contrasts, the end of which, how- 
ever, is to explain the origin of the various denominations given at 

(a) The various preparations of iodine, and the iodide of mercury 
and arsenic, merit a careful trial in elephantiasis. If the treatment 
begun at an early period of the disease, we may hope for success. 
"In Hindostan, arsenic is the remedy most generally employed, but it 
is associated with the mudarr (Asclepias gigantea) to which Playfair, 
Robinson, and others have ascribed great virtue. The most accre- 
dited form is the following : oxide of arsenic, 55 grains ; mudarr 
powder, 4 ounces and 80 grains ; black pepper, 9 ounces : the whole 
well beaten at intervals for four days, made into a mass with water 
and divided into 800 pills. Not more than two pills should be taken 
daily, which are equal to about a seventh of a grain of arsenic. Mr. 
Marshall treated 200 cases with nitric acid, a drachm in a pint or a 
pint and a half of water daily ; above one third were cured and the 
remainder were greatly benefited. The Hindoo physicians place 
their patients during treatment on the following diet: all kinds of 
game, Sushtika. rice, and Urhur." 

' Compounded of while oxide of arsenic and black pepper. — Tr. 

2 (poinxifi voJe-of, printed in ihe ordinary editions, evidently by mistake, <f>9inx». 
Mackius, in his edition of the works of Hippocrates, fol. Vienna, 1743, has restored 
the proper reading, which Foesius had only ventured to correct in a note. Galen 
speaks of a <p*mxlh vovro< by which, probably, elephantiasis is meant. M. Alexandre, 
in his Greek dictionary, quotes Herodotus as his authority for the phrase <pwiKin vovro;, 
which he translates lepra. There is another passage of Herodotus where lepra and 
leuce, X£9Tfn, r, xtuxu are mentioned together, the latter term is probably employed in 
the same sense as it is used by Hippocrates. (Herod., lib. i. p. 59. Bd. in fol. 
Francof., 1606.) 

3 " Est elephas morbus qui propter flumina Nili. 
Gingitur -Egypto in media neque praeterea nusquam. 

(De Rerum Natura , lib. iv.) 

* Medicina, lib. iii. sect. xxv. 

6 Galeni Opera. De arte curativa ad Glauconem, lib. ii. De cancro et elephan- 
tiasi: "In Alexandria quidem elephantis morbo plurimi corripiuntur propter victus 
mobumet regionis fervorem. At in Germania et Mysia rarissima hoec passio videtur. 
Et apud Scythos, lactis potatores, nunquam fere apparuit." 

« Aretaeus. De causis et signis morborum. Fol. Ludg. Batav., 1735, p. 69. De 
elephantiasi. 

70 • 



different times to the disease, such as leontiasis, satyriasis, and 
elephantiasis. Pliny 7 recapitulates the principal characters of ele- 
phantiasis, and tells "us that the disease indigenous in Egypt (JEgyp 1 ■ 
peculiare hoc malum), had not been seen in Italy previous to the 
time of Pompey. The opinion of the contagiousness of elephantiasis, 
which we find announced in Herodotus and in Galen, is more strongly 
insisted on by Cadius Aurelianus, 8 who recommends the isolation of 
those affected with it as a measure necessary to the public health. 
He also speaks of the advantages which may be derived from blood- 
letting and purgatives in its treatment. Paul of TEgina, 9 in discuss- 
ing elephantiasis, dwells more especially on the general hygeiastic 
measures adapted to strengthen the constitution. Not one of these 
Greek or Latin authors, except Herodotus, has assimilated elephan- 
tiasis with lepra or leuce. 

The Arabian writers have described elephantiasis under the name 
of juzam, which their translator have rendered by the word lepra. 
Avicenna 10 rehearses the phenomena already signalized by the Greek 
and Roman authorities, and particularizes several symptoms of an 
alarming nature. Several historical writers and others 11 have left us 
ample documents in regard to the lepra of the middle ages. Hensler, 1 * 
in these latter times, has made their accounts the subject of his par- 
ticular studies. Lepra is known still to have prevailed in Europe 
during the fourteenth and fifteenth centuries. Guy de Chauliac, 
Fernelius, Pare, Vesalius, Horstius, Forestus, &c., )3 may each be 
consulted with profit for information upon the lepra which prevailed 
epidemically during this latter period. 

Observations have since been extended, and the disease has been 
seen in most parts of the globe. In France 14 elephantiasis has been 
studied by Raymond, Joannis, Ruette, Vidal, Fodere, Valentin, and 
others ; in Spain 15 very recently by Fuchs, who has given us a map 
of the various places in which he met with the disease in traveling 
along the shores of the Mediterranean, and who has studied the 
anesthesiac variety with particular care ; in Belgium and Holland by 
P. Forest; 16 and in Russia by Martius. 17 In Jlsia Minor the disease 

7 C. Plinii secundi. Historiae mundi, lib. xxxvii., fol. Lugd., 1587, p. 642. 

8 CsbUus Aurelianus. De morbis acutis et chronicis, 4to. Amstelodami,1754. De 
elephantiasi, p. 492. 

9 Pauli iEginelae. Opus de re medicA, fol. Parisis, 1532, lib. iii. ch. i. 
io Avicenna. Canon Medicinac, fol. Venet, 1564, lib. iv. p. 130. 

" Theodoric, a physician of Bologna of the thirteenth century, has given a good 
description of the symptoms of lepra (elephantiasis), of which he reckons four varie- 
ties. 1st. Lepra elephantinu ,- a livid colour of the face and whole body, loss of the 
eyebrows, atrophy of the muscles between the thumb and fore finger,- slow course of 
the disease. 2d. Lepra leonina ,■ a citrine tint of the surface, rotunditas aviloruvi ,■ 
alteration of the voice: formation of tubercles, &c. 3d. Lepra fyria (tyrienne); puff- 
ing of the eyelids, face, legs, loss of the nails, &c. 4th. Lepra dteahans (alopecique) 
loss of the hair, leucophlegmatic phenomena; hemorrhage from the nose and gums, 
ecchymoses, &c. Chirurgia Guidonis, Bruni, Theodorici, &c, fol. Venet., 1519. 

12 Ph. Gabr. Hensler. Vom abendliindischen Aussaize im Mittelalter, &c. ; on the 
western leprosy of the middle ages, with an illustrative and historical supplement 
12mo. Hamb., 1790. In his first part, Hensler has collected the greater number of 
those passages in the older writers, especially of the middle ages and of Arabia, that 
bear upon the subject of elephantiasis ; but these are, after all, the mere materials of 
history, and required a very different arrangement to make them generally useful. 
from that they have received at the hands of Hensler. Of this truth conviction iv. 
easily obtained, by turning to page 369 of the work, where he confounds the Aral.au 
elephantiasis or Barbadoes leg, Vitiligo, the fourth impetigo of Celsus, certain squa 
mous affections and pellagra, one with the other. The judgment of the physician is 
not here combined with the erudition of the scholar. But the period at which Hensler 
wrote, may undoubtedly be charged with the sin of much that is faulty in his work". . 
the admirable disquisitions of Willan upon the diseases of the skin had not yet ap- 
peared ; Hensler was without a compass on an unknown sea; but he evidently wanted 
that spirit of penetration which catches a glimpse even of things unknown, and that 
acute judgment which bids us pause, when others of the mental powers are about, 
to enter upon an erroneous path. 

" 3 Guy de Chauliac. Chirurgiae tractatus septem, Ven. fol. 1470 (De lepra). — Fer- 
nelius. Universa medicina, fol. 1679. Coloniae Allobrogum (De elephantia). — Par.. 
GEuvres completes (De la lepre ou ladrerie). — Horstius. Opera, 4to., Gandae, 1661 
(De lepra, vol. ii. lib. vii. p. 343). — Vesalius, lib. v. cap. ix. De corporis humaui 
fabrica. — Schenek. Obs. med. rar. ; De elephantiasi seu Graecorum lepra, p. 776. 

M Raymond. Histoire de l'elephantiasis, Lauzanne, 1767. — Ruette. Essai sur 
l'elephanliasis et les maladies lepreuses, Paris, 1802, 8vo. (He does not appea: to 
have discriminated at all times accurately between the Greek and Arabian elephanit 
asis.) — Vidal. Memoire sur la lepre des Martigues (Mem. Soc. Roy. de Mid., a 
1776, p. 161.— Ibid., annee 1782, p. 168. 

is Fusch. De lepra Arabum, Svo. Wireeburgi, 1831. 

16 Forestus. Obs. medic, et ehir., t. iv. De elephantiasi (scholia"). 

" Martius (Henricus). De lepra taurica, 8vo. (Delectus opnscuiorum. N 
comi, 1827.) Martius describes a disease endemic in the Crimea, the province of 
Astrachan, and upon the banks of the Jaik, already observed by Pallas, Falk, Gmeiin, 
and Gueldenslaedt, and which presents the whole of the characters of Creel: elep!?.'- 



278 



TUBERCULA. 



has boon studied by Pococke; 1 in India by Robinson, &c. ; a m Java 

I lleyer ;' in /-V'//>/ by Prosper Alpinus, 4 Desgenettes and Larry; in 
Abyssinia by Bruce ; s on the roas/ of Africa by Winterbottom ; 6 in the 

„/• Francs by Kennis; 7 in Madeira? by Heberden, Adams, 
Heineken; in America and 5/. Luna" by Casan; in the Brazils' by 
Soaivs de Mrirelles; in &irin<H»" by Schilling ; in Cayenne 12 by 
Bajon and Bergeron, who have described it under the name of the 
red disease of Cayenne (mal rouge de Cayenne). To conclude, vari- 
ous cases and descriptions recently published may be consulted with 
advantage. 13 

Case CXL. — Greek elephantiasis ; improvement after several attacks 
of erysipelas. B * * * was born in Guadaloupe in the year 1807, of 
healthy parents, of French origin, inhabitants of Pointe-i-Pitre. B.'s 
father died in Guadaloupe of fever, never having had elephantiasis ; 
his mother resides in Paris in the enjoyment of good health. B * * * 
was suckled by his mother, as were his two brothers, both established 
in Guadaloupe, and said to be of sound constitution. Madame 
B * * * cannot tell how her son became affected by elephantiasis. 
She had, indeed, seen many persons labouring under the disease in 
Guadaloupe, where it is believed to be contagious : but she believes she 
is correct when she says, that her son never had intercourse with any 
one so affected. As to the contagiousness of the disease, Mad. B * * * 
observes that she and her son had never lived apart ; that during the 
earlier stages of the disease he frequently slept in the same bed with 
her ; and that since this period, she and his other relations have fre- 
quently embraced him without fear and without inconvenience. She 
adds that the food of the family where she lived, at Pointe-a-Pitre, 
like that of the inhabitants at large, consisted in great part of the 
fish caught in the neighbouring seas, on account of the high price of 

ill 1 11 

butcher's meat. A physician of the country, whom she had consulted, 
appeared to ascribe a certain influence to this kind of living in the 
production of her son's disease. 

Under the age of nine years, B * * * suffered only from the indis- 
positions common to children ; he, was even remarkable for his fresh 
and healthy complexion. At this time, however, and without known 
cause, several blotches (taches) and red or yellowish spots (boutons) 
appeared on the thighs and loins, and subsequently on the face and 
different other regions of the body ; the skin, from having been white, 
now acquired a colour similar to that of the mulatto ; and tubercular 

tiasis. But our author adds certain symptoms, that make the lepra taurica appear as 
a variety of this disease. He tells us, for instance, that left to itself, the lepra in- 
creases in severity every year. First year, livid spots; second, spots larger and 
blackish; third, pruritus, ardor, tubercula ; fourth, pains in the joints, tubercles, 
squamae, general symptoms, enlargements of the glands ; fifth, ulceration of the tuber- 
cles; sixth, spreading ulcers of the skin and of the mouth, aggravation of the general 
symptoms — death. This is the usual termination of the lepra taurica, which only 
appears among the populace. 

1 Pococke. A description of the east and other countries, fol. 1753. 

2 Ainlie (Whilelaw.) Obs. on the lepra Arabica, as it appears in India (Transact, 
of the Royal Asiatic Society, vol. i.). — Wilson (H. H.). On kushta or leprosy (Tran- 
sact, of the Medic, and Phys. Society of Calcutta, vol. i.). — Robinson. Transact, of 
the Med. and Ohirurg. Society of London, vol. x. — Babington. Medical and Chirur- 
gical Transact., vol. i. p. 27. — Ward. Med. and Surg. Journ., vol. xxxvi. p. 187 (at 
Malacca). 

3 Cleyer (Ephem. German., Dec. 2, mens, decemb., 8vo., 1683) has given a figure 
of the disease. 

4 Prosper Alpin (De medecina methodical, 2 vol. 4to. Lugd., Batav., 1719. — 
Medicina ^Egyptiorum, lib. i. p. 56) describes the elephantiasis of the Greeks and 
the elephantiasis of the Arabians. 

5 Bruce. Travels to discover the sources of the Nile, &c, 5 vols. 4to. Edinb., 
1790. 

6 Winterbottom. Account of the Africans in Sierra Leone, vol. ii. c. 4. 

7 Kennis. Obs. sur 1'elephantiasis comme il parait a l'lle-de-France. 

8 Heberden. Transact, of the London College of Physicians, vol. i. — Adams. 
Obs. on morbid poisons, 4to. London, 1807 (of leprosy, p. 265). — Heineken. Obs. 
on the leprosy of Madeira (Edin. Med. and Surg. Journ., vol. xxvi. p. 15). 

9 Casan. Mem. sur le climat des Antilles ; de la lepre (mem. soc. med. d'emula- 
tion, t. v. p. 102). 

10 Soares de Meirelles. Diss, sur l'histoire de 1'elephantiasis, 4to. Paris, 1827. 

II Schilling. De lepra commentarius. Recens J. D. Hahn. Lugd., Bat., 8vo., 
1778. 

11 Bajon. Mem. pour servir a l'histoire de Cayenne et de la Guyanne franchise, 
vol. i-ii. 8vo. Paris, 1777-78.— Bergeron. Diss, sur le mal rouge'obs. a Cayenne. 

'a Goguelin. Bulletins de la faculte de med.de Paris, t. ii. p. 91.— Alibert. De- 
scription des maladies de la peau. Paris, 1806 et 1818.— Lawrence and Southey. 
Tvro cases of the true elephantiasis (Medico-Chirurgical Transactions. London, 
1816,8ns vol. vi).— \1. J. A. Raisin. Essai sur 1'elephantiasis des Grecs. Paris, 
1 $20.— Cazenav*. Considerat. sur 1'elephantiasis Grecs. (Journ. hebdomd.. t. iii. p. 
146.) r 



growths, analogous to those which now present themselves (16th 
Sept., 1024), were evolved on the face and cars. Sarsaparilla was 
tried for forty days, then thirty of the medicines de Leroy, which dis- 
tressed him greatly, but all without doing any good to the disease, or 
changing the state of the skin. Madame B * * * and her son em- 
barked for France in 1822. During the passage the disease became 
considerably worse. At Blois, where they took up their residence 
on their arrival, B * * * underwent another course of tisan of sarsa- 
parilla, and of artificial Bareges baths, but without benefit. A few 
tepid baths, taken subsequently, seemed to prove serviceable. On 
his arrival at Paris, B * * * became a patient at the fourth dispen- 
sary, on the 16th of September, 1824, and I had an opportunity of 
seeing him for nearly two years afterwards. On his admission, B * * * 
was seventeen years of age, and of low stature. His form was 
European, but the colour of his skin almost that of a mulatto. The 
face and extremities were covered with tubercles ; the face, more 
severely affected than any other part, looked generally swollen. The 
forehead, which was rather high, was beset with flattened and slightly 
prominent tubercles, from four to five lines in diameter, and of the 
same bronze-like colour as the skin. There was neither scab nor 
cicatrice upon it to indicate that the tubercles had ever suppurated. 
It was crossed by deepish transverse furrows. The skin of the rest 
of the cranium was free from tubercles, and was covered with strong, 
straight, black hair ; the hairs of the eyebrows were black and scanty. 
The eyes and eyelids presented no alteration in form, colour, or di- 
mensions. The cilia were distinct but not strong. The nose was large, 
and very much flattened, and in its general configuration approached 
that of the negro. A great many small tubercles were clustered upon 
the alae of the nose, the surface of which appeared mammillated or 
lobular. Two months afterwards, the lobe and neighbouring parts 
were covered in the same manner. The tubercles in these situations 
were so numerous, that they formed, as it were, one continuous irregu- 
larly mammillated mass. Many of these small tubercles, which at 
first presented the same colour as the skin, became inflamed in suc- 
cession, and covered with little brownish and strongly adhering scabs ; 
and when several in the vicinity of each other were thus affected, 
they were all hidden under an uniform incrustation, formed by the 
union of the lesser scabs. After this kind of inflammatory process 
had subsided, which was not till a year had expired, the lobe and alae 
nasi appeared contracted, and have since continued of diminished 
magnitude. The lips were thick, somewhat shining, and beset with 
several tubercles. The chin and cheeks were swollen, and under, 
and in the thickness of the skin, a number of flat-shaped and slightly 
prominent tubercles could be distinguished. The conchae of the ears 
were much larger than in their natural state. They were swollen, 
and imbedded in their substance under the skin ; a certain number 
of tubercles, similar to those just described, could be felt. These 
various alterations gave a particular and hideous character to the 
physiognomy, but still the countenance bore no resemblance to the 
head of a lion. 

The skin of the neck and trunk was not bronzed like that of the 
face, being nearly of the same colour as the skin of a young European, 
and was free from tubercles. The upper extremities presented the 
following alterations : on the left arm, three or four tubercles only 
could be felt ; they were, however, very numerous on the corre- 
sponding forearm, covering its dorsal aspect especially. Some of these 
tubercles were no more than two or three lines in diameter, others 
were two and three times larger. Several small tubercles, rising 
above the level of the skin, and developed in its substance, were 
also seen on the back of the hand and near the wrist. The smaller 
tubercles, the size of which did not exceed that of the papulae of pru- 
rigo, were in general prominent, and appeared to be evolved within 
the substance of the skin ; the larger ones, which were like big peas, 
seemed more deeply situated, and bedded among the subcutaneous 
cellular tissue. The whole of the tubercles were of the same colour 
as the skin, and under the finger, felt exactly like little indurated lym- 
phatic glands. Some of these tumours remained stationary for several 
months, several inflamed and ended in resolution, and others suppu- 
rated and became open sores, which never showed any disposition to 
extend either superficially or in depth ; the discharge they poured out 
was sanguinolent and tenacious, so that the linen of the patient and 



ELEPHANTIASIS. 



279 



the dressings stuck readily to their surface. The secretion dried into 
brownish or black crusts ; those that covered the larger tubercles 
became prominent, and looked like those of rupia ; those that fol- 
lowed the smaller tubercles about the wrist were oval-shaped, and 
scarcely exceeded the level of the skin. Under the scabs, a cicatrice 
was slowly formed, which continued of a livid red colour for several 
months. On the right arm, which was slightly paralyzed in its mus- 
cles, nearly the same appearances and phenomena were observed as 
on the left. The hand was constantly half shut, its integument swollen 
and indurated, and subsequently stiff and shining. 

The lower limbs were slender and weakly, and the patient 
sometimes complained of a feeling of tension in them. Walking 
was fatiguing, and running next to impossible. On the thighs the 
tubercles were not numerous, but in general large. One, situated 
over the trochanter, ulcerated, and was followed by a pretty broad 
cicatrice ; another, on the buttock, became covered with a brown 
scab, larger than a shilling, which, when removed, disclosed a sore, 
with sharp cut and not very highly inflamed edges. In the groin 
of the right side, an enlarged lymphatic gland, the size of an almond, 
was discovered. The legs were more thickly covered with tubercles 
than the thighs. The ankles were swelled ; the soles of the feet 
puffy, and occupied here and there with several, broad, flat and 
distinct tubercles. The skin here was red and shining at first, but 
by and by, became pale and wrinkled or puckered in appearance. 

The hair, although strong on the scalp, was wanting on the other 
regions of the body on which it usually appears, at the age which 
B * * * had now attained ; and two years later (1819), there was not 
a single hair upon the cheek, chin or lip. Between 1818 and 1819, 
a few scattered hairs did make their appearance on the pubes and 
axillae only, situations in which no tubercles had been evolved. 

As to the functions of the skin, they appeared much less altered 
than its structure. Generally, it still preserved its sensibility even 
over the tubercles ; the sense of touch was only blunted in the soles 
of the feet, which, as I have said, were swollen and tense, and in 
the right hand, the extensor muscles of which were in a half paralytic 
state : still the sensibility, even of these parts, could always be 
aroused by pinching the skin. 

Besides the tubercular affection of the skin, and the puffing in 
places of the subcutaneous cellular tissue, there existed several other 
alterations which deserve to be mentioned. Along the middle of the 
palatine arch, for instance, there extended a band of small tubercles, 
which became regularly broader as it stretched from the incisor teeth 
towards the uvula and velum palati mollis. Several of these tuber- 
cles, of the same colour as the mucous membrane under which they 
were evolved, inflamed subsequently at different times, and ended 
in the formation of small yellowish ulcers two or three lines in 
diameter, which, after continuing stationary for a season, cicatrized 
like those of the skin. The uvula was enlarged and full of small 
tubercles. Several were also visible on the pendulous velum. The 
mucous membrane covering them was very little or not at all inflamed. 
The only other part of the mouth on which I perceived any tubercles, 
was the upper surface of the tongue, where there were three or four. 
Deglutition was easy ; the belly was soft, nowise painful, and the organs 
included within it performed their functions freely. The thorax was 
pretty well developed; the voice was hoarse, husky and sniveling; 
the patient felt no pain in the larynx ; but for some time had laboured 
under an habitual cough. An examination of the chest enabled me 
to detect a slight bronchitis. The affection proved temporary, and 
the lungs subsequently appeared to be free from all morbid affection. 
The organs of circulation were in the normal condition. The sub- 
cutaneous veins were neither more nor less developed than usual. 

With the exception of smell, the senses were possessed in perfect 
integrity. Ever since the nose had become covered with tubercles, 
and the disease had extended to the palatine arch, the patient had 
continued subject to a constant coryza, or cold in the head ; this was 
probably owing to an affection of the mucous membrane of the nasal 
fossae, similar in kind to' that of the skin and arch of the palate, the 
consequence of which was an almost complete loss of the sense of 
smell. B * * is naturally of a lively disposition, and his conversa- 
tion is that of an intelligent man. He has a taste for drawing; and 
since his right hand has become paralyzed, he has even attempted 



to gratify his taste by using the pencil with the left. The organs of 
generation are well developed, and do not appear to have been in 
any way affected by the disease under which he labours. In 1819, 
the right testis had not yet descended into the scrotum. That of the 
left side was of the usual size. No circumstance leads to the belief 
that B * * * is more insensible to the sight of women than young men 
of his age ; but neither does any particular in his conduct give room 
for suspecting that he is at all influenced by the libido inexplebilis of 
which certain writers speak. 

In the treatment of this disease, I had recourse at first to the anti- 
phlogistic system. At various intervals during the course of several 
months, I covered the face with leeches. The day after each appli- 
cation a little swelling was apparent; but this always subsided in a 
few days, and left the face what it had been before the bleeding. 
About a hundred leeches were used in this way, without any improve- 
ment, but without detriment. The tepid bath and diluents did not 
appear to exert any more powerful influence in resolving the tubercles. 
The digestive organs of the patient seeming to be healthy, I resolved, 
not without a certain degree of repugnance, on giving the pills of 
white oxide of arsenic and black pepper (pil. Asiatiques) a trial; and 
M. Chevalier had them prepared for me, according to the long and 
singular formula of the memoirs of Calcutta. B * * * took one of 
these pills, containing the one-sixteenth of a grain of the protoxide 
of arsenic, daily ; after the forty-eighth he began to show unequivocal 
symptoms of gastro-enteritis. I therefore ordered the medicine to be 
let off, and returned to the use of the tepid bath and mucilaginous 
drinks. 

At this time B * * * was advised by some one to whom the nature 
of his disease was probably not well known, to undergo an anti-vene- 
real course, and with this view, he was entered a patient of the Hopital 
St. Jacques, on the 11th of March, 1826. But the enlightened phy- 
sician of that establishment at once perceived the kind of complaint 
with which he had to do, and no mercurial medicine was prescribed. 
During his stay in this hospital, on the 24th of March, B * * * had 
a violent attack of erysipelas of the face, attended with delirium, and 
a train of other serious symptoms. The inflammation was treated by 
emollients, two bleedings from the arm, and two blisters to the 
thighs. B * * * left the Hopital St. Jaques some time afterwards, 
and I discovered that the erysipelas had had a very marked and far 
more favourable effect on the tubercles of the face than any of 
the remedies I had formerly prescribed. In the first place, the tuber- 
cles of the auricle had disappeared, having ended in resolution ; the 
skin, become less brown in its hue, was soft and wrinkled ; secondly, 
several tubercles of the cheeks and chin, and all those of the fore- 
head, save two, were resolved ; the lips were not so thick, the nasal 
fossse less obstructed, and the voice less hoarse and suppressed ; 
thirdly, many of the tubercles of the alee nasi, still numerous, were 
covered with brownish and adhering incrustations ; fourthly, the tu- 
bercles of the arms and thighs were less numerous than they had been 
before the erysipelas of the face ; several had ended in suppuration, 
and were now covered with a small blackish scab ; fifthly, the hair 
and eyebrows, which had fallen out in great part after the erysipelas, 
soon began to shoot again, and before long, appeared at least as thick 
as ever ; sixthly, the tubercles of the palate were in the same state as 
formerly. I advised B * * * to restrict himself for the present to the 
use of diluents and the tepid bath. In the month of September, 1825, 
he was a second time attacked with erysipelas of the face; and, after 
an interval of four days, with varicella, but suffered less on this 
occasion. Both of the affections got rapidly well, under the sole use 
of diluents and pediluvia. At the end of October in the same year, 
B * * * was a third time seized with erysipelas of the face, which 
got well as the others had done. These last two attacks of inflam- 
mation had a much less obvious influence than the first in bringing 
about the resolution of the tubercles. Yet the greater number of 
those of the face had now disappeared ; those that remained, had 
been but lately developed on the nose, and had not been implicated 
in the inflammation. One circumstance, particularly worthy of notice, 
is that during the invasion of the erysipelas, and the whole period of 
the febrile reaction which accompanied it, the tubercles of the ex- 
tremities became red and hot, as if each of them had been attacked 
with acute inflammation ; it was always as a consequence of this kind 



280 



TUBERCULA. 



itement, that the resolution of those tubercles which disap- 
. was accomplished. The knowledge of this physiological 
phenomenon led me, in the beginning of 1S2G, to attempt to arouse 
the indolent tubercles of the extremities, by means of friction with an 
ointment of the hydriodate of potash. This was first tried on the 
arm, and had the effect I wished : the whole of the tubercles inflamed ; 
.. ran into ulceration, and were followed by small cicatrices; 
others ended in resolution. This inflammatory process was attended 
with so much pain, that the patient expressed his decided repugnance 
to my proposal to try the effect of the same procedure on the lower 
extremities. 

From this time the disease was left to itself. Fresh tubercles went 
on making their appearance, nearly in the same proportion as others 
disappeared. B * * * became a patient in the Hopital St. Louis, in 
August, 1826. In September, he was attacked anew with erysipelas 
of the face ; the febrile reaction with which it was accompanied, was 
still felt by the tubercles of the extremities, which, as in the previous 
attacks of the same kind, became hot, red, and evidently inflamed. 
B * * * died in February 1827. 

Case CXLI. — Greek elephantiasis. Various and unavailing modes 
of treatment. Death. M * * *, a native of New Orleans, was 
sprung of parents in easy circumstances. At the age of eleven, a 
number of blotches, of a pale yellow colour, and little apparent at 
first, were observed on the thighs and forearms: these were ascribed 
to the heat of the weather, and no attention paid to them. Two 
years afterwards, these spots were both more numerous and more con- 
spicuous, and were now pronounced scorbutic by the physician who 
was consulted. Another year elapsed, during which the blotches 
extended to the face, and a number of small tubercles were evolved 
in the substance of the skin. A glass of the expressed juice of endive, 
water-cress, lettuce, and other herbs, was ordered by his physician 
every morning fasting, and a glass of a decoction of sarsaparilla and 
the woods, twice during the course of the day. This treatment did 
no good. The disease made constant progress during the next year; 
tubercles were evolved at the entrance into the nostrils, which caused 
a very copious secretion of mucus ; the face began to swell insensibly ; 
the feet were readily excoriated, and healed with difficulty. M * * *, 
feeling himself full of life and vigour, thinking little of his ailment, 
and reckoning on the strength of his constitution, gave himself up, 
without restriction, to the pleasures of the field, of the table, and of 
Venus. It was only in the spring of 1821, that he again put himself 
into the hands of his medical attendant, who prescribed whey, a 
sudorific tisan, the warm, and, occasionally, the artificial sulphureous 
water bath, made by the addition of the sulphuret of potash, at a high 
temperature. These means were followed by no amendment. The 
patient indulged in his usual habits through the succeeding winter. 
In the spring of 1822, M * * * applied to another practitioner, who 
gave him hopes of a speedy cure, from a tisan of sarsaparilla, carrot, 
&c., saponaceous baths, Belloste's pills, 1 and lotions of althea thrown 
into the nostrils. During the three or four months that this system 
was followed, several flesh blotches appeared. 

In despair at seeing his infirmity increase, M * * * now resolved 
to undertake his case himself; he purchased Leroy's book, 2 and 
began taking an emetic one day and a purge the next ; he then rested 
;i few days, and repeated the medicines; allowing a few more days 
to pass by, he returned to his vomit, &c, and so on for twenty days 
continuously. A great degree of weakness, emaciation, and some 
pain of the stomach were the only results of this emeto-purgative 
plan of treatment. In the spring of 1823, M * * *, with the advice 
of one of the physicians he had already consulted, tried a tisan of the 
leaves of the plantago psyllium internally, and the inunction of the 
sulphur ointment to the arms only. Four months of this system did 
no good. M * * *, from having been of a lively turn of mind, was 
subdued and melancholy. In the course of the same year, 1823, 
\I ' * put himself under the care of a quack, from whom he took 
a stone bottle (dame Jeanne) and a half of a medicine, the composition 
of which was a profound secret ; but having accidentally broken one 
of his large bottles, M • • * found about three pounds of garlic in 

' Compounded of mercury extinguished by rubbing, aloes, scammony, and some 
gromouc. — Tr. J 

; The Bnchar/s domestic medicine of the French, it is presumed— Tr 



pieces, and a glass and a half of antimony at its bottom. This medi- 
cine was as unavailing as every thing else. During 1824, M * * * 
look sea-water baths without benefit, and next year left his native 
country for France, where he landed on the 15th of May (1825), and 
immediately came on to Paris. There he entered a Maison deSante, 
where he underwent an anti-syphilitic course, and at the same time 
took simple and vapour baths. One of the sub-maxillary glands now in- 
inflamed and suppurated. An antiscorbutic plan of treatment was next 
proposed but rejected by the patient. Under another physician, how- 
ever, he passed through a course of iodine, and some time afterwards 
began taking the pilules Jlsiatiques, which, soon causing gastrointes- 
tinal disturbance, had consequently to be suspended. The iodine 
was tried again at different times. On the 1st of September, 1825 
the patient was in the following state : 

The face was beset with tubercles, and had a puffy appearance ; the 
complexion was of the dark or bronze colour which distinguishes the 
mulatto ; the scalp was white and showed no tubercles ; the skin of 
the forehead was in the same state as that of the face, bestrewed with 
tubercles ; and, further, furrowed with deep wrinkles. The super- 
ciliary ridges were covered with similar tubercles, very numerous, 
and much crowded, yet without being confluent. Their surface was 
traversed by oblique folds, which gave them a mammillated or 
nipple-like character ; they projected considerably above or heyond 
the orbit. The hair of the eyebrows had almost all fallen out; the 
eyelids were swelled and hard at their edges ; the whole of the eye- 
lashes had been lost. The nose was large and much flattened ; the 
nostrils were dilated, misshapen, and ran upwards. An immense 
number of tubercles were clustered on the alae nasi, the surface of 
which was knobby and uneven ; on the lobe and neighbouring parts 
they were so numerous that they formed a continuous irregularly 
mammillated mass. Several of these tubercles which had been in- 
flamed, were covered with small browmish crusts, and the little sores, 
which secreted the matter that formed these, were long of healing. 
The cheeks were swollen and also beset with tubercles, though not 
so thickly as the nose. The lips were large, thick, shining, and 
covered with tubercles ; the chin was likewise swelled, tubercular, 
and mammillated at the point. A few hairs of the beard appeared 
here and there, in those parts especially where the skin was merely 
brown without being affected with tubercles. The ears, in like man- 
ner enlarged and tumid, stuck out from the head, and were of a 
dusky-violet hue, but not occupied by any tubercles. The skin did 
not present the bronze-like and morbid hue of which mention has 
been made, lower than the inferior part of the neck. The integu- 
ment of the trunk was extremely white and fine. The hands, espe- 
cially the fingers, were swelled ; and the colour of their backs, as also 
of the outer aspects of the forearms, was the same as that of the face. 
Several brown patches and bands, which stretched down along the 
angles of the ribs, were apparent on the lower and outer extremities 
of the shoulder. The skin of the thighs and legs was of a dark- 
brown. The feet were so much swelled that the patient appeared 
plain soled. 

The arch of the palate was beset with a band of small tubercles, 
less bulky than those of the skin, but more numerous ; they formed a 
kind of mammillated band, stretching along the median line. The 
upper part of the pharynx was visibly beset with tubercles. The 
mucous membrane of the nasal fossa? seemed to be affected with 
chronic inflammation, and poured out an abundance of purulent 
secretion. The sense of smell was almost extinct; hearing and sight 
were enfeebled; taste was perfect, and it was not remarked that touch 
was blunted. The voice was rough, delivered through the nose, 
and, at times, almost suppressed. 

The organs of generation were in a normal state ; the pubes covered 
with hair, as well as the axilla?, and in a slight degree the breast 
also. M * * * exhibited nothing of the libidinous appetite mentioned 
by some writers on elephantiasis. During his stay at Paris, he avowed 
that towards the sex he felt precisely as other young men of his age. 

The patient passed the winter without submitting to any kind of 
treatment. He went little abroad, and often continued in bed all 
day. He could not now run rapidly ; a great sense of weakness in 
his hams compelled him to stop ; the slightest pressure caused excori- 
ations and ecchymoses ; and the least contusion of the legs was 



TUBERCULA. 



281 



followed by a sore, which was very long of healing. In the month of 
May, M * ' * consented to another mode of treatment proposed to him : 
a diaphoretic tisan; frictions along the spinal column, with an ammonia- 
cal liniment; and cauterization of several of the tubercles of the face with 
the incandescent iron : all that were thus treated suppurated and soon 
cicatrized. In September, M * * * complained of violent pain in the 
right side of the chest, and two days afterwards he expectorated some 
blood. He was bled to twelve ounces, and felt relieved. The blood 
abstracted was buffy. He did not recover completely, however ; the 
slighest departure from the strictest regimen caused painful indiges- 
tion and sleeplessness. October 24th, the patient had another attack 
of pain in the right side ; fifteen leeches were applied to the part, which 
did little to relieve him; he coughed a great deal, and expectorated 
little. The tongue was red, foul, and marked with white streaks. A 
w r eek afterwards, a number of leeches were applied to the epigastrium. 
The appetite had now failed ; the bowels were obstinately confined. 
All that was done proved of little avail in relieving the symptoms. 
The expectoration became purulent, pectoriloquy was detected on the 
right side, and the patient lost flesh and strength rapidly. 

The tubercles of the face were now for the most part in a state of 
suppuration ; the ears were no longer livid or swollen ; the hands" 
were emaciated and brown, instead of violet as they had been. 
November 30th, a profuse diarrhoea succeeded the obstinate constipa- 
tion which had continued till this time. On the 1st of December the 
patient became delirious, and on the 3d he expired. 

The body was opened, twenty-four hours after death, in the pre- 
sence of M. Rayer, 1 and of M. Gaide, his pupil. The skin of the 
face alone bore traces of the elephantiasis under which the patient had 
laboured whilst he lived. The greater number of the tubercles had 
been cicatrized, shrunk away, or had ulcerated of themselves. The 
left side of the chin, to the lower lip, is of a livid or sallow and 
yellowish hue. Several small striee are observed on this lip, along 
the edge, where it joins with the raucous membrane of the mouth, 
from which the cuticle, in a semi-pultaceous state, is readily removed. 
The skin of the chin presents a few irregularly circumscribed, nipple- 
like eminences, covered with cuticle, or hidden by slight squama?, 
under which the corion has a slight reddish tint, and appears in some 
places softened to various depths, in a very remarkable manner. 
Incised perpendicularly it appears hypertrophied, and on the sides of 
the chin, is at least two inches thick ; by scraping with the scalpel, 
and still better by maceration, the softened portions of the corion are 
readily removed. The bronze tint of the skin is not owing to any 
deposition of pigmentary matter upon the surface of the papillary 
body; for a perpendicular section through it shows the corion itself 
to be altered, and the colour to be a consequence of changes under- 
gone in its intimate structure. The integument of the point of the 
nose, softened in a less degree than that of the chin, is the seat of 
a number of ulcers of different depths; the surface of this region is 
covered with a whitish layer, owing to augmented secretion from the 
sebaceous follicles. This layer removed, a considerable number of 
small projecting points, of a pearly white, are perceived, which are 
nothing more than the extremities of the minute epidermic prolonga- 
tions, that dip into the cavities of the follicles, and form little tuber- 
cular offsets, that may be drawn out; after which the skin appears to 
be perforated by a multitude of conduits, capable of receiving the 
head of a large pin, which may then be made to penetrate to the 
depth of nearly a line into the corion. The integument of the fore- 
head and checks was covered here and there with a small incrustation, 
which had followed the ulceration, suppuration, or use of the actual 
cautery. The same alterations existed in several places of the limbs. 

The nasal fossae, connected together by the almost entire destruc- 
tion of the septum, presented the following alterations. The mucous 
membrane completely destroyed in some places, left the bones of the 
nose exposed ; in several places it was covered with a pretty thick 
layer of muco-purulent matter, in others it was softened and whitish, 
and here and there was coming off in irregular flaps of small extent. 
When the muco-purulent layer was removed, a considerable number 
of small nipple-like projections were exposed, from which little 
filiform bodies, from half a line to a whole line in length, could be 



M. Raisin is the narrator of this case. 



71 



extracted, formed, in all likelihood, by the concrete fluid of the folli- 
cles. In the mouth, two superficial sores, a line and a half across, 
were discovered on the tongue ; these were the only morbid appear- 
ances which this organ exhibited. The anterior aspect of the velum 
palati mollis was slightly whitish on the left side, and was beset on 
its edges with a number of very small ulcers. The anterior paries 
of the pharynx, through its whole extent, but especially superiorly, 
was of a peculiar dull white colour ; its free surface was covered with 
irregular small mammillae, a number of which could also be traced 
along that of the oesophagus, projecting, on an average, about a line 
and a half beyond the level of the mucous membrane. Between this 
indurated and mamraillated state of the mucous membrane of the pha- 
rynx and oesophagus, and the morbid alterations of the skin, there 
was a very great analogy. The mucous membrane of the larynx 
was lined on its inner surface by a purulent or pseudo-membranous 
deposit, of considerable thickness, and easily removable with the 
back of the scalpel. Under this layer, the mucous membrane ap- 
peared to be much paler than it is in the normal state. It was also 
every where thinner than usual, and presented an ulcer two lines in 
length by one in breadth, which exposed the crico-arytenoid muscle 
of the right side. The posterior aspect of the epiglottis was pos- 
sessed by a number of very minute sores, like those of the pendulous 
velum of the palate. The edges and apex of this organ, everywhere 
the seat of ulceration, were of a very decided grayish colour. At the 
place where the epiglottis is continuous with the larynx, and above 
the margin where the mucous membrane of this part joins that of the 
pharynx, a small quantity of black matter was observed to have been 
deposited. The trachea was not sensibly altered, and the bronchi 
did not exhibit any morbid changes other than the communication of 
a few of these tubes with the tubercular cavities which I am about to 
mention. The subcutaneous cellular tissue of the anterior part of the 
right side of the neck was infiltrated with pus. Several lymphatic 
glands in the vicinity were enlarged, of a yellowish-gray colour, and 
softer than natural. 

The right lung was much more affected than the left, and its supe- 
rior lobe was thickly beset with small miliary tubercles, especially 
upwards, where there was a cavity large enough to hold a pigeon's 
ego;. Between the tubercles the substance of the lung was of a red- 
dish-brown colour, and a good deal indurated. The inferior lobe 
was affected in the latter way, and showed no signs of tubercles. 
The left lung contained a good many tubercles, and several small 
cavities. It adhered slightly to the pleura; on the right side the 
adhesions were more extensive and stronger, and the pleura con- 
tained about a couple of pints of sero-sanguinolent fluid. 

The heart, soft and small, was unaltered. The mucous membrane 
of the stomach, somewhat thickened near the pyloric end of the 
organ, was, on the contrary, extremely thin near the cardiac extre- 
mity, and, in some places, appeared to be even entirely destroyed. 
Almost the whole surface of the viscus was covered with very dis- 
tinct vascular ramifications. A vascular injection of the same kind 
was visible through the whole extent of the intestinal canal, which 
was also ulcerated in three different places, and the mucous mem- 
brane softened in the lower part of the colon. The liver was healthy, 
as were the kidneys, and the mesenteric glands, and the spleen. 
The external organs of generation were of the usual size. The glands 
of the groin were very much enlarged, and, when divided, they had 
the consistence and appearance of greasy liver. 



ARTIFICIAL TUBERCULAR INFLAMMATIONS. 

787. The bite or sting of many insects, such as the wasp (vespa), 
gnat (culex pepiens), bug (cimex lectularius), spider (aranea), &c, is 
generally followed by acute circumscribed inflammation, which fre- 
quently assumes the tubercular shape. These affections have, for the 
most part, a particular appearance ; their causes, too, are generally 
known. 

788. The sting of the wasp and hornet is more painful than that of 
the common bee, and often occasions an erysipelatous inflammation. 
When the sting has been left in the skin it should be extracted as 
quickly as possible, and a compress of linen dipped in cold water or 



282 



SYPHILIDA. 



a saturnine solution applied to the part. We are assured that the 
sting of these insects has occasionally been followed by very serious 
consequences. 

789. The bites of gnats are very commonly succeeded by small 
circumscribed indurations, with surrounding cedematous swelling and 
redness. The itching occasioned by gnat-bites, is to be allayed by 
.in ether or vinegar wash. In the south of Europe, and in warm lati- 
tudes generally, these insects are so troublesome that the inhabitants 
have to defend themselves during the night by surrounding their beds 
with a musquito-net. 

790. But it is after the bites of the common bug that the skin 
appears to be covered with an eruption of a truly tubercular nature. 
In spite of all that can be done in some hospitals, this insect, secreted 
in the bedsteads, especially if they be of wood, in the flooring, or in 
the partitions of the building, torment the patients during the night, 
and hinder them from closing their eyes. I have seen patients whose 
throats, bosoms, and limbs were covered with a copious eruption of 
lenticular tubercles from this cause, each of which presented a central 
point, marking the seat of the puncture. 

791. The jka (pulex irritans), which commonly occasions a little 
red spot with a deeper central point, also gives rise to tubercular- 
looking elevations in individuals with a fine and highly irritable 
skin. 

792. The spider 1 sometimes causes a red and prominent spot, the 
irritation of which may be relieved by simply washing the part with 
cold water. The tarentula (aranea tarentula) causes accidents of a 
far more serious description. 2 The harvest bug, and other insects 
that pierce the skin, also occasion severe itching, which is soon fol- 
lowed by large papulae, or small reddish or yellow tubercles. 

793. There are several other accidental tubercles which approach 
still more closely to the true tubercular inflammations of the skin, both 
in their appearance and tardy progress. One of my pupils of a san- 
guine lymphatic temperament, whilst dissecting, chanced to scratch 
the back of his hand, and in the place there was shortly afterwards 
developed a flattened, reddish, and irregular circumscribed tubercle, 
which continued during several years, in spite of all that could be 
done to effect its discussion. I have oftener than once seen leech- 
bites, and the slight use of caustics, succeeded in individuals of scro- 
fulous constitution, by indolent, reddish tubercles. Nipple-like tuber- 
culations are also occasionally seen following small-pox, and blisters 
after they are healed up. 



SYPHILIDA, SYPHILIDES. 

Vocab. Syphilis. 

794. By the term Syphilide, I understand every alteration of the 
outer integument of the body which is produced by a general venereal 
affection of the system. Alterations of the skin of this kind are com- 
monly associated with one or several other secondary symptoms of 
lues venerea, and, in the great majority of cases, are consequences of 
a contagious specific inflammation of the external organs of generation. 
They consist of exanthemata, bulla?, vesiculae, papula?, squama?, and 
tubercula, which almost in every instance are evolved upon bases of 
a reddish-yellow, or copper colour. They also occur in the shape of 
cutaneous ulcers with yellowish or grayish bottoms, sharply cut edges, 
and occasionally possessing the phagedenic or spreading character. 
They show themselves, in fine, as special affections of the papilla?, 
and of the nails and hair. 

795. In the epidemic syphilis of the 15th and 16th centuries, vene- 
real eruptions occurred so commonly a short time after infection, that 
the disease was regarded as a contagious affection of the s/cin : at the 
present day, and indeed for a long time past, these eruptions have 
been much less frequent, and have always appeared at an epoch much 

■ Diet, des sc. med. Art. Abeille. 

■2 Baglivi. Dis.de anatome, morsu et affectibus tarentula;. Opera omnia, p. 60, 
4to. I.ugd., liio. r »r» i 



more remote from the receipt of the poison than they did formerly. 
This circumstance is explicable from the disease during several ages 
having been transmitted almost exclusively by the intercourse of the 
sexes without primary general infection. If the extreme frequency of 
primary or local venereal symptoms at the present day be considered, 
cutaneous eruptions may even be said to be rare. It would appear 
that in consequence of the great number of transmissions, the venereal 
poison had lost something of its original energy, and that its general 
effects on the system had in consequence become less common. It is 
certain, moreover, that the poison is neither so readily transmitted 
nor possessed of such virulence at every period of the existence of the 
sores and discharges by which it is propagated. 

796. The study of the syphilides cannot be entered upon abso- 
lutely, and independently of the other symptoms of syphilis, whether 
these precede, accompany, or follow the eruptions of the skin which 
characterize them. It is impossible above all to study the venereal 
eruptions apart from the primary symptoms to which they succeed after 
an interval of shorter or longer duration. The necessity of consider- 
ing the primary and secondary symptoms together, becomes the more 
imperative when we are aware of the fact that venereal eruptions do 
•not appear with similar frequency after every variety of primary 
symptom, and that this or that form of eruption succeeds this or that 
species of contagious inflammation of the organs of generation. 

797. These relations of the venereal eruptions or syphilides to con- 
tagious and virulent inflammations of the genital parts, scarcely sus- 
pected before the syphilitic epidemic of the 16th century, very obvious 
during the prevalence of that pestilence, when the eruption occasion- 
ally appeared at the same time as the affection of the genitals, and 
generally before the end of the fourth or fifth week thereafter, have 
become much less strikingly and obviously connected of late, when 
it is usual for several months at least, and often for several years to 
elapse between the occurrence and the cure of primary symptoms on 
the one hand, and the appearance of secondary infections on the 
other. 

798. Carmichael has sought to connect exclusively the appearance 
of certain venereal eruptions with the occurrence of particular primary 
symptoms. This view has been successfully attacked by Rose, Guthrie, 
Bacot, Hennen, &c, yet it would be going too far to say, that no par- 
ticular secondary symptom was more especially associated with one 
form of primary symptom than another. 

799. Primary symptoms. — The number, nature, and characters of 
the primary symptoms of syphilis have of late years been subjects of 
pretty smart dispute among medical men, whence the necessity of 
studying these symptoms, both in themselves and with reference to 
the general infection, to the end that their relations to the various forms 
of venereal eruption, and other secondary symptoms may be the better 
understood. 

800. The primary symptoms of syphilis are, 1st : — Syphilitic go- 
norrhoea ; 2d, — syphilitic inflammation of the glans penis; 3d, — the 
simple syphilitic ulcer (two varieties) ; 4th, — the indurated syphilitic 
ulcer (the Hunterian chancre) ; 5th, — the phagedenic syphilitic ulcer ; 
6th, — the gangrenous ulcer ; 7th, — the bubo. 

The whole of these affections are due to one cause, and are of the 
same essential nature ; 3 they arise from, and are reproduced the one 

3 " Six amis, apres un repas peu frugal, eurent tous commerce avec la meme fille 
qui leur donna a tous la vferole. Elle se manifesta chez eux avec des symptomes 
differens; deux eurent des chancres et des poulains; deux autres la chaudepisse; le 
cinquiame eut un chancre; et le sixieme un seul poulain." (Vigaroux. Observ. et 
remarques sur la complic. des sympt. vener. avec d'autres virus.) — "M***,negociant 
d'une ville maritime, voyageait depuis deux mois sans avoir expose sa same avec 
aucune femme. Lorqu'il fut arrive a Paris, il fit la connaissance d'une jeune fille, 
avec laquelle il cohabita. Apres huh jours il me fit appeler, et je lui trouvai le pre- 
puce et le gland couverts de chancres profonds et douloureux. Je visitai aussitot la 
jeune personne qui n'avait qu'un ecoulement, encore etait-il fort peu abondanl. 
Elle est restee sous nos yeux pendant tout le traitement de M*** et malgre les recher- 
ches les plus exactes, il ne m'a pas £\& possible d'apercevoir d'autres symptomes." 
(Obs. de Cullerier, citee par M. Lagneau. Expose de sympt. de la malad. vener. ia 
8o, 5e ed. 1818, p. 30.) Hennen relates a similar case. (Military surgery, 3d ed. 
8vo, p. 534. Lond., 1829.) (a) 

(a) In the above note Cullerier, cited by Lagneau, tells of six men 
having been inoculated after intercourse with the same female, two 
having chancres and buboes, two gonorrhoea, the fifth a chancre, and 



SYPHILIDA. 



283 



by the other at certain periods of their existence, but not with like 
activity nor in similar proportions, (a) Inflammation of the surface of 
the glans, and simple sores are so often associated that Carmichael 
believes them to be produced by a particular morbid poison. 

the sixth a bubo alone. This writer gives also the case of a person 
from a distant city, having, after his arrival in Paris, cohabited with 
a young girl, from whom he contracted numerous deep and painful 
chancres in the glans and prepuce ; although the surgeon in careful 
examination was unable to detect any thing more than mere gonor- 
rhoea in the female herself. 

The explanation of cases of this nature is, after all, not difficult 
without our still admitting an identity of the gonorrhceal and chan- 
crous in proper syphilitic virus. The person who communicated the 
two diseases had them both. Some have been infected with the one, 
some with the other, while some, again, have entirely escaped. M. 
Ricord has shown that chancres often exist deep in the vagina or in 
the os uteri. "I believe" says Mr. Herbert Mayo (Lectures on 
Syphilis in Med. Gaz., 1839), " from observation that such chancres, 
not external in women may remain for months in an indolent and 
unprogressive state. I attended a gentlemen for three successive 
chancres which he had caught, at intervals of a very few months, 
from the same woman, who would have it that she was in perfect 
health. At last she consented to allow me to examine her, when I 
found two small ulcers within the external labia which got well under 
mercury. The story of the Portuguese opera dancer, mentioned by 
Dr. Ferguson, and already quoted, is doubtless to be explained in the 
same way. 

" This woman had inoculated several with chancres ; but she herself 
continued on the stage for many months afterwards in apparently 
good health. 

" A man labouring under a slight gonorrhoea, as it may be called, but 
without any chancre in the glans or prepuce, has sometimes inoculated 
a female, with whom he cohabited, with true syphilis. Careful exami- 
nation in such a case has revealed the existence of a chancre just 
within the meatus, and explained the apparent anomaly." 

(a) As I have elsewhere stated, I believe this position to be un- 
tenable. Desirous to avoid discussion, and not to occupy space by 
needless details, I shall merely repeat on this occasion the condensed 
view presented elsewhere. 

" In detailing the causes of urethritis, I mentioned that gonorrhoea 
was produced, principally, by the contact of virus resulting from 
morbid secretion of the mucous surface of the urethra in males and of 
the vagina in females. I adverted to that other opinion, that the 
disease was also caused by the matter secreted from chancre. At the 
present time we have small reason for adhering to this last notion, 
disproved as it is by careful observations and experiments. The fal- 
lacy of the belief in the chancrous origin of gonorrhoea was kept up 
by the fact of an urethral discharge, accompanied by symptoms of 
irritation, following the introduction of the matter from chancre into 
the urethra. But more careful inspection showed that in this case 
there was true inoculation, and that an ulcer was formed in the meatus, 
the irritation and discharge from which simulated and were taken for 
o-onorrhcea. We are authorized, in the existing state of our know- 
ledge on this subject, to reject the opinion of Hunter, who tells us, as 
a reason for giving small doses of mercury in the case of gonorrhoea, 
' it is always necessary to have in view the possibility of some of the 
matter being absorbed and afterwards appearing in the form of a lues 
venerea.' 

" Inoculation affords the true test in this question, as clearly proved 
by M. Ricord [A Practical Treatise on Venereal Diseases, fyc). He 
has shown that the matter of gonorrhoea never produces chancre, nor 
does the pus of chancre give rise to gonorrhoea, when each respect- 
ively has been applied to the surfaces and tissues in which these dis- 
eases are developed in common. ' The gonorrhceal secretion, applied 
to the mucous membrane of the eye, has never produced chancres of 
the conjunctiva or eyelids, nor has the muco-purulent secretion of 
gonorrhceal ophthalmia ever produced chancres by inoculation, or 
otherwise, although the eyelids are susceptible of being injected by 
chancre. We may add, that the muco-pus of balanitis, &c, the con- 
sequence of an impure coition, or produced artificially by an irritant, 



801. Syphilitic gonorrhoea. 1 — This is a contagious inflammation of 
the urethra, glans,^and prepuce in the male, of the vagina and occa- 

has never furnished a result by inoculation, and that these affections, 
therefore, cannot be followed'by symptoms of constitutional syphilis 
whenever they have existed without chancres. 

" ' Without, in this place, entering into the discussion and history of 
all the symptoms which have been attributed to gonorrhoea, there are 
two which are pretty frequent and regular, as consecutive symptoms ; 
these are buboes (yet far less frequent than after chancre) and swelled 
testicle (epididymite). 

" ' I have ascertained by inoculation, that the pus from buboes which 
are consequent on gonorrhoea, does not inoculate, even should they 
terminate in suppuration, which is rarely the case : they otherwise par- 
take only of the nature of an engorgement or simple abscess, whose 
characters frequently correspond to strumous and not syphilitic affec- 
tions. 

" ' As to swelled testicle, which still more rarely suppurates, the pus 
never produced any thing by inoculation. 

" ' The observations made upon gonorrhoea, during my researches 
upon inoculation, lead to the following propositions : — 

" ' I. The matter of a gonorrhoea, applied to a healthy mucous mem- 
brane, causes gonorrhceal inflammation so much the more easily the 
nearer it approaches the purulent form, and therefore, contrary to the 
opinion of Wathely, the less mucous its nature. 

" ' II. Under no circumstances can it produce chancre ; but as an 
irritating matter, like that of coryza, for instance, it may excoriate the 
skin, with which it remains some time in contact, but it never pro- 
duces a specific ulcer. Convinced of these truths, which were so often 
verified, one of my pupils, M. Leon Ratier, often inoculated himself 
with the muco-pus of gonorrhoea upon the skin of the forearm, without 
any results. 

" ' III. The consecutive, undoubted, and regular symptoms of gonor- 
rhoea, do not furnish an inoculable pus. 

" ' IV. The symptoms of constitutional syphilis are not the conse- 
quence of gonorrhoea. In all the cases in which authors mention that 
it was an antecedent, the frequency of which precisely corresponds 
with that of masked chancres (chancres larves), the diagnosis was not 
correct ; the diseased surfaces not having been examined. 

" ' V. Lastly, the only correct means of diagnosis, in the present 
state of science, is inoculation. Every gonorrhoea which is tested by 
inoculation in its various periods, without producing any result, is 
only a simple affection, and incapable of communicating syphilis, 
whether primary in another subject, or constitutional in the one first 
affected.' "—Bellfy Stokes 1 Lectures, fyc, pp. 634-5, vol. i. 3d edit. 

' There is no mention made in any part of the writings of Hippocrates of a painful 
and contagious flux of the genital organs. Celsus speaks of a nimire profusions seminis, 
but not of a blenorrhagia, or flow of mucus (De re medica, lib. iv. sect.xxi) ; Swediaur, 
and several other writers, have interpreted this passage amiss. Neither does Galen 
treat of more than a flow of the seminal fluid : Igitur gonorrhoea instrumentorum 
seminis affeclio est, non pudendorurn (De Gonorrhoea priapismo, &c, in the treatise, de 
locis affectis, lib. iv. cap. vi). It would appear consequently that the Greeks and 
Romans were unacquainted with syphilitic blenorrhagia. 

We read, however, in a book much anterior to any of the writings quoted, Leviticus 
to wit, chap, xvi., some very strict ordinances relative to men labouring under a flow 
of semen, and it seems much more probable that the question here is of a true blenor- 
rhcea than of a flux of the seminal fluid, an infirmity far too uncommon ever to have 
been made the subject of any sanatary law. It is very likely, therefore, that blenor- 
rhagia was frequent among the Jews. In Europe it was certainly rare before the 
end of the middle ages. Brassavolus (De morbo Gallico) and Fernelius (De morbis 
contagiosis, lib. ii. cap. xi v.) are generally allowed to have been the first who described 
gonorrhoea as an effect of the morbid poison lids venereae, and Astruc assures us, and 
his is the opinion of Fallopius, that venereal gonorrhoea was not observed during the 
earlier periods of the epidemic of the 16th century (Astruc de Morbis Venereis, 4to. 
Paris, 1738, p. 77). 

More recently, Fr. Balfour (De Gonorrhoea viruknta, 8vo. Edinb., 1767), and W. 
Ellis (An, Essay on the cure of venereal Gonorrhoea and Gleets, 8vo., Lond., 1771), 
started the opinion that clap and pox were perfectly distinct diseases, and this opinion 
has been since espoused by Duncan, Ehrman, Lafont-Gouzi, Hernandez, and others. On 
the other hand, T. Bayford (the Effects of Injections into the Urethra, &c, 8vo. Lond., 
1772) about the same time as Ellis, and subsequently, Freteau (Consid. prat, sur la 
gonorrhee virulente, 8vo. Paris, 1815) have maintained the identity of the cause of 
gonorrhoea and syphilis. 

For my own part, the development of venereal eruptions after syphilitic gonorrhoeas 
and the engenderment of venereal sores by the contact of gonorrhoeal matter, and 
the contrary, induce me to believe that these several affections are different effects of 
the same cause. As to non-syphilitic Menorrhagias, I conceive them at the present 
day to be extremely rare. I have, however, seen true discharges from the urethra v.\ 



284 



SYPH1LIDA. 



Monallv ol the urethra in the female. In the male this affection is 
announced by the secretion of a yellowish or greenish-white fluid with 
scalding and pain in making water, and involuntary and frequently 
repeated erections. This of all the primary symptoms of syphilis is 
that which i< most frequently observed at the present day. 

802. In the female attacked with syphilitic gonorrhoea, the inflam- 
mation may extend from the vagina, where it begins, to the urethra, 
the cervix uteri, and pudenda; it is occasionally accompanied with 
excoriation of the labia majora and minora. In its acute state, this 
inflammation gives rise to a flow of yellowish or greenish fluid, wdiich, 
inoculated by the intercourse of the sexes, reproduces the same, or 
some other form of venereal disease. 1 This character distinguishes 
syphilitic Menorrhagia from leucorrhcea, and every other form of dis- 
charge, such as that which depends on a rheumatic or arthritic cause, 
the irritation of teething, fee., to which these parts are subject. 

803. In the male, the venereal swelled testicle, the swelling of the 
prostate and Cowper's glands ; in the female, the inflammation of the 
uterus or of the ovaries ; in both the ophthalmia, (a) the iritis and 
gonorrhceal arthritis, are the secondary mischiefs of most frequent 
occurrence ; but severe erysipelas and even gangrene have been ob- 
served attacking the glans and prepuce in a few rare and very bad 
cases. 

The buboes occasionally observed along with gonorrhoea are gene- 
rally less serious than those which accompany syphilitic sores, or 
which are developed during their treatment. Venereal arthritis is 
more common after gonorrhoea than any other form of primary symp- 
tom. 

804. Cutaneous eruptions, secondary to gonorrhoea, are rare : they 
occur especially in a much smaller ratio than after syphilitic ulcers, 
whether superficial or deep. Yet I have seen every form of syphilide 
as consequences of gonorrhceal infection. Considered in regard to 
their relative frequency, they may be arranged in the following order: 
— papula 1 , exanthemata, psydracious pustules, squamae, syphilitic 
tubercles. 

805. Syphilitic gonorrhoea, treated by means of rest, cooling diet, 
local and general baths, occasionally by the local, and even by the 
general abstraction of blood, and in its latter stages by the balsam of 
Copaiba, or Cubebs pepper, gets well in general between the twentieth 
and thirtieth day. Neglected or mismanaged, the disease is apt to be 
followed by stricture of the urethra, &c. After the discharge has 
ceased I am in the habit occasionally of prescribing the pills of Bel- 
loste, or of Sedillot 2 for a time, with a view of modifying the consti- 
tution, and of preventing secondary mischief. 

806. Syphilitic blenorrhcea of the glans. 3 A muco-purulent con- 

(a) Gonorrhceal ophthalmia requires a very bold and vigorous 
practice — the chief points of which will consist in early and free blood- 
letting, and the application of stimulants and astringents to the eyes. 
The nitrate of silver is the preferred article on these occasions. 

children cutting their teeth (Mem. sur. les inflam. non-virulentes des membr. muq. 
des org. de la generat. des enfans, 8vo. Paris, 1821) ; and I have met with several 
cases of arthritic discharges, upon which Bell (on Gonorrh. Virulenta, &c, 8vo. 
Edinb., 1793), Swediaur (Tr. des Mai. Vener., pp. 56, 60), Barthez (Tr. des mal. Gout- 
teuses, t. ii. p. 324) and Cuecon (Rec. period, de la Soc. de mod., t. ix. p. 156) have 
published interesting observations. With regard to the epidemic Menorrhagias that 
sometimes prevailed, I refer to the remarks of Bias (Obs. Chirur. Med., Magd., 1731), 
and of Winkler (Rec. period, de litt. med., etrangere, p. 152). 

1 Hunter thought that gonorrhoea could produce chancre, and vice versa. Bell 
disputes this opinion, and informs us that, in an experiment in which the matter of 
gonorrhoea was placed between the prepuce and glans, the disease that followed was 
clap, whilst the poison of a chancre, inserted into the urethra, produced a sore of the 
same description. I believe that matters turn out most generally as Bell has stated 
them; but his experiment does not by any means prove that the matter of gonorrhoea 
can never produce a chancre. According to Carmichael, not only will gonorrhoea 
not produce chancre, but gonorrhceal infection will be followed by eruptions of a dif- 
lerent order from those that succeed chancre. The erroneousness of this assertion 
has to inv mind been demonstrated. Hunter (oh the venereal) gives two cases of 
general infection (ulcers of the throat, pustules), happening after gonorrhoea, and M. 
Lagneau relates the case of a young man who, eight months after having had gonor- 
rhoea, was attacked with ulcers of the velum palati, lenticular tubercles over the whole 
surface of the body, and incrustations of the hairv scalp. Vide also Lombard, 
de Chirurgie Practique sur la maladie venerienne, f. ii. p. 50).— Swediaur. 
(Traite complet. des mal. syphilitiques, 8vo., 7e ed. 1817.)— Fabre. (Traite des mal. 
ven., 4e cd., p. 47.) 

« The blue pill— that of Beloste being combined with aloes and aromatics— that of 
- Hot being made with the blue ointment, gum, and su^ar. Tr. 

s Sydenham describes this affection : "Ipse vhU virulentara hujusmode materiam 



tagious discharge from the surface of the glans and inner aspect of the 
prepuce, of a vivid red generally, and in some places denuded of their 
epithelium. This discharge, which is transmissible by sexual inter- 
course, may give rise to other venereal symptoms, (b) In this disease 
the discharge is not poured out from every point of the surfaces of the 
glans and prepuce, but from irregular, highly inflamed, and occasion- 
ally excoriated patches, upon which M. Desruelles has sometimes 
seen false membranes deposited, which subsequently formed adhe- 
sions. 

807. Syphilitic blenorrhcea of the glans and prepuce requires to 
be carefully distinguished from an increase of the secretion poured 
out by the sebaceous follicles of these parts, and from accumulations 
there of the fluid of the follicles, through neglect of cleanliness. It 
must also be distinguished from eczema of the glans and prepuce, in 
which the discharge, more serous in its qualities, is independent of all 
venereal indication, whether primary or secondary. 

Blenorrhcea of the glans is sometimes associated with urethral 
gonorrhoea, and with simple venereal ulcers of the penis ; when it 
occurs without such complications, it may be cured in a few days by- 
attention to cleanliness, and the use of cold lotions with the extractum 
saturni. 

808. Blenorrhcea of the glans, without complication, is very rarely 
followed by secondary symptoms ; when cutaneous eruptions have 
been seen to succeed the affection, it will almost always be found to 
have occurred associated with gonorrhoea, or venereal sores. 

809. Primary venereal sores. 4 — These sores occur under five differ- 

(b) The remarks, made in a former note, on the difference between 
urethral or common gonorrhoea and chancre, apply to syphilitic blenor- 
rhcea of the glans (balanitis). This latter is caused by gonorrhceal virus 
and neither causes nor is induced by chancrous matter. 

per substantiamglandis porosam exudare, non per urethram ejectam.nulloque ulcere 
vel glandem occupante vel prEeputium. (Opera medica, 4to. Geneva?, 1769, t. i. 
Epist. ii. p. 205.) . J. Vercelloni also mentions it. (De pupendorum morbis et lue 
venerea letrabiblion. Asti, 1716, 8vo.) 

M. Desruelles has given a good account of the affection, and is the first who speaks 
of the variety with pseudo-membranous deposits. (Of two hundred and ten men 
attacked with the disease, fifty had it in the simple form; one hundred and fifty-five 
had it complicated with gonorrhoea or ulcers.) 

Astruc saw a young man labouring under ophthalmia, from having carried his 
fingers, impregnated with the matter of a blenorrhcea of the glans, with which he 
was affected, to his eyes. (De morbis venereis, lib. iii. cap. iii. De gonor. spuria.) 

4 A loose interpretation of the descriptions left us by the Greek and Roman writers, 
of ulcers of the genital organs, neglect of the writers of the sixteenth century, imper- 
fect details of cases, and purely hypothetical notions in regard to the predisposing 
and essential causes of these ulcers, have conspired to introduce confusion into the 
determination of their species, and accounts of their several characters. Had the 
study of anterior works not been neglected, we should not iiave had certain appear- 
ances, observed and described previously to the use of mercury, attributed to its 
exhibition, and distinctions made with care by the practitioners of the sixteenth cen- 
tury, would not have first been held as impossible or useless, and subsequently 
been reproduced, from new data, by the more accurate among the observers of later 
times. 

Hippocrates mentions, but does not describe, ulcers of the pudenda. (De nattita 
muliebri, sect. v. ed. Foes. p. 582.) Celsus gives a careful account ofphymosis, and 
of simple, phagedenic, and gangrenous ulcers of the glans and prepuce ; but he does 
not say that these sores are contagious, or followed by secondary consequences. (De 
re medica, lib. vi. sect, xviii. 2-4.) Galen speaks of ulcers of the penis and pudenda 
(de locis affectis, lib. vi. cap. vi. — De compos, pharm. secund. locos, lib. ix.), but is 
much less complete than Celsus. 

Lanfrancus (Chirurg. magna et paiva, fol. 1490, torn. iii. cap. ii.), and Gulielmus de 
Saliceto (Chirurgia, fol. 1476, lib. i. cap. xiii.), in the thirteenth century, are the first 
who speak of ulcers and pustules of the glans happening post odium cum feeda 
muliere. In the fourteenth century, Bernard Gordon, Guy de Chauliac, and Arnaldus 
de Villanova, severally make mention of sores contracted propter decubilum cum 
muliere feeda. 

During the height of the great syphilitic epidemic at the end of the fifteenth and 
beginning of the sixteenth century, contagious sores of the genital organs were ob- 
served and commented on as one of the symptoms of the disease, by* great numbers 
of writers. (Casp. Torella. — De ulceribus in pudendagra tractalus.) 

Fallopius has left a good account of venereal ulcers. He distinguishes three kinds, 
which very evidently correspond with the three species described with great care in 
these latter days by Carmichael : — " Signi cariei benignx sunt : primum enim stibon- 
untur pustules quajdam parvaa et Candida?, qtiasquidem nonexcedunt crassitiem unius 
grani panici minimi; pustulae erumpunt; his ruptis remanet ulcusculum rotundtim, 
in medio habens punctum candidum, penetrans, aliquantulum simplex, vel dupli- 
catum; aliquando tola corona glundis inficilur hujusmodi ulceribus, quandoque simul 
copulantur, et ex duobus, vel tribus, vel quatuor unum fit, ita ut sit veluti linea cin- 
gens, et coronans glandem; istaest sinedolore; leviset moderatus pruritus; facillime 
cedit medicamento (this is the simple sore of Carmichael).— Secunda species soevior 
est, et ista et genus quoddam ulceris rotnndi.sed in medio non adest punctum album; 
adest livor in ulcere, et labra leniter attoluntnr,purpureo colore infecta; aliquantisper 



SYPHILIDA. 



285 



ent forms: 1st, the simple sore; 2d, the indurated sore (the Hun- 
terian chancre) ; 3d, the phagedenic sore ; 4th, the gangrenous sore ; 
and 5th, the venereal sore becomes cancerous. They have the com- 
mon and essential character of being produced by the same morbid 
poison, and of being followed by venereal eruptions, and other se- 
condary symptoms of various character. 

810. Ulcers are less common than gonorrhoea as the primary symp- 
toms of venereal infection. They are divided and distinguished from 
one another by their progress and appearance ; their cause and their 
secondary consequences separate them from every other description 
of sore, accidental or factitious, affecting the organs of generation. 
All are not alike severe : the phagedenic and the gangrenous ulcer 
occasion local mischief, often of a serious nature; the indurated sore, 
or Hunterian chancre, is healed with greater difficulty than the simple 
ulcer. As to the relative frequency and extent of secondary symptoms 
after each, opinions are divided, and data are yet wanting upon which 
accurate conclusions may be formed. I have fancied that secondary 
mischief was both more frequent and more severe after the indurated 
sore than any other form of local affection. 

811. The simple venereal ulcer. 1 — (Venerola vulgaris, Evans; the 
common chancre of several French pathologists.) Primary sores, acute 
in their character, contagious, arising from local infection, the edges 
of which are neither callous nor deeply indurated. These are the most 
common of all the forms of venereal ulcer. 

Simple sores present several varieties in their appearance, their 
number, their seat, their course, and their continuance. 

812. A variety of the simple ulcer is occasionally observed on the 
glans and inner surface of the prepuce, the bottom of which, before 
long, becomes raised, and, as it were, fungous (ulcus elevatum). 
When these sores, which are seldom seen in greater numbers than 
two or three together, are evolved on the inner surface of the pre- 
puce, or upon the body of the penis, they begin in the shape of a 
small pustule, that continues for a day or two ; a slight scab is then 
formed, which, on being thrown off, leaves exposed a small exca- 
vated ulcer, of a round or oval figure, and surrounded with some 
redness. The bottom of this sore begins to fill up in the course of 
the second week, and at a later period rises gradually above the level 
of the surrounding integuments, presenting a smooth surface of the 
usual colour of a simple wound, but without granulations, and having 
something of a fungous appearance. It is when the sore is in the 
latter state that patients commonly first seek advice. 

813. Other simple sores (common chancres) are evolved behind 
the corona glandis and on the parts of the prepuce immediately con- 
tiguous to it. In this case there are almost always several sores, 
generally four or five, and I have counted as many as fifteen, when 
they have all the look of an eruption. First period (excavated pseudo- 
membranous state). Each of these sores begins as a little red spot, 
which is soon replaced by a yellowish-white point that might be 
covered with the head of a pin. In the course of a few days this 

profundum est hoc ulcus (this is the sore of the pustular venereal of Carmichael). — 
Ultimo in loco est pessimum et vakle malignum ulcus, non rotundum, sed varia 
figura figuratum, ac variis depictum coloribus, livido, purpureo, etc.; callosa habei 
labia, serpit sasvissime, et aliquando nome conjunctam habet, hoc est putredinem 
(this is the phagedenic ulcer)." (G. Fallopii de morbo Gallico tractatus, cap. 82 ; de 
tribus cariei gallica? speciebus.) 

Carmichael (an essay on venereal diseases, 2d ed., 8vo., London, 1825), has pre- 
sented us with an excellent description of primary venereal ulcers, and I have adopted 
his species. Mr. Evans (Path, and Pract. rem. on ulcerations of the genital organs, 
8vo., Lond., 1819), has uniied under the name of venerola vulgaris or ulcus elevatum, 
the two first species of Carmichael, (the sore which he believes proper to the papular 
venereal disease, and that which, according to him, precedes the pustular form of the 
malady), and has contended for the phagedenic state being regarded as an evidence or 
effect of a constitutional taint. M. Desruelles has distinguished venereal ulcers into 
simple and complicated ,• he thinks that the differences observed in their appearance 
are due to diversity of seat, and to merely accidental circumstances. Hennen (Prin- 
ciples of Military Surgery, 3d ed. 8vo., Lond., 1819), is also of opinion that the differ- 
ent appearances presented by venereal ulcers, are owing to their variety of situation, 
on the outer or on the inner surface of the prepuce, behind the corona glandis, on the 
frenum and on the body of the glans. Boyer distinguishes venereal ulcers into benign 
and malignant; the latter comprehend — 1st, the callous chancre; 2d, the gangrenous 
ulcer; and 3d, the ulcer which has a fungous and cancerous appearance. 

' These sores are indicated by Fallopius under the name of caries benigna. Of 
late Carmichael has described two appearances as characteristic of ulcers proper to 
two distinct forms of lues venerea— the papular and pustular. Mr. Evans speaks of 
them under the title of venerola vulgaris. Carmichael has published several cases 
of these sores in the Lond. Med. Gaz. 
72 



point attains the dimensions of a large hemp seed, and acquires the 
form of a small, slightly excavated ulcer. Its bottom is covered with 
a yellowish-white, very adherent substance; its edges slightly in- 
flamed, not prominent, are neither hard nor callous, and its base is 
not indurated. When several of these little ulcers are in contact by 
their corresponding edges, they run together, and a broader and fre- 
quently irregular pitted ulcer, with the same general characters, is the 
consequence. When they appear near the origin of the frenum, it 
this part is accidentally torn, they spread in the direction of the rent, 
so as to form a slight superficial furrow, the bottom of which is 
covered with a yellowish-white substance. These little sores occa- 
sionally form a kind of ring around the outer opening of the prepuce, 
and if they chance to run together, a succession of ulcerated arcs or 
portions of circles succeeds. Sores of this description are occasion- 
ally evolved in succession during the course of the week following 
the appearance of those first developed. Second period (excavated, 
state, without false membrane). Towards the end of the second, or 
beginning of the third week, and occasionally even sooner, the bot- 
tom of the ulcer rises, the edges, that were slightly swollen, sink, 
and cicatrization is completed in the course of the fourth week, 
under the influence of the antiphlogistic plan of treatment, without 
other assistance than the application of the nitrate of silver to those 
sores whose granulations shoot beyond the level of the general surface. 

The appearance and the course of these benign ulcers may be 
modified by neglect of cleanliness, by fatigue of body, the application 
of irritating dressings, &c. Their surface then becomes dusky, and 
apt to bleed, their edges are hard and prominent, and the period of 
their cicatrization is longer of arriving. The mean duration of the 
ulcers of this class varies between three and six weeks ; but this, 
too, may be modified by the state of the constitution, the manner of 
living, &c. The ulcerative process and the extension of the inflamed 
areola appear to stop as soon as granulations begin to be formed. 

These sores are frequently accompanied with blenorrhcea of the 
glans, with urethral gonorrhoea, and with phimosis. They have also 
been seen accidentally complicated with gangrene or with phlegmon 
of the prepuce. 

814. These ulcers may be caused by the matter of gonorrhoea, and 
the fluid they secrete has the power of reproducing them. 2 

815. I have seen this variety of venereal sore appearing on the 
inner surface of the prepuce under the guise of two small eminences 
covered with a layer of yellowish and very adherent matter, and 
bathed with pus. These projections, when they had lost this pseudo- 
membranous covering, at a later period, presented the fungous appear- 
ance of which I have spoken above. 

816. I have observed every variety of venereal eruption and vene- 
real growth as consequences of these two varieties of primary sore. 
Carmichael believes that nodes occur very rarely after them. 3 

817. Simple venereal ulcers occasionally present yet another ap- 
pearance: after the detachment of the layer of grayish adherent 
matter observed on their surface during the first period, they some- 
times assume a reddish-brown hue, and their edges become promi- 
nent and sharp. Sores of this kind are not excavated out of the 
glans or prepuce, like the Hunterian chancre; their bottom, on the 
contrary, is on a level with the surrounding parts, or is even raised 
above them. 

This peculiar appearance of the simple ulcer is commonly seen 
when the outer surface of the prepuce, or body of the penis, is the 
part affected. Several of these sores frequently form a circle around 
the orifice of the prepuce; and after they get well, are often followed 
by a phimosis which is only remediable by the operation. 

The progress of these simple raised sores is generally slow ; they 
seldom show any disposition to extend superficially or to penetrate 

i Two men visit the same woman labouring under gonorrhoea ; one of them con- 
tracts clap, the other venerola vulgaris — Evans. Three experiments of this gentle- 
man go to prove that the matter of these sores is more contagious when they are in 
their first stage, in the excavated state, than afterwards when the discharge from them 
is purulent. 

3 In a thousand cases of papular venereal disease, Carmichael assures us he had not 
met with a single instance of well-marked exostosis, nor any of those deeper affec- 
tions which are so common in the other forms of venereal disease. The results of 
my observations differ from those of Carmichael. I have several times seen exostosis 
following ulcers of the description in question. 






SYPHILID A. 



, .11 j in rise from that of a split pea to that of a shil- 
Tbe elevation of their edges gives them an excavated appear- 
ince, which they exhibit for two, three, four, and even a greater 
number el weeks. This elevation of their edges distinguishes them 
from simple ulcers of corona glandis, which commonly heal up with- 
out presenting this kind of circular swelling. These ulcers with 
raised edges never have the smooth and prominent surface peculiar 
to the fungous sore. They are distinguished from the indurated 
ulcer (Hunterian chancre) by the want, of the callous edge, and base 
of cartilaginous hardness. They differ from the phagedenic ulcer in 
baring a well-defined margin, and a surface which is not irregular, 
and as it were eroded, as well as by being unaccompanied with the 
acute pain that always attends the progress of the eating ulcer. 

The mean duration of ulcers with prominent edges is greater than 
that of the simple sores which do not become fungous, and the edges 
of which do not get separated from the subjacent parts, which are 
commonly seen on the corona glandis. I have observed every variety 
of venereal eruption after these ulcers with prominent edges. 1 

818. The antiphlogistic mode of treatment is applicable in the 
majority of cases of simple venereal ulcer. Under the combined 
influence of rest, especially of rest in bed, low diet, the tepid bath, 
emollient topical applications, and bleeding when the inflammation 
runs high, these ulcers always improve, and commonly heal up 
entirely within from twenty to thirty days. By touching the fungous 
sore with sulphate of copper, its cure is often expedited. Sores of 
the body of the penis are frequently found to heal more rapidly when 
they are dressed during their second period with the unguent, oxidi 
zinci, or of the hydrarg. nitratum. In this stage I am also of opinion 
that alterative doses of one of the preparations of mercury, and purga- 
tives generally prove useful. Carmichael in addition recommends 
antimonials. 

Carmichael tells us that he has used caustic with success to the 
simple sore in its excavated state. B. Bell was of opinion that this 
practice was apt to cause buboes. 

819. The cicatrices of primary venereal ulcers of the organs of 
generation are generally small, slightly depressed, of a bluish-white 
colour, and frequently numerous on the corona glandis. Save in 
those cases in which the frenum is destroyed, they do not occasion 
any evident deformity. Previously to complete cicatrization, the 
neighbouring parts, and the prepuce especially, continue puffy and 
enlarged, often for a very considerable length of time, but those livid 
indurations are never seen under the cicatrices which are occasionally 
observed after indurated ulcers. 

820. The indurated syphilitic ulcer, 2 the Hunterian chancre. This 
form of sore occurs much more rarely than the simple venereal ulcer. 
It is commonly seen on the glans penis. It is constantly circular in a 
greater or less degree in its form, excavated, without granulations, 
and covered with a whitish adhering matter. Its base is callous, its 
edges hard and thick. This hardness and thickening are primary, 
very accurately circumscribed, end suddenly, and do not blend with, 
or melt gradually into, the surrounding parts. This character of indu- 
ration is not limited to the edges of the ulcer in question, but extends 
over the whole surface of the sore, and frequently spreads beyond it. 
Ulcers or chancres of this kind are often seen, the extent of whose 
ulcerated surface is trifling in comparison with that of the induration. 

1 According lo Carmichael this kind of ulcer must be very different from the first 
variety ; he adds, that in every case of the second variety to which he could attach 
constitutional symptoms, they were essentially different from those that followed the 
first. He relates several interesting cases : Case 9ih, ulcer with raised edges on the 
outer surface of the prepuce; ulcerated bubo with raised edges ; phlyzacious pustules. 
— Case 10. Body of the penis encircled by a series of ulcers with raised edges; an 
ulcer on the external surface of the prepuce; five weeks afterwards, phlyzacious 
pustules, and a hard and indolent bubo.— Case 1 1. Ulcer extending from the back of 
the penis to the pubes, \vith raised edges, covered with a thick and adhering matter; 
seven weeks afterwards, eruption of phlyzacious pustules, pain, ulcers of the throat! 

s John Hunter is generally supposed lo have fixed the characters of this ulcer; but 
they had been described wiih great exactness long before : '• Interdum in virgd, non- 
nulla ulcera cum duntie et collositate quse sanari exacte nequeunt, perpetitur, quod 
morbi gallici cerium sig , nifu est] maxime cum jn . . M essei ^ t apost * ma 

quod bubonem dicunt.' (AJoysii Loberce, de morbo gallico, tradatus.) Massa had 
equally well indicated «h«s character : « Ulcera v.rg* qua, sun, mala cam duritie cal- 
Aphrod.s.acu*, p. 46) Still John Hunter has particularly insisted upon the 
c.rcamscnbed hardness of the edges and of the base of this ulcer, .he characters of 
which he has well described. (On the Venereal Disease, 4to. London, 1786 ) 



Carmichael informs us that he has met wiih primary indurated tuber- 
cles without ulceration; this form of primary syphilitic affection is 
exceedingly rare : by questioning patients we almost invariably dis- 
cover that a small sore had been formerly situated in the sanx 
as the induration, and that it had only healed up within a few days. 

821. When the indurated chancre is developed on the body of 
the penis; the ulcer is not in general excavated; it is of a dusky or 
livid colour; its bottom is on a level with the surrounding parts; its 
edges and base are always less hard, less callous than those of the 
same description of sore evolved upon the glans. The size of this 
ulcer occurring on the body of the penis varies from that of a sixpenny 
to that of a half-crown piece, or rather less ; the sore, indeed, has 
been seen extending completely round the member. Its edges are but 
slightly raised ; the induration of its base is easily recognizable by 
the touch, but is never so strongly marked as in the indurated ulcer 
of the glans. 

822. Phymosis and inflammation of the prepuce complicate the 
indurated sore or chancre more rarely than the other forms of ulcer ; 
and when this complication does occur it is almost always owing to 
some accidental circumstance. 

823. The duration of the indurated ulcer is on an average from five 
to six weeks. After the first inflammatory symptoms have subsided, 
the administration of mercury causes this ulcer rapidly to assume a 
favourable appearance. When this medicine is not employed, the 
livid tint of the ulcer often alternates with a slight tawny colour ; the 
induration of the base obviously increases, and the ulcerative pro- 
cess commences anew. The indurated ulcer or Hunterian chancre, 
however, gets well locally without mercury. This ulcer often leaves 
a circumscribed callous and livid induration behind it, which was 
particularly noted by the writers of the sixteenth century. 3 After 
getting completely well, this sore is generally followed by a broad and 
deep cicatrice, which on the glans is commonly single. 

824. This variety of ulcer is usually readily distinguished. Simple 
sores, after being repeatedly irritated, may indeed present, accidentally, 
some degree of swelling, and a slight induration in their circum- 
ference ; but this induration does not convey to the same amount the 
sensation of positive hardness which is perceived when the edges and 
base of the Hunterian chancre are touched. Farther, this accidental 
induration of simple sores does not end abruptly at their circumference 
as in the indurated ulcer, but is lost gradually and imperceptibly 
amidst the surrounding parts. 

The indurated ulcer differs from those of a phagedenic and gangre- 
nous character, not only in its appearance, but in being for the most 
part free from pain, and in the slowness with which it spreads. And 
yet, when the indurated ulcer has spread over a considerable extent 
of surface, and it is situated on the body of the penis, its livid and 
dusky appearance bears some analogy to that of the phagedenic ulcer ; 
it may, however, be distinguished from this last by its elevated edge 
and the hardness of its base. The progress of the indurated ulcer, 
moreover, is, as I have said, slow, and within a few days acquires a 
tawny aspect. In the gangrenous syphilitic ulcer, again, eschars are 
continually formed until the part affected is destroyed. 

825. Syphilitic eruptions of the skin are more frequently observed 
after the indurated ulcer or Hunterian chancre, than after any other 
primary symptom ; they occasionally even make their appearance 
during its existence. 4 Carmichael tells us that he has never seen any 
other than exanthematous and squamous eruptions succeeding this 
form of sore ; I have seen eruptions possessing various other element- 
ary forms, and tubercles perhaps oftener than any other. 

826. Consecutive ulcers also occasionally show themselves in the 
mouth, on the velum palali, &c. Periostoses and exostoses, too, may 
follow the indurated ulcer, events which are very often preceded by 
an obvious derangement of the constitution. 

S27. The phagedenic syphilitic ulcer. 5 I have never had an oppor- 

3 "Callosa cicatrix... mobilis loco, crassa, livida, dura, et rotunda ... aliquando 
quidem veluti nervns post cariem remaneat qui durus per pudendum percurret... 
Siy/?j/?romaf«nondumcurati morbi gallici." (G. Fallopia. De cicatrice callosa, cap.87.— 
Aphrodisiacus, p. 816.) 

4 Carmichael. Op. cit., case xlix. "Phymosis, discharge under the prepuce; 
ulcer of the size of a bean, of a fivid colour, with callous and slightly raised edges, 
situated on the body of the penis ; syphililic exanthema during its continuance" (Roseola 
anntilata). I have observed several analogous cases. 

5 Fallopius has clearly described this ulcer, § 788.— Torrella also distinguishes it 



SYPHILIDA. 



28? 



hinity of seeing this ulcer in its earliest stage, and I do not know 
■whether it begins in the shape of a solid elevation, of a vesicle, or of 
a pustule, or whether or not it passes immediately into the phagedenic 
state. Carmichael states that he has seen a great number of phagede- 
nic ulcers, and assures us that in two or three cases, these sores, before 
acquiring the decidedly phagedenic character, were excavated and 
covered with a white adhering film. 

The phagedenic ulcer has an eroded aspect ; its surface presents no 
granulations, and the soft parts that surround it are not callous nor 
indurated. It sometimes spreads with great rapidity, and commits 
much havoc in the space of a few days. At other times it creeps 
slowly onwards, healing even on one side and advancing on another. 
It most frequently attacks the penis first, but as regularly spreads to 
the prepuce, which it often destroys entirely ; and it may continue its 
ravages until the whole of the glans has fallen ; when this happens, 
the ulcer commonly stops suddenly and makes no further progress. 
The occurrence of hemorrhage occasionally brings about a favourable 
change, and the bleeding in this case is sometimes so profuse as to 
soak the linen and bedding of the patient ; Carmichael was on one 
occasion compelled to pass a ligature around a vessel which had been 
eroded. In some rare cases the destructive process has not stopped 
until the whole of the penis was destroyed. 

According to Carmichael this ulcer has one very peculiar character ; 
it is that of its frequent occurrence upon parts which it has primarily 
affected, but which it had not destroyed completely. 

828. The phagedenic syphilitic ulcer may be readily distinguished 
from all the others of this class. It presents the phagedenic character 
at so early a stage, that this circumstance ought to suffice for its dis- 
tinction from the other ulcers which become phagedenic accidentally, 
which they do most generally from excessive stimulation. These 
sores thus rendered phagedenic are much more common than the sore 
that is primarily so. M. Desruelles 1 has given a particular account of 
its characters : " From the time," says he, " that a common sore passes 
into the phagedenic state, the patient feels uneasy ; his skin becomes 
hot and dry; his pulse is sharp and frequent; he complains of thirst; 
his tongue is red towards the point ; the sore is affected with a sensa- 
tion of intolerable heat and itchiness, succeeded before long by one of 
burning pain, as if a lighted coal were applied to the ulcer ; shooting 
twinges are further felt from time to time, as if a sharp and burning 
body were passing rapidly through it. These painful sensations extend 
to the penis ; the edges of the sore swell ; an intense degree of redness 
extends widely around it ; the bottom is covered with a grayish or 
blackish, uneven and very adhering membrane ; the ulcer extends 
both in breadth and depth. These phagedenic ulcers destroy the glans 
and frenum with rapidity ; they have been observed to destroy the 
penis by layers as it were ; their progress is announced by the forma- 
tion of a grayish or blackish false membrane, or of a putrescent layer, 
which is observed each time the sore is dressed, and which is renewed 
repeatedly; the patient then loses his appetite, his countenance changes, 
&c. &c." With phagedenic ulcers of this kind, the phagedenic sore 
described by Welbank must be assimilated. 2 

The phagedenic differs from the indurated ulcer in its external cha- 
racters, and also in the circumstance that far from being improved like 
the latter by the administration of mercury, it is, on the contrary, made 

from other venereal ulcers. " Ulcera virulenta a corrosivis non differunt nisi secun- 
dum magis et minus. ...et si talis corrosio non multum profundetur, tunc tale ulcus 
dicitur umbululionna (Aphrodisiacus, p. 536. Torella. De ulceribus in padendagra) — 
George Sydenham describes phagedenic syphilitic ulcers, (Epislolu ii. rrsponsoria v. i. 
p. 207,) but these are consecutive ulcers. Carmichael has given a very good de- 
scription of the phagedenic ulcer. Evans, with many other pathologists, has con- 
sidered the phagedenic and gangrenous character of venereal ulcers as connected 
with a peculiar morbid state of the constitution. According to him, this constitu- 
tional derangement is of two kinds: 1st. A febrile state, or at least a pulse both hard 
and full, without any remarkable frequency. 2d. An anadynamic state. These two 
states may exist in the same patient at different periods of the disease. Evans relates 
two cases which prove that phagedenic and gangrenous ulcers may be communicated 
by connection with persons only affected with simple ulcers of the genitals. (J. 
Evans, Pathological Remarks on ulcerations of the genital organs: appendix on 
phagedcena and sloughing, 8vo. London, 1819. Case 3d, p. 124.) 

1 Desruelles. Seconde momoire sur les maladies veneriennes (Recueil des me- 
moires de med. chir. et phar. milit., t. xxvii. p. 165). — Ibid., t. xxv. p. 99. — Obs. d'un 
ulcere silue sur le prepuce, devenu phagedenique sous l'influence du mercure. — Lag- 
neau, expose des sympt. de la maladie venerienne, 8vo. Paris, 1818, 5e ed. pp. 90-98. 
Obs. d'un ulcere simple devenu phagcdenique par un traitement local excitant. 

* Welbank, on sloughing phageda?na. (Med. Chir. Transact., vol. xi. p. 361.) 



worse and more rebellious by such a plan of treatment. The phage- 
denic differs from the gangrenous syphilitic ulcer in this, that the 
destruction of parts is not accomplished as in the latter, alternately, 
by gangrene and erosion, but always in the latter mode. Phagedenic 
sores, however, may accidentally become gangrenous, 3 and present the 
twofold mode of destroying parts mentioned. 

829. Carmichael conceives that buboes are more unfrequent after 
the phagedenic than after any other form of syphilitic ulcer ; and he 
adds, that the buboes which do occur in its train, have their edges 
loosened 4 and irregular, and that they can only be healed up after 
being pared off or destroyed by caustic. 

830. Every form of secondary symptom, and every variety of cuta- 
neous eruption are observed to follow the phagedenic ulcer, 5 but I have 
not had an opportunity of witnessing a sufficiently great number of 
cases of this kind of sore, nor of eruptions following in its train, to 
condescend upon any statement of their relative frequency; the whole 
of the published data, indeed, up to the present day, are inadequate 
to furnish grounds for such a computation. 

831. Carmichael inclines to believe that it would be advantageous 
to touch phagedenic ulcers with caustic at their very outset. Whether 
this practice has been enforced or not, recourse must afterwards be 
had to the antiphlogistic treatment: rest in bed, emollient cataplasms, 
soothing and narcotic lotions, local or even general blood-letting in 
proportion to the degree of pain, inflammation and fever, the warm 
bath, &c. Antimonial medicines, in nauseating doses, have also been 
recommended by Carmichael, according to whom the scarification of 
the edges of the ulcer occasionally affords great relief. M. Desruelles 
has sometimes obtained the same good effects by applying leeches 
upon the middle of the ulcer. At a subsequent period, when the 
part affected is no longer painful, when the sore, though it may be 
spreading in one place, shows a tendency to cicatrize in another, its 
surface may be advantageously touched with a solution of the nitrate 
of silver. When any bands extend from one part of the ulcer to 
another these must be destroyed. 

832. After their cure, phagedenic ulcers always leave broad and 
deep cicatrices behind them. They rarely get well before the end of 
the second month, and the treatment may even extend over the fifth 
month. 

Phagedenic and gangrenous ulcers are the great causes of those 
deformities and mutilations of the external organs of generation often- 
times observed after syphilitic affections. The glans and prepuce are 
sometimes seen eroded in the most singular manner, and are occa- 
sionally destroyed altogether. When this has happened, a small tuber- 
cle, which marks the orifice of the urethra, is seen upon the extremity 
of the stump. The external organs in women, after having been 
affected with ulcers of the same description, also present unseemly 
cicatrices which furrow or pucker the surface of the labia majora. 
The irregular, eroded and deep appearance of the cicatrices distin- 
guishes them from those left by the other varieties of primary syphilitic 
ulcer. 

833. When a phagedenic sore is accompanied or followed by 
syphilitic eruptions or secondary syphilitic ulcers, mercury must never 
be used till all febrile symptoms have subsided, which is announced 
by the desquamation of several of the patches or tubercles. 

834. The gangrenous syphilitic ulcer. 6 — This ulcer is still more 

3 Carmichael. Case 36. Phagedenic and gangrenous ulcers ; consecutive ulcers 
on the abdomen — Case 42. Phagedenic and gangrenous ulcer; scabs on the thighs 
and head; ulcers on the lip. 

4 Carmichael. Case 17. Phagedenic ulcer and bubo. 

5 Carmichael. Case 21. Phagedenic ulcer followed by thickening of the perios- 
teum. — Case 23. Phagedenic ulcers followed by prominent scabby ulcerations. — Case 
24. Phagedenic ulcers followed by ulcers on the forehead. — Case 25. Phagedenic 

ulcers followed by pustules on the face and body, with ulcer of the velum palati. 

Case 28. Phagedenic ulcers followed by pains in the joints, by a large tubercle, and 
ulcerations. — Obs. 29. Phagedenic ulcers followed by pustules, scabs, and swelling 
of the testis. — Obs. 30. Phagedenic ulcers followed by pustules and scabs. 

6 Celsus (De re medica, lib. vi.sect. xviii. p. 4) and Paulus J2gineta (De re medica, 
lib. vi. 57) have described a gangrenous ulcer of the penis, but they do not say that 
this ulcer arises from infection, that it is contagious or followed by secondary symp- 
toms. The bishop Palladius, who lived in the fifth century, relates that a hermit, named 
Heron, after an habitual intercourse with a dancing girl, was attacked with a car- 
buncle (anthrax) upon the glans. G. Torella, in a chapter, De ulceribus putridis, 
describes the gangrenous syphilitic ulcer. (De ulceribus in pudendagra tractatus.) 

Swediaur assures us that a gangrenous affection has been observed in the north of 
I the United States, which attacks the virile member and makes rapid progress. 



288 



SYPHILIDA. 



destructive and serious than (he phagedenic; it is very seldom that 
we have occasion to observe its commencement. The first symptoms 
are attended with so little pain that the patient pays little or no atten- 
tion to them. According to Carmichael, a small black spot, very simi- 
lar to a load drop, both in size and colour, is the first indication of this 
ulcer. The practised eye detects a small gangrenous eschar in this 
state. This continues to enlarge on the succeeding days, and occa- 
sionally attains three or four times its original dimensions before a 
line of separation is established between the sphacelated and living 
parts. When the line of demarkation is formed, we do not find under 
the slough, as in simple gangrene, a granulating ulcer of good appear- 
ance, but a gnawing phagedenic sore, which commences the work of 
destruction in another manner, and possesses all the virulence, if not, 
perchance, all the rapidity of the gangrenous process which preceded 
its formation. Some days afterwards the affected parts are attacked 
with acute pain, become of a bluish colour, and within a day or two 
are again covered with a new eschar. In this way, by a succession 
of eschars and erosive processes, the disease often continues to extend 
until the whole penis, scrotum, pubes, and perineum, are destroyed 
or denuded in the male, the labia majora, orifice of the vagina, skin 
of the perineum, verge of the anus and sides of the buttocks in the 
female. The pulse under these circumstances generally beats from 
100 to 130 in a minute, and when the ulcers are extensive the tongue 
is dry, brown, and even black, as it is in the - advanced stages of 
severe dothinenteritic affection. 

Should the gangrenous syphilitic sore have been happily arrested in 
its progress, and a portion only of the penis been destroyed, particular 
attention is required to keep the orifice of the urethra sufficiently per- 
vious after the cicatrization of the sore ; for without this it is very 
apt to be left so much contracted as to oppose a great obstacle to the 
free evacuation of the bladder. 

835. It is of importance to distinguish this gangrenous syphilitic 
ulcer from the gangrene which occasionally happens to the glans in 
consequence of a paraphymosis. 1 It is also essential to distinguish 
the syphilitic ulcer, primarily gangrenous, from the gangrenous state 
which occasionally and accidentally complicates different other ulcers 
of venereal origin. 2 In the first case, a phagedenic sore is seen which 
advances by eroding, and causing eschars so long as the specific 
cause of the disease exists, whilst in the second, the sore is observed 
to be covered with granulations as soon as the eschar is thrown off. 
This specific gangrene must also be carefully distinguished from the 
simple gangrene with which the genital parts of young girls are occa- 
sionally attacked. 

836. When the syphilitic gangrenous ulcer has made considerable 
progress, the prognosis is very unfavourable. If one-half of the penis 
be already destroyed, the most skilful treatment seldom succeeds in 
arresting the destructive process and saving the remainder of the 
member; but if a portion of the prepuce or of the glands only be 
affected, we may hope, with judicious measures, to arrest the further 
progress of the mischief. An excellent stimulating application under 
these circumstances is Venice turpentine or balsam of copaiba, mixed 
with two parts of olive oil, according to Carraichael, who has often 
seen very extensive ulcers of the penis and integuments of the groin, 
which were extending rapidly, checked by one or other of these appli- 
cations, and made to assume a granulating and healthy appearance 
under its continued use. The same writer informs us that no advan- 
tage is to be derived from the application of emollient cataplasms to 
these ulcers. When the eschars were considerable, terebinthinate 
applications, or a lotion consisting of one part of tincture of myrrh, 
and seven parts of camphor mixture, was employed with excellent 
effect in destroying the fetor of the eschars and in favouring their de- 
tachment ; but unfortunately these measures do not hinder their pro- 
duction. Change of air and residence in the country were followed 

Hunter has described the mortification produced by paraphymosis. Swediaur has 
noticed that gangrene appeared sometimes in the genitals of individuals, who, bein* 
attacked with gonorrhoea, took the putrid fever ° 

Carmichael, op. cit, p. 291 (phaged. vener. 'disease, or sloughing ulcer,) gives a 
good desenpnonofthe syphilitic gangrenous ulcer 

i M. Desruelles has related a remarkable example of it: Mem. de Med. Chir. et 
Pharm. Miliiaire, t. xxv. pp. 208-162. «««• «=■ 

< The gangrenous ulcer shows itself in those who have been d 
mercury for several weeks. (Carmichael. Op. cit., obs xv xvi ) 



in every case by the happiest consequences, and so intimately con- 
vinced is the author I am quoting of the utility of this measure, that 
his first advice to invalids is usually to get into the country. 

He has never seen any advantage from the administration of bark; 
on the contrary, he has observed the sores rather to spread more 
rapidly than before. Opium and conium in large doses seemed to 
produce good effects. Mercurials in every shape are injurious during 
the whole of the gangrenous period. When the ulcer is healing 
however, recourse must be had to them in order to modify the con- 
stitution. 

837. Secondary syphilitic symptoms, and particularly cutaneous 
eruptions are very frequently observed to follow the gangrenous pri- 
mary sore ; this, indeed, is one of the principal characters of this 
ulcer. 3 

838. The degenerated syphilitic ulcer (the cancerous syphilitic ulcer 
of some writers)." 1 This ulcer is not primary ; it is a mere degenera- 
tion of some other, and particularly of the simple and of the indu- 
rated ulcer, upon which fungous excrescences have made their 
appearance. The patient then suffers very severe pain ; the part 
affected swells enormously ; the glans is destroyed by the progress of 
the ulcer, and the penis presents the appearance of a kind of cauli- 
flower, flattened and attached to the pubes. 

839. These degenerated syphilitic ulcers must be distinguished 
from the primary sores of the penis which begin in the form of small 
flat tubercles, not painful at first, and which may become ulcerated 
shortly after sexual intercourse. This distinction, which positive 
information in regard to the circumstances that preceded the appear- 
ance of the ulcer, on the form and aspect which it presented in its 
earliest stages, occasionally enable us to make, is of so much the 
more importance as mercurial preparations, mentioned by some prac- 
titioners as the touch-stone, are generally injurious in cases of cancer- 
ous disease. 

840. It is commonly agreed that the general and local abstraction 
of blood, the exhibition of opium both internally and to the parts 
affected, emollient topical applications, the tepid bath and the anti- 
phlogistic regimen are the means best adapted to check the progress 
of this species of ulcer. 

Some surgeons imagine, and I am of their opinion, that independ- 
ently of this antiphlogistic treatment, it is often advisable to take 
away the fungous surface of this description of ulcer, and that there 
are cases in which it is even proper to remove the whole of the dis- 
eased parts with the knife. 5 

Should there be any symptoms at the same time of general infection, 
it would be necessary to attempt a modification of the constitution by 
the administration of alterative doses of the blue pill, &c. 

These degenerated syphilitic ulcers, happily of rare occurrence, 
are frequently fatal. I am not aware that any secondary syphilitic 
symptoms have been observed after their cure. 

841. Syphilitic Buboes. — A bubo is a tumour, developed in the 
inguinal region, and accompanied with a greater or less amount of 

3 Carmichael i obs. xxvi. Ulcer of the body of the penis, of a gangrenous appear- 
ance, followed by an ulcer on the upper lip, pains in the joints, fiat coppery tuber- 
cles. — Obs. iii. Phaged. ulcer of the gland ready to become gangrenous, followed 
by a^ superficial ulcer of the pharynx and with thickening of the periosteum. 

* The following case is from the work of M. Lagneau. " H. portait depuis quelque 
temps un chancre superficiel, qui avait resiste a l'emploi des topiques emolliens. II 
consnlta un chirurgien, qui lui prescrivit des frictions mercurielles et cauterisa l'ul- 
cere avec le vitriol bleu et la pierre infernale. Ce traitement e'tant sans succes; un 
second medecin fut appele: il ordonna un pansement tout aussi peu rationnel avec 
l'eau phagedenique, et le malade ajoutait encore a ces mauvais effets en cauterisant 
lui meme son chancre avec le vitriol bleu. Des-lors l'uleere prit un mauvais carac- 
te-re, devint rongeant et couvrit bientot tout le gland, dout le volume s'etait enorme- 
ment accru; il rendait un ichor fetide et les bords en etaient renverses. Le malade 
entra dans cet etat a l'hospice des veneriens, ou il fut panse avec les emolliens et les 
caimans. Mais le maletait trop avance pour qu'on en obtint la guerison; il se de- 
yeloppa une tumeur lymphatique dure et indolente a la base de la verge, laquelle 
jointe a un engorgement semblable de l'un des cordons spermatiqucs vint contrarier 
l'amputation de l'organe deja projetee." Lagneau, op. cit., p. 96. 

I have also seen a case of cancer of the prepuce, with enlargements of the glands 
of the groin, which had followed an ulcer of the glans, which had been considered 
and treated as syphilitic; amputation was not had recourse to, and the patient died. 
M. Devergie has related several cases of venereal ulcers which had become cancerous 
after a stimulating plan of treatment. (Clinique de la maladie syphilitique. Paris, 
4to, 1826, p. 88, et sequent.) 

5 M. Devergie relates three cases of these degenerated ulcers, in which amputation 
was performed either by himself, M. Boyer, or M. Gilbert. 



SYPHILIDA. 



289 



pain, after impure sexual intercourse. These tumours most gene- 
rally accompany or follow other primary syphilitic symptoms; but 
there are cases on record, the accuracy of which is unquestionable, 
which prove that buboes may make their appearance as primary symp- 
toms of venereal infection. 1 (a) 

842. This species of bubo differs from the inflammatory and sym- 
pathetic enlargement of the lymphatic glands of the groins, observed 
in some cases of gonorrhoea, in the circumstance of the latter usually 
becoming resolved, and not giving rise, like the former, to venereal 
ulcers after ending in suppuration, which is their usual termination. 
It must also be distinguished from the adventitious inflammation of 
the lymphatic glands of the groin produced by a blow, or violence of 
any kind, by the inflammation of a toe, by a wound or ulcer, a boil 
or a carbuncle on the leg or thigh, an abscess in the plevis, &c. In 
conclusion, it is easy to distinguish the syphilitic bubo from the gan- 
grenous bubo of plague, from those inflammations of the glands of 
the groin which are occasionally observed in women who have just 
lain in, in individuals attacked with Barbadoes leg, or in scrofulous 
subjects. 

843. Syphilitic buboes, in their earlier stages, are to be treated 
upon the antiphlogistic system generally, and by means of the topical 
application of ice ; when matter is formed, they ought to be opened 
early ; after the cessation of inflammatory symptoms, mercurial pre- 
parations become extremely useful. (6) 

844. Cases of primary bubo are of such rare occurrence, that 
opportunities have still been wanting, duly to study the form, the fre- 
quency and the duration of the syphilitic eruptions and the other 
secondary symptoms to which they give rise. 

845. The venereal poison may be transmitted to nurses by new- 
born infants labouring under syphilitic sores of the lips and mouth. 2 
The local and primary symptoms which are observed around the 
nipples of nurses infected in this way are almost always ulcers ; occa- 
sionally, however, flat tubercles are observed around the nipple in 
these circumstances. 

846. Mew-born infants' sometimes present, from the very moment 

(a) The test by which to determine the true character of bubo, is 
stated by M. Ricord to be inoculation. If the bubo be venereal, the 
pus in it will give rise to chancre and its sequences ; but otherwise not. 

(b) A succession of blisters with intervening dressings of lint 
moistened with a solution of bichloride of mercury, and then a simple 
poultice or cooling lotion, or a solution of opium, is the latest French 
practice. Both by hospital and army surgeons, it has been found to 
be very successful. 

1 Fatlopius has observed bubo as a primary symptom of venereal affection: Nam 
solet oriri bubo (Gallicus) absque gonorrhoea et carie (Gabrielis Fallopii de morbo 
gallico tractams, cap. 90. De bubone gallico. — Aphrodisiacus, t. ii. p. 819, in-fol. 
Lugduni Batavorum). Massahad already mentioned consecutive bubo. (Et sequntur 
apostemata inguinum. — Aphrodisiacus, p. 146.) 

We have often seen, says Mr. Desruelles, inflammation of the glands in men who 
had neither at the time nor previously laboured under any other venereal symptom. 
In this case the inflammation of the glands does not usually show itself till a some- 
what remote period from the dateof infection. The shortest period I have known for the 
incubation of bubo is from eight to ten days, and the longest from thirty-five to forty 
days. (Second memoir, loc. cit. p. 274.) I have myself observed several examples 
of these primary venereal buboes. If patients be not carefully questioned, one might 
imagine them to be much less frequent than they really are, for patients often present 
themselves for the treatment of a bubo after the cure of a simple syphilitic ulcer. 

2 " Videmus plures infantuloslactantes, tali morbo (gallico) infectos, plures nutrices 
infecisse. (Jacobi Catanei de morbo gallico tractatus, cap. iii. — Forestus. De lue 
venerea, lib. xxxii. obs. ii. — Hunter, op. cit., p. 413.) 

3 Schenck quotes the case of a woman whose husband was attacked with syphilis, 
and who was delivered of a child covered with scabby sores. (Obs. medic, lib. vi. 
De lue venerea, ibid. vi. obs. 5.) Rosen speaks of a child which came into the world 
entirely covered with ulcers and scabby pustules. The father had died several 
months before its birth of an inveterate lues, and the mother also died of the same 
disease shortly afterwards. (Maladies des Enfans, p. 314.) One of my pupils, M. 
Desir, delivered a woman of a child whose body was covered with a tubercular 
syphilitic eruption. Berlinghieri was wrong (Traite de la maladie venerienne, trad. 
par Alyon, 8vo., Paris, 1800) in stating that the child had not contracted syphilis 
before its birth. Doublet says, and with truth, that a child may be born affected with 
syphilis. Swediaur says that this very rarely occurs ; he relates two instances, how- 
ever. "A woman having apparently been affected by constitutional syphilis which 
had never been radically cured, gave birth to a child evidently labouring under the 
symptoms of this disease, which it communicated to its nurse, who was in perfect 
health (t. ii. p. 9, 116). — A dragoon had a syphilitic ulcer in the throat; in this state 
he cohabited with his wife; she became pregnant, and was delivered of a child, which 
showed, some weeks after its birth, a syphilitic ulcer in the same place that had been 

73 



of their birth, but more frequently several weeks or some months 
afterwards, eruptions and other syphilitic symptoms. Among these 
some may be regarded as contracted by the infant in its passage 
through the infected genital organs of the mother (of this number 
are ophthalmia and blenorrhcea of different descriptions) ; others are 
evidently the result of a constitutional infection transmitted heredi- 
tarily (tubercles, pustules, ulcers, &c). 

847. It is generally thought now that the nurse labouring under a 
syphilitic affection of the genital organs does not transmit the disease 
by giving suck, if there be no specific disease of the nipples (Girtan- 
ner, Van der Haar, Hunter, &c.;) others, however, are of a different 
opinion. 4 

848. The syphilitic poison is most commonly communicated by 
sexual relations ; but it may be transmitted by the application of the 
virus to a part that is excoriated, or the epidermis of which is very 
thin. s 

849. Syphilis may be transmitted by the inoculation 6 of the matter 
of primary sores, or if gonorrhoea, by means of one or more punctures 
with the point of a lancet. 

This experiment, however, does not always succeed : Bertin and 
his colleagues of the Hospice des Veneriens 7 constantly failed in their 
numerous attempts to produce the symptoms of syphilis, by inoculat- 
ing the matter of venereal gonorrhoeas, of primary chancres, the dis- 
charge of the virulent ophthalmia of children, or by placing these 
matters in contact with the surface of mucous membranes. In con- 
trast with these experiments, which humanity brands as infamous, 
and no love of science will justify, are to be placed those cases in 
which medical men, practitioners in midwifery, &c, have accidentally 
inoculated themselves with syphilis. 8 (a) 

850. To conclude, towards the end of the 15th, and beginning of 
the 16th century, a syphilitic disease appeared as an epidemic in Italy, 
France, Spain, &c. 9 This disease spread not only in consequence of 
the intercourse of the sexes, but from simple contact of the person, 10 
and even by means of the air, as other contagious epidemic diseases 
do. Since this epoch epidemics analogous in their nature have been 

(a) See the summary of M. Ricord's experiments and observations 
on this point in a preceding note. 

affected in the father (op. cit. t. ii. p. 9). — Mahon admits that children maybe born 
with unequivocal symptoms of syphilis (Considerations sur les symptomes de la 
maladie syphilitique des enfans nouveau-nes. — Mem. soc. med. d'emulation, t. ii. 59. 
— Ibid., t. iii. p. 27). Hunter speaks of a woman covered with venereal pustules, 
who was delivered of twins, both of whom had pustules on their bodies when born, 
and who died soon after. (Op. cit. p. 310.) 

4 Potus lactis mala qualitate infecti, rlato quod nulla cutanea infectio appareat 
(Jacob. Cutanei, op. cit. cap. iii). Gardien. Traite d'accouchemens, 8vo. Paris, 
1807, t. iv. p. 189. 

s " Per oscula vero facile recipitur hie affectus, quoniam vibratio ilia et linguarum 
conflictus caliditatem auget; linguas rarescunt (Brassavola, de morbo gallico liber. 
Aphrodisiacus, p. 673). — Cullerier, Swediaur, etc., have seen primary venereal in- 
flammations of the navel, of the mouth, of the rectum, ears, etc. Syphilitic eruptions 
have been known to appear after the transplantation of a tooth. See Hunter (op. cit. 
p. 418. — On diseases occasioned by transplanting teeth, which have been supposed 
to be venereal), who, in his remarks on the case related by Watson, seems to me to 
have made use of little conclusive arguments. — Swediaur (op. cit. lib. ii. p. 16). 

6 A man who had venereal pustules on different parts of the skin, was inoculated 
in those parts which were exempt, with the matter of a chancre as well as with that 
of his own ulcers. The wounds which were impregnated with the matter of the 
chancre, became well characterized chancres, but the others healed tip. I have fre- 
quently repeated this experiment, and the effects have always been the same. Having 
inoculated a person with the matter of a true venereal ulcer which appeared upon 
the tonsil, and with the matter of a gonorrhoea, the matter of the gonorrhoea produced 
a chancre; that taken from the ulcer of the tonsil had no effect. (Hunter. Op. cit. p. 
390.) 

i Bertin. Traite de la maladie venerienne chez les enfans nouveau-nes, 8vo. 
Paris, 1810.— Prem. partie, p. 52-58. 

8 Swediaur. Op. cit. t. ii. pp. 11,15. A young soldier affected with gonorrhoea in- 
oculated himself accidentally with the matter of the discharge, by touching a slight 
wound on the chin with his fingers which were soiled with it; shortly after, considera- 
ble psydracious syphilitic eruption, beginning on the face and extending over the 
whole body; two months afterwards, ulceration of the throat, pains &c (Delpech 
Chir. Clinique, 4to., t. i. p. 335.) v 

s Upon this memorable epidemic, consult the collection published by Ludovico 
Luvigini: Aphrodisiacus sive de lue venerea, fol. Lugduni Batavorum, 1728, and 
the supplement given by C. G. Gruner: Aphrodisiacus, sive de lue venerea, in'duas 
partes divisus: quarum una continet ejus vestigia in veterum monumenti's obvia ; 
altera quos Aloysius Luisinus temere omisit scriptores, fol. Jena?, 1789. 

'« " Evenit ei dormiendo in eodem Iecto cum fratre suo infecto (Gasparis Torrelhr 
Consil, quartum). 



200 



SYPHILIDA. 



red to prevail partially (vide Scherlivio, Morbus Anglicus, &c); 
:n these the infection was general, and followed by all its effects. 

In other c a-.s of infection the disease appears to be local, at 
leas) in several individuals, and during a certain time. In effect expe- 
rieoce has shown that many primary symptoms, particularly blenorrhcea 
of the elans and gonorrhoea are very seldom followed by general con- 
stitutional infection. But on the other hand, the number of cases in 
which symptoms of general infection have occurred after the cure of 
primary venereal ulcers, is so considerable, as to prove that the treat- 
ment of primary symptoms can only be held as complete when, by its 
means, the general system is guarded against the liability to secondary 
contamination. Unfortunately this desirable end has been attained by 
none of the methods of treatment hitherto pursued ; and opinions are 
even at present very much divided in regard to the efficacy of the mer- 
curial and the non-mercurial treatment, with one or other of which all 
the rest may be assimilated. 1 

852. Secondary symptoms. These symptoms are extremely varied: 
but I shall confine myself almost exclusively to the consideration of 
the venereal affections of the skin (syphilides), besides which, we have 
ulcers of the mouth, throat, nasal fossae and other parts, affections of 
the bones and periosteum, of the articulations, of the eye, &c, all of 
which have peculiar characters. 

853. The alterations produced in the integuments by the venereal 
poison may be classed under one or other of the elementary forms of 
cutaneous inflammation and its consequences : 1st. Syphilitic exanthe- 
mata ; 2d. Syph. bulla; ; 3d. Syph. vesiculae ; 4th. Syph. psydracious and 
phlyzacious pustulae ; 5th.. Syph. papulae; 6th. Syph. squamae; 7th. 
Syph. maculae ; 8th. Syph. tubercula ; 0th. Syph. secondary cutaneous 
ulcers; 10th. Syph. cutaneous excrescences ; 11th. Syph. onychia ; 12th. 
Syph. alopecia. These various forms of disease occur at the present 
day nearly in the following order of relative frequency : Tubercles, 
squamae, papulae, excrescences, exanthemata, secondary cutaneous 
ulcers, phlyzacious pustules, psydracious pustules ; alopecia, onychia, 
bullae, vesiculae. I shall describe them in the order I have followed 
in treating of the other cutaneous eruptions, and according to which 
I have named them first. 

854. The syphilida or syphilitic cutaneous eruptions, except in a few 
exceedingly rare instances, are only observed at the present day after 
the occurrence of primary symptoms of greater or less severity. During 
the epidemic of 1405, eruptions on the skin were occasionally the first 
symptoms of the venereal disease observed. 2 The disease, however, 

1 The objectors to mercury maintain that under the influence of antiphlogistic 
treatment and non-mercurials, the cure of primary symptoms is more prompt, and 
the malady thus cured less rarely followed by secondary affections. In aid of this 
assertion, they quote the account of experiments made in Sweden during five years, 
upon sixteen thousand nine hundred and eighty-five patients, the result of which 
showed, that relapses or secondary symptoms occurred in the following proportions: 

1st. After the treatment by means of low diet (without mercury) of seven and a 
half per cent. 

2d. After local treatment or other methods (without mercury), of seven per cent. 

3d. After mercurial treatment, of fourteen per cent. 

4th. After the treatment by cinnabar fumigations, of twenty-two per cent. (Bullet. 
Uoirers.de Fernssac, t. xiii. p. 152). M. Desruelles obtained results very similar. 
To these conclusions I might oppose those come to by Dr. Hennen, a partisan of the 
non-mercurial treatment, who declares notwithstanding "that secondary symptoms 
supervene more frequently, and at shorter and more determinate periods, after the 
treatment without mercury, than when the mercury has been used." But on the 
other hand he affirms, that after treatment without mercury the secondary eruptions 
have not been very severe, that they have not ulcerated, that they were easily cured, 
ami that the bones of the nose or other parts were never affected with caries. (Hennen, 
op. cit. p. 535.) He says, besides, that iritis is more frequent after the non-mercurial 
treatment, and that in this case mercury may be resorted to with success (p. 555). 
According to his calculations, of nineteen hundred and forty individuals treated without 
mercury, ninety-six have had secondary symptoms; about one in twenty, in the 
interval of nearly two years. — Of twenty-eight hundred and twenty-seven individuals 
treated with mercury, and who presented a greater proportion of the Hunterian 
chancre than the preceding number, fifty-one had secondary symptoms; about one 
in fifty-live (p. 551, and following). With respect to the primary symptoms, the 
results obtained are similar to those of M. Desruelles. The mean length of the treat- 
ment without mercury was 21 days, with mercury 33 days. The results obtained by 
M. Rose (Trans, of the Med. Chir. Soc, vol viii.) are still more unfavourable to the treat- 
ment without mercury; for he assures us that secondary symptoms took place in a 
third of the cases treated in this manner. In the York hospital and some others, the 
proportion of individuals presenting secondary symptoms was less unfavourable- 
one in six ; but in all ihe cases the rarity of affections of the bones and the mildness 
of the secondary symptoms generally have been remarkable. 

* Cum rnulli laborent et laborarunt tali aegriiudine (morbo gallico), qui numquam 
in vinli membra, aut in vulva quicquam passi sunt, et nihilominus omnes fere regro- 
tabant paries corporis, ut in mollis vuli, qui erant infecti ulceribus, doloribus, aposte- 



even during this epidemic, very generally showed itself upon the 
external organs of generation before appearing upon other regions of 
the body. 3 

855. The title of incubation is given to the interval that elapses 
between the date of infection and the appearance of the eruption, or 
the attack of fever which in some case precedes its evolution. Syphi- 
lida sometimes make their appearance' during the continuance or very 
shortly after the invasion of primary symptoms. 

856. Most commonly, however, it is after several months, and 
even after several years have elapsed from the date of an apparent 
cure of every primary symptom, that signs of secondary infection, and 
especially of venereal eruptions, make their appearance, (a) In the 
epidemic of the 15th and 16th centuries, these eruptions, when they 
supervened upon local affections of the genital organs, like all the 
other secondary symptoms, occurred in general much earlier than 
they do at the present day. 5 

857. Syphilitic eruptions are sometimes preceded by febrile symp- 
toms, 6 which often cease as soon as the eruption is accomplished, but 
which also occasionally continue during a longer or shorter period of 
time afterwards. Frequently, too, patients complain before these 
eruptions of nocturnal pains in the bones or joints; they are, farther, 
very commonly attacked with ulcers in the throat before their appear- 
ance. The duration of these precursory symptoms varies from one to 
two or three weeks or more. A vapour bath or violent exercise seems 
often to hasten the outbreak of the eruption. 

858. Whatever the elementary form of the syphilitic eruption, it 
very uniformly shows itself upon the external organs of generation, 
about the verge of the anus, on the face, especially on the forehead 
and angles of the mouth, on the back, &c. Syphilitic eruptions have 
a peculiar colour, the shades of which vary from a violet red to an 
earthly yellow, 7 but which is commonly characterized by the general 
term coppery. 

850. Syphilitic eruptions are almost always accompanied by differ- 
ent other secondary symptoms ; and they occasionally alternate with 
one or several additional symptoms of venereal infection. 

860. Syphilitic eruptions generally display a great tendency to 
ulceration, which often assumes peculiar characters; this circumstance 
was observed very long ago. 8 

(a.) The period between the appearance of primary syphilis and 
the occurrence of secondary disease varies. It may be two weeks ; 
more commonly it is two or three months, and, as stated in the text, 
even longer. The stationary nature and occasional suspension of all 
the secondary symptoms are well described by Dr. Colles. — {Practi- 
cal Observations on the Venereal Disease and on the Abuse of Mercury.) 

matibus, et pustulis, quorum pudendum nihil patiebatur — tres hoc anno curavi ego 
pueros, unum estate trium annorum,alterum,33tatesexannorum,et eratpuella, tertium 
undecim annorum, isti non sumpserunt lac infectum — neque coiverunt. (Massa. De 
morbo gallico, cap. ii.) 

3 Morbus gallicus est pustulas ex varia humorum corruptione generalae, propter 
nimiam aeris in calore atque humiditate praesertim intemperiem, pudenda primum, 
deinde reliquum corporis, cum magno plerumque dolore occupantes. (Leoniceni. 
De Epidemia quam Itali morbum gallicum vocant.) 

4 Syphiliticexanthema sometimes occursduring thetreatment forchancre. Papulce 
and spots are also sometimes formed a short lime after the appearance of primary 
venereal ulcers. The greatest number of syphilitic eruptions show themselves in 
the two first years which follow the infection. 

6 Nicolaus Minor Valentinus, mihi inlima caritate conjunctus, Eetatis xxiv anDO- 
rum fere, mediocris statural, atque habitudinis, complexionis sanguineas.ad choleram 
tendentis, de mense Augusti habuit rem cum muliere, habende pudendagram ; quare 
eadam die ipse fuit eodem morbo infectus; quoe infectio, incepit apparere in virga, ut 
solet ut plurimum aliis evenire; nam sequenti die apparuit ulcus in virg'i cum qua- 
dam duritie longa tendenle versus inguina ad modum radicum sorditie et virulentia. 
Post sex dies ulcere semicurato, arreptus fuit ab intentissimis doloribus capitis, colli, 
spatularum, brachiorum, tibiarum,et costarum,et praesertim in eorum musculis, cum 
maximis vigiliis, a quibus molestabatur, non nisi in nocte, post primum snmnum. 
Elapsis postea X diebus, apparuerunt multae pustute, in capite, facie, collo, etc. 
(Gasparis Torrellae Consil. primum. — Aphrodisiacus, p. 546.) 

c These febrile symptoms were remarked by Massa; " Et aliquando accidit/fin- 
cula ante adventum cum aliquo dolore capitis vel frontis— fiunt pustula; et cessant 
dolores, et aliquando non cessant si materia est plurima. (Massa. De morbo gallico, 
p. 45, cap. v.) Hecker and Morelli studied syphilitic fever; Carmichael has men- 
tioned it in several cases, and I have myself often observed it. 

7 Attendendo colorem ptistularum subalbidum, aliquand6 subnigram, aliquando 
aliquali subrubedine. (Aquilanus. (Seb.). De morbo gallico. — Aphrodisiacus p. 3.) 

8 Fiunt etiam ab his pustulis et apostemalibus,cum rumpuntur, ulcera diversorum 
generum. In quibus reperiuntur materiae albas viscosac adhserentes cum tenacitate. 
Quae quidem materia in aliis ulceribus non reperiuntur. El ulcera isla, cum pro- 



SYPHILID A. 



291 



861. Syphilitic eruptions are almost constantly accompanied with 
other symptoms of constitutional infection, such as pains in the bones, 
ulcers in the throat, &c, and they alternate sometimes with other 
symptoms of lues which cease on their appearance ; farther, they are 
occasionally replaced by diseases of the bones, and different other 
grave affections ; lastly, they now and then disappear for a time on 
the invasion or during the course of a serious disease, to recur for 
the most part with greater virulence on the establishment of conva- 
lescence. 

862. It is difficult, if it be not perchance impossible, to fix the time 
at which the cure of a venereal eruption can be said to be accom- 
plished : instances of relapse of these eruptions, and of the manifes- 
tation of other venereal symptoms are, therefore, of very frequent 
occurrence. 1 These relapses would be much rarer did not the patients 
of public hospitals so generally insist on their discharge before having 
had time to undergo a complete course of treatment, and did not 
patients in private life so commonly refuse to go on with the treatment 
prescribed for some time after they are apparently well, in the idle 
fear of having their constitutions impaired by the continued use of 
mercurial preparations. 

863. The syphilitic exanthematous eruption 2 presents three appear- 
ances, distinguished from each other by their several colours, into the 
red, the yellow and the violet. The two first are frequently seen 
united in the same individual, and then the skin has a peculiar parti- 
coloured look, which has been compared to that presented by the sur- 
face of certain species of trout (J. L. Petit. Hennen). 

The red syphilitic exanthema (roseola syphilitica) may be primary 
and acute, that is to say, it occasionally accompanies primary symp- 
toms, for I have never known it to exist primarily and independently 
of other symptoms. It often precedes or accompanies other secondary 
symptoms; 3 but it does not often, as it has been said to do, accom- 
pany primary symptoms, and especially gonorrhoea ; might I draw an 
inference from my own observations, I should say that it accompanied 
gonorrhoea very rarely. I have several times seen it coincide with a 
considerable eruption of flattish tubercles, this twofold eruption ap- 
pearing several months after the cure of a chancre. The exanthema 
in question more rarely exists alone. 

The eruption is characterized by spots of a coppery red, or of a tint 
very similar to that of measles. The spots, most generally dissemi- 

longanlur, fiunt profunda, virulenla, livida, corrosiva, sordida, cum duritie labiorum 
et came ostracosa et aliquand& fiunt arabulativa— et aliquandd sunt perforata multis 
perforalionibus. (N. Massa. De morbo galJico, cap. v.— Aphrodisiacus, p. 45, folio. 
Lugduni Batavorum, 1728.) 

1 Et saspe post curationem haec segritudo recidivat et recidiva quandoque est cita 
et saepe stat per annos, qure in multis est deterior. (Massa. Op. cit. p. 45.) 

2 This eruption is described by Torrella, in his Consilium secundum: "Infecta 
autem virga, post xxx dies, post somnum prolixum hora tertia excitans se a somno, 
invenit totum corpus infectum maculis latis, rubeis, sine pustulis, etc. Fernelus has' 
given its exact characters: (altera species) paulo deterior est qui cutis universa 
crebris maculis minime extuberantibus conspergitur, iisque parvis, lentiginis instar, 
ac modo rubris, modo flavis, qua* non ante- deleri extinguive possunt, quam morbi 
radix sit evulsa ...quam nulla graviora sequuntur incommoda." Fernel. De lue 
venera. — Aphrodisiacus, p. 613.) Hafenreffer has given this description word for 
word. Hunter mentions exanthematous spots of a syphilitic nature. Willan, in his 
article on syphilitic psoriasis gyrata, mentions an exanthematous eruption of an an- 
nular form, which shows itself in patches upon the face, the extremities, and other 
parts of the body; this exanthematous eruption lasts several weeks, or even months, 
before any desquamation takes place; it is also accompanied with fever, pains in the 
head, limbs, <fec. (Willan on cutaneous diseases. 4to. London, 1778— 1814, p. 164.) 
There are some particular cases in different periodical publications: Syphili'de exaii- 
themateuse guerie par les acides. (Journ. Hebdom. Ire serie, t. i. p. 24.) I have 
seen a great many instances of this affection. Cullerier and his pupils speak of the 
syphilitic exanthematous eruption under the name of pustules for mieese. 

3 Syphilitic exanthema has often been seen with other secondary symptoms; in 
fifteen cases of eruptions, without other accompanying symptoms, mentioned byDr. 
Hennen, and which made their appearance after Hunterian chancres, six were tuber- 
cular, five exanthematous, two pustular, one had something of a tubercular form, 
another was tubercular and vesicular. Of four cases of eruptions appearing after 
the same form of sore, and complicated ulcer of the throat, two were tubercular, one 
tubercular and squamous, and another tubercular and exanthematous. Of twelve 
eruptions appearing after ulcers, different from those described by Hunter, and without 
other symptoms, six were pustular, three were exanthematous, two were tubercular, 
and one tubercularand squamous. In six cases where the eruption was accompanied 
with ulcers of the throat, three were exanthematous, two tubercular, one papular, 
squamous and tubercular, and one pustular and tubercular. 

Of three hundred cases of syphilitic eruption, after different primary symptoms, I 
have not observed the exanthematous eruption more than ten times! But this erup- 
tion may have been more frequent, as patients would scarcely present themselves at 
an hospital on account of so slight a symptom. 



nated over the trunk and extremities, are irregular, sometimes rounded , 
but much more commonly without any determinate figure, extremely 
superficial, not prominent, and disappearing completely under the 
pressure of the finger. Very conspicuous when patients have just 
taken active exercise, or when they come out of a vapour bath, they 
are scarcely visible when patients have been at rest for some hours 
and the temperature of the surface is low. To distinguish them 
readily, it is sometimes necessary to place the trunk and parts affected 
in such a manner as to make the light fall on them obliquely. 

These patches very seldom coalesce, and the skin presenting its 
natural colour in the intervals between them, has a marbled appear- 
ance. When these spots are examined narrowly and with great atten- 
tion, especially those developed upon the outer parts of the thighs, 
in those places where minute projections are observed at the roots of 
the hairs, each of them appears to be formed by the aggregation of 
four or five violet-red coloured points, slightly or not at all prominent, 
over which is spread a tint of less intensity that vanishes under pres- 
sure, exactly like a blotch of measles. 

The spots of syphilitic exanthema are not generally attended either 
with heat or itchiness, although patients do occasionally complain of 
a slight degree of pruritus. Usually evolved without febrile symptoms, 
and unknown to patients, these spots often appear in the course of a 
few hours. 

The red tint of the exanthema commonly disappears within a few 
days ; the spots fade, become slightly yellowish, 4 like those of common 
measles, and remain in this state longer than these last. The desqua- 
mation that follows this eruption is extremely insignificant or alto- 
gether insensible ; a few minute grayish or mealy-looking points are 
all that are ever seen on the surface of the skin. 

864. This syphilitic exanthema is readily distinguished from the 
other syphilitic eruptions by its form, and from the exanthemata in 
general by the following character. From measles it differs in the 
absence of febrile and catarrhal symptoms, the duration of the erup- 
tion, etc. This duration of the eruption, and certain other concomi- 
tant syphilitic symptoms, also serve to distinguish syphilitic exanthema 
from roseola. Further, if roseola vulgaris and syphilitic roseola present 
nearly the same outward appearance at first, or during the few first 
days of their eruption, the red and slightly violet hue of the syphilitic 
efflorescence is more permanent than that of the common roseola, and 
is usually succeeded by a yellowish tint at a period when all traces of 
this less important malady have disappeared. It is still more easy to 
distinguish syphilitic exanthema from urticaria, in which the wheals 
are either paler or more rosy than the skin at large, are prominent and 
accompanied with pruritus of a very severe description, and often 
appear and disappear spontaneously once or oftener in the course of 
the four and twenty hours, — so many characters which are never 
presented by the syphilitic affection. 

The small yellow irregular, flimsy and fleeting spots of syphilitic 
exanthema in its decline, are much slighter than the larger patches of 
chloasma ; they are also in general disseminated over a much greater 
number of regions. The spots of measles as they are going off bear 
a pretty strong resemblance to those of the syphilitic exanthema be- 
come yellow ; but in measles the symptoms which preceded the erup- 
tion, and in syphilitic exanthema the concomitant symptoms leave no 
room for uncertainty in regard to the diagnosis. I shall by and by 
specify the characters, by means of which syphilitic exanthemata may 
be distinguished from syphilitic spots or maculae. 

865. As to the exanthematous or erythematous inflammations of the 
throat, conjunctiva, prepuce, vagina, &c, of a syphilitic nature, their 
diagnosis would be attended with insuperable difficulties, were not 
these affections accompanied with other characteristic phenomena 
(squamae, tubercula, ulcers, &c), and were not their contagious nature 
unquestionable. 

* Syphilitic exanthema has sometimes, from its commencement, the yellowish tint 
which is observed more frequently on the decline of the rosy exanthema. "We 
have also observed, during the treatment of phagedenic ulcers, an eruption of yellow- 
ish spots on the skin. They are neither pustules nor papula?, since they do not rise 
above the level of the skin; nor are Ihey coppery spots, having none of ihe general 
characters of these, nor are they of so long continuance ; the spots of which we speak 
disappear at the end of ten or fifteen days." (H. M. J. Desruelles. Second memoire 
insere dans le, recueil des mcmoires de medecine, de chirur. et de phar miliiaires t 
axvii. p. 177.) V 






SYPHILIDA. 



A chrome exanthematous sorethroat 1 is one of the most common of all 
the constitutional symptoms of syphilis. It differs in its appearance and 
in several other phenomena from simple or even phagedenic ulceration 
affecting the pharynx, which is for the most part attended with little 
difficulty in swallowing, whilst this symptom is always very decided 
in the syphilitic affection of the same parts. When the inside of the 
throat, and especially the posterior part of the pharynx and uvula are 
examined, these parts are generally observed to be red and swollen. 
'The tonsils are occasionally a little enlarged, and the same may be 
said of the submaxillary glands. This tumefaction of the glands, 
which is in general accompanied with little pain, has been confounded 
with scrofulous swellings of these structures. Hunter is of opinion 
that this erythematous inflammation may be propagated along the 
oesophagus. The affection is analogous in its nature to chronic vene- 
nal ophthalmia. 

The exanthematous is justly regarded as the least serious of all the 
forms of syphilitic eruption. 

866. Macula syphilitica, syphilitic spots* are occasionally observed 
on the trunk and extremities, but are much more commonly seen on 
the face, and especially on the forehead. These macula? are rounded 
or oval in their figure, and vary in size, from that of a shilling or 
something less, to that of a half crown piece. They are of a very 
deep yellow coppery colour, their centres often darker than their cir- 
cumferences, and disappear in some measure, but always imperfectly, 
under the pressure of the finger. They are occasionally accompanied 
with some pruritus. In general they are few in number ; and they 
rarely become affected with evident desquamation. In the aged, and 
individuals of cachectic constitution, these macula? are sometimes seen 
of a deep brown, and even of a blackish hue. 

The duration of primary syphilitic macula?, always less protracted 
than that of the stains which are consecutive to other elementary 
forms of eruption, especially when these have been followed by ulcer- 
ation, is at all times difficult to calculate, and varies between one 
and several months. They generally get well from the circumference 
towards the centre, assuming the pale yellow colour of withered 
leaves. 

867. These syphilitic macula? are distinguished from chloasma by 
the small size and regular form of the spots, which in chloasma are 
always extensive and regular ; the patches of chloasma further appear 
most commonly on the fore part of the breast and abdomen, and are 
never of a reddish-yellow or copper colour. They are also occasion- 
ally attended with a considerable degree of pruritus, and almost 
always affected with an evident furfuraceous desquamation. But it is 
much more difficult, especially in the absence of accurate informa- 
tion, to distinguish primary syphilitic macula? from the spots or stains 
which syphilitic squamous patches and unulcerated flat tubercles leave 
behind them after their disappearance. The yellow spots of the syphi- 
litic exanthema are always evidently slighter, usually of smaller size, 
and less regularly circumscribed. 

Syphilitic macula? are almost always accompanied with other symp- 
toms of venereal affection of the system. 

868. Syphilitic eruptions are very rarely seen to affect the bullous 
form ; I shall, however, by and by have occasion to describe an 
eruption which frequently accompanies the phlyzacious form of syphi- 
lidc, and is characterized by large pustules, at the base of which a 
bullous areola is formed, and which at a later period becomes covered 
with a broad and prominent brownish scab, similar to that of rupia 
(§ 300.) 

The following case induces me to imagine that syphilis may mani- 

This description of venereal exanthematous inflammation is more frequent than 
is generally believed. I have seen several examples even without eruption on the 
skin. Carmichael has described this exanthema very accurately ; Hunter has also 
mentioned it. 

^ -Accidunt et macule corpora valde infestantes, quae corpore purgato tollunter 
sifuennirubeae.sangisugajapplicentur.quaamateriamsugantjsi nigra, fortiterabster- 
gentibusutendumest; si cum his fuerint tubercula, difficilius removentur; si sols 
mire juvat amygdal.num oleum (Francisci Frizimelicae. De morbo gallico tractatus. 
-Aphrod.siacus, p. 998)._Hinc, ergo cutis macula; planae, non extuberantes, ephe- 
Iidibus Mm.les. discrete... lahtts expansee si in pluribus locis continuis; livescentes, 
purpura, rosea-, flava:, etc. (Astruc. De morbis venereis, 4to. Parisns, 1738, V . 

Secondary spots have been designated under other names (Defa>dationes, vestigia 
pusiularum et ahorum ulcerum (Massa); Blotches (Hennen). 



fest itself on the skin under a shape more completely bullous. A man, 
aged 58, of good constitution, came to consult me as an out-patient 
at the Hopital de la Charite, on account of an eruption which two 
months before had made its appearance on the upper extremities, and 
within the last month had showed itself upon the buttocks. The ap- 
pearance of this eruption was not in every place the same ; where it 
seemed to be beginning, a small bleb was observed, transparent or 
nearly so, not very prominent, and of the size of a hemp-seed or small 
pea, standing in the middle of a spot slightly vinous in its colour, and 
as large as a sixpenny piece or a shilling, the part which was not 
raised by serum forming a broad areola around the bleb, well defined 
and not melting gradually into the surrounding skin. In other places 
these bulla? evolved on spots, which presented the same general tint, 
were succeeded by a small laminated, yellowish scab prominent in 
its centre, surrounded by a white rim not very distinct from the edge 
of the spot. On other spots, again, the scab which covered their 
centre was still smaller, and surrounded by a broader areola, of a 
yellow copper colour, separated from the healthy skin by an irregular 
rim ; lastly, between these scabs and bulla?, the breadth and peculiar 
colour of whose areola? distinguished thern sufficiently from pemphi- 
gus, there existed many oval spots of a dirty yellow, and several 
others which were smooth and shining on the surface, and of a yel- 
lowish-red colour. 

Several years before, this man had had three chancres on the corona 
of the glans, which had been treated and healed up under the influence 
of mercurial inunction continued for a month. A year before this he 
had also suffered from a gonorrhoea of which he got well after having 
taken the liquor of Van Swieten 3 for six weeks. Two years after- 
wards he contracted gonorrhoea, again ; from this attack he also re- 
covered, under the use of the same medicine continued for two 
months. From this time he has on several occasions laboured under 
excoriations on the penis, sores in the mouth, and spots upon his 
body. Very lately he has also suffered from pains in the joints and 
superficial bones. 

I recommended him to make use of the tisan of Feltz 4 and the 
Sedillots pills. 3 I regret being unable to state the definitive issue of 
this treatment ; the patient soon felt relieved, and then ceased his 
visits at the hospital. 

869. There is another form of venereal eruption fully as rare as the 
preceding : this consists of a crop of vesicles analogous in form to 
those of eczema simplex, but a little less voluminous, and surrounded 
by a coppery and characteristic areola. I have taken notes of no 
other than the following case of this eruption ; indeed I only remem- 
ber to have met with the disease once besides, which was less dis- 
tinctly marked and much more doubtful. A man of good constitution, 
and formerly a soldier, aged 35, had a gonorrhoea in his 20th year, 
(1819,) which was speedily and radically cured. A second clap, 
caught in the following year, did not last longer than a fortnight. 
Three years later, from a fresh infection, a chancre appeared upon the 
prepuce ; this sore was dressed with mercurial ointment, and healed 
rapidly. A month after the chancre was whole, the patient began to 
feel pains during the night in the shoulders. The patient then took 
Van Swieten's liquor for a fortnight, and the pains left him. In 1827 
nodes began to be formed on the left shin, and were treated with the 
tisan of Feltz. The pains of the bones which had attended them for 
three months ceased under the use of this medicine. The patient has 
long complained habitually of sore throat ; but since October 1830, 
his distress from this cause has very much increased, and lately he 
has felt his food, in the act of swallowing, escape into the nasal fossa?. 
Night and day he suffers with violent pain in the head, and he once 
passed eight days without sleeping. For a year past he has followed 
the strictest regimen, eating little, abstaining from wine, and taking 
milk night and morning ; this system did him no good ; on the con- 
trary, he lost flesh very much. * More recently he has taken a tisan of 
the sudorific woods. 

On the 18th of July, 1834, an eruption made its appearance on the 
hands and forearms, forehead and trunk, which, on the 2d of August, 
presented the following characters : On the forearms several irregular 

3 An alcoholic solution of corrosive sublimate. 

4 A compound decoction of sarsaparilla and sulphuret of antimony. 

6 The blue pill made with grease instead of syrup or confection of roses. — Tr. 



SYPHILIDA. 



293 



clusters of minute reddish elevations, of the size of pins' heads, con- 
taining a turbid or opaque fluid. These vesicles were not itchy; 
they were more prominent and more globular than those of simple 
eczema, which they also exceeded somewhat in dimensions, but they 
were inferior in size, not so transparent, and disposed in clusters less 
regular than those of herpes ; their reddish and rather livid tint dis- 
tinguished them from the pustules of impetigo. In other situations 
the eruption formed small rings, analogous both in shape and size to 
those of measles. Many of the vesicles in several of the clusters had 
declined, and were succeeded by a slight exfoliation of the epidermis, 
presenting in some places a slender rim, which indicated exactly the 
former size of the vesicles. Wherever this exfoliation had taken 
place, the skin presented spots having precisely the same appearance 
as ordinary syphilitic macula;. The eruption differed from syphilitic 
psydracia, the pustules of which are larger, more acuminated, and 
usually followed by scabs, and often by ulcers and cicatrices. A 
portion of the uvula and velum palati was destroyed ; the posterior 
pillar of the left side and corresponding part of the velum palate had 
contracted adhesions with the opposite surface of the posterior pari- 
etes of the pharynx ; a grayish ulcer, as large as a silver two-penny 
piece, was perceived on the right side of the palatine arch, near the 
median line and the commencement of the pendulous velum ; the 
patient made no complaint of pain in the throat although he now no 
longer followed any system of regimen. 

I recommended a course of the tisan of Feltz and pills of Sedillot, 
which the patient immediately entered upon and continued for some 
time with advantage. I saw him shortly afterwards ; the vesicles 
had disappeared, but the spots still remained ; I am not aware, how- 
ever, whether the cure was complete, the patient having soon discon- 
tinued his visits at the hospital. 

In another case of constitutional syphilis, I saw an eruption of small 
vesicles with violet-coloured bases in the hollow of the foot, which 
were probably of the same nature as those described in the preceding 
case. 

870. The general character of this vesicular syphilide will only be 
accurately specified when a greater number of particular and more 
complete cases have been recorded. M. Gilbert 1 has published a case 
similar to the one I have detailed, and the Messrs. Cazenave and 
Schedel 2 have given another in which the eruption presented a dif- 
ferent appearance. 

871. In those who are labouring under syphilis, a number of psy- 
dracious pustules, 3 about the size of those of rosacea, are often 
observed. These small pustules may appear on any region of the 
body, but their most frequent seat is the forehead and the shoulders. 
The date at which this species of eruption makes its appearance, after 
that of the primary infection, is as uncertain as it is in regard to all the 
other syphilitic eruptions. I have occasionally observed it to super- 
vene very shortly, sometimes only four or five weeks after this event. 
The eruption is sometimes preceded by fever, pains in the head, 

1 " Un malade, offrant bien d'autres symptomes vSneriens consecutifs, portait a la 
face externe et posterieure de l'avant-bras une large tache d'un rouge cuivre, obscur, 
semce de petites vesicnles sereuses, pasant a l'etat de dessication, et assez analogues 
a. celles de l'eczema. La teinte cuivree et livide de cette eruption, bien diffdrente de 
la coloration rosi-e on rouge de l'eczema, I'aspect flctri des vesicules, l'absence des 
excoriations squameuses de la dartre squameuse humide, la marche de la maladie, les 
phenomdnes concomitans, etablissent des caracteres distinctifs suffisans." (Gilbert. 
Manuel des maladies spociales de la peau, 12mo. Paris, p. 203.) 

8 Cazenave et Schedel. Abrege pratique des maladies de la peau,8o. Paris, 1828, 
p. 419. 

3 Of one hundred and three cases of syphilide which I have seen, no more than 
six consisted of psydracious pustules. This form was pointed out long ago: "Est 
cum pustulis acutis, non latis, et festine, generatur in ea sanies quasi laudabilis." 
(G. Torrella. Ue pudendagra tractatus). The psydracious pustular syphilide is also 
vaguely indicated by J. Benedictus: "Pustulae parvaetendentes cum rubore ad citrini- 
tatem, et velocitur exeuntes, et ulcerantes, facientes in cute asperitatem et dolorem, 

etc Si sunt, parvas, dnrre ad nigredinem tendentes cum privatione doloris," etc. 

(Joannes Benedictus. De morbo gallico libellus, cap. iii. — Aphrodisiacus, p. 171.) 
Hunter appears to have known this species of eruption. (Op. cit. p. 338.) M. Alibert 
has given a good representation of this eruption, under the name of syphilide pustu- 
leuse lenticulaire, p. 43. Under the name of papular disease Carmichael has reunited 
the psydracious syphilitic eruption and the papular syphilitic eruption. He gives 
two cases of psydracious pustules: Case 1. Gonorrhoea, phymosis, inflammation of 
the glans, buboes, swelling of the scrotum ; diminution of the symptoms ; four months 
and a half after the attack, redness and excoriation of the throat; three days after, 
fever and eruption of psydracia; pains of the joints; small ulcers on the scrotum. 
Case 6. Superficial ulcer of the gland, buboes, fungous ulcer; eruption of psydracia. 
74 



shoulders, and larger articulations. After appearing on the shoulders, 
the eruption may spread to the extremities. The fever does not 
always cease on the evolution of a first eruption ; it continues so long 
as fresh crops of pustules make their appearance. The articular pains 
are usually more severe during the night than the day. 

872. The pustules are at one time extremely numerous and almost 
confluent on the face, back, and belly ; at other times they are fewer 
in number, and disseminated over the whole surface of the body. 
They vary in colour from a pale to a deep crimson-red. They do not 
all make their appearance at once, and aftera primary febrile paroxysm: 
they appear successively, so that in the same subject pustules in a nas- 
cent state, and in a state of maturity, are frequently to be seen at the 
same moment. The pustules individually are conoidal, of a dull red 
colour ; their base is hard, surrounded by a coppery areola, their sum- 
mit, slightly acuminated, is filled with serum or pus. In their decline 
the pustules are covered with a small scab, of a dirty yellowish-gray 
colour, under wdiich there is found an ulcer, of such insignificant 
dimensions, that it might be covered with the head of a small pin. 
By and by, a small circular, brown, depressed cicatrice, which gra- 
dually acquires a dull white hue, succeeds the sore, around which a 
kind of tawny yellow areola is for a very longtime perceived. After 
the fall of the scabs, however, it sometimes happens that nothing 
remains beyond small brownish spots or stains, without any appear- 
ance of ulceration or of cicatrice. 

873. Syphilitic psydracious pustules are apt to be preceded, espe- 
cially in individuals of bad constitution, by violet or nearly black 
stains, which only disappear very incompletely by pressure. These 
stains are occasionally very much crowded together, indeed, con- 
fluent, so as to form broad patches, as large as a five-shilling piece, 
and very commonly of an oval form. These spots become covered 
with a great number of small and slightly acuminated pustules, which 
for the most part fall into a state of irregular and generally superficial 
ulceration. After these get well, numbers of broad yellowish-brown 
patches remain on the skin, which are commonly beset with small, 
whitish, and depressed cicatrices. 

874. When syphilitic psydracia have appeared as an abundant 
eruption upon the trunk and extremities, the diagnosis is seldom un- 
certain. The disease cannot be confounded with impetigo sparsa, 
the discharging pustules of which do not ulcerate, (§ 532,) nor with 
any form of accidental or artificial pustular eruption (§ 568). It is 
more difficult to distinguish the eruption of which we are treating, 
from that of acne and rosacea, when its principal seat is the back, and 
shoulders, and face. Yet as the pustules of acne rest on a red base, 
and those of rosacea are surrounded by a bright erythematous areola, 
whilst those of the syphilitic eruption stand in the midst of a copper- 
coloured injection ; and, further, as rosacea does not ulcerate, and is 
not followed by the peculiar depressed cicatrices, observed after the 
greater number of syphilitic psydracia ; and, lastly, as in acne, the 
skin generally looks shining and unctuous, and is often covered with 
spots and indurations, whilst in the syphilitic affection it is healthy, or 
rather dry, in the spaces between the pustules ; there seems no great 
hazard of confounding one of these eruptions with the other. To con- 
clude, these small syphilitic pustules are readily distinguished from 
venereal papulae, when these several eruptions are at their height. 
The period at which the pustules dry up, differs also considerably 
from that at which the papulae begin to shrink and desquamate. 

875. Psydracious venereal eruptions are liable to be accompanied 
or followed by various other secondary symptoms. 4 

876. Syphilitic phlyzacious pustules. 5 An eruption of pustules, of 

4 Dr. Carmichael assures us that in several hundred psydracious and papular erup- 
tions which he has treated, he has never once met with exostosis at the same time. 
This complication is rare ; nevertheless I have seen several cases of it. 

6 Torrella appears to have described this species of pustule: "Juvenis infectus 
pupendagra phlegmatica, cum pustulis grossis crustosis, ex quibns exibat sordities 

grossa ad alba fuscedinem tendens." (Gasparis Torrellee. Consilium tertium. 

Aphrodisiacus, p. 549.) Fallopius, in his description of crusted venereal pustules, 
appears to include phlyzacious pustules and syphilitic rupia : "Secundum genus 
pustularum est habentium crustam, et istee rotundre sunt, ut plurimum et crustas 
adeo crassas faciunt, et prominentes ut veluti cornuum principia videantur: isti 
cortices aliquando aridi, aliquando turgentes sanie sunt. Sanies aliquando lutea, 
veluti mel: aliquando alba, veluti pituita, aliquando subnigra, etc." (De morbo gal- 
lico tractatus.— Aphrodisiacus, p. 824.) Carmichael has lately described and repre- 
sented syphilitic ecthyma and rupia (pi. iii.), which he considers as eruptions peculiar 






SYPHILIDA. 



a larger size tlian those that have just been described, of a flattened 
form, not at all prominent, generally distinct, surrounded by a cop- 
iae, containing, at their height, a yellowish fluid in their heads, 
which, by and by, dries into a blackish adhering scab, is frequently 
seen appearing upon the nape of the neck or shoulders, occasionally 
on the check-, or parts covered by the beard, more rarely on the ex- 
tremities, and still more rarely on the other parts of the body, as a 
secondary symptom of syphilitic infection. 

The eruption in this case may be scanty, the pustules appearing far 
apart ami extensively disseminated, or, on the contrary, they may be 
rather crowded, regularly grouped, now in the shape of a kind of band 
passing from one cheek to the other across the chin, again in symme- 
trical lines upon the nucha, and down the shoulders on each side of 
the median line, so as to cover the region of the trapezius, or in di- 
rections which recall the course of the latissimi dorsi. Although I 
have occasionally met with this kind of symmetry in other cutaneous 
eruptions, I think I have seen it more frequently along with phlyza- 
cious syphilids than any other form of disease. When the eruption 
appears occupying extensive regions, many pustules are commonly 
observed here and there in clusters, whilst others are scattered irregu- 
larly in the intervals between these. 

This form of venereal eruption is rarely preceded by fever. It often 
shows itself after pains in the bones and joints have been complained 
of, — after ulcers have been seen in the pharynx, &c. Each pustule 
appears at first upon a reddish spot, the centre of which becomes 
purulent, whilst its base, as it extends, is surrounded with a slight 
areola of a deep or livid-coloured brown. Some of these pustules 
always remain of insignificant size, like those of ecthyma at their 
origin ; the fluid they contain, as it dries, seems to become incorpo- 
rated with the epidermis, and forms a small set scab, the centre of 
which is black, or nearly so, whilst the circumference is surrounded 
by the cuticle detached and dried. After the spontaneous fall of 
these scabs, the skin presents a spot of a coppery red, the centre of 
which is commonly occupied by a small depressed cicatrice. These 
consecutive spots or stains are much more conspicuous where the 
pustules are clustered. 

The small phlyzacious venereal pustule differs from the psydracious 
pustule of the same description, in the circumference of the former 
being still somewhat the larger of the two, in its scab being also larger 
and more regularly set within a rim of cuticle, which membrane is 
also more extensively loosened around its circumference. 

877. Phlyzacious syphilitic pustules approximate more closely in 
the particulars of form and size to the phlyzacious pustules of ecthyma 
and variola. Like these, for instance, they are almost always dis- 
seminated. The greater part of their surface, when they have attained 
their height, is of a yellowish- white, and the coppery circle which 
surrounds their base is broad and tinged. They begin to dry off in 
the centre, which presents a scab of a yellowish and brownish or olive 
green colour, of a flattened form, separated from their edge by a small 
circle, which is gradually effaced as the drying advances. When this 
process is completed, if the scab be detached, it is found to have 
penetrated the substance of the corion deeply, and to have concealed 
a little ulcer, which generally implicates the entire thickness of this 
membrane. 

878. These consecutive ulcers are particularly remarkable among 
new-born infants after they have been several times immersed in the 
tepid bath, and the scabs by this means detached. They are also 
very apparent about the margin of the anus, on the upper and inner 
parts of the thighs, &c, situations in which the natural moist state 
of the skin prevents the formation of proper hard scabs. These 
ulcers, as I have said, are followed by depressed and very evident 
cicatrices. The form and dimensions of several of them seem occa- 
sionally to proclaim that they had succeeded ulceration of a serpigi- 
nous kind ; but this is in appearance only, for instead of the cica- 
trized furrow succeeding this form of ulcer, the bands which here 
appear are found to be made up of a chain of circular cicatrices, 
touching each other by their edges. 

The evolution of phlyzacious syphilida being successive, we may, 
in particular cases, often observe at the same time copper-coloured 

lo the phagedenic venereat disease. Cullurier designates them as scabby pustules: 
but he also applies this denomination to ulcerated tubercles, covered with scabs. 



flattened pustules; pustules of the same general form and appearance, 
but of much larger dimensions ; small laminated scabs, and others 
more prominent and more deeply set within the corion ; livid and yel- 
lowish-coloured blotches; cicatrices of the same aspect, and when of 
an older date, depressed, and of a dull white; the sum of these 
appearances is very characteristic of the nature of the eruption. 

879. It sometimes happens in a case of phlyzacious eruption, that 
a certain number of pustules, after attaining their height, increase in 
consequence of a considerable detachment of the cuticle effected by 
means of a deposit of purulent matter around their circumference. 
These pustules, the base of which becomes bullous, and which are 
subsequently covered with large and prominent incrustations, have 
been designated by reason of their appearance, under the title of syphi- 
litic rupia. In this variety the scab is not only broader but more 
prominent, especially at its centre. 1 It cracks and becomes irregularly 
loosened around its circumference, and the skin in the latter situation 
is of a coppery hue, but is not ulcerated. After the central part of 
the scab is detached, a sore of greater or less extent is always exposed, 
which presents the general characters of syphilitic sores, and this 
latter circumstance is the one which distinguishes syphilitic rupia from 
rupia simplex, for both of them present central ulcers surrounded by 
a circular red surface and an epidermic border or rim. 

880. When syphilitic rupia is left to itself, ulceration continues to 
go on under the scab, which becomes ever more and more prominent, 
and acquires the appearance of the non-venereal rupia prominens 
already described. When the scab is pressed upon, some purulent 
matter is made to exude from under it ; its circumference also continues 
bathed in pus for a time. This secretion diminishes by slow degrees; 
the base of the incrustation then hardens ; the cuticle loosens and 
cracks around its circumference ; portions of the scab are next de- 
tached, so that it is lessened in thickness or diameter. The cicatriza- 
tion of the sore goes on from its circumference towards its centre. 
When the whole of the scab is removed, and the ulcer completely 
healed, the cuticle which covers the cicatrix remains subject to repeated 
exfoliation for some time afterwards. The ulcer seldom exceeds in 
dimensions the size of the bleb which preceded it, unless it has been 
irritated by exercise when situated on one of the legs, or by stimu- 
lating applications, when any other part of the body is its seat. 

881. I have seen syphilitic rupia presenting all the appearances of 
rupia escharotica in a woman who was labouring under a squamous 
syphilide. On the outer and lower part of this patient's right leg there 
was a gangrenous sore nearly as large as a crown piece, the surface of 
which was of a brownish black colour, spongy, covered with blackish 
or gray filaments, and which exhaled a gangrenous odour. A circular 
groove of considerable depth surrounded the eschar and separated it 
from the neighbouring skin, the cuticle of which was raised like a 
ring by the effusion under it of a quantity of purulent matter. After 
the detachment of the slough the ulcer presented the characters of 
syphilitic sores in general, and healed up as the other symptoms of 
the constitutional affection yielded under the influence of mercury. 

882. Yellowish lenticular spots are occasionally observed on the 
palms of the hands and soles of the feet, of individuals labouring under 
syphilitic eruptions of different elementary forms. These are very 
similar in appearance to the pustules of small-pox, developed in the 
same situations in their stage of desiccation. If the cuticle covering 
these spots be removed with the point of a pin or a lancet, a small 
yellowish-coloured disc is discovered under it, which may be taken 
away, like that of small-pox, to which it bears the greatest resemblance. 
Through the cuticle these discs have a yellowish copper colour. When 
this eruption is not interfered with, the altered portion of cuticle and 
lenticular disc are detached. The palm and sole then look very much 

• Here is a case of this rare variety. A man nearly thirty' years of age had con- 
tracted the venereal disease four different times. The last infection was followed 
by gonorrhoea and ulcers on the corona glandis (treatment by mercurial friction, 
liquor of Van Swieten and tisan of Feltz). Shortly after he was seized with venereal 
pains, and after several vapour baths, an eruption of large pustules, similar lo those 
of ecthyma, with coppery red edges, showed itself upon the breast, and successively 
on the trunk and limbs. The matter of these pustules, on drying, gave place to 
scabs of a dusky brown, most of them conical, similar to those of rupia prominens. 
In falling off, these scabs left bare ulcerations, which had the appearance of venereal 
ulcers. This serious disease was successively treated with subcarbonate of ammonia, 
muriate of gold, and nitric acid, and it was only after six months' care that the cure 
was accomplished. I have seen another case which also belonged to this variety. 



SYPHILID A. 



295 



as they do when they are affected with a squamous syphilitic eruption; 
but the presence of the disc under several spots, enables us to distin- 
guish between these two forms of the disease. Further, in this erup- 
tion there is a less marked tendency to the reproduction of squamae 
than in syphilitic psoriasis. 

These venereal eruptions in the palm of the hand and sole of the 
foot, can never be mistaken for syphilitic rupia, the development of 
which, in these situations, is extremely rare, and which is, besides, 
sufficiently characterized by its central scab and the ulceration it 
occasions. 

883. Syphilitic papula 1 are firm elevations, solid or containing no 
fluid, scarcely ever accompanied with pruritus, and generally ending 
in resolution and desquamation, but occasionally also in little depres- 
sions and small cicatrices. 

This form of eruption may appear almost suddenly, or in a slow 
and successive manner. 

884. When the eruption is rapidly evolved, it takes place within 
from twenty-four to forty-eight hours; it is sometimes preceded by 
general febrile symptoms, and with pains in the joints, symptoms 
which are especially relieved by blood-letting, when the state of the 
constitution does not contra-indicate the practice. The blood ab- 
stracted is almost uniformly buffy. The eruption shows itself most 
usually at once, or nearly at the same time over the whole body, but 
especially upon the back and the face. It is characterized by small 
solid elevations of a coppery red colour, slightly conical, but little 
prominent; and which only cause a trifling amount of pruritus, if per- 
chance they occasion any. These papula; are sometimes very closely 
crowded together, and almost confluent, so that the skin of the back 
and face presents a uniform reddish coppery colour. It very rarely 
happens that they are disseminated and isolated ; often on the con- 
trary they form small oval clusters, the size of a shilling or somewhat 
larger, separated from one another by spaces covered with thinly dis- 
seminated papulae. Within a few days the eruption begins to fade ; 
the papula; shrink ; may desquamate slightly ; all leave small yellow- 
ish stains upon the skin which vanish very shortly. 

885. Syphilitic papulae are occasionally evolved in another man- 
ner, and present a different appearance. They make their appearance 
slowly and successively, commonly on the limbs and in the sense of 
extension, sometimes on the forehead and surface of the hairy scalp, 
larger than in the first instance, flattened, and of the size of small 
lentils, very regularly circumscribed and slightly raised above the 
general level; they are of a yellowish copper colour, not itchy, with- 
out any inflamed areolae surrounding their bases, and separated by 
intervals in which the skin is healthy, or sallow and shriveled, an 
appearance which it is particularly apt to present in the aged, or indi- 
viduals of indifferent constitution. The cuticle is detached from the 
summit of each of these papula, arrived at its height, in the form of 
a small dry and grayish-coloured pellicle, more strongly adhering at 
its centre than towards its circumference, and sometimes in the shape 
of a small disc. This desquamation is repeated from the surface of 
the papulae until they have shrunk completely, and are replaced by 
little lenticular spots or stains of a grayish yellow, which continue 
visible for a very long time. 

These broad yellow desquamating papulae maybe so much crowded 
over regions of such extent, as to simulate a squamous eruption, 

1 Syphilitic papula; have been indistinctly described under the name of pustules 
siccse, which the older writers have also made use of to designate tubercles and 
squama;. Willan has very well described syphilitic, violet-coloured and ulcerating 
papulae, and has distinguished them from lichen lividus. (Art. lichen lividus.) M. 
Alibert has given the principal characters of syphilitic papula;, scattered or in groups, 
under the name of syphilide pustuleuse miliaire. A case is published under the 
erroneous name of scabies venerea. — (Journ. Gen. de Med., t. xli. p. 377.) Several 
pupils of the school of Cullerier (senior), describe them under the name of miliary 
and itchy pustules (Guerin Alex. Diss, sur les pustules veneriennes. — These. 4to. Paris, 
1813, p. 17). Carmichael has reported several cases: Case iii. Phymosis, discharge 
from the glans, pains of the joints, more violent during the night; five months' 

illness; — the sixth month, papular eruption, cure, relapse, tumours of the tibia. 

Case iv. Superficial ulcer on the prepuce; a general papular eruption in clusters, 
and confluent; flat tubercles on the scrotum; pains in the joints.— Case v. Superfi- 
cial ulcers; discharge from the glans and the urethra buboes; papula; on the abdomen 
and breast. — Case vi. Discharge from the glans, superficial ulcer without induration ; 
papular eruption; excoriation of the pharynx; pains in the joints: six months' illness. 
Case vn. Phymosis; discharge from the glans and urethra; excoriation of the throat; 
scattered yellow papula;. Of one hundred and three cases of venereal eruption, I 
have only observed fifteen papular. 



especially if the neighbouring skin, dry and shriveled, is itself the 
seat of a desquamation at all considerable. 

886. Syphilitic papulae occur with a third appearance : they are of 
a brownish livid or violet colour, and are evolved slowly, and in suc- 
cession like the yellow papulae, the very considerable dimensions of 
which, however, they never attain. They are also less flattened, 
more prominent, and more constantly arranged in clusters ; they con- 
tinue long stationary at their height. Some of them, after the fall of 
the small epidermic disc that covers them, shrink away slowly, and 
the skin, in the corresponding points after their disappearance, 
presents a small wrinkled depression of a dirty brown colour, which 
might be covered with the head of a pin. Others ulcerate on their 
summits, and become covered with a small brown scab, similar in 
size to that which follows psydracious pustules. The ulceration does 
not extend to the whole surface of the papulae ; their base and their 
bodies shrink, and besides the small brownish depression in the point 
which they had occupied, the skin, at a later period, presents a little 
central point, of a bluish-white colour, which is occasioned by a true 
cicatrix. 

After the shrinking of the clusters, they leave behind them oval 
spots or stains as large as a half crown, and even as a crown piece, 
of a yellowish brown, and occasionally of a livid colour, the surface 
of which is sprinkled over with small points of a deeper shade of 
the same tints. These little marks differ from those that succeed 
psydracious pustules in clusters, not only in the circumstance of their 
following papulae, but in being commonly less crowded together, and 
more wrinkled than those that are the consequence of the pustular 
eruption in question. 

887. The papular syphilitic eruption presents itself with yet a 
fourth appearance, and this is the last I shall mention; it occurs in 
the guise of large oval clusters, pretty regularly circumscribed, which, 
as in ordinary lichen circumscriptum, continue for some time to spread 
around their circumference, whilst they are getting well in their centre. 
The syphilitic may be distinguished from the simple eruption men- 
tioned, by the greater size of the papula?, and by their violet and 
coppery colour. In some cases, the centres of these circumscribed 
syphilitic lichenous eruptions ulcerate, sometimes to such an extent, 
as to leave broad cicatrices behind them. These are at first of a 
bluish colour, but at a later period, become of a dull white, and some- 
times more than two inches in diameter. 

This variety of the papular syphilitic eruption is extremely rebel- 
lious; it is of very rare occurrence. 

888. Syphilitic squamous eruptions. 1 — These are characterized by 
coppery patches of a more or less regular round shape, smooth and 
shining, little or not at all affected with itchiness, the surface of which 
is the seat of an epidermic exfoliation. 

889. These patches are generally met with on the face, forehead, 
surface of the scalp, and more rarely on the back of the body. In 
the majority of cases, the patches of these squamous eruptions are 
nearly of the same size as those of psoriasis guttata, i. e., from six to 
eight lines in diameter. They generally appear six to eight weeks 
after the cure of primary syphilis: sometimes, how T ever, they are much 
later of making their appearance. 

They are most frequently distinct, slightly prominent, irregularly 
rounded, and covered with thin squamae, which adhere pretty firmly. 
When these squamae are detached, the skin beneath them is smooth, 
shining, of a coppery colour, and slightly raised and rounded. Each 
of the spots or patches is very regularly surrounded by a whitish rim 
or border, formed by the epidermis dried and detached or torn circu- 
larly. This edging of raised epidermis does not differ essentially from 

2 Massa has particularized the appearance of certain syphilitic eruptions, § 891. 
Hunter has described the syphilitic squamous eruption, (especially of the hands and 
of the soles of the feet,) and has remarked that the eruption was modified in its ap- 
pearance, where two contiguous surfaces of the skin were in contact, as on the labia, 
about the circumference of the anus, &c. — (Op. cit., p. 339.) Willan has described 
psoriasis and syphilitic lepra, which he has distinguished, very properly, from lepra 
nigricans. Dr. Carmichael believes this form of venereal eruptions to be a consecu- 
tive symptom peculiar to the Hunterian chancre; and, as according to Dr. Carmichael, 
this ulcer is rare, he has been led to advance, that squamous syphilitic affections had 
been observed by him in a very small number of cases only, during the six or eight 
years which had preceded the publication of the second edition of his work; iUs, 
notwithstanding, one of the most common forms of syphilitic eruption. In one hun- 
dred and three cases I have observed it eighteen times. 



296 



SYPHILIDA. 



that which is observed to follow the desiccation of the small bullae in 
some cases of pemphigus after the detachment of their laminated 
scabs; bul the spots in the squamous syphilide surrounded by these 
CUticular rims, are raised and rounded in their centre, and of a red- 
dish coppery hue, Whilst the marks that remain after the detachment 
of (he crusts of pemphigus are level, of a pale rose colour, and neither 
so smooth nor so shining. These remarks are also applicable to the 
red stains left by rupia simpler, after the complete or partial detach- 
ment of its scabs, which presents this peculiarity, that the epidermic 
edging around them is much broader and more irregular, and that 
the centres of the spots are often ulcerated and covered with scabs. 

After the fall of the original discs or epidermic laminae, which 
cover each syphilitic patch, the desquamation from their surface be- 
comes much more trifling, and occasionally even insensible. If treated 
appropriately, the patches sink, become pale and disappear, without 
leaving cicatrices, after the lapse of one, two, or three months. 

890. Syphilitic squamous eruptions occasionally present themselves 
in irregular groups, in which case their usual seat is the legs. The 
clusters blend by their adjacent edges ; epidermic discs and laminae 
are thrown off from several points of the surface of these broad irregu- 
lar patches, which appear partly smooth, and partly covered with 
squamae, and in other places of a coppery yellow colour. Besides 
these clusters isolated spots, covered or uncovered with squamae, are 
almost always to be detected, existing on other regions at the same 
time. 

891. Besides these two great divisions of the squamous syphilitic 
eruptions (squamae discretce; squamae confertce), they occur with a 
variety of particular appearances according to the regions of the body 
affected, which demand attention. 

892. On the surface of the scalp the squamae are always furfura- 
ceous, and often of a yellowish, sometimes even of a slightly greenish 
tint. Here the spots when freed from squamae, are not observed to 
be surrounded by the usual cuticular rim. The raised and rounded 
appearance of their surface is also less evident ; yet the finger passed 
carefully over them distinguishes a slight degree of swelling, much 
less evident than that presented by the flat, tubercular elevations 
which have been described, and which we shall immediately describe, 
under the name of syphilitic lepra. 

893. In the palms of the hands and soles of the feet, syphilitic 
psoriasis 1 is almost uniformly distinct; fit makes its appearance by a 
number of spots, of from three to four lines in diameter, but little or 
not at all prominent, or raised above the general level, and of a 
yellowish colour, very similar to that of the thick horny indurations 
of the cuticle often seen in the palms of the hands. If at this stage 
of the disease, a portion or the whole of the altered epidermis be 
removed from one of the spots, a thin layer of a yellowish substance 
will frequently be found deposited between the surface of the cutis 
and detached cuticle. Small lamellar scales of epidermis are very 
regularly thrown off from the palmar aspect of the hand, and sole of 
the foot, which almost always present a mixture of yellow, of red, 
of violet, and of copper-coloured spots or blotches, surrounded by an 
epidermic rim. The spots of syphilitic psoriasis are occasionally 
arranged in the form of a large ring on the palm of the hand ; at 
other times they present the appearance of a kind of arc of a circle, 
something like psoriasis gyrata. 

When the spots are evolved between the toes, they are first moist 
and whitish, then excoriated and red, and at length accompanied 
with rhagades or fissures. 

When palmar or plantar syphilitic psoriasis is of considerable 
extent, and no means are taken to arrest its progress, the eruption is 
repeated several times in the course of a few months, and the skin 
cracks extensively in various directions. These rhagades are very 
much increased by using the hands in any way, especially by the 
constant motions required in handicrafts of all kinds, by the action 
of cold, the contact of acid baths, or alkaline leys, &c. When 

' Psoriasis syphilitica palmariset ptantaris.has been observed from the beginning 
of the epidemic of the middle ages. " Et cum ista ajgritudo prolongate, apparent in 
aliquibus fissura, et squamae in volis manuura, et plantis pedum, et sunt albas, dura, 
sine humiditate, et aliquando mvadunt alias partes corporis."— (Massa. De morbo 
gall.co, liber cap. v.-Aphrodisiacus, p. 45.) Astruc gives its characters under the 
name of pelarelle. — (De morb. \ ener., lib. iv. cap. i.) 



squamous syphilitic eruptions occur by the edges of the nails, the 
parts around them are often very severely chapped, and true syphi- 
litic onychia has occasionally been seen following this affection. 

894. Those who are the subjects of syphilitic squamous eruptions 
of the nature of psoriasis, almost always exhibit about the axilla-, the 
inner and anterior parts of the thighs, the scrotum, labia majoru, 
margin of the anus, commissures of the lips, &.C., certain spots oi 
patches which have many of the characters of flattened tubercles: 
this difference of appearance, however, in the squamous spots, seems 
to depend on difference of local situation. (a) 

(a) Mr. Skey (Lectures on the Venereal Disease, in Med. Gaz., 1839) 
has the following remarks on the principal syphilitic eruptions. — "The 
eruptive disease exhibits itself in one or more of three forms, of 
which the first and simplest is that which is called mottling ; but it is 
important to observe that, although a frequent attendant on it, it is 
not peculiar to syphilitic disease. 

"It consists in a patchy discoloration of the skin, varying in depth 
of colour from the lightest pink to a distinct red, abrupt in its mar- 
gin, and slightly rough to the touch. Like a large variety of cuta- 
neous eruptions, it fades on the approach of cold, appearing more 
distinct on the application of any forms of stimuli that tend to pro- 
mote the cutaneous circulation. It appears most generally on the 
chest, front of the arms, and on the groin ; it may also appear on the 
face or forehead. The patches are often very large, giving an altered 
tint to the surface, of some inches square. 

"The two eruptions, however, that especially characterize syphilis, 
are psoriasis and lepra. 

" Syphilitic psoriasis appears in the form of circular spots, about 
the size of a small finger-nail, generally round, or nearly so. These 
spots are based on disease, not of the cuticle, but of the skin, which 
is inflamed and thickened, giving to the spots a slight degree of ele- 
vation, perceptible to the touch on passing the finger over them. The 
base is red, or of a reddish brown, and from which the cuticle peels 
in dry scales or flakes, from the period of their first appearance ; they 
are therefore characterized throughout by the scaly eruption. The 
process of desquamation occurs not in large, but often in minute and 
broken scales of morbid cuticle, and much less considerable than in 
some other forms of scaly disease ; and this constitutes the prominent 
feature of the affection from the commencement, by which it is dis- 
tinguished from the desquamation of pustular, vesicular, or papular 
eruptions, for in these the desquamation attends the latter stage only. 

" The syphilitic psoriasis often makes its first appearance on the 
scalp and forehead, on the chin or upper lip, and back of the neck, 
and more frequently extends to the chest, abdomen, front or inner 
surfaces of the arms, chiefly about the elbow-joints, to the palms of 
the hands; also to the front and inner part of the thighs. Eruptions 
of all kinds are modified by the density of the surface they occupy; 
therefore we are not surprised to find syphilitic eruption of the palms 
somewhat peculiar. It forms what has been called a honeycomb 
eruption ; the cuticle separates slowly in circular patches, and is 
imperfectly reproduced. Mr. Carmichael first remarked also the 
peculiar appearance of syphilitic eruption, when situated on commis- 
sures of skin, or where two cutaneous surfaces are in contact, as at 
the nates, or between the toes. Here there is no desquamation nor 
dryness, the eruption being more inflammatory and moist, like a 
soft and highly-organized wart. I am inclined to think, however, 
that this appearance is not peculiar to syphilitic disease, as I have 
seen it in phagedena, as well as in other eruptions, unequivocally 
not venereal. It is very rare that phagedenic eruption appears on 
the palms, but I have seen it distinctly marked in more than one 
instance. 

" The third form of eruption is that of lepra, which is obviously 
pathologically identical with the last-described eruption, but appears 
in larger and deeper patches, surrounded by a narrow inflammatory 
ring, and based rather on the subcutaneous tissue than on the skin. 
These eruptions form incrustations of a brown colour, raised consi- 
derably above the surface, which separate as the substratum ulcerates. 
The crusts might be mistaken for the rupia of phagedenic disease, 
but they are slower in forming, and may be determined by the cha- 
racter of the eruption around. The eruption of syphilis — be it pso- 



SYPHILIDA. 



297 



895. The coppery colour of the patches of the squamous syphilitic 
eruption, aids essentially in distinguishing it from simple psoriasis. 
In the syphilitic affection, too, the cuticle is detached from the skin ; 
but there is not, as in ordinary psoriasis, an abundant production of 
squamae. 

896. The venereal disease may proclaim itself upon the skin in 
another form of squamous eruption, which has been described as 
venereal lepra (Willan). 1 This eruption, at its height, is character- 
ized by rounded or oval-shaped patches, depressed in their centre, 
generally of a livid red colour, but occasionally almost black, from 
half to three-quarters of an inch in diameter, and covered on the 
surface with grayish epidermic lamella?. 

This eruption, which may be diffused over almost the whole body, 
is sometimes confined to a single region, as to the nucha and shoul- 
ders, to the hypogastrium and upper parts of the thighs, to the fore- 
head and hairy scalp, &c. The patches severally commence as 
papular elevations of the livid or blackish colour mentioned, smooth 
on the surface, and not covered with squamae. These elevations 
spread circularly until they are three or four lines in diameter, when 
their centres become depressed, whilst their edges, sharply defined, 
rise very distinctly above the level of the skin around them. The 
cuticle which covers them, now begins to assume a gray and some- 
what yellowish tint, most conspicuous on those patches which are 
lightest in colour; and, by and by, it splits, and is cast off from dif- 
ferent points of the surface, but especially from the centres of the 
patches. This desquamation is several times renewed, but it is 
never abundant as it is in lepra vulgaris, or in psoriasis. The cuticle, 
of no great thickness, smooth, shining and diaphanous, masks the vio- 
let tint of the corion, which it covers very imperfectly; it is, in fact, a 
simple desquamation of the cuticle that takes place upon these syphi- 
litic spots, not an evolution of true squamae. When the patches 
acquire a larger size, the desquamating process continues to go on 
from their margin, after it has ceased upon their centres, which are 
then smooth and shining, and of a yellowish coppery colour. 

897. The advance of the syphilitic patches in question, towards 
recovery, is indicated by the sinking of their edges and their chang- 
ing colour, passing from a livid or blackish red to a coppery yellow. 
The edges of the patches commonly sink in an irregular manner ; 
they appear to break at intervals, and to change into flattened arcs of 



riasis or lepra — is always characterized by desquamation of the morbid 
cuticle throughout its progress. The entire eruption appears depend- 
ent on one single cause, and that a general, and not merely a local 
one. If one part advances, the whole advances. We need not 
expose the entire person of a patient, with the view to ascertain the 
condition of the eruption on a remote part of the body, as is required 
in the. case of phagedenic disease, in which we find the actions of 
health and of disease variously intermingled — some spots desqua- 
mating in the last stage, while new ulcers or rupial crusts are forming 
elsewhere ; but, as in the exanthemata, the whole surface appears 
obedient to one common influence. Syphilis, unless in a very ad- 
vanced form, rarely affects the whole surface ; those parts I have 
already mentioned being most obnoxious to it; whereas phagedena 
is less discriminate in the surfaces it involves. As a general rule, 
subject, however, to exceptions, the front surface is the seat of early 
syphilitic eruption, the back in a greater degree that of phagedena." 

1 Syphilitic lepra is only mentioned in an extremely vague and uncertain manner 
by the modern writers, before Willan, who has described it under the name of 
venereal lepra, and has well distinguished it from the lepra vulgaris and the lepra 
nigricans. Venereal lepra, says he, differs from lepra vulgaris and lepra nigricans, 
by the absence of a hard scaly edge to the circumference of the patches, which are 
never covered with thick squamas. Besides, the venereal patches are soft and supple, 
not dry and rough, and they sometimes ulcerate, which the patches of ordinary lepra 
never do. Carmichael mentions syphilitic lepra, following Willan particularly in his 
description. M. Alibert has given a case of it under the name of pustular syphilide: 
— These spots, of a dusky red, do not at first rise above the level of the integuments, 
but they soon begin to do so, especially around the edges, which gradually become 
more elevated than the centre, and are at the same time covered with small white 
squamae. These patches had hard, raised, circular edges ; the centre was paler than 
the circumference ; in the centre, slight asperities were observed, which were covered 
with epidermic squamae ; their coppery colour proclaimed their syphilitic nature. 
(Precis. Theor. et Prt. des Mai. de la Peau, t.ii. p. 227.) I have myself seen several 
cases of this kind. The Messrs. Cazenave and Schedel have detailed a case in 
which the patches were extremely dark in colour. 
75 



circles, showing a greater intensity of colour than the areas they em- 
brace. It sometimes happens that the whole of the patches begin to 
fade at the same time, and nearly in an equal degree, over every pait 
of the individual patches: the raised edges which distinguished them 
then disappear, and the skin presents mere rounded copper-coloured 
spots, that scarcely desquamate, similar to primary syphilitic maculae. 
For several weeks after every trace of elevation has vanished from 
the margin, the spots continue in the guise of blotches, of an earthy 
yellow colour, which retain the form, and very nearly the dimensions, 
of the patches. 

898. The colour of these squamous patches, and the appearance of 
their surface, may be modified by various topical applications — by 
baths, washes, &c. Under the influence of the vapour bath, I have 
seen their colour gradually deepen until it became nearly black, and 
their surface, freed from squamae, only become covered again after an 
interval of several weeks. The dark colour disappeared to a certain 
extent, but still very imperfectly, under the pressure of the finger. 
In this state it might be found very difficult to distinguish these 
syphilitic patches from certain forms of lepra (lepra livida), the spots 
of which had also been freed from squamae. The spots of simple 
lepra, however, it may here be observed, are generally larger and 
rounder than those of syphilitic origin, which are far more frequently 
oval than circular in their outline, and much more rarely confluent, 
and united into broad bands and patches, than those of lepra. 

899. Another circumstance further contributes very commonly to 
distinguish these eruptions, — it is this : in the centre of one or more 
of the large patches of the squamous syphilide (lepra syphilitica), a 
purulent point makes its appearance; or, otherwise, their circumference 
is in parts traversed by irregular sero-purulent looking bands. Small 
scabs, the form of which is in accordance with that of the purulent 
deposit beneath the epidermis, to which they are due, then cover a 
portion of the surface of the patches, which continue squamous over 
the rest of their extent. After the detachment of these incrustations, 
and of the altered epidermis, slight excoriations are perceived, which, 
in their turn, are succeeded by superficial cicatrices. Nothing of this 
kind is observed to happen in connection with patches of common 
lepra. Indeed the squamous syphilide itself, unless when thus com- 
plicated with accidental pustules, is never followed by excoriations 
or cicatrices. 

900. When the squamous syphilide appears between the buttocks, 
on the scrotum, about the navel, and over the upper parts of the 
thighs, where two contiguous surfaces of integuments are in contact, 
the patches present a very different appearance ; their surface is then 
soft, moist, covered with a whitish unctuous and fetid matter, and 
the cuticle, instead of desquamating, is continuous, smooth, and of a 
dull white or grayish colour. 

901. Of all the forms under which syphilis shows itself upon the 
skin, the tubercular is the most frequent. 2 Syphilitic tubercles are 
of a livid or coppery red colour, smooth, or covered with squamee, flat 
or prominent, dry or moist on the surface, sometimes supporting 

fungous growths, frequently occupied by circumscribed ulcerations, 
and covered with thick scabs, or degenerating into extensive sores of a 
phagedenic or serpiginous character, hidden under rugous and broad 
incrustations. 

Syphilitic tubercles appear scattered or clustered, or arranged in 
circular bands, which circumscribe, more or less completely, spaces 
of the skin, which is indifferently healthy, or altered in a greater or. 
less degree. 

902. We occasionally observe on the face, especially on the cheeks 
and alae nasi, a number of oval or pyriform tubercles, very prominent, 
of various sizes, from that of a pea to that of a small olive, either 
clustered together, or irregularly disseminated over a surface of vari- 
able extent. Smooth and shining on their surface, they do not show 

2 Massa certainly points out tubercles as a species of pustulae. — " Demonstrativa 
(signa morbi gallici) sunt pustulae cum quadam duritie, aut eminentia, et malo colore 
in capite toto, vel fronte circa originem capillorum, vel in aliis corporis partibus, ei 
maxime in angulis oris, et hoc saepe in infantibus accidit, et in adultis quandoque. 
qua? sunt eminentes humidas." (Aphrodisiacus, p. 46.) The word pustule has like- 
wise been employed as a generic term, to indicate several different alterations of the 
skin, such as squamae, pustula?, tubercula,&c, by almost all the writers who described 
the epidemic syphilis of the fifteenth century, as well as by those who have followed 
them. Leoniceni, however, has made use of the word (uberculum. (Aphrodisiacus. 
p. 38.) 



298 



SYPHILIDA. 



any tkmg like desquamation ; neither do they occasion pain ; and they 
intinue for months, and even for years, without undergoing any 
change. They seldom or almost never ulcerate; but, in the course 
of time, the cuticle upon their surface ends by exfoliating. This is the 
rarest of all the tubercular syphilitic eruptions. It is not uncommon, 
however, amid the more ordinary forms of the tubercular syphilitic 
eruption, to distinguish a certain number of tubercles which continue 
stationary, whilst those in their vicinity are desquamating, or falling 
into a state of ulceration, and becoming covered with scabs. 

903. Instead of being even, smooth, and shining, like the tubercles 
that have now been described, syphilitic tubercles are occasionally 
affected with a true desquamation of the cuticle covering their sur- 
faces (squamous tubercles). 1 A single tubercle of this description is 
occasionally observed to be developed on the upper lip, along with 
other symptoms of syphilitic infection. Or, a number of smaller tu- 
bercles, but little larger than papulae, are often seen clustered upon 
one of the alai of the nose, a situation in which, if the disease be left 
to itself, rhagades and fissures are formed at a later period. These 
squamous tubercles are often disposed like a wreath, or in the form of 
a ring, upon the forehead and neck. A series of round tubercles, as 
large as peas, and of a coppery colour, are frequently seen, accurately 
arranged side by side, and forming complete circles of varying 
diameter. From the summits of these, and occasionally even from 
almost their entire surface, a small, dry, hard, and grayish-coloured 
disc is detached. This desquamation does not take place from the 
whole of the tubercles at the same time, and every trace of it may 
disappear after the use of the tepid and vapour baths. The tubercles 
then look smooth, like those of a stationary nature, but they are never 
so prominent as these last. The skin of the interior of the rings is 
generally healthy. When the constitutional disease is yielding to 
appropriate treatment, the tubercles shrink ; they approach more and 
more nearly to the level of the skin ; the exfoliation becomes less and 
less conspicuous, and before long, nothing more remains than a red- 
dish or yellowish stain, which, in its turn, vanishes likewise. 

904. A particular variety of tubercle, the flattened form of which 
distinguishes it from all the others, is frequently spoken of under the 
name of the flat tubercle. This variety is most usually developed on 
the genito-anal region, and is always moist and often excoriated. 
Upon the scrotum, on the penis, on the pubes, on the anterior and 
inner parts of the thighs, the round or oval-shaped tubercles of* this 
description occasionally attain a size little less than that of a shilling. 
They are sometimes several lines in thickness, and stand out in very 
prominent relief upon the integument of the verge of the anus, of the 
labia majora, &c. Their surface swells, becomes wrinkled, often 
presents linear excoriations, and secretes a dirty white, and faint and 
sickly smelling matter. These tubercles are sometimes clustered 
around the anus, so as to form a large ring, flattened, but still pretty 
prominent, whose sanious surface is traversed by numerous chaps and 
crevices, the deepest of which sometimes penetrate even into the 
cavity of the rectum. It more frequently happens, however, that 
these tubercles are evolved at some distance from the edge of the 
anas, and this is one among several other circumstances, which 
serves to distinguish them from hemorrhoids. 

When these tubercles are neglected or improperly treated, when the 
fetid discharge they pour out is left bathing their surface, the wrinkles 
they present are not only transformed into deep chaps, but into ragged 
ulcers, the appearance of which is grayish, eroded, and granular, like 
that of several other syphilitic sores. The edges of the tubercles 
swell, and become more prominent, whilst their centres appear de- 
pressed. Under the influence of appropriate treatment, on the con- 
trary, these tubercles shrink, the fluid they secrete diminishes in fetor 
and in quantity, and ceasing at length to discharge, a slight exfolia- 
tion of the epidermis takes place from their surface, which goes on 
during a certain time. 

The scrotum is occasionally covered with these tubercles. They 
are in general isolated, of an exact round figure, extremely prominent, 

• These are apparently the tubercles which Fallopius has indicated in the following 
passage :-At major pars (pustularum) nihil sub se continent, et praecipue quae nas- 
cuntur .n cap.ie, rotunds sum, crus.amquehabent tenuem; quotiesego video pustulas 
1 stas m captteaut rhagades m mambus, indicium cerium proferoGallicifcastera 
stgna fallunt nos, haec certtssima sunt. (Aphrodisiacus, p. 824.) 



and furrowed or wrinkled on the surface by the natural inequalities of 
the part. 

On the glans penis, the inner surface of the prepuce, of the labia 
majora, and minora, on the commissures of the lips, in the inside of 
the mouth, &c, these tubercles, instead of the deep red colour which 
they present on the inner and upper aspects of the thighs, on the body 
of the penis, and other regions, have a bluish-gray tint, owing to a 
thickening of the epithelium covering these parts. Between the toes 
too, this flat description of tubercle appears under the form of small 
whitish or grayish, and prominent patches, often excoriated in the 
centre, and accompanied with rhagades between the digits. These 
patches differ from the corns that are sometimes developed between 
the toes, 2 by being attended with a greater degree of puffing of the 
corion at their base. 

About the commissures of the lips, this same description of tubercle 
does not commonly exceed the size of a large lentil, divided across 
its middle by a furrow which frequently changes into a chap. The 
nipples of woman who have become infected by suckling a syphilitic 
infant, are sometimes covered with flat-shaped tubercles, which the 
continued suction of the child causes to chap, to become excoriated, 
and to inflame in a very painful manner. These tubercles in some 
cases even ulcerate to a greater extent than they are ever observed 
to do in any other part of the body. Upon the navel, and within the 
meatus auditorius externus, these tubercles have nearly the same 
smooth and reddish appearance which they present on the inner and 
upper parts of the thighs. 

905. The flattened tubercles of the scrotum and vulva are occa- 
sionally mixed with other forms of tubercles, which are covered with 
true fungous growths {vegetations). 1 These excrescences never attain 
such magnitude as those which are designated by the titles of cauli- 
flowers and cock^s combs (choux-fleurs et cretes de coq.) 

906. On the hairy scalp, the flattened syphilitic tubercle appears 
under the form of spots of a reddish-yellow colour, nearly of the size 
of a silver three-pence, and covered with minute yellowish, and occa- 
sionally greenish squamae. On applying the finger to the surface of 
these patches, it will be discovered that they are produced like those 
of syphilitic lepra, by a positive increase in the thickness of the skin ; 
but their centres are not always depressed. These flat-shaped tuber- 
cles often form a band on the upper part of the forehead, and to- 
wards the roots of the hair, which spreads regularly over the temples; 
they are apt to ulcerate and become covered with thick scabs. 

907. Other tubercles are of a nature essentially disposed to ulcer- 
ate, and form a very remarkable group, to which several varieties 
belong (§§ 908, 909, 910, 911, and 912.) 

908. Upon the forehead and those parts of the cheeks which, in 
men, are covered with the beard, are sometimes seen a number of olive- 
shaped and very indolent tubercles, of a coppery hue, the surface of 
wdiich is traversed by a small sinuous and irregular furrow that appears 
perforated and worm-eaten in parts. Upon these sinuous furrows and 
within these small holes, little greenish scabs are formed of a very 
adhering nature. The particular character of these small ulcers, is 
their linear disposition and the little tendency they show to unite, even 
when they are contiguous. After the shrinking and healing of these 
tubercles, the surfaces which they have covered appear stained, and 
covered with cicatrices, like those of serpiginous syphilis in miniature. 

909. We sometimes see developed on the skin of the elbow, upon 
that which covers the head of the fibula, on the ridge of the nose, &c, 
circular or semi-circular clusters of tubercles, three or four lines in 
diameter, slightly elevated in the centre, and of a very deep livid or 
violet hue. Inflammatory action is before long set up in the tubercles, 
in the middle of these groups, or in those at the greatest distance from 
the edge of the clusters, as a consequence of which a purulent point 
is formed on their summits, that afterwards dries up into a black or 
brown-coloured scab. These tubercles shrink and leave violet-coloured 
blotches covered with minute cicatrices, surrounded by a raised and 

2 " Si vero in dictis ulceribus superficialibus, et prassertim pedum, essent aliquas 
materia;; induratss ad modum clavorum," etc. — (Torrella. De ulceribus in pudendagra, 
tractatus. Aphrodisiacus, p. 540.) 

3 These fungoid tubercles are mentioned by De Vigo: "Pustulaecrustosae etinterdam 
cum carnositate elevatae ad modum verrucae super fron'.em, caput, collum, et faciem, 
brachia, et tibias et fere per totum corpus diffusa:."— (Aphrodisiacus, p. 449.— De- 
vergie, op. cit. pi. 17.) 



SYPHILIDA. 



299 



very well-defined tuberculous circle or arch, which is extended and 
increased by the addition of new tubercles, in the manner of eccentric 
eruptions generally. If the disease is allowed to run its own course, 
the middle tubercles of these clusters ulcerate more and more, and 
after a certain lapse of time, when the healing of the ulcers has taken 
place, the skin presents livid cicatrices of a circular or semi-circular 
shape, traversed by whitish bands, surrounded by a circle of tuber- 
cles, or edged with a tubercular arch, on which are often seen small 
angular ulcers, sometimes covered with scabs, the shrinking and 
healing of which do not take place till a much later period. 

910. Broad syphilitic ulcers 1 which have entirely destroyed the skin 
and subjacent parts, are sometimes seen at the angles of the mouth, 
about the alee nasi, or on the cheeks, and more rarely on other parts 
of the body. Similar ulcers sometimes begin, as I have ascertained 
in several cases, by broad tubercles which ulcerate at the top after 
having remained stationary for a considerable time. Several of these 
tubercles, three, four, or a still greater number, often appear almost at 
the same time on one of the places which I have just mentioned ; 
their bases soon join, they suppurate at the top, and the various small 
ulcers thus produced, by uniting, give place to a sore whose edges, 
hard, livid, raised, and tubercular in some parts, jagged and angular 
in others, are deeply cut as if with pinking irons. The surface of this 
ulcer, of a yellowish-gray colour, and bathed in a sanious pus of a bad 
description, is uneven and beset with reddish points, but not very 
painful. If an ulcer of this description is left exposed to the air, it 
becomes covered with a yellowish brown-coloured incrustation, which 
is deeply set within the rim of the sore. When this scab is pressed, 
a sanious fluid often exudes from some point in the circumference of 
the sore, where the ulcerative inflammation appears most active. 
These sores generally show a disposition to destroy parts both super- 
ficially and more deeply ; they are succeeded by irregular cicatrices, 
and often by considerable deformity. 

Tubercles of the description that engage us are often evolved on 
the alas of the nose, and end in phagedenic ulcers, which occasionally 
destroy no more than the skin ; these sores are followed by deeply de- 
pressed cicatrices. When both of the alas nasi are implicated at once, 
or when an erysipelatous inflammation of bad character takes posses- 
sion of these parts, they are apt to be completely destroyed by the 
ulcerative processes, the energy and rapidity of which can then only 
be compared to what is observed in certain cases of lupus. Lastly, 
cases occur in which the syphilitic inflammation is propagated, even 
into the nasal fossae, causing ulceration of the pituitary membrane, the 
destruction of the cartilages, necrosis of the ossa nasi, turbinated 
bones, &c, and occasioning a characteristic deformity of the most 
hideous description. 

911. The title of the serpiginous syphilids 2 has been given to the 
secondary venereal ulcers which appear most commonly on the back, 
and pursue their course superficially in lines or in spirals in different 
directions. Ulcers of this description are also observed on the extre- 
mities and in the neighbourhood of the great joints. These ulcera- 
tions usually commence with a tubercle, of a ruddy violet or livid 
colour, oval and deep, which, after remaining stationary for a considera- 
ble time, inflames and suppurates, and is replaced by a deep ulcer, 
the dimensions of which do not exceed that of the tubercle. But 
this ulcer shortly spreads either at one end or the other : it forms a 
deep furrow, often the width of the little finger, which extends further 
and further, sometimes forming a complete circle, which circumscribes 
a larger or smaller surface of healthy skin ; at other times taking the 
form of the letter C. or E., as in psoriasis gyrata, or irregularly cir- 
cumscribing almost all the skin of the back, or of the interior parietes 
of the abdomen. It is worthy of notice, that whilst these serpiginous 
ulcers are making their way on the skin, by spreading in this manner 
from one end, they cicatrize at the other, even when no treatment has 
been had recourse to to stop their progress. These ulcers that appear 
in grooves or furrows, independently of this particular form, have other 

1 Rubra aut flavae pustnlae, primtim quidem circa frontem ac tempora, poneque 
aures, dein in capite aique eliam in reliquo corpore, erumpunt et extuberant rotundo 
schemate, siccae, sine pure, quae dein sicca crusta ohducuntur: atque si negligantur, 
serpunt in ambitum, excavantque cutem, dum ex pustula verum ulcus fiat. — (Fer- 
nelii Universa medicina. Colonise Allobrogum, in-fnl., 1670, p. 585.) 

1 Massa, Torrella, &c, have spoken of this species of ulcer under the names of 
ulcus ambulativum, and ulcus esthiomenum. 



special characters ; they are attended with little or no pain ; inflamma- 
tion extends very little way beyond their edges ; and they are sharply 
and deeply cut. 

The discharge in which these large ulcerated grooves are bathed, 
dries in yellowish or light brown scabs, upon exposure to the air. 
These scabs are interrupted here and there along the furrows, by ulcer- 
ated surfaces, bathed in pus. When these serpiginous ulcers are seen 
on the back, on the belly, or the legs, arranged in large rings, the 
diseased skin almost always presents a mass of ulcerated circles 
covered with brown scabs, furrows whose edges are bathed in pus, 
and deep cicatrices in narrow stripes of a bluish or whitish hue, ac- 
cording as they are of more ancient or more recent date. This variety 
of syphilis is very rebellious. 

912. Serpiginous ulcers are sometimes seen in arcs or circles, 
which, while their internal edge cicatrizes, spread in an eccentric 
manner from their external edge, so as always to preserve the form of 
a furrow in attacking the surrounding parts. 

Lastly, consecutive ulcers are sometimes developed on the trunk, 
and more frequently on the face, which, in their progress, partake, at 
the same time, of the character of the eating ulcer of the angles of the 
mouth and of that of the serpiginous ulcer ; this description of ulcer 
has been designated, under the name of the phagedenic consecutive 
ulcer. 3 

It is seldom observed at its commencement. When it is developed 
on the face, a swelling of a tubercular nature sometimes appears on 
one of the cheeks, followed by erysipelatous tumefaction ; the skin 
becomes of a ruddy violet colour and shining ; the little hard and cir- 
cumscribed point which appeared primarily, suppurates and ulcerates; 
small analogous ulcerations often form in the same manner not far 
from each other; some become covered with a yellowish-brown scab, 
which adheres pretty firmly, and continues long attached to them; upon 
other ulcers in the neighbourhood of the angles of the mouth, the 
secretion of pus is too active and abundant to allow any scabs to 
form, or the natural motion of the parts tends constantly to detach 
them. These ulcers increase in the same manner as the phagedenic 
ulcers of the angles of the mouth. Others, arising near the zygomatic 
arch, extend towards the lower edge of the jaw and follow its contour; 
a thick matter of a yellowish-white colour, formed by mortified cellu- 
lar tissue, sticks to their bottoms ; their hard edges differ from those 
of ordinary serpiginous ulcers, in the skin that surrounds them almost 
always undergoing change, and becoming covered with squama? and 
scabs, or being traversed by bands, and marked with cicatrices. 
When the face has been thus scarred by several phagedenic ulcers, it 
frequently becomes the seat of an erysipelatous swelling, sometimes 
preceded by pretty severe febrile symptoms, after which the disease 
is improved or aggravated according to the state of the constitution. 
When the cure of this frightful malady has been effected by methodi- 
cal treatment, the face does not present, as after serpiginous syphilis, 
regular cicatrices in the form of bands ; it is seamed rather, traversed 
with cords, as after burns or the lupus exedens, which destroys the skin 
superficially. 

913. Small tumours are often developed in the subcutaneous cellu- 
lar tissue, particularly in that of the limbs, about the size of a pea, 
movable, not painful, and not causing the skin to change colour, 
(subcutaneous syphilitic tubercles). They subsequently increase in 
size, inflame, contract adhesions with the skin which covers them, 
and become red. These tubercles then soften and perforate the skin ; 
the result of this is the formation of small ulcers, whose edges are 
loosened, and whose openings are narrower than their bottoms, which 
are of a yellowish or dirty white. 4 This appearance is the effect of a 
sort of slough, formed of mortified cellular tissue, which sooner or 
later is detached, and leaves bare a red unequal surface, that continues 

3 This is the ulcus manducativum of Torrella; several ancient writers, and of late 
Cannichael, have designated it under the name of the phagedenic ulcer. 

* Ego seepe studiosa aperui pustulas morbi gallici, et quamvis extra apparebant 
rubicund®, vel alterius coloris, apertis tamen, in basi et in profundo erat qusedam 
materia alba, densa, viscosa — hanc eandem materiam videmus quotidie in apostema- 
tibus duris, quae vulgares gummata appellant. (Nicolaus Massa. De mvrbo gallico, 

cap. iv. Aphrodisiacus, p. 43.)— Filius familias cladem gallicam patiebatur sed 

de repente centum pene locis tubercula apparuerunt aiheromaiis similli, et parvarum 
lupinarum instar. Ballonii. Paradigmata 20. Oper. Omn. Ed. J. Sthewart, 4to., Ge- 
nevas, 1762, t. ii. p. 527.)— Cullerier. Art. Gomme syphililique. (Diet de med. et de 
chir. pratiques.)— Bacot. (Lond. Med. Gazette, vol. iii., p. 149, 1829.) 



300 



SYPHILIDA. 



to be bathed in pus of a bad description. These ulcers may assume a 
better appearance, but the redness of the granulations is generally 
bidden beneath a layer of whitish matter, as if their surface had been 
touched with a weak solution of nitrate of silver. These ulcers left 
to themselves extend slowly, and almost always by the destruction of 
their loosened, livid, or violet-coloured edges. When an ulcer of 
this kind remains exposed to the open air, it becomes covered with a 
brownish-yellow scab, deeply set within its edges ; it may become 
sanious and bleeding from walking, if seated on the lower limbs. 
When these tubercles are thus ulcerated, and when the disease has 
lasted for a month or longer, other subcutaneous tubercles in different 
stages, and a number of cicatrices are always met with scattered over 
the limbs. 

914. After the development of one subcutaneous tubercle, more 
frequently after it has become softened, and ulceration has taken 
place, several others appear in its neighbourhood, which in their turn 
soften and burst the skin. When similar groups of subcutaneous 
tubercles form on the legs, the skin becomes of a very deep violet- 
red colour, in the spaces between them, and the perforations which 
they make are often so near to each other, as to give the skin the 
appearance of a sieve. 1 Two or three of these ulcers sometimes ter- 
minate by uniting, and giving place to larger and more irregular 
ulcerations. Between the ulcers, the subcutaneous cellular tissue 
often swells unequally, and forms hard and prominent ridges, of a 
still deeper tint than that of the surrounding skin, which stretch away 
from the clusters. When the cure is completed, the skin of the legs 
remains marked with large yellowish or violet-coloured blotches, in- 
tersected with circular-shaped depressed cicatrices, and only recovers 
its natural colour and former pliancy very slowly, and after a long in- 
terval has elapsed. 

915. Besides the sores which follow pustules, tubercles, &c, there 
are other cutaneous ulcers which succeed gummy tumours (tumeurs 
gommeuses), thickenings of the periosteum, caries of the bones, inflam- 
mations of the lymphatic glands, &c. Thus the tumours with soft 
centres and hard edges, which are evolved upon the superficial bones, 
more especially on the os frontis, having been preceded and accom- 
panied by nocturnal pains, are followed by perforations of the skin, 
the edges of which are extensively detached, whilst the bottoms of 
the sores look grayish or white, and are often occupied by the bone 
naked and in a state of caries. These ulcers are never healed but 
very slowly and with extreme difficulty. 

916. Chronic syphilitic inflammation of the lymphatic glands of 
the neck and axilla, is not only followed by considerable enlargement 
of these glands, but in many cases by fistulous ulcers, the edges of 
which are hard and livid, and the bottoms grayish. Sores of this 
description are also very rebellious, although less serious in their 
nature than those last mentioned. 

The fistulous ulcers that follow venereal enlargement of the testis 
rarely become extensive. 

917. I must here also give an account of the appearances presented 
by ulcers of venereal origin, developed on the external organs of 
generation. After the consolidation of chancres, we frequently see 
the cicatrices giving way, and the ulcers now formed more frequently 
assuming the aspect of secondary than of primary syphilitic sores. 
Secondary sores may also be, and indeed frequently are evolved on 
the penis and pudenda, in consequence of venereal eruption upon 
these parts with an ulcerating tendency. These sores are generally 
circumscribed with tubercular bases ; sometimes, however, they have 
the characters of serpiginous ulcers, which traverse the skin of the 
penis and scrotum in circles, and zigzag lines ; and in a few rare cases 
they show the phagedenic tendency, when they destroy, both super- 
ficially and in depth, a greater or less extent of the organs of gene- 
ration. 

918. In those who are labouring under constitutional syphilis, 
leech bites are occasionally known to be followed by sores, which 
acquire all the characters of secondary syphilitic ulcers, and become 
covered with scabs, very similar to those of the ulcerated phlyzacious 
syphihde. The bites of leeches, applied in the vicinity of the genital 

i Massa speaks of ulcers which unite the principal characters of consecutive 
ulcers w«h those of subcutaneous tubercles; " Ulcera perforata multis perforationi- 
bus,'— (Aphrodisiacus, p. 45.) y 



organs, in the treatment of primary venereal sores and buboes, are 
also occasionally observed to degenerate into ulcers of a venereal 
aspect ; and it is a very remarkable fact that, in the same individuals, 
or in different circumstances, the bites of leeches rarely change into 
venereal sores, when the animals have been applied to parts remote 
from the genital organs: this remark has already been made by M. 
Desmelles. 

919. When secondary syphilitic ulcers are long kept in an irritable 
state, by means of stimulating applications, or indulgence in wine 
rich food, &c, in individuals disposed to cancerous affections, the 
diseased parts harden, become covered with yellowish excrescences 
and are attacked with acute lancinating pains {degenerated venereal 
ulcers). 

920. Secondary venereal ulcers have also been frequently observed 
on different mucous membranes. Those of the velum palati, of the 
uvula, of the posterior surface of the pharynx, of the tonsils, &c, are 
by much the most frequent of any ; but they are also encountered on 
the gums, on the inner aspects of the cheeks, in the vagina, &c. Like 
secondary venereal ulcers in general, those of the throat are not pain- 
ful, and patients are frequently only admonished of their existence 
by the difficulty they experience in speaking or in the act of swal- 
lowing. The bottom of these ulcers at their outset, is of a grayish- 
white, like that of primary venereal sores. The colour is due to the 
presence of a layer of solid matter, proceeding from a kind of mortifi- 
cation of the tissues. This kind of eschar is very superficial at first, 
and resembles a strongly adhering false membrane; by and by it is 
detached, and leaves exposed a deep and well-defined ulcer pro- 
duced by this loss of substance. This chancre-like inflammation 
frequently occasions the destruction of the uvula and velum palati. 

In other cases these pharyngeal ulcers are preceded by flat tuber- 
cles; their progress is then less rapid. After the cure of venereal 
ulcers of the pharynx, cicatrices of a bluish tint, but which become 
white in the course of time, are observed on the surfaces they occu- 
pied. In some cases, moreover, considerable deformity of the pillars 
of the velum palati are observed to ensue. These parts are very apt 
to contract adhesions with the posterior parietes of the pharynx. 

On the inner aspect of the cheeks, along the edges of the gums, 
and on the palatine arch, venereal ulcers frequently present the serpi- 
ginous character; their edges, which are irregularly jagged, and their 
surface, almost always present a bluish-white cast of colour, very 
distinct from the usual colour of venereal ulcers of the throat. The 
serpiginous venereal ulcer of the inner surface of the cheeks, like that 
of the skin, frequently heals up at one end whilst it is advancing by 
the other. When completely whole, the cicatrice is often torn by the 
motions of the parts occasioned in speaking and mastication. 

Ulcers and their cicatrices are occasionally seen in the vagina, and 
even in the oesophagus and larynx. Ulcers of the nasal fossa? coin- 
cide for the most part with affections of the bones of these parts or of 
the arch of the palate. 2 

2 Some cases go to prove that syphilitic ulcers may be evolved in other parts of 
the internal mucous membranes. Joubert tells us that he had observed them in the 
trachea; and ulcers of the large intestines have been discovered in the bodies of 
those who either died whilst labouring under constitutional syphilis, or who had, at • 
some former period of their lives, suffered from this cause, which bore a great re- 
semblance to syphilitic serpiginous ulcers of the skin. Although the following case 
may not be held conclusive, I am tempted to state it briefly: A man about thirty 
years of age, and of fair constitution, was recommended to my care at the Hopital 
de la Charite, on account of a disease of the great intestine, which was accompanied 
with the excretion of a certain quantity of pus, which was at one time passed along 
with the feces, and at another came away pure or mixed with blood. The finger, 
passed up the rectum, detected neither stricture nor swelling. M. Uostellat, by means 
of his improved bougie (porte meche), showed us that the ulcer was situated at the 
upper part of the rectum. The patient's appetite was good, and there was no visible 
derangement in any other part of the intestinal canal, nor in any other apparatus of 
the system. The patient had not observed that his evacuations were purulent for 
more than seven or eight months ; he made no complaint of pain in the abdomen, 
and very strong pressure was required over the recognized seat of the disease to 
cause any even there. The absence of acute pain, and of all the other general 
symptoms proper to cancerous affections, did not allow me to entertain the idea that 
the ulcer was of this nature; but it was in vain that I persevered during the course 
of two months in the use of every means I thought likely to bring about the cicatriza- 
tion of the sore — no progress seemed to have been made in the cure. The patient 
having at a former period laboured under a venereal affection, although there was 
now no evident symptom of the disease, I determined on trying the effect of the pills 
of mercurial ointment, (three of Sedillot's pills daily,) and in the course of a fortnight, 
under the influence of this remedy, the purulent discharge began to diminish, and at 
the end of two months ceased entirely, when the cure appeared to be complete. 



SYPHILID A. 



301 



921. Although the appearance of secondary syphilitic ulcers is 
very nearly the same as that of primary sores, many, since the publi- 
cation of Mr. Hunter's experiments, have imagined that the nature 
of these two species of ulcer was not identical ; that primary sores 
were contagious, for example, and that secondary ones were not. 
Still, the greater number of observers admit, with Hunter, that both 
of these varieties of ulcer, especially the latter, are advantageously 
treated by the exhibition of mercury. This circumstance has been held 
by other practitioners as a sufficient proof of identity in the nature of these 
ulcers, and they have admitted all indiscriminately as contagious, (a) 

922. On the mucous membrane of the genital organs, around the 
anus, more rarely on the common integument of the body, and on 
the mucous membranes of the nipples, of the mouth, pharynx, &c, 
we frequently observe excrescences evolved in the form of warts, 
cocks'-combs, cauliflowers, &c. These are due to morbid thickening 
of the corion, vascular rete and epidermic lamelke, and to increase 
of size in the papillae of the skin. 

These excrescences are of two descriptions: syphilitic and non- 
syphilitic. To distinguish them, attention must be paid to the situa- 
tion in which they are evolved, to the previous state of the surface 
upon which they have appeared, to their progress, and to the coinci- 
dence or otherwise of syphilitic symptoms generally, rather than to 
the physical characters of the growths themselves, which generally 
bear the greatest resemblance to each other, whether they be specific 
or not. Hunter 1 and several other writers have denied the existence 
of any excrescence truly syphilitic in its nature. They regard the 
whole of these growths as the consequence of simple inflammation, 
and rest this opinion mainly or altogether on the fact of the little 
influence possessed by mercury in their treatment. But if the in- 
flammation of chancre has the power of causing what may be called 
primary excrescences, numerous cases leave no doubt of the fact, 
that certain excrescences are owing to the syphilitic cachexia, and 
that they sprout without evident inflammation. 

(a) " The general proposition, that secondary syphilis in all its 
stages is incommunicable, is liable to some exceptions. A mother 
labouring under syphilis may communicate it to her child in utero, 
and the child may be infected after birth by a nurse who has at the 
time syphilitic ulceration of the nipples, or by its mother under the 
same circumstances, if the disease of the nipple have been derived 
from a strange child ; but we are told, curiously enough, that no 
instance is known of a child, diseased in the manner just specified, 
infecting its own mother, although it will readily transmit the syphi- 
litic disorder to a strange nurse. A woman thus affected, and in 
whom, together with ulceration of the throat and cutaneous erup- 
tions, there are moist excrescences about the pudenda, may transmit 
the disease to the husband. Dr. Codes believes that the secondary 
form of syphilis may be farther imparted to other members of the 
family, by contact, use of the same utensils,, &c. He asserts that its 
contagious property, but not its virulence, increases in proportion as 
it extends farther from its source." — Bell Sf Stokes's Lectures, fyc, pp. 
565-6, vol. ii., 3d ed. 

As regards the order of causation in syphilida generally, there is 
no little difference of opinion. M. Cazenave asserts, that they may 
appear simultaneously with the primary disease, chancre, gonorrhoea, 
&c, and hence be themselves primitive, as well as, a more common 
case, occur after a longer period from the first infection, being then 
secondary or consecutive syphilida ; or, finally, be congenital, consti- 
tuting hereditary syphilida. This author, like Carmichael, contends 
that syphilitic eruptions may ensue on simple gonorrhoea, and even, as 
it would seem from some estimates, more frequently after this disease 
than chancre. The period of incubation, or that between the primary 
infection and the appearance of the syphilida, has been stated in the 
text (§856 and note). M. Cazenave makes the average about five years; 
and their early development most probable after chancre complicated 
with bubo. The papular and exanthematous syphilida appear in the 
shortest, and the tuberculous in the longest period after the primary 
disease. 

' Hunter (J.) on the Venereal Disease, 4to. London, 1786. Part iv., chap. 5, sect. 
4.— Cooper (S.) Dictionary of Practical Surgery, 6th edition, 8vo. London, 1830, Art. 
Wart. 
76 



Excrescences of the description under review have been met with 
in many parts — about the verge of the anus, on the navel, on the 
wrists, near the angles of the mouth, around the neck, &c. 

About the verge of the anus, 2 they have always a broad base, and 
generally extend in the form of broken arcs of circles or imperfect 
rings; they are flattened, nearly of the same colour as the skin, often 
moist on the surface, and the neighbouring integument is occasion- 
ally red and slightly excoriated. When one of these warty bands is 
put upon the stretch by drawing the skin opposite ways, especially 
in the direction of its breadth, the surface is made to exhibit a great 
number of clefts, some of which, deeper than the rest, show them- 
selves as true rhaghades. Those excrescences, the surface of which 
looks flattened, are occasionally formed by a succession of foliaceous 
prolongations applied one over the other. When they are removed 
with a knife, they are found to be formed by an hypertrophy of the 
corion, the development of which has not been equal at every point. 
Under the magnifying glass, this inequality of development is very 
apparent ; the vessels which shoot into the different points of excre- 
scence, are, however, generally obvious even to the naked eye. The 
cuticle which covers them is frequently softened. 

The excrescences with broad bases are very distinct from those 
fungous tubercles upon which excrescences are only evolved after 
they have fallen into a state of ulceration. 

In the perineum, excrescences occur more rarely than they do about 
the margin of the anus. They are oftenest seen extending along each 
side of the raphe, and have all the characters of those of the funda- 
ment. 

I have met with syphilitic excrescences surrounding the wrist, 3 in 
the shape of a broad band, and forming a kind of warty nap or pile, 
by the assemblage of an infinity of minute papillary prolongations, 
several lines in length, redder than the surrounding skin, and in 
several places covered with a cuticle of considerable thickness. The 
excrescences that are occasionally observed about the alse of the nose, 
on the eyelids, or in the meatus auditorius externus, approach in 
their general appearance to those of the wrist and perineum. 

Cutaneous excrescences may show themselves, especially on the 
neck, under another guise, that namely of small flattened tumours the 
size of a lentil, of a yellowish or brownish colour, soft to the touch, 
not cleft on the surface, and in which the morbid growth of the corion 
appears to have taken place evenly and in circumscribed points. 

923. Excrescences of the mucous membranes of the genital organs 4 
appear most frequently among men, in the depression which separates 
the corona glandis from the prepuce, sometimes on the prepuce itself, 
more rarely on the glans itself, or about the orifice of the urethra. 

2 The excrescences, with broad bases which are evolved in the neighbourhood of 
the rectum, were known to, and have been more or less accurately described by, the 
ancient authors, under the name of thymi and condylomata. (Celsus, de re medicu. 
lib. v., sec. 18, 8. Lib. vii., sec. 30.— C. Plinii. Sec. Histories mundi, lib. xxx. c. 8. 
fol. Lugduni, 1587.) Galeni Opera, fol. Basil, 1562. CI. iii. p. 170, et chap. v. p. 41 1 . 
Cselius Aurelianus, de morbis acutis et chronicis, J. Conrado, edente, &c. Amste- 
lodami, 4to. 1549, p. 393.— ^Etii, Tetrabiblos, editio Cornarii: Basil, 4to. 1749, de 
affectionibus sedis, p. 739. — Paul -Egineta?. Opus de re Medica, lib. vi.cap. 80, Pa- 
risis, 1532. ^Etius has given a good description of the other species of excrescences 
which appear round the anus, under the name of thymi and sycosis: 

"Thymi enim in corpore tuberculosa? sunt eminentias, asperae, subrubrae, oblonga?, 
praeter naturam auclae, sanguinem efFundentes dum auferuntur amplius quam pro 
apparente magnitudine. Abundat autem hsee affectio circa sedem et pudenda ac 
media femora. Quandoque etiam in facie constitit. Et quidam sane parvi sunt et 
vocantur thymi: aliqui vero magnitudine excedunt, et appellantnr ficus. Mansueti 
igitur thymi, carunculas sunt parvae quidem, verum inasquales, obscuris emineniiis 
exasperates, albicantis colons, aut subrubrae et doloris expertis ...Medicamenta quae 
consumunt ac resiccant thymos, sunt ea quae communiter curant etiam reliquas 
verrucas." (Op. cit. p. 741.) These excrescences appear even to have been known 
to the Roman poets: "Sed podici laevi cceduntur tumidce medico ridente marescse'' 
(Juvenalis. Satyr ii.) Celsus seems to regard them as the consequences of inflam- 
mation. 

3 An old man, who had had a dozen different attacks of venereal disease, came 
under my charge at La Charite, as affected with rheumatism. On the palmar aspect 
of the wrist, he had a large reddish spot, in shape something like a horse-shoe, the 
surface of which was beset with papillary warts covered with thick cuticle, which 
could be detached by the use of warm fomentations. They then appeared under the 
guise of a kind of turf or nap, very similar to those syphilitic excrescences which 
occur at the root of the glans. Were these excrescences syphilitic or not] They 
were certainly in a situation where such growths are rarely seen, and had all appeared 
in the course of the last five or six years. 

* Excrescences of the penis appear to have been mentioned by Celsus : "OccaN 
lescit etiam in cole interdum aliquid, idque omni pene sensu caret quod ipsum quoque 
excidi debit." .Etius describes them more clearly: " De thymis in sede diximus, 



302 



SYPHILIDA. 



Among women they occur most frequently on the inner surface of the 
labia raajora, or at the junction on the labia minora. Different titles, 
such as coc&s-comb, cauliflower, and raspberry excrescence, have been 
u'lvcn according to the general forms and appearances of these growths, 
which often occur severally, but frequently also blended together in 
particular cases. 

By cauliflower venereal excrescences are understood small reddish 
or whitish tumours, single or manifold, which arise from the mem- 
brane upon which they are developed, by means of a kind of peduncle 
or foot-stalk, and expand into a voluminous granular head, occasion- 
ally bleeding or covered with a puriform secretion. These excre- 
scences, by their numbers or their size, impede in a greater or less 
degree the functions of the parts upon which they sprout. Thus, 
when they are evolved about the extremity of the prepuce in indi- 
viduals labouring under phymosis, or when they nearly close up the 
meatus urinarius, they render the excretion of urine difficult. They 
have been seen evolved beneath the prepuce as large as a walnut, 
projecting in very strong relief externally, and accompanied with a 
fetid discharge. In some cases, too, in which the prepuce has chanced 
to be perforated by a syphilitic ulcer, venereal excrescences have been 
observed evolved near the corona glandis, which penetrating and 
passing through this opening, expanded greatly externally. In fe- 
males, an extensive crop of these excrescences has been seen, obstruct- 
ing the orifice of the vagina, and proving an obstacle to sexual inter- 
course and parturition, until removed by an operation. 

924. On the surface of the tongue and in the throat, excrescences 
have frequently been known to exist, the nature of which was never 
ascertained. Excrescences of the cauliflower kind, have been known 
to occur in the pharynx, 1 and to attain such dimensions, that after 
having altered the voice, and impeded respiration more and more, 
they finally caused death by suffocation. 

Cases in which excrescences of a venereal aspect were evolved on 
the inner membrane of the heart, 2 and great vessels, have been re- 
corded. If, in some instances, there be a show of probability in con- 
sidering such excrescences as syphilitic, there is not one on record in 
which they have been proved irrefragably to have been so ; and on 
the other hand, it is undoubted that they have been met with in indi- 
viduals who had never in their lives suffered from syphilis. 

925. Syphilitic alopecia or baldness, (Pelarola, Brassavolus,) 3 which 

fiunt autem et-hic thymi aut in sola glande, aut in cole, aut in praputio. Antea vero 
dictum est quod mansueti facile curantur, maligni difficiliter et per affect® partis 
ablationem sanantur." — (Opus cit., de ihymis in pudendis, p. 748.) The historians 
of the syphilitic epidemic of the middle ages seem to have paid little attention to 
these excrescences of the genital organs and verge of the anus. Yet Fallopius 
describes them with care, and speaks of their proper treatment. He observes that 
they are consequent on ulcers : " Ultimo sanatur caries in pudendo, et solet semper 
loco cicatrices subcrescere quadam verruca, veluti carunculae," etc. — He distin- 
guishes them into syphilitic and non-syphilitic. — " Harum (op. cit., p. 817), duplex est 
genus, aliud gallicum, aliud non gallicum, major pars non est gallica." He remarks, 
however, that excrescences not syphilitic may become contagious through negli- 
gence of proper cleanliness. (Of late M. Desruelles has given a very particular 
account of these excrescences in his Second Memoire, inserted in the Mem. de Med., 
&c. Mililaire, vol. xxviii. p. 337.) 

1 Marcellus Donatus has given a case which is quoted by Schenckius (lib. i. de 
faucibus, obs. ii.). "Civis habitu corporis melancholico prsedilus verrucis quam- 
pluribus gutture, faucibus et radicem linguae occupantibus diu vexatus fuit." — Albu- 
casis (Chirurg., lib. ii. cap. 36), relates the case of a woman, in whom excrescences 
in the interior of the throat impeded respiration and deglutition. Andral has given a 
case of growth within the larynx (Precis d'Anatomie Pathol., t. 2eme partie, p. 472). 
M. Ferrus showed a preparation very nearly similar to that described by Andral, at 
one of the meetings of the Acad. Royale de Medecine. I met with a third instance of 
the same kind at the Hopital de la Charile, in the body of a woman, aged about fifty. 
The tumour was attached near the upper edge of the left ventricle of the larynx, and 
expanded above its upper orifice. M. Roux had already discovered this portion of 
the tumour with his finger ; and its presence was farther proclaimed by a distressing 
dyspnoea, and a peculiar whistling of the air, especially as it entered the larynx in 
inspiration. Had not symptoms of inflammation of the lungs been detected, and led 
me to augur unfavourably of the result of an operation, M. Roux would have per- 
formed tracheotomy ; and possibly this might have been done with success. 

2 Corvisart gives two cases of excrescences of a venereal appearance existing on 
the mitral valves of individuals who had been formerly affected with venereal dis- 
eases.— (Essai sur les Maladies, &c, du Coeur, 8vo. Paris, p. 217.) Laennec has 
described two species of excrescence of the lining membrane of the heart. — 1st. 
Vegitatiotu verruqueuses,- 2d. Vegetations ghbukusa ,- but he thinks we have no ade- 
quate grounds for speaking of them as syphilitic in their origin.— (Traite de TAus- 
c.ultalion mediate, t. ii. p. 618, 2eme ed. Paris, 1826.) Messrs. Benin and Bouillaud 
believe that the influence of syphilis, in the production of these excrescences, has 
at all events been greatly exaggerated.— (Traite des Mai. du Cceur, 8vo. Paris 1824 
p. 232.) 

s H. Fracastorius speaks of the loss of the hair and beard, as one of the frequently 



was a frequent symptom of constitutional infection, during the latter 
half of the sixteenth and beginning of the seventeenth century, is at 
the present day one of the rarest phenomena of the disease. For 
more than twenty-five years, says Cullerier, during which I have seen 
from two to three thousand venereal cases annually, I have not met 
with more than three or four instances of general alopecia, and fifty 
or sixty of the partial affection. 1 

I have myself noted no more than a single case of general baldness 
from a venereal cause ; but I have repeatedly seen the hair partially 
lost, among individuals who exhibited the characteristic symptoms of 
constitutional syphilis. 

Syphilitic alopecia cannot be distinguished from the other varieties 
of the same affection, save by the nature of the symptoms which 
accompany or precede it; one of its most striking characters is its 
accompaniment by nocturnal pains in the bones. 

926. The nails as well as the hair undergo several changes in con- 
sequence of venereal infection. We have to specify, 1st. Inflamma- 
tion of their matrices, generally known under the name of syphilitic 
onychia; 2d. Certain changes of structure in the nails; 3d. Loss of 
the nails (syphilitic ungueal alopecia). 

Syphilitic onychia 5 is observed to occur more frequently in the toes 
than in the fingers. Several toes are usually affected at the same 
time ; and it is not uncommon to see the whole of them either simul- 
taneously or in succession attacked with this kind of inflammation, 
which is almost invariably accompanied with unequivocal symptoms 
of general venereal infection; in some rare instances, the disease is 
seen expending its virulence almost exclusively on the matrices of the 
nails. 

In the greater number of cases, the border which externally marks 
the root of the nail and extends along its sides, swells in one or more 
places without any great amount of pain. The swollen parts have a 
violet or livid red colour ; after the lapse of several days, their surface 
becomes excoriated. It frequently happens, too, that a sero-purulent 
exudation takes place between the root of the nail, and the swollen roll 
of skin which covers it ; ulcerative inflammation then commences, and 
destroys this fold of integument to a greater or less extent, and ex- 
poses almost the whole of the root of the nail. If the disease be left to 
itself, the neighbouring integuments swell, the edge of the ulcer be- 
comes painful, and has a grayish colour; a sanious discharge lodging 
between the nail and its matrix, loosens it partially at first, and ulti- 
mately brings about its complete detachment. The matrix of the nail 
thus exposed, has the look of a sanious ulcer, surrounded by a red and 
swollen marginal roll, which, in one or several places, is the seat of 
ulcers often characteristic in their appearance. If no steps be taken 
to check the progress of the disease, the edges of the sore become 
fungous ; shapeless horny productions are thrown out from the surface 
of the matrix on those places that have escaped ulceration ; and in 
this state the mischief is always remedied with extreme difficulty; the 

occurring symptoms pf syphilis: " Et quod mirum omnibus visum est, capillorum.et 
reliquorum pilorum casus homines fere ridiculos facit, aliis sine barba, aliis sine 
superciliis, aliis glabro capite in conspectum venientibus: quod infortunium prius 
putabatur ex medicaminibus evenire, praesertim ex argento vivo : mox certiores facti 
omnes, sciunt ex ipso morbo immutato procedere, quin immo (etquod pejus est) jam 
nunc multis videntur labefactari derites, quibusdam etiam cadere (Opera omnia, 4to. 
Venetiis, 15-84. De morbis contagiosis, cap. ii. ; de syphilide, p. 91). This symptom, 
which has been ascribed to the action of mercury, was consequently observed among 
individuals who had undergone no kind of treatment. Vide Forestus (De lue venerea, 
lib. xxxii. obs. 25), and the passage of Fracast as quoted. Massa also speaks of the 
loss of the hair in syphilis : " Et quoniam inter quamplurima morbi gallici accidentia 
depilationes capillorum, barbae, aliarum partium corporis," etc. (Aphrodisiacus, p. 
103.) Ferri (De morbo gallico.— Aphrod., p. 438), J. B. Montanus (De morbo gallico. 
— Aphrod., p. 584), B. Victorius (De morbo gallico.— Aphrod., p. G45), G. Fallopius 
(De morbo gallico. — Aphrod., 822), h. Botallus (Luis vener. curandi ratio.— Aphrod., 
p. 875), D. Leonus (De morbo gallico.— Aphrod., p. 906), F. Frizimelica (Be morbo 
gallico tract.— Aphrod., p. 998), and a great number of other authors speak of the phe- 
nomenon, with more or less ample details. On this the reader may farther consult 
Fernelius (De lue venerea.— Aphrod., p. 613), A. M. Brassavolus, (De morbo gallico. 
— Aphrod., p. 650,) who make a distinct species of syphilis of it. 

4 Diet, des Sciences Med. Art. Alopecie Venerienne. 

5 In the Aphrodisiacus, several passages having reference to the loss of the nails 
may be found; but inflammation of their matrices is no where clearly mentioned. In 
latter times, Astruc, and several other authors have spoken of it,or have given cases: 
Delpech (Chirur. clinique, 4to. Paris, 1833, t. i. p. 364 : ulceration du contour des 
ongles). — Lelut (Etudes anatomico-pathologiques sur I'onglade).— Devergie (Clinique 
de la maladie syphilitique, 4to., t. ii. pp. 221, 403, Art. Onglade).— Recamier (Revue 
Medicale, mars 1830). — Ratier (Journal Hebdomadaire, 2eme serie, t. viii. p. 48).— 
Rynd. On onychia. (The Dublin Hospital Reports, t. v. p. 274.) 



SYPHILID A. 



303 



affection of the ungueal matrix has then gone to such lengths, that the 
production of a well-formed nail becomes impossible in future. 

927. By contrasting these characters with those of scrofulous 
onychia, (§ 739,) little difficulty is usually experienced in distinguish- 
ing the two diseases from one another. With regard to primary syphi- 
litic sores which have been occasionally seen evolved on the fingers, 
the venereal poison having been inoculated by means of a scratch or 
an abraded surface, they differ essentially in their progress from the 
chronic inflammation of the ungueal matrix, known under the name of 
onychia. 

Syphilitic onychia does not always appear with characters so de- 
structive as those which have been indicated : after the ulceration of 
the fold of skin which covers the root of the nail, this last is thrown off 
without the matrix itself becoming ulcerated ; a new nail is ere long 
produced, the inflammation abates, and the disease goes on to recovery; 
but this amendment frequently proves no more than temporary, and 
the disease makes its attacks upon one or several others of the digits. 

The distinguishing feature of this species of onychia is its occur- 
rence independently of all appreciable outward cause. It is also very 
constantly distinguished in one case, by the grayish and eroded ap- 
pearance of the sores ; in another, by the other general syphilitic 
symptoms with which it is accompanied ; in a great number of cases, 
however, the influence of mercurial preparations in its cure, is the 
final and irrefragable criterion of its actual nature. 

928. According to Astruc, 1 the inflammation and suppuration of the 
ungueal matrices which constitute syphilitic onychia, may be preceded 
by an alteration of the nails themselves, which become hard, brittle, 
and similar to those we shall have occasion to describe in the follow- 
ing paragraph : this must be a very rare occurrence, however, for I 
have never met with it myself, and in all the writers I have consulted 
op the subject, I have observed no mention of a similar case. 

929. Under the influence of an inveterate syphilitic infection, the 
nails occasionally undergo a remarkable change in their appearance 
and in their structure. 2 From their extremities, and to a certain dis- 
tance upwards, they become thicker, drier, more brittle, and more 
opaque than usual ; they are frequently of a yellowish-white colour, 
and exfoliate or throw offpieces from their surface, which then appears 
rugous, cracked, and uneven. The extent of this alteration is accu- 
rately shown on the nail by the change of colour in the part affected. 
I have had patients under my care, who, though they had repeatedly 
taken away with a file or pen-knife, almost the whole of the nails thus 
affected, assured me that the nails were constantly reproduced with the 
same alteration of structure, and the same general appearance. The 
act of cutting these thickened nails is almost always painful, on account 
of concussion given or traction exercised during the process being com- 
municated to the root of the ungueal matrix. 

This alteration of the nails is sometimes observed in different 
degrees, on those both of the fingers and toes at the same time. It 

i Demum ungues, qui extremce cutis appendices sunt, inaequales, crassi, rugosi, 
scabri fiunt, et obortis ad radices reduviis, panarilio, inflammatione, ulcere sponte 
decidunt unde Von glade. — (Astruc de Morbis venereis, 4io., lib. iv. cap. i. p. 333.) 

2 Contingit et in hoc gallico affectu unguium casus, quem ungiarulam vulgus vocat: 
affectus potius fccdus, quam dolorosus : nam decidunt ungues et capilli, ut denies 
faciunt, et hie affectus nonnnnquam capilloram casum sequitur, nonnunquam ante- 
cedil, tamen semper ilium proecedunt, aut bubo, aut penis exulceratio, aul oris exul- 
ceratio, etc. (Ant. Musae Brasavoli de radicis China? usu tractatus. — Aphrodisiacus, 
p. 727.) Consult, in addition, Augerii Ferrerii de pudendagra, liber secundus. — 
Aphrod., p. 925; J. Hunter, Traitedes maladies vene'riennes, trad, de l'anglais, p. 340; 
Cullerier, Dictionnaire des scien. med., Art. syphilis. 

"Si quis ungues veluti leprosos habeat, hoc morbo gallico referat acceptum. Hcec 
nutem affectio vulgo ab unguebus (onglade) vocatur." — (G. Rondolet. De morbo 
gallico. — Aphrudis., p. 939.) I was lately consulted by a man of vigorous constitu- 
tion, aged fifty-four, who, when only eighteen years old, had contracted bubo and 
several chancres, which had got well under the use of mercurial inunctions and fifty- 
four days confinement. At the age of thirty-five, he contracted gonorrhoea, which, 
treated at first by emollients, and afterwards by the balsam of copaiva, was followed 
by pains in the joints. These went off, and he continued well till the age of forty- 
seven, when the nails of the feet began to change without pain: a yellowish dry 
matter was first deposited between the inferior surface of the nail and thecorion; 
the nails themselves became in part yellow and brittle. Shortly afterwards the nails 
of both hands became affected in the same manner. These the patient filed away to 
near their roots, in the hope of seeing them reproduced of natural appearance. The 
alteration of the nails was speedily followed by plantar pains of such severity as to 
prevent the patient from sleeping. I prescribed a course of blue pill and tisan of 
Feliz ; after three weeks the pains in the soles had almost ceased, and the nails were 
shooting forth much less altered in their appearance: every thing promises a speedy 
and complete recovery. 



is frequently accompanied with considerable pain, which is com- 
plained of, especially during the night, and about daybreak, in the 
soles of the feet. I have observed this alteration of the nails in indi- 
viduals who had formerly suffered under syphilis, and occasionally 
when no other trace of the disease remained. In these cases, I was 
only led to look on the alteration of the nails as engendered by a 
syphilitic cause, from finding that the pains which accompanied it, 
disappeared under the influence of the administration of mercury, 
and that the diseased nails were, after the course was completed, re- 
placed by others of normal appearance. 

This affection of the nails is extremely rare, and must not be con- 
founded with that which occasionally occurs in the course of invete- 
rate lepra, psoriasis, and pityriasis, and as a consequence of chronic 
eczema of the fingers. 

Several authors mention a syphilitic ungueal alopecia, (unguiarola 
Brassavolus,) or loss of the nails without previous syphilitic local 
symptoms, in individuals labouring under constitutional syphilis. 

930. Several writers mention the alteration and loss of the teeth, 3 
(Dentarola, Brassavolus,) analogous to those of the nails, in conse- 
quence of a syphilitic taint of the constitution. Were I to decide 
according to my individual experience, I should say that such affec- 
tions of the teeth were extremely rare at the present day; perhaps I 
have not investigated the point with all the attention necessary. 

931. The whole tribe of syphilitic eruptions are frequently compli- 
cated with one another: it is common enough at the same time, and 
in the same individual, to meet with tubercles, squamous patches, 
papular eruptions, maculae, &c. And these simple or complicated 
tegumentary affections, are almost always preceded and accompanied 
with a variety of other symptoms proper to constitutional syphilis. 

932. Articular pains,* and pains in the bones, are the most frequent 
of all the symptoms of constitutional syphilis. Their distinguishing 
peculiarity is their greater severity during the night than during the 
day, and the readiness with which they yield to the administration of 
mercury. The more superficial bones, the tibiae, the humeri, the 
cranium, the clavicles, &c, are the most frequent seats of these 
syphilitic nocturnal pains. 

933. Syphilitic periostosis, exostosis, caries, and necrosis, 5 occa- 
sionally follow the cutaneous eruptions which are due to the same 
cause ; always more obstinate than these last, they often continue 

3 These affections of the teeth, as symptoms of syphilis, are mentioned by the older 
writers: " Addite (de signis morbi gallici) corruptionem palati et dentium." G. Fal- 
lopii de morbo gallico tract. — Aphrod., p. 781. — Aug. Ferrerii, de pudendagra, lib. 
secundus, cap. ix. Ad commotos et infectos dentes. — Aphrod., p. 926. Itaque, si una 
cum pilorum defluvio, dentes unguesve decidunt .. .citra tamen unguentum exhydrar- 
gyro, et suffimentum ex cinnabari utendum. (Alex. Sraj. Petronii. De morbo gallico. 
Aphrod., p. 1336.) Others have spoken of the loss of the teeth; but it appears 
probable, from their mode of expressing themselves, that they intended to signify the 
loosening and loss of the teeth consequent on the destruction of the gums by venereal 
ulcers. "Et corrosionem gingivarum et casus dentium causat." (A. Massa. De 
morbo gallico. — Aphrod., p. 103.) 

* These pains, which, by some pathologists, have been attributed to the action of 
mercury, were frequently complained of on the first appearance of the epidemic 
syphilis, in the middle ages, shortly after the invasion of the disease, and before any 
kind of treatment had been tried : " Nicolaus minor Valentinus, mini intima caritate 
conjunctus, setatis xxiv., annorum fere, mediocris staturee, atque habitudinis, de mense 
Augusti habuit rem cum muliere, habente pudendagram; quare eadem die ipse fuit 
eodem morbo infectus, qute infectio incepit apparere in virga, ut solet ut plurimum 
aliis evenire. Nam sequenti die apparuit ulcus in virga cum quadam duritie longa, 
tendente versus inguina ad modum radii cum sorditie et virulentia. Post sex dies, 
ulcere semicurato, arreptus fuit ab intensissimis doloribus capitis, colli, spatularum, 
brachiorum, tibiarum, et costarum, et praesertim sic eorum musculis cum maximis 
vigiliis a quibus molestabatur non nisi in nocte post primum somnum" (Gasparis 
Torrellse. Consilia adversus pudendagram.— Aphrodisiacus, p. 548). Invenit ei 
dormiendo in eodem lecto cum fratre suo iufecto, et incipit a. doloribus, tandem post 
duos menses, facto tota die laborioso exercitio, in nocte, hora qua molestabatur a 
doloribus, a capite usque ad pedes correptus fuit a pustulis grossis, crustosis cineri- 
ceis, et postea non fuit molestatus a doloribus. (Ibid., p. 550.) 

I have myself known pains of this description to occur in consequence of gonor- 
rhoea, and other primary symptoms, which had been treated without mercury. 

s "Corosiomalaossis... fit que duriliesjuncturarem cum tumore in morbo inveterato" 
(N. Massa. De morbo gallico. — Aphrodisiacus, p. 46.) Fallopius gives a more ample 
description, and appears to have been the first who broached the opinion, adopted by 
so many of the recent writers, relative to the influence which the use, and especially 
the abuse of mercury, has on the production of these affections of the bones. "Saeva 

valde est in morbo gallico ossium corruptio ita ut tolum viderim cranium exesum: 

ego habeo infinita exempla; sed aliquando etiam corrumpuntur ossa palati, ut totium 
palati os recedat, et non solum palati ossa id patiuntur, sed etiam narium : et sciatis, 
quod non in omni inveterato gallico hoc fit, sed lantum in illis, in quibus inunctio 
facta est cum hydrargyro." (Fallopii. De morbo gallico tractatus. Aphrod., p. 827.) 



304 



SYPHILIDA. 



after the disappearance of the cutaneous affections, and then require 
particular modes of treatment for their cure. 

The gummy tumours, (gummata, atheromata, 1 ) situated more 

, than syphilitic subcutaneous tubercles, and very frequently 

developed over bones, are frequently followed by ulcers in the form 

'rations or holes ; they are very rarely met with accompanying 

a first attack of syphilitic eruption. 

Under the title of caclvexiu syphilitica, medical writers have 
described a profound and serious implication of the general system, 
which cannot usually be satisfactorily explained from any great severity 
in the evident symptoms of a syphilitic taint, nor from the extent of 
the lesions which have preceded it, nor from the influence of any 
measures of cure which may have been employed in previous stages 
of the complaint. We do occasionally, in fact, meet with adults, and 
men still in the vigour of life, who, having contracted syphilis, appear 
to sink prematurely into old age ; their skin sallow, loose, and earthy 
to the touch, seems more than adequate to surround their shrunken ex- 
tremities. With this cachexy of adults, we must assimilate that under 
which those unfortunate children almost always labour, whose parents 
are affected with constitutional syphilis : these infants have the look 
of diminutive old men. 

936. Phagedenic ulcers of the amygdalae, velum palati, and pha- 
rynx, 1 are very frequently encountered at the same time as venereal 
eruptions. Serpiginous ulcers of the gums, of the tongue, and inner 
aspects of the cheeks, are much less commonly met with. 

937. Purulent syphilitic ophthalmia is often associated with vene- 
real eruptions among newborn infants ; and ophthalmia without puru- 
lent discharge and unaccompanied with pain, but frequently followed 
by small ulcers, spots, and partial opacities of the transparent cornea, 
is often observed along with syphilitic eruptions in adults. Iritis is 
found to occur along with various forms of syphilide, but more fre- 
quently with the papular than any other. I have several times seen 
the affection supervene after the apparent cure of this eruption, and 
without the recurrence of any other form of syphilide. 

938. Several diseases of the nervous system, amaurosis, deafness 
from paralysis of the auditory nerve, paralysis of the limbs, neuralgia, 
6cc, and different internal inflammatory affections, as of the oesopha- 
gus, larynx, trachea, and even of the bronchi and intestinal canal, 
observed in individuals suffering under cutaneous eruptions and 
various other serious symptoms of constitutional syphilis, are phe- 
nomena which have been called in question on account of their 
extreme rarity, but of which the 'reality can be proved by incontest- 
able facts. The venereal nature of such accidental and grave diseases 
is rendered still more probable by the circumstance of their yielding 
readily to mercury. 

939. To conclude, almost the whole of the simple inflammatory 
affections of the skin, such as scabies, eczema, prurigo, &c, &c, may 
be accidentally associated with an eruption of a truly syphilitic nature : 
in the public prisons it is by no means uncommon to find scabies com- 
plicated with constitutional syphilis, (a) 

If the diagnosis of these complex cases require much discrimination 
on the part of the physician, there are other complications, the treat- 
ment of which is surrounded with peculiar difficulties : such are those 
in which constitutional syphilis is associated with scrofula, with scor- 
butus, or chronic inflammation of the ccecura and colon. 

940. Diagyiosis. — I have already made known the distinguishing 
characters of the different varieties of syphilitic eruption, from those 

(a) A good description of venereal eruptions will be found in Mr. 
Babington's Notes on Hunter (on the Venereal Disease. — Am. Ed., p. 
2 12-4,) and a yet fuller one in M. Cazenave's Traite des Syphilides. 

6 "Prseterea sunt aposlemata dura, adhcerentia paniculis et ossibus ut sunt ossb 
furculae pectoris, crurum, et frontis quae a vulgaribus gummata appellantur...hanc 
eamdem materiam videmus quotidie in apostematibus duris quae vulgares gummata 
appellant. Nam quanda inciduntur, aut ex se rumpuntur, sunt plena materia albas, 
nscosse, et aliquando cum lividitate, quandoque vero cum rubedine aliqua secundum 
diversam admistionem." Massa (Aphrodisiacus, p. 46— 43). G. Fallopius (De gum- 
matous galhci.—Aphrod., p. 826), distinguishes gummata galltca into topkacious or 
hard, which appear to have been nodes and thickenings of the periosteum, and soft, 
which included three varieties; one, of the consistence of lard; another, pultaceous 
(Atheroma galltcum) ; and a third, soft like honey (Meliceris gallica). 

' " A pnncipio apparent in gutture mollificatio uvoe et apostemata, sclerotica mala 
quae non maturantur nisi raro, et ulcerantur ulceratione maligna, quae apostemata in 
recidiva s«pe apparent," etc. (N. Massa. De morbo gallico.— Aphrodisiacus, p. 46 ) 



unspecific eruptions, of like elementary forms, or which bear any 
resemblance to the syphilides in outward appearance, or any analogy 
with them in their progress. (§§863 — 914.) I have also given the 
proper and distinguishing symptoms and characters of primary and 
secondary ulcers. To complete the diagnosis, I have only farther to 
exhibit the characters which distinguish syphilis from some other 
diseases, to which it bears a certain resemblance. 

941. Hunter, Abernethy, and several others, have spoken of certain 
eruptions having the appearance of true syphilides, and requiring to 
be distinguished from these, as differing from them essentially in their 
nature (pseudo-syphilis ; syphiloid diseases, Abernethy). 

I shall, by and by, examine (vide Vocab.), with reference to their 
similarity to syphilis, the affections entitled scherlivio, sibbens, rade- 
syge, yaws, maladie de la baie de Saint-Paul, morbus Brunno-gallicus, 
&c, which have been considered by some pathologists as distinct 
diseases, and by others, and more frequently, as peculiar or still 
undescribed forms of syphilis. Mean time the works of Hunter and 
Abernethy may be consulted for information in regard to the diseases 
which have been entitled pseudo-syphilitic. 2 

s Hunter (on the venereal, pt. vii.chap. ii.on the diseases which resemble syphilis), 
has endeavoured to show the analogy which scorbutic spots may in some cases 
present to venereal eruptions, of syphilitic to rheumatic pains, and of venereal tume- 
faction of the bones and periosteum, to that which is sometimes occasioned by scro- 
fula and rheumatism. Hunter asserts, moreover, that there are certain affections 
which resemble the venereal disease, not only in appearance, but in their mode of 
contagion ; that they give rise immediately to analogous effects, and produce conse- 
cutive symptoms resembling those of syphilis. In support of this opinion, he quotes 
the case of a surgeon, who, on opening an abscess in the shoulder of a negress 
labouring under yaws, accidentally inoculated one of his fingers, which was slightly 
excoriated, with the matter, and was attacked with tumours, that were unsuccessfully 
combated by mercury, with nocturnal pains of the tibia and fibula, afterwards with a 
scabby eruption on different parts of the body, and at a still later date with a dis- 
charge of viscid mucus from the throat and nostrils. 

To this case, which Hunter thinks ought to be distinguished, both from the venereal 
disease and the yaws, he adds two others: one is that of a man who, after being 
cured of a chancre, had, about six weeks after another sexual intercourse, an excoria- 
tion of the prepuce, which became very deep and painful; the woman was attacked 
with a swelling in the groin, which suppurated, and was cured at the end of six 
weeks ; but during that time the skin became covered with crusted pustules, some 
occurring on the face and thighs, though the hands and feet were more particularly 
the seat of the eruption, and there the epidermis was detached in scales. The whole 
of these eruptions got better without mercury. The second case is that of a man of 
debauched habits, who had a painful ulcer on the glans penis, which was made worse 
by the use of mercurial preparations; a considerable tumour existed on the right 
side of the frontal, and on the left parietal bone, together with spots on the inner part 
of the left tibia; these two symptoms disappeared; but some months afterwards, the 
tumour of the cranium reappeared ; several abscesses formed ; the bones of the skull 
became carious, and several ulcers were the consequence. 

A nurse gave the right breast to her own child, and the left to a child of a neigh- 
bour; about six weeks afterwards, several ulcers formed round the left breast, the 
glands of the axilla swelled, the ulcers spread, and the nipple was destroyed ; cicatriza- 
tion took place at the end of three months; the child had aphthae in the mouth, and 
ulcers on different parts of the body. This woman subsequently suffered from pains 
in the bones and joints, and these were succeeded by an eruption on the arms and 
thighs, which terminated in ulceration ; she was unable to take mercury on account 
of its always producing fever; she afterwards became pregnant, and was delivered 
of a diseased child, whose body was covered with a scabby eruption, and which lived 
about nine weeks. The child, for some time before its death, had been entrusted to 
the care of a wet nurse; before long, the nurse was attacked with pain in the head, 
sore throat, and an ulcer on the breast ; the bones of the nose and palate also exfoli- 
ated. The mother of the child again became pregnant, and was delivered of a sickly 
infant, which died at the end of a month. About a year afterwards, this woman's 
ulcers broke out afresh, and although they were treated with mercurial dressings, 
and mercury was also administered internally, it was not till the end of the year that 
they began to cicatrize. 

The first of these cases quoted by Hunter, will be particularly examined when we 
treat of yaws; the remainder do not appear to me to differ from ordinary cases of 
venereal infection, excepting as regards the inefficacy of the mercurial treatment, 
which, as is well known, is not applicable in all forms or at all periods of syphilitic 
disease. With regard to the cure of ulcers on the genital organs without mercury, 
we are no longer at liberty to conclude any thing from that against their venereal 
nature, since it is now an ascertained fact, that every form of ulcer of the genital 
organs is capable of being healed without the exhibition of this mineral. 

M. Abernethy (Surgical Observations, 8vo., London, 1804: on diseases resembling 
syphilis). "A gentleman thought he had infected a slight cut on his hand (which 
was situated in front and just below the little finger) with the discharge from a bubo 
in the groin, which he had opened. The wound fretted out into a sore, which he 
showed me, about the size of a sixpence, and which I affirmed had not the thickened 
edge and base, and other characters of a venereal chancre. I therefore recommended 
him to try the effect of local means and not to use mercury. In about a month the 
ulcer contracted in its dimensions, and assumed a healing appearance. A considera- 
ble tumour arose over the absorbing vessels which proceed along the inner edge of 
the biceps muscle. The tumour was discussed, and the sore healed without mercury. 
Three weeks afterwards, in each tonsil, there was an ulcer deeply excavated, wiih 
irregular edges, and with a surface covered by adhering matter; ulcers in short, 
which every surgeon who depends on his sight as his guide, would have pronounced 



SYPHILIDA. 



30.* 



Whilst the epidemic elephantiasis of the Greeks, (the leprosy of 
the middle ages,) was still frequently observed in Europe, and when 
syphilis prevailed extensively at the same time, it became of import- 
ance to point out the distinctive characteristics of these two diseases, 
both of which were looked upon as contagious, and both of which 
deeply deranged the constitution, produced spots, tubercles, and 
ulcers on the skin, caused the hair, eyebrows, and beard, to fall off; 
occasioned ulcerations in the mouth, nose, nasal cavities, and larynx. 

In the present day, well-determined differences in their appear- 
ance, progress, and above all, in the mode of development of their 
primary symptoms, would no longer leave any uncertainty as to the 
diagnosis of these two diseases, even if elephantiasis had not ceased 
to exist among us. 

Scorbutus can never be confounded with the cachectic state which 
is sometimes observed in constitutional syphilis, or after the abuse of 
mercurial preparations. 1 

With regard to scrofula, the glandular enlargements, the ulcers, 
caries and fistula?, which it produces, and the cicatrices which these 
leave behind them after cure, the inflammation of the eyes, the affec- 
tions of the throat, and enlargements of the tonsils, the discharge 
and ulcers of the nose, the swellings about the joints, and other dis- 
eases of the articulations which it occasions, have likewise peculiar 
appearances which, in almost all cases, prevent their being con- 
founded with affections of a syphilitic nature exhibited in the same 
parts. But a degree of real uncertainty is sometimes experienced 
when we find a person of scrofulous habit attacked by secondary 
syphilis, and presenting disorders of the nose and eyes, the appear- 
ance of which is neither decidedly scrofulous nor decidedly syphilitic, 
and endeavour to distinguish the influence of the constitutional pecu- 
liarity from that of the venereal virus, on the development of these 
disorders, with a view to determine their treatment. These difficult 
cases, which are unfortunately of too frequent occurrence, are always 
very troublesome. 2 

942. It is a very general opinion that syphilitic eruptions, left to 

to be syphilitic. Shortly after, also, some copper-coloured eruptions appeared on his 
face and breast, which were declared to be syphilitic by several surgeons. A cir- 
cumscribed thickening and elevation of the pericranium covering the frontal bone 
appeared at the same time. The young man went into the country, and the symp- 
toms disappeared in a fortnight without the use of mercury." This last circumstance 
confirmed Mr. Abernethy in the opinion he had formed, that the disease was not 
venereal: persuaded as he felt, that a disease which got well spontaneously and with- 
out mercury, could not be syphilitic; an opinion which a multitude of well-authenti- 
cated facts contradict sufficiently now-a-days, to justify me in considering as really 
venereal the disease under which this young gentleman laboured. 

Carmichael, in his "Essay on Venereal Diseases," chap, v., when speaking of dis- 
eases most likely to be confounded with those of venereal origin, details several 
cases, the venereal nature of which appears to me to be very probable, and which 
cannot with propriety be separated from the history of syphilis; he makes mention, 
however, of a case of phagedenic ulcer of the throat, which made its appearance 
without previous syphilitic infection either of recent or older date, according to the 
testimony of the patient. 

1 Sebastianus Aquilanus (De morbo gallico. — Aphrodisiacus, p. 5) maintains the 
identity of elephantiasis and the morbus gallicus. P. Maynard (De morbo gallico 
tractatus. — Aphrod., p. 389), and several others, are of the same opinion. Other 
writers have thought with reason, that syphilis was a distinct disease ; among those 
of this opinion, I may particularly mention N. Leonicenus (De epidemia, &c. 
Aphrod., p. 17); G. Fallopius (De morbo gallico tractatus. — Aphrod., p. 763); H. 
Fracastorius (De syphilide seu morbo gallico lucubratio. — Aphrod., p. 203, &c). 

2 The abuse of mercurial preparations has long been held the cause of very serious 
injury to many individuals attacked with syphilis. This opinion has lately obtained 
extensive credit in England, France, and Germany; and the physiological school has 
contributed powerfully to its propagation. See on the ill effects of mercury, Fallo- 
pius (De morbo gallico tractatus. — Aphrod., p. 809). — Sintelaer. " The Scourge of 
Venus and Mercury, &c, with the true way of curing the mercurial pox, found to be 
more dangerous than the pox itself." — London, 1737. Ludolff "Demonstrate, quod 
atrocissimae luis venerea symptomata non siut affectus morbi, sed curae mercuriali- 
bus institutsc." Erford, 1747. Consult also Hunter on the danger of giving mercury 
when the disease is not venereal, that is to say, when the symptoms are not such as 
those which he considers exclusively venereal. — (Traite des maladies Veneriennes, 
Paris, 1787, p. 407), and even in the diseases which he believed to be syphilitic, 
(idem. p. 361). For my own part, my conviction as to the specific and curative 
action of mercury in the treatment of venereal diseases is now stronger than ever; 
and I do not recollect a single case in which I have had reason to regret having em- 
ployed it. This leads me to conclude, that there is much exaggeration in what has 
been said in regard to the ill effects of mercury, always admitting that salivation,' 
hydrargyria, and mercurial fever are serious evils, the occurrence of which cannot 
always be effectually guarded against, even by administering this medicine in doses 
calculated with the utmost care. But these accidents rarely supervene when mer- 
cury is cautiously exhibited, and though they did happen much more frequently than 
they do, they are slight evils to place in opposition to a curative influence, which has 
never been approached in power by any other mode of treatment devised. 

77 



themselves, are not susceptible of spontaneous cure: 3 nevertheless, 
we do occasionally find venereal eruptions, and other secondary 
symptoms of syphilis disappearing of their own accord for a time ; 
but they almost always reappear afterwards, either in the same form 
or under some different aspect, (a) 

(a) See note in a subsequent page, in which Mr. Mayo's observa- 
tions on this point are stated. 

In summing up the characteristic features of syphilitic eruptions, 
with a view to diagnosis, we may lay down the following propositions. 

The colour of syphilida depends on a morbid secretion of the 
corion, constituting the pigment, or, as it is now called, the chromato- 
genous apparatus; and, in this respect, their study might come under 
the head of disorders of this apparatus. Swediaur was the first to 
designate the hue of syphilitic eruptions by the term red copper- 
colour, which sometimes passes into a yellowish-blue, as we see after 
a bruise. M. Cazenave ( Traite des Syphilides) says, that the colour 
varies from a coppery-red to a brownish-gray ; and he regards it as 
diagnostic. It is met with in the papulae and tubercles, and at the base 
of the pustules and vesicles ; it constantly accompanies the squamous 
elevations, sometimes the squamae themselves. It is but partially 
removed by pressure of the finger; and constitutes sometimes the 
entire disease. It is of a more lively hue at the beginning of the 
eruption, and becomes more and more gray as it is about to disappear. 
This colour will sometimes remain after the eruption itself has dis- 
appeared, and 'particularly so, if the latter has left behind it any 
cicatrix. 

Another peculiarity of syphilida is the great tendency to assume a 
circular form. This is manifest, not only in separate patches, limited 
to a small surface, but it is also seen when the eruption is disseminated 
over a large space, in which we can still detect a circular arrange- 
ment or segments of circles. This latter trait is chiefly noticed in 
serpiginous syphilida. We cannot, however, claim for this circular 
arrangement a diagnostic value in the syphilida generally, since in 
some of them it is not seen, and in other cutaneous eruptions, not of a 
syphilitic nature, it is met with, as in simple herpes, lepra vulgaris and 
some varieties of lichen, &c. Besides, it is worthy of remembrance, 
that in syphilitic eruptions of other orders, as in the tuberculous, for 
example, there is a constant tendency to this circular arrangement. 
This feature has been noticed by authors, who describe a venereal 
eruption, particularly when affecting the face, by the term corona 
veneris. 

Another feature in syphilitic eruptions is their chronic duration. 
Even when the premonitory symptoms seem to announce an acute 
disease, the eruption itself is slow in its progressive changes. If it 
be a pustular syphilide, we often see it with a large indurated base, 
terminating in a minute point of suppuration. If vesicular, the vesicle, 
though voluminous, remains unchanged, without rupture or loss of 
transparency, during a period of four, five, six and even eight days, 
surrounded by a red areola. The progress of the eruption is always 
slow, suppuration difficult, and cicatrization still more so — a chronicity 
this, which it is important to remember, in forming our diagnosis of 
syphilida. 

As regards the secondary lesions, we find the squamae to be thinner 
and drier than in simple squamous affections ; and they are not so 
large, as they never entirely cover the eruption or pustule, around 
which they form a whitish band. Biett laid considerable stress on 
this appearance. The squama? are formed again very slowly ; and 
hence we so often find the papular elevations in syphilitic psoriasis 
and lepra deprived of their squamae. 

The scabs are commonly thick, greenish, sometimes bluish, hard, 
furrowed as it were, and very adherent. It may be that they cover 
an ulceration, and then they are softer, larger at their base, and in a 
measure surrounded by a soft coppery circle which overlaps them a 
little ; or, again, they may rest on a cicatrized point, and they are then 
retracted, horny at their base, which is unequal, and which, by suc- 
cessive separations, displays gradually a cicatrix into which it is seem- 
ingly implanted by mammillated terminations that are surmounted by a 
small, dry and whitish desquamation. 

s Wilson. — Observations on the Natural or Spontaneous cure of Syphilis. (Trans- 
actions of the Edinburgh Medico-Chirurgical Society, vol. iii. p. 1.) 









SYPHILIDA. 



— In general a venereal eruption, considered in 
is the more serious in proportion to its tendency to terminate 
in ulceration. There are, besides, certain kinds of ulcers, (the serpi- 
and phagedenic,) which have a greater tendency than others to 
spread superficially, or to penetrate in depth. The prognosis is also 
more or less unfavourable, according to the seat of the ulcers, and 
the importance of the parts which are implicated, and which are 
liable to be disorganized or destroyed by them ; it is almost super- 
fluous to add, that syphilitic exanthemata, vesicular, acute papula?, 
squama* , and non-ulcerating tubercles, are not otherwise serious than 
;in evidences of the cause which has produced and continues to main- 
tain them. 

Nevertheless, several of these superficial lesions must be consi- 
dered as the more serious, on account of certain disorders which 
usually follow them, or habitually supervene during their existence. 
Thus phagedenic ulcers of the velum palati, more frequently accom- 
pany the squamous syphilide than any other form of venereal erup- 
tion ; iritis is oftener associated with papulae, &c. The prognosis 
may be rendered still more unfavourable by the long standing of the 
disease, by the effects of ineffectual modes of treatment, and by the 
multiplicity or serious nature of concomitant symptoms, for example, 
of diseases of the bones. Independently of these considerations, the 
coincidence of scrofula, the decay of the constitution under the influ- 
ence of the syphilitic virus, or of a chronic affection of one or more 
of the viscera, and frequently also the mode of affection, for the dis- 
ease is always more malignant if received by hereditary descent, by 
nursing or inoculation, than when caught by sexual intercourse, are 
circumstances which render the prognosis particularly unfavourable. 
Farther, there are many circumstances which oppose themselves to 
the successful treatment of the disease — such as the necessity of re- 
siding in cold and damp situations, fatigue, and even active bodily 
exercise, improper diet, excesses of every kind, &c, which all tend 
to render the prognosis more or less unfavourable. 1 fn) 

944. Treatment. The treatment of the syphilitic eruptions, like 

These observations suggest the further remark, that in all the sy- 
philida, if we except the exanthematous and squamous, there is a 
great tendency to destruction of tissue, as we see in the indelible 
cicatrix, whether it be preceded by ulceration or not. 

The circular form of syphilitic ulcers is a constant feature and is 
especially observable in those following ecthyma. As just intimated, 
there may be loss of parts without ulceration. These singular results 
obtain in the papular and tubercular syphilida, without there having 
been any wound or the slightest ulceration. The ulceration succeed- 
ing to a tubercle or pustule, is very minute ; and if, sometimes we see 
a shoulder or half of the arm covered with a large cicatrix: this last 
will be found to be the effect of an union of several tubercles and 
ulcerations which have successively run into one another. This cir- 
cumstance will, also, serve to explain the apparent irregularity of the 
rounded form of the eruptions and ulcerations. 

If to these different characters of syphilida be added the little, even 
local excitement or reaction, the absence of heat, acute pain, and 
above all, of pruritus, even in forms which, generally, in the simple 
state, are accompanied by extreme itching, we shall have a picture of 
the symptoms common to syphilitic eruptions, and which, when present, 
constitute the main outline of their diagnosis. For farther details on this 
head, including a minute description of the particular symptoms of 
the syphilida, etc., I refer the reader to Cazenave's work, already 
quoted. 

(a) Vesicular syphilide may sometimes become a grave disease by 
its obstinacy and the pains that accompany it, as well as by the 
irregular and deforming cicatrices left after it. These remarks apply, 
however, only to a rare variety, the syphilitic eczema impetiginodes. 

Bullous syphilide is always of grave import, whether it shows 
itselt under the form of the pemphigus of children newly born, a 
disease which M. P. Dubois has always found to be fatal, or ap- 
pears under the form of rupia, an affection which commonly indicates 

• Preterea gulosi, bibuli et rnultum coeuntes, et sine regula omnia comedentes, et 
male se , haben es >n reg.m.ne re l.quarum rerum non naturalium, non sanantur nis 
rara. (M. Massa. De morbo galhco.— Aphrodisiacus, p. 47.) 



that of almost all chronic diseases of the skin, imperatively requires 
that regard should be had, not only to the form, extent, and duration 
of the eruption, but also to the age and constitution of the patient. 

Under the title of preparatory treatment are included those dietetic 
and general measures, — change of regimen, rest in bed, and those 
preliminary steps, which have for their object to bring the constitution 
into the most favourable state for the administration of curative and 
specific means. In my opinion, this preparatory treatment, too often 
neglected, is of the utmost importance. 

945. Persons of sanguine or plethoric temperament ought to be bled 
once or twice during the first fortnight of treatment: they ought to 
continue in a state of constant repose in bed, and be kept upon very 
low diet of a cooling kind f and in cases complicated with fever 
phagedenic ulcers of the throat, and inflammations of the conjunctiva 
or of the iris, the blood-letting, both local and general, ought to be 
repeated at intervals less remote : in short, in this first stage, and under 
such circumstances as we have described, it is of advantage, even 
after all symptoms of febrile excitement have ceased, that the patient 
should remain for several days in bed, and not swerve from the regi- 
men prescribed. 

Persons of a dry and irritable temperament, and habitually subject to 
obstinate constipation, should undergo, for eight days or so, a prepara- 
tory course of tepid baths and gentle aperients. We should aim, on 
the contrary, by means of nutritious diet and the moderate use of good 
wine, at fortifying the lax constitution of persons of a lymphatic or 
scrofulous temperament; by the same means we should also endea- 

a broken-down constitution, and which leaves behind it deep, and 
deforming scars. 

But of all syphilitic eruptions, the most alarming, under every 
aspect, is unquestionably the tuberculous form, which is usually an evi- 
dence both of a secondary syphilis and of deep contamination. From 
its habitual seat in the face and sometimes scalp, the deep and ex- 
tensive destruction of parts, and the often frightful cicatrices which 
it causes, tuberculous syphilide, and especially the perforating and 
serpiginous variety, combines, in itself, all the conditions which consti- 
tute both the absolute and relative gravity in the prognosis of syphilis. 

In conclusion, as M. Cazenave (op. cit.) has well remarked, the 
syphilida in themselves alone, may give rise to serious disorders, 
followed possibly by frightful deformities ; but they cannot be said to 
be the cause of death. When the patient sinks under the disease, 
happily a rare case, it is owing to deeper seated lesions — laryngeal 
phthisis, or more frequently ulcerous enteritis. This result may also 
be owing to a cachectic habit of body, and to a union of concomitant 
symptoms which attack all the tissues, and which are manifested in 
hectic fever, diarrhoea, hemorrhages, fetid sweats and finally death. 

2 Already, in the time of Massa, several physicians attributed the cure of syphilis, 
not to medicine, or to decoction of guaiacum, but to regimen : "Multi, qui ad pauca 
respiciunt, ausi sunt dicere, quod sanitas qua? sequitur per potionem dictam, non est 
ab ipsa virtute ligni, sed a tenuitate dietse, qui etsi sine ratione et experimenlo, hoc 
dicant," &c. (Massa, ibid., p. 65.)— "Si multa quantitas cibi cum dicta decoctione 
admiscereter, extingueretur ejus vis.et sic, aut multum debiliter operaretur, aut nihil. 
(Massa. De morbo gallico, cap. vii. — Aphrod., p. 65.) He proves the necessity of 
abstinence upon physiological grounds, and the case of a man who had made use of 
the wonted remedies without obtaining a cure, in consequence of having failed to 
observe any regular regimen, and neglected the use of purgative medicines; the 
patient having afterwards submitted to the same plan of treatment, with restricted 
diet and the use of aperients, the pains, swellings and ulcers were cured in the space 
of twenty days. 

Massa, Ul rich Von Hutten, and almost all the practitioners of their times, have 
insisted on the necessity of observing a strict regimen, and for food have prescribed 
white meats, fresh eggs, &c. The diet recommended by Massa is as similar as pos- 
sible to the curafamis of the moderns — "et ejus prandium sunt uncise quatuor pants 
bene fermentati non saliti et uncioe tres carnis vituliniB vel haedinae, sive pullorum 

galinarum parvorum, etc et sint conditee istce carnes sine sale, etc — et sic facere 

oportet usque ad vigesimum diem et plus si virtus aegri toleraverit." (Massa. De 
morbo gallico. — Aphrod., p. 63.) At the same time the patients were kept quiet, and 
took warm decoction of guaiacum, in order to promote perspiration. The food was 
afterwards gradually increased in quantity. During the cura famis or dietetic mode 
of treatment practised in the hospital for venereal subjects at Stockholm, the patient 
is confined to his room for about six weeks, and receives no more than about four 
ounces of roast beef, and five ounces of the best wheaten bread, daily ; his beverage 
is a decoction of similax china. If this regimen is found considerably to reduce the 
strength of the patient, which seldom happens, the quantity of food is increased. 
All the symptoms have generally disappeared in the space of three or four weeks; 
and at the end of six, the treatment is suspended for three weeks, and then resumed 
for three weeks more. — (Bulletin des sc, med. de Ferussac, t. xiii. p. 152.) 



SYPHILIDA. 



30? 



vour to recruit a constitution which is enfeebled by age, or which has 
suffered by privation. I have found that, in women attacked with 
chlorosis, dysmenorrhea, and amenorrhoea, the cure of venereal erup- 
tions was facilitated by modifying the constitution at the same time by 
means of chalybeate preparations and bark. 

The patient ought carefully to guard against exposure to cold or 
damp, and should sedulously abide by the regimen proper to his state 
and constitution. 

The duration of the preparatory treatment may be diminished or 
increased according as the syphilitic symptoms appear to require prompt 
measures for their relief, or as the absence of severity in these allows 
more active treatment to be deferred. 

946. Of all the therapeutic means we possess of combating a gene- 
ral or constitutional venereal taint, there are none more certain in 
their effects than the preparations of mercury ; but experience has 
shown that these ought not to be administered during the existence 
of febrile symptoms, or of any very decided signs of local irritation. 
Under such circumstances, they not only do not act favourably, but 
are often positively prejudicial ; whereas the antiphlogistic regimen 1 
always moderates the symptoms, and not unfrequently causes them to 
disappear entirely, at least for a time. It frequently happens that it 
is only after this preparatory treatment that mercury can be made to 
act beneficially. 

947. For several years past, I have adopted, as the ordinary 
method of treating syphilitic eruptions, the use of mercurial ointment, 
made into pills, internally; 2 and every day's experience satisfies me 
of the superiority of this method above all others. It has the advan- 
tage over the administration of mercurial ointment by friction, of being 
more certain in its curative effects, and of being exempt from the 
filthiness and destruction of linen which the other necessarily entails. 
Many comparative experiments have satisfied me that the absorption 
of mercury, administered internally, is more certain and regular than 
when employed by way of inunction ; the quantity actually taken into 

1 For the last thirty or forty years, several practitioners of great merit, among 
whom may be reckoned Thomson, Hennen, Ferguson, Guthrie, Rose, and others in 
England, and Desruelles, Devergie, &c, in France, rejecting, in a great degree, the 
idea of the specific action of mercury in this disease, have agreed to meet it on the 
general principles pursued in the treatment of inflammatory diseases, (a) Some of 
the disciples of the physiological school, still more strongly imbued with the doctrine 
of simple irritation, deny altogether the specific character and virulent nature of the 
disease itself; and treat its primary, and even its secondary symptoms, which they 
look upon as sympathetic, by simple antiphlogistics. 

Dr. J. Thomson and Dr. Hennen. Edin.Med. and Surg. Journ., vol. 14.— J. Hennen. 
Principles of Military Surgery, 3d edition, 8vo. London, 1829.— Ferguson. Obs. on 
the Venereal Disease in Portugal, &c. Med. Chir. Trans. 8vo. London, vol. 4.— 
G.J.Guthrie. On the Treatment of the Venereal Disease without Mercury. Med. 
Chir. Trans, vol. 8.— Rose. Obs. on the Treatment of Syphilis. Med. Chir. Trans., 
vol. 8, 1832. — H.M.J. Desruelles. Memoires, inserted in the Recueil de Memoires de 
Med. Chir. et Pharm. Militaires, 8vo., Paris, &c— Devergie. Clinique de la maladie 
syphilitique, 4to. Paris, pi. L. F. R. S. Richond de Brus. De la non-existence du 
virus venerien. Paris, 8vo. 1826. 

2 F. Fritze (Handbuch fiber die venerischen Krankheiten, Berlin, 1790, 8vo.), 
Terras (Remarques et observations sur l'usage et les bons eftets de l'onguent mer- 
curiel.administre al'interieur,saus la forme de pilules, pour la guerison des maladies 
veneriennes. Journ. general de med. t.xxi. p. 33), Sedillot (Remarques sur un savon 
mercurial. Journ. general de med. t. xvi., p. 37), have dwelt on the advantages of 
this method of administering mercury: and the reason of its not having been more 
generally appreciated is probably to be ascribed to the dose having been recom- 
mended to be carried as far as twelve pills a day, a quantity which inevitably pro- 
duces salivation. I have adopted the formula of Sedillot, in the preparation of the 
pill of mercurial ointment, viz.: mercurial ointment, one drachm; Spanish soap, two 
scruples; powder of althea root, a scruple; mixed well together, and made into pills 
of the weight of four grains each.and prescribed in doses of two or three, very rarely 
of four, a day, for a month or six weeks. ■ 

Plenck (Jos. Jac.) (Methodus nova et facilis argentum vivum wgris labe infectis exhi- 
bendi, Vindob, 1776), also employed mercury internally with very great success: the 
pills and mercurial mixture of Plenck, the pastils of M. Lagneau, blue pills, SfC, are 
preparations whose action is similar to that of the pills of Sedillot. Schlesinger 
recommends a mercurial mixture, analagous to the mixture of Plenck, which he used 
with much success for children. Finally, Chaumette (Aut) {De morbo gallico, chap. 
7, curatio per pilulas mercuriules. Aphrod., p. 855), gives a formula which may be 
considered as the origin of all the preceding compounds. 



(a) To these we may add the names of Wallace, Ballingall, Car- 
michael and Ricord, and in our own country Dr. Thomas Harris, 
who has promulgated his opinions on the subject. As regards prac- 
tice, I have for a number of years treated syphilis in all its stages 
without mercury, except as an occasional alterative, used after the 
same indications as in a great number of other diseases. 



the system then depending on the greater or less degree of diligence 
used'in rubbing in the ointment, and on the aptitude or disposition of the 
skin to absorb the mineral, which is known to vary in every indi- 
vidual. Since I have depended on this method of administering mer- 
cury, and I have long employed it with a degree of success truly re- 
markable, I have not had, either in my private practice, or in the 
course of my duty at the Hospital of La Charite and its dispensary, a 
single bad case of salivation or mercurial inflammation of the mouth 
or throat. Whenever the action of the mercury showed itself upon 
the gums, I have always succeeded in obviating the mischief which 
was impending, either by diminishing the dose of mercurial ointment, 
or by suspending the use of this remedy for some days. To adults 
and persons of mature age, I have prescribed two, and sometimes 
three, of the pills of Sedillot, 3 to be taken fasting, every morning, for 
a month or six weeks — seldom for a longer period. If the affection is 
of long standing, I almost always prescribe at the same time, a pint of 
the tisane de Feltz* daily, and the tepid bath two or three times a 
week ; and where the eruption is accompanied by pains in the super- 
ficial bones or joints, I recommend a grain or a grain and a half of 
the gummy extract of opium at night. 

Under the influence of this treatment, it is not unusual to observe 
a marked change in the state of syphilitic eruptions, ulcers, tubercles, 
&c, by the twelfth or fifteenth day from its commencement, and some- 
times even sooner ; and I have not met with any case of syphilitic 
eruption in persons of unbroken constitution, which a month or six 
weeks of this treatment has not made to disappear. In those cases in 
which the syphilitic virus has extended its action to the osseous sys- 
tem in any remarkable degree, and those in which numerous ulcers 
had formed upon the extremities, in consequence of the softening and 
suppuration of subcutaneous tubercles, or in persons who exhibited 
other symptoms of syphilis of long standing, I have sometimes admi- 
nistered considerably larger doses of mercurial ointment than those 
mentioned, prescribing every day, for a fortnight towards the close 
of the treatment, from four to five of the pills of Sedillot. But the 
cases in which this more active mode of prescribing mercury (which 
is liable to be followed by salivation) is necessary, are very rare ; 
and I never have recourse to it except when I conceive that the in- 
convenience of salivation will be more than compensated by the ces- 
sation of rebellious symptoms, and the more rapid progress of the 
disease towards a cure. Finally, I ought to add, that the mercurial 
ointment, thus administered, never produces any marked derange- 
ment in the functions of digestion ; the patient in general experiences 
no other sensible effects from its use than the progressive diminution 
of his venereal symptoms, followed by a complete and permanent 
cure. In this latter respect the preparation of mercury now recom- 
mended, has incontestable advantages over the corrosive sublimate 
exhibited internally. 

948. Although the external application of mercurial ointment, 5 
either by friction or otherwise, is less certain in its effects on the con- 
stitution in the majority of cases, it nevertheless presents certain 
advantages under particular circumstances. For instance, when a 
syphilitic eruption is accompanied by a chronic enlargement of the 
testicles without pain, when buboes of the groin exist at the same 
time, mercurial inunction practised upon the lower extremities is 
always of advantage. The same mode of administering mercury by 
rubbing in on the forearm and arm, ought also to be recommended in 
those cases in which the syphilitic poison has been accidentally inocu- 
lated by punctures or excoriations of the finger, and has been followed 
by enlargement of the axillary glands, and cutaneous eruptions. 

3 Vide Formulae at the end. * Ibid. 

6 Several ointments containing mercury and litharge, originally employed by the 
Arabians in chronic diseases of the skin, and subsequently by Theodoric, Guy de 
Chauliac, Arnaldus de Villanova, &c, were afterwards used by Massa and his co- 
temporaries, in the treatment of the venereal disease. After having been prepared 
by a course of baths and purgatives, the patients usually rubbed in a dose of the 
Saracen ointment, as it was called, before the fire, every evening on going to bed. In 
some serious cases accompanied with cachexia, Massa, after having tried mercurial 
inunction and cinnabar fumigation in the ordinary manner without effect, sometimes 
suspended the treatment on the twelfth day, for ten, fifteen, or twenty days, and even 
a longer period, during which time, wine and generous diet were ordered for the 
patient, who was again subjected several limes in succession to this double influence 
of mercury, and an analeptic or nutritious regimen till the cure was accomplished. 
This method appears to me to be applicable to several analogous cases. 



308 



SYPHILIDA. 



Moreover, mercurial ointment applied by way of friction, and directly 
Bfl a dressing to syphilitic eruptions, to tubercles, and, above all, to 
the moist tubercles of the margin of the anus and genital organs, and 
in ulcers, exercises, independently of its specific and general action 
on the constitution, a topical influence which expedites the cure of 
the local affections. 

After taking several baths for the purpose of cleansing the surface 
of the skin, and shaving the hair from the legs, the patient generally 
rubs in for the space of fifteen or twenty minutes daily, from the ankle 
to the knee, halt a drachm of the strong mercurial ointment. The 
following day, the inunction is applied to the thigh of the same limb; 
and the day after that, the patient takes a bath and recommences 
rubbing in, in like manner, on the opposite extremity: the patient 
should wear stockings and drawers by night as well as through the 
day, in order to avoid staining his bed and body linen with the oint- 
ment, which leaves marks that are very difficult to be effaced. 
The dose of mercurial ointment may be increased to two scruples or 
a drachm daily, when, after the twentieth friction with the smaller 
quantity, the disease continues stationary, or but little modified in 
its appearance, and when there are at the same time no symptoms of 
swelling of the gums, or other phenomena indicative of a mercurial 
affection of the system. I may add that, in very long standing and 
inveterate cases of syphilis, which have resisted the more ordinary 
modes of treatment, I have seen the inunction of large doses of 
mercurial ointment, cause all symptoms to disappear, after having 
produced a violent attack of fever and copious salivation. 1 When 
recourse is had to this method of treatment by salivation, it is neces- 
sary to examine the posterior fauces very carefully, and to attend to 
the state of the respiration, in order to meet at once any symptom of 
(edematous inflammation of the glottis or base of the larynx, should 
this appear. 

In ordinary cases, from forty to fifty frictions, administered in com- 
bination with a decoction or infusion of the sudorific woods, gene- 
rally suffice, in adults, to complete the cure. 

The activity of the function of absorption in children and its inac- 
tivity in aged persons, require that the dose of ointment, and number 
of frictions, should be materially diminished for the former, and that 
the time of inunction especially should be prolonged for the latter. 

949. The bichloride of mercury (corrosive sublimate), 2 adminis- 

1 Similar cases, and the additional fact, confirmed as it is by daily observation, 
that mercury is in general the more efficacious in proportion as its peculiar effects 
are more easily excited in the system, and as the gums are more readily affected dur- 
ing its administration, undoubtedly gave rise to the opinion formerly universally 
entertained, that salivation was necessary to accomplish the cure of the venereal 
disease. (Sysieme de M. Boerhaave sur les maladies veneriennes, trad, en Francais 
par M. de la Metrie, Paris, 12mo., 1735.) 

2 Strongly recommended by Blancard, and Frick, and its effects better studied by 
Hoffman and Boerhaave, the use of corrosive sublimate internally has become general 
in Europe since the numerous experiments made by Locher, a pupil of Van Swieten, 
were made known, who, with this preparation, treated four thousand eight hundred 
,ind eighty venereal patients successfully. (Obs. Tract, circa luem veneream, etc. 
Vienna?, 1762, 8vo,) In France, J. J. Gardanne, (Recherches pratiques sur les differ- 
entes Manieres de trailer les Maladies Veneriennes, 8vo. Paris, 1770.) Cullerier, 
and several of his pupils, have highly eulogized this remedy, which continues to be 
roach employed at the present day, but which was not a favourite with Astruc and 
Swediaur. h has been charged with producing hemoptysis, phthisis, with causing 
abortion, &c. Gardanne frequently administered the sublimate conjointly or alter- 
nately with mercurial inunction, a method approved by Dehorne. — (Exposition raison- 
nee des differentes methodes d'administrer le mercure, etc.,8vo. Paris, 1774.) Pibrac 
has exaggerated the ill effects of the sublimate, but has made some useful remarks on 
the inconveniences attending its interna! administration, and particularly on the 
danger of its application to ulcers, &c. — (Mem. sur 1'usage du sublime corrosif. 
Mem. de I'Acad. de Chirurg., t. iv. p. 153, 4to.) 

Dzondi has proposed to administer sublimate in somewhat large and constantly 
increasing doses. He makes use of the following pills: — R. Hydrargyri sublimati 
corros., gr. 12; Solv. in aq. distill, q. s.; add. micre pains albi, sacchari albi a a q.s. ut 
f, pilul. gr. j. No. 240; and observes, — lstly. The pills must only be taken every 

•ther day. 2dly. They are not to be taken oftener than once in the day, and that 
immediately after dinner, a little water being drank after them. 3dly. The patient 
commences by taking four pills, and increases the dose by two each time, so as to 
lake thirty on the last day of treatment, which makes a grain and a half of sublimate 
.it a time. 4ih!y. The large doses may be divided into fractions of five, six, 
and eight pills, swallowed one after the other. 5ihlv. If the pills are rejected by 
vomiting, an equal number is given a short time afterwards with two, three, or four 

Irops of tincture of opium. 6thly. If colickv pains of the abdomen are complained of, 
:hree, four, or five hours after the dose is swallowed, from two to six drops of tincture 
..f opium maybe administered. 7thlv. The treatment is continued during three times 
nine days, and no ordinary circumstances must be allowed to interfere with its full 
enforcement in all its points if we would be certain of a radical cure, though all the 
..yroptoms should have disappeared during the first half of the course. 8thly. Should 



tered in doses of a quarter, a third, and sometimes of a half a grain a 
day for one or two months, is also a very efficacious remedy in vene- 
real eruptions, and other symptoms of constitutional syphilis ; but it is, 
in my opinion, a remedy which ought not to be employed until after 
mercurial ointment has been already repeatedly but ineffectually ad- 
ministered, and the necessity is felt for having recourse to some other 
preparation. The sublimate occasions salivation more rarely than 
friction with mercurial ointment; it is easily administered, not expen- 
sive, and it causes certain symptoms, and in particular, nocturnal 
pains in the bones, to disappear rapidly. But it has often, and justly, 
been charged with deranging the stomach, and, in some cases, with 
determining gastro-intestinal and pulmonary inflammations. 

950. In the hope of obviating at least some of the bad effects of this 
remedy, without depriving it of its advantages, it has been proposed 
to dissolve it in water, and administer it in baths, hand and foot- 
baths, in lavements, and in gargles, or to employ it by way of inunc- 
tion in combination with grease. 

I have made many trials of the sublimate bath ; 3 and in some cases, 
this mode of using the preparation has appeared to me to be of real 
efficacy ; I have, for example, found it particularly useful among 
children, females, and persons whose skin was delicate. But I 
should never recommend the sublimate bath to be ventured on where 
the surface of the body was covered with numerous or extensive 
ulcers. Gargles of a weak solution of the sublimate, have appeared 
to me of service in ulcerated states of the throat, accompanied with 
little inflammation. 

I have sometimes had recourse to mercurial foot-baths' 1 in cases of 
syphilitic ophthalmia, in conjunction with mercury administered at 
the same time in other modes, which were, however, as I appre- 
hended, incapable of acting in the same precise manner as the pedi- 
luvia. 

I have never put mercurial lotions 5 or lavements 6 to the test of expe- 
riment. 

I have tried frictions on the soles of the feet, with Crillo's subli- 
mate ointment, the efficacy of which appeared to me very inferior to 
that of the common mercurial ointment. 

The iodides of mercury, 7 combined with lard, and employed with so 
much success in friction against tubercular eruptions, are of peculiar 

any especial cause, salivation for instance, render it imperative to suspend the treat- 
ment for some days, as soon as the reason for pausing is removed, the pills must be 
resumed at the number at which they were left off, so as to fulfil the whole period of 
four weeks. 9thly. Besides the pills, decoction of sarsaparilla must be given daily, 
and drank at intervals, particularly in the afternoon, either hot or cold. lOthly. The 
patient ought to be made to perspire slightly during the whole time of treatment, even 
on these days when the pills are not taken ; he ought not to leave his room in winter, 
and only at noon in summer; he should be warmly clothed, and avoid exposure 
to damp and currents of air, not going near the windows; in short, he should take 
every precaution against getting chilled or catching cold, for a week or a fortnight 
after the cure is completed, llthly. The patient should confine himself to half his ordi- 
nary quantity of food if he be a moderate eater, and to the third or fourth only when 
he is in the habit of eating much. He should take but little fluid, and not exceed a 
small roll morning and evening. 12thly. He may eat or drink what he pleases, with 
the exception of pork, goose, duck, game, cheese, acids and milk, and must be mode- 
rate in the use of spirituous liquors. 13thly. No local means should be resorted to 
for "the purpose of accelerating the cure, farther than preserving the parts affected 
from the impression of cold air, and procuring a free outlet for any matter that may 
be formed. 

3 Sublimate baths, introduced by Baume, and extolled by Gaffe, (Avantages des 
bains mercuriels dans le traitement des maladies cutanees et veneriennes, 4lo., Paris, 
1815,) and by Wedekind, (Arch. gen. de med., t. xxiii. p. 275,) have also been recom- 
mended in inveterate venereal cases, four drachms of corrosive sublimate, and the 
same quantity of muriate of ammonia, previously dissolved in water, being added to 
an ordinary tepid bath. F. M. B. Bonnardel has made use of this remedy in syphilitic 
and other arthritic complaints.— (Gazette Medicale, t. ii. p. 418, 1834.) 

« F. Tambone asserts, that by means of mercurial pediluvia, he cured twelve 
patients labouring under inveterate syphilis (Bulletin des Sciences Medicales de 
Ferussac, t. xxii. p. 407). Verducci states, that he has employed mercurial pediluvia 
successfully in cases of chronic ophthalmia and ulcers of the throat.— Archives gen. 
de Med. t. xxvii. p. 281.) 

5 Mattioli was the first who substituted fomentation with a solution of sublimate, 
for mercurial inunction. (De morbo gallico. Aphrod.) 

Royer. Diss, sur une nouvelle methode de guerir les maladies veneriennes par 
les lavemens, Paris, 17G4. Ferrand. Obs. sur les differentes methodes de trailer les 
maladies verier, avec par les lavemens Mercuriels. Narbonne, 1770, 4to. 

' AT. Biett was the first, I believe, who employed the iodurets of mercury in the 
treatment of syphilitic eruptions. I have also prescribed these preparations in the 
same circumstances for several years, at the Hospitals of Saint Antoine and La 
Charite. I now make use, almost exclusively, of the dento-ioduret; the usual dose, 
internally, is the twelfth of a grain; externalli/, I employ it in proportions of one- 
twentieth or one-twenty-fourth in the composition of ointments. 



SYPHILIDA. 



309 



utility in subduing induration of the spermatic cord, and certain glan- 
dular enlargements, which, in their appearance and progress, seem 
to partake at once of a venereal and a strumous character. In such 
circumstances, and where venereal eruptions exist at the same time, 
they may generally be employed in preference to any other prepara- 
tion of mercury : their activity requires that their effects should be 
attentively watched. I frequently employ the deuto-iodide internally, 
and generally in doses -of one-twelfth of a grain. I have several 
times observed transient inflammation of the targe intestines super- 
vene during its administration, but this always promptly disappeared 
by the suspension of the remedy, the use of' which I did not resume 
till after an interval of several days, (a) 

951. There are various other preparations of mercury, which have 
been employed with success in the treatment of the syphilides. I have 
myself made trial of several of these but a very few times, and of 
some of them I have never studied the action at all. Thus, calomel 
has been recommended 1 in its simple form, or combined with hem- 
lock and aconite, with dulcamara, or antimonial preparations. But 
calomel so often produces salivation, even when combined with gentle 
aperients, that after having employed it in the papular syphilide com- 
plicated with iritis, I was induced to abandon its use, and substitute 
for it pills of mercurial ointment, or corrosive sublimate. Calomel 
blown upon ulcers of the cornea, in quantities of a grain daily, has 
often appeared to me to be of very great utility ; I have ordered it to 
be drawn up the nostril with less evident advantage, in cases of ozaena. 
Some practitioners have recommended its being taken in this manner 
into the nostrils when not ulcerated, with a view to obtain the effects 
of its absorption ; others have proposed to rub the gums and inner 
surface of the cheeks with calomel. 

952. The bromide of mercury, 2 the cyanide of mercury, 3 and Hahne- 
mann's soluble mercury, 4 appear to be remedies of undoubted power, 
and might very properly be substituted for the preparations which I 
have first and most particularly recommended, should the effects of 
these be found to be trifling, or not at all apparent ; in my own prac- 

(a) The iodides of mercury were introduced into therapeutical use 
by Biett, and have since then been largely employed in the treatment 
of secondary syphilis. Of all the preparations of mercury, of all the 
means lauded in the treatment of secondary syphilis and especially 
syphilida, there are none, says M. Cazenave, that can compare with 
the iodides of mercury. 

The entire value of this eulogy will be better understood by collat- 
ing it with what the same author says of iodide of potassium. This salt, 
he tells us, acts sometimes with a promptitude which can only be com- 
pared with the effects of the proto-iodide of mercury. He has em- 
ployed them both of late years, and with nearly equal success. My 
own experience with the iodide of potassium in tuberculous syphilide 
and ulcerated sore throat, induces me to place the utmost reliance on 
its rapidly curative powers in the diseases in question. M. Cazenave 
tells us, that his observation confirms the remark of Biett, that opium 
combined with the proto-iodide of mercury neutralizes, in a measure, 
the effects of the latter; and hence he forbids the union under these 
circumstances. See next note. 

' P. Clare ("A new method of curing Lues Venerea by the introduction of jMer- 
cury through the orifices of the absorbent vessels on the inside of the mouth," 3d 
edition, London, 1780), was in the habit of using calomel, in doses of half a grain, or 
a grain rubbed upon the mucous membrane of the mouth; this application ought to 
be repeated several times a day, and it is necessary to avoid drinking or spitting out 
the saliva. 

Calomel, gum guaiacum, and black sulphuret of antimony, enter into the compo- 
sition of Plummer's pills, which have been, and still are much in use. 

2 According to Werneck, the prolo-bromate of mercury acts in the manner of 
calomel, and the deuto-bromate has medicinal properties analogous to those of cor- 
rosive sublimate. The first dose, ought not to exceed the twenty-fifth part of a grain, 
but should be augmented by two-twenty-fiflh's every second day. (Journal fur c/tir. 
Augenlteil/tunde, t. xiv., p. 215. Extrait dans le Bulletin des sc. med. de Ferussac, t. 
xxiv., p. 206.) 

3 The cyanuret of mercury, first employed by Chaussier, has been specially 
studied by M. Parent (Nute sur I'emploi du cyanure de inercure dans le traitemcnt de la 
syphilis. Gazette med. in 4to. Paris, 1832, t. iii., p. 386). The dose is, in the first 
instance, the sixteenth part of a grain, and is gradually increased to half a grain. 
(Ibid., p. 810.) ° 

* Hahnemann's soluble mercury (the ammoniacal sub-proto-nitrate of mercury), 
has been employed in doses of from half a grain to a grain, generally combined with 
opium. 

7S 



I tice, however, I must say, that I have never had occasion to go 
beyond the preparations in general use. (a) 

953. Experience having shown that, in very inveterate venereal 
cases, considerable advantage is often derived from combining the 
action of mercurial preparations with those of the sudorific woods, 
with purgatives, as well as with the preparations of antimony and 
arsenic, the result of this observation has been the introduction and 
very general use of several kinds of tisans, of several compound reme- 

(a) " In the first stage or secondary form of constitutional syphilis, 
that in which the mucous membranes and skin are more especialh 
affected, mercury finds its most numerous and rational advocates ; 
nor does scrofulous complication prevent its use by some of the most 
experienced of these. In English and American practice, inunction 
and the blue pill, or calomel and opium, are more commonly directed. 
In France and on the continent generally, a marked preference is 
given to corrosive sublimate, combined with opium or aconite. I 
ought, however, to except M. Ricord and a few others who recom- 
mend at this time the proto-iodide of mercury. He begins with one 
grain for a dose, combined with opium or extract, cicut., the latter 
in quantity from three to five grains, and he carries the iodide as fat- 
as six grains in the day, but does not exceed this. Where there are 
much restlessness and irritability, no uncommon associates of consti- 
tutional syphilis, opium, extolled almost as a specific in the earlv 
times of the venereal disease in Europe, has been of late more appre- 
ciated for its curative virtues, in addition to its purely anodyne pro- 
perties. As an adjuvant to mercury and iodine, it is worthy of all 
notice. I shall not pretend to deny the utility of the mercurial prac- 
tice in secondary syphilis, but I can speak confidently after positive 
experience of the success attending the use of iodine in tincture, and 
of the iodide of potassium, with the compound syrup and decoction 
of sarsaparilla in cases of venereal disease, both of the tonsils and 
mouth, and in tubercular ulcerations — after mercury had been pre- 
scribed by those who preceded me in vain." — Bell §• Stokes' 1 s Lectures 
on the Practice of Physic, vol. ii., p. 567. 

To these remarks of mine I may add, that, they who are constitu- 
tionally lymphatic and anemic, or who, from long dissipation and 
destitution, are thrown into a cachectic condition, will be materially 
benefited by tonics, both medicinal and nutritive. Of the former, the 
iodide of iron will do double service, both by giving tone and re- 
moving, in a degree at least, the syphilitic disorder. 

In syphilitic psoriasis and lichen, and in ulcerative psoriasis, lepra, 
tubercle, ecthyma and rupia, the iodide of potassium is both the safest 
and most efficient remedy. M. Herbert Mayo (loc. cit.), recommends 
it to be administered in doses of a scruple three times a day (for 
ulcerative syphilida of the skin) ; but it is proper to begin with small 
doses, giving at first five or seven grains only, and gradually increas- 
ing the quantity, which may thus be raised to half a drachm, with 
half a grain to a grain of iodine in combination. " Sometimes it will 
appear prudent to continue the use of the iodide in scruple doses three 
times a day for two or three months at a time ; when it happens, that, 
although fresh ulcers are continually breaking out, while the first are 
healing, yet on the whole the patient's strength and general condi- 
tion are progressively improving under the treatment. In other cases 
the influence of the iodide is temporary only, and to reacquire effi- 
ciency, it must be disused for a fortnight or longer, and this frequently." 
Opium is beneficial : first, by calming pain and giving sleep ; secondlv, 
by preventing the iodide of potassium from disordering the system. 
Similarly strong testimony to the curative powers of the iodide of 
potassium in secondary syphilis, including tubercular and other cu- 
taneous eruptions, is borne by MM. Cullerier, Ricord, Cazenave 
and Dr. Wallace. M. Ricord sometimes begins with the use of 
the iodide of mercury, as already described, but rarely for a lono- 
period ; and he continues the iodide of potassium in gradually increas^ 
ing doses. Very commonly he makes use of the latter alone and 
relies on it, even after the tubercles have become ulcerated. 

Mr. Mayo advocates the propriety of letting some cases of syphilitic 
psoriasis wear themselves out; and he intimates that when the disease 
is suspended by treatment, it returns after an interval, and its dura- 
tion may thus be lengthened. 



310 



SYPHILIDA. 



rfcpirical formuhe, and of different plans of treatment 
generally, in some instances too highly extolled, in others too much 
depreciated. 

954. The expense and want of cleanliness inseparable from the 
practice of mercurial inunction, independent of the salivation which 

Ins mode of administering mercury frequently occasions, the various 
bad effects attributed to the prolonged use of corrosive sublimate, 
and the less certain action of the other mercurial preparations, and a 
kind of prejudice against mercury in any shape, have combined to 
stimulate practitioners to look around them for other anti-venereal 
remedies. Of these the nitric acid, the subcarbonale of ammonia, 
certain preparations of gold, of antimony, and of arsenic, and several 
articles of vegetable origin, have been proved to be the most gene- 
rally useful. 

955. The nitric 2 and nitro-muriatic acids have been repeatedly 
recommended as anti-syphilitic in their action on the. economy, 
and I have several times seen papular syphilitic eruptions disappear 
completely during the use of a nitric acid sherbet ; but, as out- 
patients do not always present themselves at the hospital when they 
suffer a relapse, the trials I have made of this acid are too few to 
enable me of my own knowledge to assert, that it is adequate to ac- 
complish a complete and permanent cure. 

956. It has also been proposed to substitute ammonia and subcar- 
bonate of ammonia, 3 for mercurial preparations in the treatment of 
syphilis ; I have had considerable opportunities of trying the effects 
of these medicines, and although I have known some complete cures 
to result from their employment, I am inclined to regard them as less 
efficacious than mercury. 

957. The preparations of gold 4 were also from a very early period 
recommended in the treatment of the venereal disease, but had fallen 
into almost entire disuse, when M . Chrestien, in 1810, again directed 
attention to their efficacy in certain cases. 

958. I have seldom combatted venereal eruptions, or other syphi- 
litic symptoms exclusively, by means of arsenical preparations; 5 but 

' See, in the list of formulas: Arts. Tisanes de Fellz, Tisane d'Arnoult; Tisane 
Royale, &c. ; decoction de Zittman, &c. 

2 F. Beddoes, "Reports principally concerning the effects of nitric acid in the 
venereal disease," &c, in 8vo. Bristol, 1797. — Alyon, " Essai sur les proprieies 
nicdicinales de l'oxygene," etc., in 8vo. Paris, an. 7. — W. Blair, "Essay on the vene- 
real disease, and the effects of nitrous acid," &c, in 8vo. London, 1808. C. Plait, 
"An inquiry into the efficacy of oxygen in the cure of syphilis," in 8vo. London, 
1802. Kollo, " Cases of diabetes, with the results of the trials of certain acids," &c, 
in 8vo. London, 1806. 

3 Peyrilhe, "Remade nouveau contre les maladies veneriennes, etc.; ou essai sur 
la vertu anti-venerienne des alcalis volatils," in 8vo. Paris, 1774. After a preparatory 
course of purgatives, baths and diluents, Peyrilhe prescribed a sudorific alkaline in- 
fusion, prepared by infusing for an hour, by gentle heat in a covered vessel, half an 
ounce of senna leaves, and four ounces of the leaves of the melissa officinalis in two 
pints of water. To twelve ounces of this infusion, four ounces of sugar, and a drachm 
or a drachm and a half of subcarbonate of ammonia were added. This dose was 
divided into four portions, of which the patient took one in the morning fasting, and 
one in the evening, four or five hours after dinner. This treatment was continued 
without interruption for eight days; the patient then pause.d for eight or ten days ; 
during which time he confined himself to his ordinary beverage (a weak infusion of 
melissa) ; he then took an aperient, and recommenced the alkaline infusion. The 
treatment was then suspended and resumed two or three times. According to 
Peyrilhe, eighteen days continuance of the ammoniacal beverage suffice, in the 
greater number of cases, and thirty in those of a more inveterate description, to com- 
pleie the cure. The dose of subcarbonate requires to be increased or diminished ac- 
cording to its effects upon the different systems of organs. 

* Lecocque, so early as 1540, makes mention of preparations of gold. Horat speaks 
in high commendation of his "diaphoretic gold," a mixture of calomel, chlorate of 
t;old, and a little gold in its metallic state. On the method of administering the pre- 
parations of gold, consult J. A Chrestien. De la methode iatraleptique, etc., et sur 
mi nouveau remede dans le traitemem des maladies veneriennes et lymphatiques. 
Paris, 1811, 8vo., 3erae edition, — 1825, 46me edit. — Chrestien. Mem. et obs. sur un 
nouveau remede dans le traitement des maladies veneriennes et lymphatiques (Annates 
de la Soc. de Med. de Montpellier, t. xxii. p. 166 ; et t. xxiv. p. 382). — F. Gozzi. Sopra 
l'uso di ulcuni remedii aurifici nelle malattie veneree, etc. Bologna, 1817. — J. G. 
-Niel. Recherches et observations sur les effets des preparations d'or du docteur 
Chrestien, dans le traitement de plusieurs maladies et notamment des maladies 
-yphilitiques. Paris, 1821, 8vo. — Lallemand. Considerations et obs. sur les effets 
des preparations d'or (Nouvelles Ann. Clin, de Montp. 1822).— A. Legrand. De Tor, 
de son emploi dans le traitement de la syphilis recente et inveteree et dans celui des 
dartres syphilitiques. Paris, 1828, 8vo. 

6 Gmelin asserts, that arsenic is used in syphilitic cases by the inhabitants of 
Siberia. Zugenbuhler (Hufeland and Himly, Journal des Prakt. Arzneikunde, 1809, 
Hasc. 5).— Girdlestone (Lond. Med. and Physic. Journ. Feb., 1806).— Adair (Medical 
Commentaries of Edinb., t. ix. p. 35).— Kupperman, (Diss, de medicamentorum ex 
aunpigments praeparatorum praestantissimo usu medico, prceses Bruchner, 1758, 
4io..) have also mentioned the efficacy of arsenical preparations in venereal diseases. 
— See also Edinb. Med. and Surg. Journal, vol. vi. p. 56. 



one of the remedies which I most frequently employ, the tisanr de 
Fellz, contains a very small yet sensible quantity of arsenious acid in 
its composition, and I have become satisfied that this acid is not with- 
out its share in the general efficacy of the medicine. Fowler's solu- 
tion and other arsenical preparations have also been satisfactorily 
proved to have been useful in certain cases of inveterate syphilis, after 
the disease had resisted the power of mercury. 

I ought, however, to add, that I invariably prescribe the pills of 
mercurial ointment internally, at the same time with the arseniated 
decoction of sarsaparilla, or tisane of Feltz. This method of treat- 
ment, by which the effects of mercury and arsenic are combined, suc- 
ceeds so perfectly in almost every instance, that it is, according to my 
experience, more efficacious than any other. 

959. Several vegetable preparations have long possessed, and still 
enjoy an extensive reputation for their influence in subduing venereal 
symptoms. In the first rank of this class of remedies must be placed, 
the diet drinks, entitled sudorific, the active principles of which are 
extracted from sarsaparilla, sassafras, guaiacum, and smilax china ; 
and next to them the decoctions of daphne mezereum, lobelia syphili- 
tica, and arctium lappa. 

960. The efficacy of the guaiacum officinale? has been very unne- 
cessarily called in question of late ; a decoction of this substance, in 
large doses, is often indisputably useful, and has the advantage of 
being much less costly than that of sarsaparilla. 

The employment of sarsaparilla 7 in venereal diseases, is also of very 
ancient date. The best mode of preparing the decoction, is to put 
two ounces of the root, without being split or washed, to steep for 
four and twenty hours in a pint of water; this quantity is then to be 
reducecf one half by gentle boiling. The patient, being in bed, should 
take the half pint of decoction lukewarm, and sweetened with syrup 
of sarsaparilla, in three different doses in the morning fasting. 

This root is the basis of the tisane de Feltz, and enters into the com- 
position of almost all the compound vegetable drinks and decoctions, 
which have been found really useful in the venereal disease. 

The decoction of the smilax china 8 is looked upon as less efficacious 
in general than those of guaiacum and sarsaparilla. I have myself 
used it but very little. 

The infusion of the wood of the laurus sassafras, 9 combined with 
an equal quantity of the decoction of guaiacum, or of sarsaparilla, is 

6 It being generally the custom in France, to employ a combination of all the 
sudorific woods in the preparation of anti-venereal tisans, or decoctions, and as 
their action is almost always associated with that of mercury, it is necessary to turn 
to the writings of those authors who were in the habit of employing one or other of 
these kinds of wood exclusively, to obtain convincing proofs of their utility. 

In this respect the observations of Oviedo, in Spain, of Poll, in Germany, and of 
Massa, in Italy, are perfectly conclusive. Poll asserts, that nearly three thousand 
persons, who had been reduced to the most deplorable condition, owed their cure 
to guaiacum. (De cura morbi gallici per lignum guayacanum. — Aphrodisiacus, p. 
241.) Massa has described with much precision and detail, in his valuable work, 
the preparation of the decoction of guaiacum which was prescribed in large doses, 
as well as the strict regimen which the patient was required to observe during the 
use of this remedy, to which he attributes very great efficacy — an opinion which he 
supports by very full and conclusive cases (De morbo gallico. — Aphrod., p. 65). 
Ulrich von Hiitten has also treated, with much attention and ample details, the man- 
ner of administering guaiacum, and dw r ells strongly on the necessity of following a 
very strict regimen during its use. His plan is, in fact, a cura famis (De morbi 
gallici curatione per administrationem ligni guaiaci. Aphrod., p. 275). Hunter con- 
sidered this wood to possess great efficacy in syphilitic cases. 

7 Massa (De morbo gallico, cap. x., de radice salsasperiliee, etc. — Aphrod., p. 81), 
has described with much care the method of using it. From his time to the present, 
it has been customary to make infusions or long macerations of this root, which are 
afterwards concentrated and given as tisans. It is in this manner that the syrups of 
sarsaparilla and of Cuisinier, as well as the tisane de Feltz, rob de Laffecteur, etc., 
are prepared. 

Mr. Richard Battley (Edinb. Med. and Surg. Journal, vol.xvi., p. 473),is of opinion, 
that the most active principles of this root reside in the cortical part, and (hat these 
are completely extracted by cold infusion. M. Hancock, a Brazilian physician, also 
satisfied himself, that a protracted process of boiling was very destructive of the 
medicinal effects of this substance. — (Journal de Pharm., t. xvi. p. 31.) 

s N. Massa (De morbo gallico, cap. xii. in quo de radice China; disseritur. 
Aphrod. p. 95). Andrea Vesalius (De radice China; epistoloe. — Aphrod., p. 585), 
A. Brassavola (Tractatus de radicis China; usu.— Aphrod., p. 711), have all studied 
the action of this root very particularly. 

9 Before their conquest by the Spanish arms, the natives of Florida employed sas- 
safras against syphilis. The Spaniards transmitted the knowledge they acquired of 
the properties of this plant to Europe in 1555 (Voyage de Francois Coreal aux Indes 
Occidentales, trad, de 1'Espagnol, Amsterdam, 3 vols. 12mo., 1722). But it has not 
been made the subject of so many experiments as guaiacum, sarsaparilla and smilax 
china. A. Monavius has published a treatise on this subject (De ligno fasniculato 
sive sassafras, 1582). Joannes Varandeaus (Tractatus de elephanliasi seu lepra, de 



SYPHILIDA. 



311 



often more readily borne by the stomach than either of these pre- 
parations singly, and in this point of view may be considered as of 
real utility ; but sassafras is in general considered as a less efficacious 
medicine in venereal eruptions, than guaiacum and sarsaparilla. 

961. Opium 1 has never appeared to me to possess any curative 
influence on venereal eruptions, when administered internally; but 
when applied externally to certain ulcers, and particularly to those 
with sprouting surfaces, it expedites their cure in a remarkable manner. 
Farther, in allaying the pains of the bones and joints which fre- 
quently accompany venereal eruptions, and in procuring sleep to 
patients exhausted by long and incessant suffering, opium contributes 
powerfully to aid the action of the general curative means employed. 
Indeed I rarely think of treating constitutional venereal symptoms, 
without administering opium at the same time. In fine, when pa- 
tients have suffered from the use of mercurial medicines, and symp- 
toms of nervous or gastro-intestinal irritation intervene, the employ- 
ment of opium will be found beneficial during the whole of the inter- 
val in which the mercurial treatment is suspended. 

962. The anxiety to find substitutes among our European vegetables 
for the exotic woods and roots, particularly sarsaparilla, the expense of 
which is so great as to place it beyond the reach of the poorer classes, 
the popular notions of the virtues of several of the more common herbs 
in some districts, and the adoption of these notions by practitioners, 
have led to numerous experiments, the results of which, however, 
are not thoroughly determined. 

Among the vegetable substances thus examined, the following have 
been the subjects of most frequent experiment, viz. : — aconitum na- 
pellus ; 2 anemone pratensis ; 3 astralagus exscapus ; 4 arctium lappa; 1 
buxus sempervirens ; 6 lobelia syphilitica; 7 conium maculatum; 9 cle- 
matis recta ; 9 juniperus sabina; 10 daphne mezereum ; u gratiola officina- 
lis ; 12 carex arenaria ; 13 saponaria officinalis, 14 &c. But the well esta- 
blished sufficiency of mercurial preparations in combination with the 
use of the sudorific woods, in subduing every variety of venereal 
symptom, has left me no inducement to make trial of the above- 
named articles of the materia medica, always excepting hemlock, 
which has appeared to me to be of evident service in cases of syphi- 
litic eruption accompanied with pain or ill-conditioned ulcers, and the 
mezereum bark, the very active decoction of which is of unquestiona- 
ble use in the squamous syphilides, complicated with pains of the 
bones. 

lne venerea et hepatide, Geneva?, 1640, 8 vo.), remarks, with truth, that sassafras is 
especially serviceable in cases of syphilitic cachexia. 

' Schoepff (Schreiben von der Wirkung des Mohnsafts in der Lustseuche, Erlan- 
gen, 1781, 8vo.), made known the excellent effects obtained by Nooth, by prescribing 
opium in syphilis; they have since been studied by Carminati, (Opuscul. Therapeut., 
to), i. p. 6,) by Pasta, (Delia faculta dell' opionelle Malattie Veneree, Bergamo, 1788,) 
and Rudolph, (Diss, opii in luis venera? sanatione efficacia, Erlang., 1792.) 

2 Stoerk. Li bell, quo demonstrantur stramonium, hyoscianum, aconitum, etc., 8vo. 
Vindob., 1762. 

3 Stoerk. Libell. de usu pulsatillse, etc., Vindob. 1771, 8vo. 

< Gil-tanner, (Abhandlung liber die venerischen Krankheiten, Gottingen, 8vo., 
1788-93). Quarin (Animadversiones practicae, cap. xvi. p. 186, 8vo. Brussels, 
1787). Endter, Wegerich, and Crichton, also state that they have employed the 
astragalus with advantage. 

s Bodard. Mat. Med. Comp., t. ii. 132. 

* Amatus. Lusitanus, curat, cent., ii. No. 95. 

' P. Kalm. Description d'une specifique contre le mal venerien, viz., Lobelia 
syphilitica (Memoirs of the Academy of Stockholm, t. xii. 1750, translated from the 
Swedish, and inserted in Ancien. Journ. de Med., t. xii. p. 174). 

8 Stoerk (Ant.). Libellus de cicuta, Vindob., 1760. — Libellus, 2dus. Vindob. 
1761. — Libellus quo continuantur experimenta. Vindob., 1765. 

» Miiller. Diss, de Clematide Vitalba. Erlang, 1786. 

10 Quarin. Animadv. Pract. cap. xvi. de morbis venereis, p. 190 (combined with 
antimony, formula 43). — The bark and wood of the box-tree were anciently recom- 
mended by Leo Africanus, Brassavola, and Auger Ferrerius. 

" Russel has very strongly recommended the daphne mezereon against exostosis 
and periostosis, (M6d. obs. and inquiries, vol. iii. p. 189,) and Cullerier has found it 
efficacious in certain venereal eruptions. 

12 J. Kostrzewski, (Diss, de gratiola, Vienna, 1775, 4to., fig.), says that the internal 
use of this plant cures venereal ulcers of the nose and throat, nodes of the bones, &c. 
Dehaen, in venereal complaints of long standing and bad character, used a mixture 
consisting of three grains of sublimate, six ounces of elder rob, two drachms of the 
extract of gratiola, and one drachm of extract of aconite. The dose was a teaspoonful 
two or three times a day, and the patient was made at the same time to take an infu- 
sion of althea root, and veal broth. 

13 Gleditsch, Murray and Reuss propose to substitute the roots of the carex arena- 
rius for those of sarsaparilla, in consequence of the moderate price they bear, and 
even their greater efficacy. 

m Ludolf. Diss, de saponaria ejusque virtutibus specificis, Erf., 1756. — Jurine 
(Journ. de Med. t. lxvi. p. 478). 



963. External treatment.— Independently of the means calculated 
to subdue the general venereal infection of the system, there are 
others which are especially applicable to divers kinds of eruptions, 
ulcers, concomitant symptoms, &c. ; these are almost always external 
or topical applications, which are generally limited in their operation 
to effects of a merely local nature, but which, nevertheless, do occa- 
sionally extend their influence to the constitution at large. 

964. Syphilitic exanthema, the vesicular psydracious, the pustular 
and the simple papular forms of syphilitic eruption, always disappear 
under the influence of general treatment, with which simple or vapour 
baths may be occasionally associated. 

965. The phlyzacious pustular syphilide and syphilitic rupia require 
particular local treatment in addition to the general measures pre- 
scribed. When the pustules are very much crowded, and the skin 
in the intervals between them is inflamed, emollient tepid baths, 
soothing cataplasms, and the application of pieces of perforated linen 
rag spread with some mild mercurial cerate, check the progress of 
inflammation, and prevent the formation of larger ulcers if the prin- 
cipal seat of the disease be the inferior extremities, the shoulders, &c. 

966. The resolution and cure of moist and flattened tubercles de- 
veloped in the neighbourhood of the genital organs, or on the margin 
of the anus, are singularly expedited by covering them with dressings 
of soft linen, spread with a mild mercurial cerate. 

Gentle frictions, with an unguent of the proto-iodide and deuto- 
iodide of mercury, or of the iodide of sulphur over the large non- 
ulcerating tubercles which sometimes occur on the scrotum, the 
superior and internal surface of the thighs, under the armpits, on the 
face, &c, almost always and very speedily succeed in discussing 
them. These large tubercles are also occasionally very promptly 
made to disappear by the aid of fumigations of cinnabar, 15 which 
have also been used in other forms of venereal affection. 

The local treatment of ulcerating tubercles is very similar to that 
proper for syphilitic ulcers. 

967. With regard to syphilitic maculce, whether primary, or 
secondary to other forms of venereal eruption, they may be quickly 
made to fade and gradually to disappear, by being anointed with 
weak mercurial ointment, or the use of a bniment of muriatic acid. 

968. The squamous syphilitic affections are advantageously modi- 
fied by fumigations of cinnabar, used alternately with vapour baths ; 
but they almost always get well without any kind of specific local 
treatment, by merely cleansing the surface of the skin by the use of 
the tepid bath from time to time. 

969. The treatment of ulcers of syphilitic origin is much more 
complicated, and requires to be modified according to their state, 
their standing, and the various circumstances which may have acci- 
dentally contributed to ameliorate or to subdue the inflammatory 
actions of which they are the seat. Emollients and bleeding are 
only indicated in those cases where, after walking or other exciting 
causes, venereal ulcers of the inferior extremities have become pain- 
ful, and their bases the seat of a tumefaction, which extends in a 
greater or less degree beyond their circumference. In those indivi- 
duals whose general constitution did not appear to have suffered, I 
have repeatedly practised bleeding in cases where the skin around 
the trochanters, and the external parts of the shoulder, was thickly 
beset with small round ulcers, intermixed with numbers of subcuta- 

15 Si unctiones non sanant, fortissimum medicamen est suffimigium (Massa. De 
morbo gallico. — Aphrodisiacus, p. 101). Massa used half an ounce of cinnabar, and 
two drachms of olibanum, which were placed on a pan over hot coals, in a kind of 
tent {tentorium), in which the patient remained for a period short or long in propor- 
tion to his strength. Mattioli, Lobera, Fallopius, Rondeletius, etc., have also recom- 
mended fumigations of cinnabar, a subject on which Lalouette (Anc. Journ. de Med., 
t. xlv. p. 195), and Werneck (Bull, des sc. Med. de Ferussac, t. xxii. p. 406), have 
published some interesting observations. When the fumigation is general, the cin- 
nabar is placed on a porcelain or earthenware tile, exposed to the flame of a spirit 
lamp, and the vapour is confined under a cloak of oil-cloth which envelops the 
patient. Each fumigation, performed at night, in a room at 18° of Reaumur, lasts 
for a quarter of an hour, after which the patient is put to bed. Eighteen or twenty 
fumigations, of from twenty to forty grains ( Werneck) suffice for a cure. I generally 
employ a much larger quantity of cinnabar at the hospital of La Charite ; half an 
ounce of cinnabar is thrown upon a hot plate, and the vapour rises into the fumi- 
gating box in which the patient is enclosed. Massa projected the cinnabar on hot 
coals; I have employed the cinnabar successfully in this manner, in local fumigations 
directed to the nose or face; but in this case the sulphuret of mercury is in great part 
decomposed, and the fumigation contains mercury in a state of vapour and sulphurous 
acid gas. 



312 



SYPHILIDA. 



. and these regions were the seat of pretty severe 
local pain and puffing of the cellular membrane; I have almost 
always found the blood let, in such circumstances, bully. I have 
also on several occasions had recourse to bleeding and emollient 
applications in cases where similar subcutaneous tubercles, deve- 
loped in groups on the calf of the leg, formed hard irregular masses 
under the skin, from whence knotty cords extended in different direc- 
tions into the cellular substance around. When there are many small 
ulcera very much crowded together, on the top of the shoulder, for 
example, and the skin is detached to a considerable extent after the 
expulsion of the sloughs at their bottom, it is scarcely ever either 
necessary or proper to divide the kind of bridges of integument 
which separate the different ulcerated orifices from one another; I 
have often been struck by the rapidity with which these parts become 
reunited, and cicatrize under the influence of mercurial treatment. 
It is therefore sufficient in the greater number of cases to dress the 
ulcers with pledgets of perforated linen, spread with mercurial cerate, 
and to apply plenty of soft lint over all. When the eruption occurs 
on the lower extremities, slight compression with a roller is an after 
means that contributes powerfully to the recovery of the parts affected. 

It is generally considered sufficient to dress the slight superficial 
ulcers of the flattened species of tubercles with mercurial cerate; this 
dressing is also mostly applicable to simple and circumscribed second- 
ary venereal ulcers, which show no tendency to spread rapidly either 
in breadth or in depth. When fungous granulations arise on the 
surface of these sores, it is advisable to touch them lightly with 
nitrate of silver, or they may be sprinkled with calomel, and the 
cure is then usually accomplished without any other local attention. 
Phagedenic ulcers imperiously require that their condition should be 
modified by topical applications of greater energy. Frequent expe- 
rience has demonstrated that the greatest advantage is often derived 
from touching the surface of these ulcers with a hair pencil or dossil 
of lint dipped in the solution of the acid nitrate of mercury. 1 In 
some cases it is necessary to repeat this caustic application once or 
oftener, if not to the whole extent of the ulcer, at least to several 
points of its surface. Nitric acid, a strong solution of nitrate of 
silver, and other caustics, have also been employed in similar cir- 
cumstances ; but they are less frequently used in the present day 
than the acid nitrate of mercury, with which cauterization, either 
deep, or superficial, may be made, and apparently with better effect 
than with any other species of escharotic. 

When ulcers of this kind occur on the face, and erysipelas super- 
venes, whether in consequence of the use of escharotic remedies, or 
spontaneously, the inflammation, if it be not accompanied with gene- 
ral symptoms of a very serious nature, must be left to itself; for it 
has frequently been noticed that after the subsidence of the erysipelas, 
these ulcers advanced more rapidly towards cicatrization, and that 
tubercles, when any existed in the neighbourhood of the region 
affected, afterwards disappeared with great celerity. 

The ulcers of syphilitic rupia and those that succeed the large 
tubercles which become perforated in their centres like boils, are 
generally found covered with prominent crusts, adhering more or 
less firmly, which it is advisable to detach by means of cataplasms 
and warm baths, in order that the ulcers they conceal may be pro- 
perly dressed ; but it is in vain attempting to obtain the cicatrization 
of these by the use of escharotics, unless the constitutional disease, 
of which they form but one of the symptoms, has been previously 
subdued by appropriate medication. 

Serpiginous ulcers require general measures for their cure, much 
more than any form of topical application, however energetic. It is 
familiarly known, indeed, that they constantly cicatrize spontaneously 
at one extremity whilst they continue to make progress at the other ; 
and in several attempts which I have made by cauterizing deeply the 
edges of the ulcerating extremity, and even interesting the healthy 

i Godart (Diss, sur le nitrate acide de Mercure, 4to., Paris, 1824).— Swediaur 
(op. cit. t. n. p. 381).— Hatin (Nouvelle Bibliotheque Med. 1826, t. iv. p. 188). The 
deuto-mtrate of mercury entered, in the proportion of the nineteenth part of a grain, 
into the preparation of the Sirop de Belief, a remedy which is not to be relied on, and 
which varies in its composition, according to its mode of preparation, its age, &c. 

\\ ard s white drops celebrated in England, are a solution of one part of the crys- 
tallized proto-nitrate of mercury and ammonia, in three parts of rose-water; dose, 
Irom two to three drops. r ' 



skin, with a view to check the morbid processes, I have had the morti- 
fication to see the parts goon ulcerating beneath the eschar, and the evil 
continue to spread and furrow the skin till its progress was arrested by 
a recurrence to general constitutional treatment. 

970. When excrescences can be conveniently attacked with cutting 
instruments, it is advisable, in the majority of cases, to remove them 
with flat curved scissors, and immediately to cauterize the small wound 
which results from this trifling operation with nitrate of silver. This 
excision ought in general only to be practised after the constitutional 
affection has been subdued, and when there is no longer reason to fear 
that the excrescences may be reproduced by the cause which gave 
them birth in the first instance. When these excrescences are only 
slightly elevated above the level of the skin, they may sometimes be 
made to shrink, and disappear by the use of a strong opiate lotion a 
strong solution of corrosive sublimate, the application of the powder of 
sabine leaves, &c. It is possible to remove pediculated excrescences 
only with the ligature ; and even in the cases to which this means 
is applicable, it is less certainly efficacious and more tedious than 
excision. 

971. Syphilitic onychia, independently of the general and specific 
treatment which it above all things requires, may possibly have occa- 
sioned such an alteration in the secreting matrix of the nail, as to make 
some form of local treatment indispensable. In ordinary cases, it is 
sufficient to envelop the extremities of the diseased fingers in emol- 
lient cataplasms, and subsequently to dress them with soft lint spread 
with a mild mercurial cerate. When ulceration has occurred about 
the roots, or along the edges of the nails, and they are completely de- 
tached from their matrices which have ulcerated, become fungous, or 
are surmounted on various points of their surface by irregular horny 
productions, it occasionally becomes necessary to extirpate these horny- 
growths, and even to excise the matrices of the nails entirely. 

With regard to the fall of the nails (alopecie ungueale), and the other 
alterations they undergo from a syphilitic cause, these require nothing 
beyond the general constitutional anti-venereal treatment, and parti- 
cular attention to local cleanliness. 

972. In venereal alopecia or baldness, it would be in vain to attempt 
to provoke the secretion of the hair, by the use of stimulating or aro- 
matic unguents until the general affection had been destroyed ; this 
result once obtained, the secretion of the hair is re-established of 
itself. 

973. I shall confine myself to a few remarks on the treatment of the 
venereal symptoms which almost always accompany the syphilitic 
eruptions. Several of these symptoms disappear under the influence 
of the general means employed against the eruption; there are never- 
theless certain symptoms which require measures of treatment peculiar 
to themselves. 

Ulcers of the mouth and throat, in their first stages, and particularly 
when they have been preceded by fever, are advantageously modified 
by bleeding, emollient applications round the neck, soothing gargles, 
and a bland or milk diet for some days. These ulcers, when no longer 
painful, or when in their chronic state, sometimes heal rapidly under 
the constant use of mercurial gargles, or even of occasional slight 
cauterizations with the acid nitrate of mercury. 

The acute syphilitic inflammatory affections of the larnyx, always 
extremely serious, for I have seen them produce orthopncea and suffo- 
cation, just as simple oedema of the glottis does, require to be vigorously 
and immediately combatted by general bleeding, followed by the appli- 
cation of leeches to the fore part, and of a blister to the nape of the 
neck, aided by stimulating baths or sinapisms to the feet, and an emetic 
of tartrate of antimony administered within the first twenty-four hours 
of the attack. In a case of this kind, I have seen the treatment re- 
commended dissipate symptoms of suffocation of such urgency, that a 
celebrated surgeon was on the point of performing tracheotomy for 
their relief. When, on the subsidence of the danger, the voice con- 
tinues considerably altered, and there is a good deal of laryngeal 
wheezing, whether these symptoms have preceded the attack of suffo- 
cation, (which is most generally the case,) or have succeeded it, and 
there seems reason to apprehend their continuance, two small issues 
should be applied to the region of the larynx ; this last remedy is 
also applicable in cases of syphilitic caries of the cartilages of the 
larynx. 



SYPHILID A. 



313 



In ozcma and caries of the bones composing the nasal fossae, great 
dependence should be placed on the insufflation of calomel as a topical 
means of arresting and curing the mischief. 

Syphilitic lachrymal tumours and fistulee ought not to be operated 
upon till after a complete mercurial course, by which means I have 
known several cases cured : moreover, without this preliminary treat- 
ment, the operation might be followed by a recurrence of the evil and 
other serious consequences. 

974. Patients attacked with syphilitic ophthalmia and inflammation 
of the cornea, and of the iris, ought to protect their eyes from the 
light. Blood-letting should be performed once or oftener, and, in 
cases of a serious nature, blood should be taken by cupping from the 
mastoid or temporal regions, and a blister applied to, or a seton in- 
serted into, the nape of the neck. The patient should take in the 
morning fasting, two drops of croton oil, mixed up in twelve drops 
of elderberry rob ; in some cases perfect abstinence from every kind 
of solid food should be observed during two or three days, and in all 
others the very lowest diet ought alone to be allowed. 

The inflation of calomel, and collyria containing the vinum opii, 
or extract of belladonna, are often of great service in leading syphilitic 
inflammatory affections both of the external and internal tissues of 
the eye to a happy termination. 

975. Vapour baths, aromatic baths, and fumigations of cinnabar, 
and flying blisters, employed either alone or in combination with the 
internal exhibition of opium, have appeared to me the most powerful 
of all the therapeutic agents we possess in allaying pains of the bones 
and articulations. The administration of opium and sublimate in com- 
bination, is one of the best means for effecting their permanent cure. 

976. With regard to swellings of the periosteum, recent and painful 
exostoses, and to subcutaneous gummy tumours, local blood-letting, 
by the repeated application of leeches, is the most prompt method of 
procuring relief. Blisters employed as rubefacients (vesicatories 
volans) are sometimes useful ; but the relief procured by these means 
can only be rendered permanent by submitting the patient at the same 
time to a general mercurial course, in combination with arseniated or 
slightly purgative sudorific drinks. 

977. After the removal of the exciting cause, syphilitic caries of 
the bones of the extremities is sometimes arrested in its progress by 
alkaline lotions if the affection is superficial, or by cauterizations with 
the concentrated mineral acids, or the application of the actual cautery, 
if the disease is more deeply seated. 1 

978. The treatment of the syphilitic cachectic state of constitution 
presents peculiar difficulties : this condition is frequently accompanied 
by chronic inflammation of the large* intestines, or by a diarrhoea 
which demands the use of emollient hip-baths, lavements of poppy- 
heads, or small doses of opium, several times a day. Too often, also, 
it is complicated with chronic enlargements of the liver, which must 
be combatted by occasional mercurial frictions of the belly and right 
hypochondrium. 

" The diet in this cachectic state ought to be nourishing, and should 
consist of mutton, beef, and other good meats, broiled or roasted, 
taken twice a day ; a light decoction of sarsaparilla and guaiacum 
will be found to make by no means an unpalatable beverage, which 
may be drunk at meals, and in the morning and evening a cup of a 
stronger and more concentrated decoction of the same substances may 
be taken. Should nocturnal pains or want of sleep be complained of, 
a dose of opium should be administered at night. 

If, after a month of this treatment, the state of the constitution 
appears ameliorated, should there still be any traces remaining of 
syphilitic eruptions or ulcers, the radical mercurial treatment may be 
cautiously entered upon. In fine, I have several times seen the con- 
stitution materially strengthened during convalescence, by the patient 
being made to take two sulphur baths weekly. 

979. It still remains for me to mention some particular modes of 
treatment applicable to pregnant women, nurses, and new-born in- 
fants. A pregnant woman affected with syphilis should be treated so 
much the more particularly as her infant is exposed to feel the fatal 
effects of this cruel disease ; I am even of opinion that a pregnant 
woman after being cured of primary symptoms ought to be made to 

1 Boyer. Traite des Maladies Chirurgieales, 8vo. Paris, 1814, t. iii. p. 475. 

79 



undergo mercurial treatment, upon the presumption that she is con- 
stitutionally infected, although this does not appear from any external 
manifestation. Pregnant women bear the pills of mercurial ointment, 
and the use of the tisane de Feltz, prepared after the formula of the 
Hopital de la Charite, without any apparent derangement of theii 
health. Mercurial fumigations to the genital organs, vapour-baths, 
and prolonged and repeated sublimate baths ought not to be recom- 
mended to them. 

980. When a mother suckles her child, and both are affected with 
the venereal disease, it is sufficient to subject the mother to anti- 
syphilitic treatment, the curative effects of this being transmitted by 
the milk of the mother to the child, and rendering it unnecessary that 
the child should be treated directly. This well-demonstrated fact has 
induced several practitioners to treat children, who are weaned or 
suckled by artificial means, by feeding them with the milk of a goal 
or an ass which has been subjected to mercurial inunction. 2 I have 
never had occasion to administer mercurial ointment internally to 
children ; I have no doubt, however, but that this might be done 
successfully, by reducing the dose to about an eighth part of that 
which is usually prescribed for an adult. 

981. Finally, whatever plan of treatment may have been adopted, 
it is necessary to continue it 3 for a fortnight at least, and sometimes 
even for a month after the complete disappearance of the symptoms. 
The cicatrization of a syphilitic ulcer should only be considered com- 
plete when all induration has disappeared from beneath and around 
the cicatrice. The yellow or livid spots which syphilitic pustules, 
and sometimes syphilitic tubercles leave behind them, are not a symp- 
tom of general infection, for they disappear of themselves, in the course 
of time. 



History and particular Cases. 

982. Our knowledge of venereal eruptions dates from the appear- 
ance of the great epidemic of the fifteenth and sixteenth centuries ; all 
the forms now described with so much care were then well known, 
and their characters briefly but clearly indicated. Massa, so remark- 
able for the accuracy of his descriptions and the excellence of his 
therapeutic principles ; Sorella, so interesting for his particular cases 
(consilia) ; Fallopius, whose treatise presents a more complete picture 
of symptoms and their treatment ; and Fernelius whose exposition and 
division of secondary symptoms are so elaborate, deserve to be con- 
sulted above all the writers of their age. Our information on the 
most efficacious modes of treatment dates also from this period ; and 
the various effects of these were so much the better appreciated, as 
the extent, the violence and long continuance of the epidemic, 
afforded opportunities of repeating them on immense masses of indi- 
viduals. The collection 4 of the principal works published on this 
memorable epidemic is even now one of the best sources from whence 
accurate and extensive knowledge of the nature and treatment of 
venerea] diseases is to be acquired. 

Forestus, 5 a learned observer, has gathered together a great number 
of particular facts relative to venereal diseases. Schenck, 6 in a very 
erudite and methodical work, the fruit of most laborious research, has 
also collected several rare cases which are well worth consulting ; 

2 This plan, proposed by Levret, (L'art des accouchemens, etc., 8vo. Paris, 1766, 1 
has been generally approved; Journal de Med., t. lxiii. pp. 290-64, p. 1.— Swediaur, 
op. cit. vol. ii. p. 120.— Gardien. Traite d'accouchemens, etc., 8vo., vol. iv. p. 201. 

3 Massa relates several cases of constitutional syphilitic disease, the treatment of 
which had been continued for fifty days. Several cotemporary authors restricted 
the patient to a very low diet, during several months after the disappearance of the 
symptoms. These opinions still continue to influence practice. Hunter considers it 
necessary to continue the treatment for a fortnight in the greatest number of cases, 
and for three weeks or a month, when the symptoms have disappeared very rapidly. 
According to Swediaur, the treatment should be continued for nearly two months in 
ordinary cases, and for three or four months in more serious ones. M. Dupuytren 
advises a continuance of the treatment for as long a time afterwards as had been re- 
quired to cause the symptoms to disappear. 

* Aphrodisiacus, sive de lue venerea,&c. Ab Aloysio Luisino edito. fol., Lugduni 
Batavorum 1728.— Grilner. (Chr. Gottfr.) Aphrod. sive de lue venerea; in dua.s 
partes divisus, etc., fol. Jense, 1789. 

6 Forestus. Observ. curat, medic, t. ii. lib. xxxii. de lue venerea, p. 519, fol. 
Rothomagi, 1653. 

• Schenck. Observ. med. rariores., lib. vi., de lue venerea, fol. Lugduni, 1644. 






SYPHILIDA. 



UtriK. s dedicated! his pages to (he consideration of 

eal affections of the skin and of its dependencies. 

Hunter,- whose works and opinions have exercised so great an in- 
upon the views entertained respecting syphilis, says very little 
in venereal eruptions, and only regards those as truly syphilitic in 
heir nature which require the use of mercury for their cure. Swediaur, 3 
who also has not given all the attention they deserve to eruptions of 
the skin, assures us that a decoction of the husks of the walnut is very 
Hi ctire in several of them, in which the best remedies fail, he says, 
if not combined with the use of the tepid or vapour bath. 

A. L. Petit, 4 who, under the name of pustules, comprised all vene- 
real eruptions, has divided them into dry and moist, scaly and scabby, 
fitc. Cullerier 5 and his pupils r> preserve these species and describe 
them with more care and precision. M. Alibert classes them all under 
the name of syp/rilides, and gives representations of several of them of 
_;reat accuracy ; 7 but it must be acknowledged that it is only since 
Willan's classification 8 has been employed in their study, that their 
nomenclature, their form, their appearance in different stages, and their 
diagnostic symptoms, have been shown with all the desirable exactness 
and precision. 

Dr. Carmichael has more particularly studied the syphilides under 
one point of view, namely, that of their relation to primary symptoms. 
Close observation of a great number of cases and the almost unani- 
mous testimony of the profession, do not allow me to adopt his theo- 
retical notions, although I acknowledge the merit of his descriptions, 
and the value of his views in regard to the treatment of primary and 
secondary venereal symptoms, as well as of his remarks, with re- 
ference to the general and constitutional phenomena which accom- 
pany them. 

Much time has been spent upon inquiries into the origin of syphilis, 
and the nature of its cause, or of the venereal virus. As to the dif- 
ferent modes of treating the disease, particularly the simple mode, and 
that with a thousand known and unknown remedies which have been 
boasted of as capable of destroying it in all its forms, I refer to the 
works of Astrue, 9 and to the dictionary of Cooper, 10 for an account of 
those most worthy of notice, and shall confine myself here to the 
simple mention of the best works, recently published in France on 
this subject; namely, those of MM. Delpech, 11 Jourdan, 12 Desru- 
elles, 13 and Devergie." 

Case CXLII. — Syphilitic, phlyzacious pustules, terminating in ul- 

'Astruc. De morbis venereis, 4to., 1738 (Maculae ephelidibus similes.— Herpetes 
<:l lichenes.— Scabies venerea.— Rimae et fissurse in volis manuum. — Pustulae cutanea;. 
— Ulcera contumacia.— Unguium vitiaet casus. — Ophiasis et alopecia. — Porri,cristce, 
verruca?, et condylomata). 

2 J. Hunter. On the venereal disease, 4to. London, 1771. 

3 Swediaur. Traite sur les symptomes, etc., des maladies syphilitiques, ii.fc'vo., 7e 
ed. Paris, 1817. 

* J. L. Petit. Traile des maladies des os, 4to. Paris, 1705. 
6 Cullerier. Art pustules. Die. des sc. Med., in 8vo., Paris. 

6 Lagneau. Expose des symptomes de la maladie venerienne, 5 ed. in 8vo. Paris, 
1818. Guerin (Alex.). Diss. (Inaux.) sur les pustules veneriennes, 4to. Paris, 
1813. r ' 

7 Alibert. Precis theorique et pratique sur les maladies de la peau, 2d ed. Pari*: 
3vo., 1822, art. syphilides, folio, pi. 40, 41, 42, et 43. 

8 Willan. On cutaneous diseases, in 4to., London. Art. Lichen syphiliticus. — 
Syphilitic psoriasis and lepra. Carmichael (Richard). An Essay on Venereal Dis- 
eases, 2d ed. 8vo. London, 1825. Cazenave et Schedel. Abrege pratique des mala- 
dies de la peau, 8vo. Paris, 1828. Art. Syphilides. 

9 Astruc (op. cit. p. 406. Index chronologicus auctorum qui de lue venere scrip- 
-erunt). 

10 S. Cooper (Surgical Dictionary, 6th ed. 8vo., London, 1830. Art. Venereal 
Disease). 

" Delpech (Considerations sur des maladies veneriennes; Chirurg. clinique de 
Montpellier, t. i. p. 263) has made some important practical remarks, and has studied 
ihe complication of syphilis particularly. 

12 A. Jourdan (Traite complet des maladies veneriennes, 8vo., 2 vol. Paris, 1826) 
has given in detail, and with much care, the history of syphilis and the different modes 
>f treatment recommended in this disease. 

s Desruelles (1st et 2d Memoires sur les resultats comparatifs abtenus par les 
.livers modes de traitement mercuriel et sans mercure inseres dans les Memoires du 
Med. de Uhir. et Pharm. Militaires, 8vo. Paris, t. xxv. et xxvii.), has published the 
results of particular experiments made on a great number of patients ; these experi- 
MhloS st'c'.reaimenu pr ° mplness of lhe cure of P rimar y symptoms by simple kn.i- 

M M N.Devergie. Clinique dela maladie syphilitique in 4 to. Paris, 1826, et 1832. 
in I mng r n!oce n nt a a;,: s . CarefU " y ^"'^ *** ^™* ^ "Ordinary accuracy 

The memoirs of Messrs. Abercrombie, Ferguson, Rose, Guthrie, Hennen Thomson 
Bacot, &c; the report upon the curafumU, &c, in' the German journals, and J 1 ™' 



ccration, inflammation of the lungs.— A child, five and twenty months 
old, was admitted to the Hjpital des Enfans on (he 16th of March, 
1825. The parents had already lost one child which had been 
affected with violent ophthalmia and ulcers of the face ; this one, 
brought up by hand, had thrived well till it reached the age of nine 
months. At this period several ulcers appeared on the body and 
were cured by the use of the tepid bath, and a salve of the composi- 
tion of which the parents are ignorant. In the month of February 
1825, inflamed pustules of about a line in diameter, appeared on dif- 
ferent parts of the body of this child, and particularly on the belly on 
the buttocks and genital organs, which, after becoming filled with a 
whitish pus, ulcerated. 

On the 29th of March a great number of ulcers, with grayish bot- 
toms, and sharply defined edges, appeared on the hypogastric region 
the genital organs, the buttocks and the insides and outsides of the 
thighs ; some of these were oblong, others circular ; some, of one line 
in diameter, others of two, three, or even more. Several ulcers of 
the same kind, but isolated, and few in number, were developed on 
the arms, the hands and the chest; in other parts small cicatrices 
around which the skin was violet-coloured and furfuraceous, were 
seen. From the time of entering the hospital, the child's skin was 
always hot, the pulse frequent, the thirst great: it expressed its suf- 
ferings by crying continually. 

After eight-and-forty hours, rather profuse diarrhoea came on (bran 
baths, gum-water for drink). For the last three days the ulcers had 
been dressed with soft lint, and a perforated linen rag, spread with 
mercurial ointment, and had assumed a better appearance. 

March 30th. — The same general state; pulse very frequent; 
moaning ; cough ; rather profuse diarrhoea. Some of the ulcers had 
become covered with whitish eschars. A mucous rattle was heard 
in the whole of the posterior parts of the two lungs. March 31st. — 
The breathing is short; the weakness extreme, profuse diarrhoea con- 
tinues; the extremities became cold, and the child died without con- 
vulsions at five o'clock in the morning of the 1st of April. Sectio 
cadaveris in the morning of the 2d of April. On the posterior parts 
of the body, on the region of the loins and buttocks, on the genital 
organs, on the hypogastric region, and on the insides and upper parts 
of the thighs, the ulcers of which I have spoken were seen ; they 
were uneven and sharply cut in the edges, as if with a pinking-iron ; 
some were isolated, others had united or very nearly so ; they were 
generally deep and implicated the whole thickness of the skin. The 
subcutaneous adipose tissue in the seat of the ulcers was injected ; the 
skin in the region of the loins and buttocks was redder than that of the 
hypogastrium and of the insides of the thighs ; on other parts of the 
skin, small circular cicatrices appeared, proceeding from old ulcers. 
On the hairy scalp in the left parietal and frontal regions, several yellow 
incrustations were discovered. Fibrinous concretions filled the supe- 
rior longitudinal sinus; the blood in the other sinuses was either 
fluid or simply coagulated. The brain and its investing membranes 
were healthy, the cineritious and white substances of their natural 
consistence ; there was a little serum in the lateral ventricles. The 
cerebellum was healthy. The larynx, the trachea and the bronchi 
were the same. The inter-bronchial glands of the right side were 
tubercular and of small size. Both lungs were of a pale white colour. 
The superior and inferior lobes of the right lung and the posterior 
part of the left lung were gorged (engorges). The left ventricle of 
the heart was twice the thickness of the right one. The river, the 
spleen, the mesenteric glands, the stomach and intestines, were in a 
healthy state; some red spots appeared on the descending colon. A 
thick and whitish mucus had accumulated between the glans and the 
prepuce. 

Case CXLIII. — Eruptions of flat tubercles, depressed in their cen- 
tres, several of which were excoriated in their circumference; syphilitic 

remarks on the syphilides and their treatment inserted in the Journal Hebdomadaire 
and other French periodicals, may be consulted with advantage, (a) 

(a) To these may be added the articles Syphilides in the Dictionn. 
de Med., and in the Dictionn. de Med et de Chir. Prat. ; also Traite 
des Syphilides ou Maladies Venhiennes de la Peau, &c, par P. L. 
Alphee Cazenave. See, likewise, the Lectures of Mr. Skey, and of 
Mr. Herbert Mayo,, and the work of Mr. Colles already referred to. 



SYPHILIDA. 



315 



exanthema, rapid cure by SedilloVs pills. — A waiter at a wine shop, 
of a good constitution, sanguine temperament, born of healthy parents, 
and twenty-five years of age, contracted for the first time, in 1830, a 
syphilitic disease, characterized by a chancre on the prepuce, which 
appeared five or six days after having had intercourse with a woman 
of the town. The chancre was dressed with strong mercurial oint- 
ment, and subsequently cauterized with nitrate of silver. 

A general mercurial course was begun immediately ; but the 
chancre being healed up by the fifteenth day, the patient discon- 
tinued taking the bichloride of mercury, the preparation prescribed 
for him. Since 1830, this man did not contract any new venereal 
disease; in 1834, during the month of May, a number of prominent 
tubercles appeared on the glans, on the prepuce and in the groins ; 
and shortly afterwards similar tubercles made their appearance on the 
forehead and hairy scalp also ; no treatment had been attempted when 
the patient entered the Hopital de la Charite. 

Prominent rounded tubercles of the size of a silver three-pence and 
of a coppery colour, were then visible on the corona glandis, on the 
prepuce, on the scrotum, on the groins, and about the verge of the 
anus; those of the scrotum and verge of the anus were excoriated; 
on one of the groins a brownish exudation had taken place between 
the dermis and epidermis; the epidermis was not destroyed but 
merely raised by the fluid exhaled over the surface of the tubercles. 
Tubercles of very similar character appeared on the forehead and 
hairy scalp; those of the forehead formed a sort of wreath which ex- 
tended from one temple to the other, following exactly the line of the 
roots of the hair ; two tubercles only were situated out of this line in 
the middle of the forehead. All these tubercles, of a circular form, 
with a coppery and prominent surface, and in general depressed in 
their centres, were nearly of the same size as those of the groins. A 
small ulcer or a slight scab of a curved form, was perceived on some 
of these tubercles, principally towards their circumference, sometimes 
occupying only the third or the half of their extent. The epidermis 
covering the remainder of the tubercle, could be raised and removed 
with the point of a needle. 

The tubercles on the hairy scalp, scattered, and few in number 
were less prominent ; they were perceptible by their coppery colour, 
and the circumscribed tumefaction of the dermis of the spot which 
they occupied. None of these tubercles occasioned either itchiness 
or sensations of smarting. 

On the body and extremities there were several rosy red spots, 
which did not rise above the general level of the skin ; they were 
some what larger than a lentil, of a round form, pretty near to each 
other, unaffected with desquamation, disappearing when pressed 
upon long by the finger, and separated by narrow spaces, where the 
skin preserved its natural colour. These spots, more numerous on 
the upper than on the lower limbs, were of a deeper colour on 
the latter than on the former; they were not accompanied with 
itchiness, and the patient, who had not remarked them, could not 
inform us how long they had existed. This man did not experience 
any pain in the bones of the extremities ; the throat had never been 
sore ; the sleep and appetite were both excellent, and he had no 
symptoms of a febrile nature. The patient took three of Sedillot's 
pills every day, with the tisane de Feltz as a drink. The tubercles 
of the glans were dressed with mercurial ointment; baths were 
administered from time to time, and the patient was put upon the 
half hospital allowance. From the eighth day the exanthematous 
eruption had disappeared; the scabs which covered the tubercles 
were loosened; and the tubercles themselves shrunk; those which 
were excoriated were cicatrizing, and several were covered with a 
new epidermis; on the fifteenth day, the tubercles no longer rose 
above the surface of the skin, and nothing but coppery blotches re- 
mained on the points which they had occupied ; the patient was not 
salivated, and experienced no inconvenience from the treatment. On 
the 23d of July he was well, and requested his discharge ; he was 
advised to continue the treatment for some time longer, although all 
symptoms of infection had now disappeared. 

Case CXLIV. — After more than one venereal infection, clusters of 
prominent tubercles, and ulcers of the leg covered with scabs : cure, by 
SedilloVs pills, and the tisane de Feltz. A * * *, thirty years of age, 
of a good constitution and sanguine temperament, was affected with 



gonorrhoea at the age of eighteen ; the discharge ceased at the end of 
a month after antiphlogistic treatment. Four years ago, this man had 
a bubo, which suppurated, and healed without mercurial treatment; 
and two years since, after an impure sexual intercourse, he contracted 
a chancre, which spread over a considerable portion of the glans, and 
destroyed the frenum. 

The patient was treated by means of mercurial inunction, and the 
chancre healed at the end of two months. Shortly after its cure, pro- 
minent tubercles made their appearance on the fore part of both legs. 
A * * * underwent a second course of mercury, by pills containing 
the bichloride of mercury ; the ulcerated tubercles cicatrized, became 
depressed, and the cure was completed, or believed to be so, after four 
months of this treatment. The patient then set out for South America : 
but shortly after his embarkation, ulcerated syphilitic tubercles ap- 
peared afresh on the left leg. He had not recourse to any kind of 
treatment on this occasion, but returned to Europe, and entered the 
Hopital de la Charite on the 9th of June, 1834. A large spot with- 
out prominence of the corion still appeared on the right leg, covered 
with a wrinkled cuticle, the deep colour of which did not disappear 
on pressure ; on this place, a year previously, a very large cluster of 
syphilitic tubercles and ulcers had existed. On the fore part of the 
left leg, in front of the tibia, over a space ten inches in length, by 
three in breadth, the skin was swollen, hard, violet-coloured, adhering 
to the tibia, thickly beset with large prominent livid tubercles, ulcer- 
ated in the centre, and covered with a brownish and shining scab, 
from under which exuded a quantity of purulent sanies. These tuber- 
cles were separated from each other by portions of indurated skin, 
the colour of which was like that of pale wine lees ; the tibia did 
not appear to be affected, and the patient did not experience pain 
either in that or any other of the bones and joints ; the throat had 
never been sore, but the different courses of mercurial treatment he 
had undergone had often produced salivation, and several teeth had 
fallen out ; those that remained were foul and black ; the breath was 
foetid; the sleep was good, and the appetite excellent. This patient 
was treated with Sedillot's pills and the tisane de Feliz, being put 
upon the half hospital allowance. An emollient poultice brought off 
all the scabs, and the tubercles were dressed with mercurial ointment. 
They shortly shrank, and cicatrized; the swelling and induration of 
the skin, and its coppery colour, decreased a little. The patient ex- 
perienced no inconvenience from the treatment to which he was sub- 
jected for more than a month, after which the tubercles healed. At 
this period there was still, on the inside of the left leg, a livid-coloured, 
uneven, and indurated surface in every point where a tubercle had ex- 
isted. The small cicatrices were prominent, hard, black, ecchymosed, 
indolent, and did not change colour on pressure by the finger ; the 
cicatrice appeared perfectly sound, and was not painful to the touch ; 
the patient was advised to continue the treatment for a fortnight longer. 

Case CXLV. — Subcutaneous syphilitic tubercles on the shoulder, 
with perforation of the slcin ; exostosis of the clavicle ; pills of mer- 
curial ointment ; tisane de Feltz ; cure. S * * *, widow, sixty years 
of age, of a lymphatic temperament, and broken constitution, was 
not aware of having been at any time affected with the venereal 
disease ; for several years she had suffered much from pains in her 
limbs, which she attributed to rheumatism. For the last year these 
pains were principally felt in the right shoulder, the skin of which 
became ulcerated, at the same time that a considerable swelling of 
the inner extremity of the right clavicle took place. This patient 
entered the Hopital de la Charite, the 11th of May, 1834. At this 
time the sternal extremity of the right clavicle was about the size of 
a small hen's egg; it was painful upon pressure, and habitually the 
seat of a good deal of pain, particularly during the night; there was 
no swelling of any other bone ; the joint of the right knee was the 
only one in which pain was complained of, and this caused a little 
difficulty in walking ; the skin that covered the acromial region 
was red over a space about as large as the palm of the hand, and 
pierced with several round holes from the size of a sixpence to that 
of a shilling, through which exuded a yellow and thick pus. The 
skin was thin and detached round each of these openings to the 
extent of several lines, where it possessed its natural colour ; three 
small, rounded, hard and immovable tubercles, about the size of 3 
large pea, without apparent change in the texture of the skin, but 



316 



SYPHILIDA. 



adhering to it, were perceptible under the dermis. These tubercles 
were painful upon pressure. The patient was subjected to mercurial 
treatment ; she took each day three of Sedillot's pills, and a pint of 
the tisane de Feltz. Under the Influence of this treatment, the exos- 
; the clavicle diminished in size, and became less painful; 
the skin where it was detached and thin, was destroyed by degrees; 
as a consequence of this, an ulcer of considerable extent was pro- 
duced, over the bottom of which cellular and vascular granulations 
were soon developed ; as they became rather fungous in their appear- 
ance, they were touched with the acidulous nitrate of mercury. The 
subcutaneous tubercles became more painful; the skin which covered 
them grew red and inflamed ; the tubercles softened ; the integuments 
gave way, and a thick yellowish pus was discharged; at the bottom 
of the ulcers a yellowish adhering substance was perceived, like the 
core of a carbuncle or boil, which came away in shreds several days 
afterwards, from the middle of the small round openings formed. 
The loosened integument became thin, was destroyed in parts, and 
larger ulcers appeared, the bottoms of which presented, from time to 
time, instead of the granulations of a simple sore, a red surface covered 
with a flimsy whitish pellicle, as if the surface had been slightly touched 
with nitrate of silver. These ulcers were dressed with mercurial oint- 
ment, and before long cicatrized completely. The skin of the acromion 
then presented several small depressed cicatrices of a livid colour, and 
adhering to the subjacent parts ; there was no longer any tubercular for- 
mation round them, and the pains of the shoulder had entirely ceased ; 
the patient left the hospital on the 30th of June, cured. She had con- 
tinued taking Sedillot's pills during the whole time she remained in 
the hospital, with the exception of a very few days, when this remedy 
was suspended on account of a considerable diarrhoea, which speedily 
subsided under the influence of opiates and mucilaginous drinks. 

Case CXLVI. — Serpiginous cicatrice on the left side of the back, 
the consequence of a serpiginous ulcer, treated by simple dressings; 
serpiginous eccentric ulcer on the right side of the back, developed three 
months after the cure of that on the opposite side. Josephine M., 
twenty-five years and a half old, a girl of the town, who entered the 
Hotel Dieu on account of a serpiginous ulcer, situated on the right 
side of the back, stated, that a large circular cicatrice, waved in its 
circumference, and covering the whole of the skin of the left side of 
the back, was the consequence of an ulcer, which, after lasting five 
months, cicatrized without the use of mercury, by being merely 
dressed with blotting-paper spread with cerate. This cicatrice, very 
prominent in some parts, where it was of a coppery red colour, was 
depressed in others, where it was of a whitish hue. The patient 
added, that five years previously she had been treated at the Hopital 
Saint Antoine, for an ulcer under the arm : and that two years after 
that, she had had the itch. This girl, sent to the hospital by order 
of the police, was of very equivocal character; but she persisted 
in affirming that she was not affected with the venereal disease ; 
her general health appeared very good. 

The right half of the back was occupied by an extensive ulcer, 
four or five times the size of the hand, spreading under the axilla, 
and covering the outer half of the right breast. This large ulcer 
was superficial, and seemed only to implicate the skin to a certain 
depth. The surface of the ulcer was red and granular; its circum- 
ference, well defined, was rounded and waved ; the skin which 
bounded it was sharply cut, and healthy beyond the limits of the 
sore, which was covered with a sanious pus of so offensive a nature, 
that the patients in the neighbourhood were greatly annoyed ; the 
patient had scarcely any symptom of fever and suffered no pain. On 
questioning this girl again as to the origin of this horrible ulcer, she 
informed M. Robert and myself, that she had felt very little the mat- 
ter with her back eight days previously, but that being detained by 
the police, the part affected had not been dressed, and that during 
this time the disease had become rapidly worse. She added that this 
ulcer, like that which had eroded the skin of the opposite side of the 
back, had begun by small swellings like pimples or boils (des clous), 
which had soon ulcerated, and that these ulcers had united so as to 
form one, which then went on extending from its centre towards its 
circumference. 

This woman was bled, and the ulcerated parts were covered with 
large perforated compresses, spread with cerate, over which a quantity 



of soft lint was laid. The inflammation diminished rapidly, and by 
the third or fourth day, the centre of the ulcer was cicatrized. The 
cicatrice extended progressively from the centre to the circumference, 
while the latter continued completely stationary, so that at the end of 
eight or ten days, there only remained a kind of band or stripe, half 
an inch wide, which, by waving irregularly, showed the limits to 
which the disease had reached. 

From the first moment, M. Dupuytren conceived this ulcer to be 
of a venereal nature ; the patient, nevertheless, persisted in denying 
that she had ever had any other affection of the genital organs than 
a leucorrhceal discharge of a few days continuance ; she refused an 
examination of those parts, saying, that before having been sent to 
the Hotel Dieu, she had been examined by a physician, who, had he 
seen reason for it, would have ordered her to the hospital for venereal 
diseases. 

A sudorific tisan and syrup, and three pills a day, each pill con- 
taining two grains of extract of guaiacum, half a grain of gummy 
extract of opium, and the sixth of a grain of corrosive sublimate 
were prescribed. Arrived at the state we have just described, the 
ulcer remained stationary in some points, and cicatrized in several 
others; it then spread in several places, though slowly, along its 
external edge, whilst the internal edge cicatrized. M. Dupuytren 
tried the effects of calomel to the ulcer, but at the end of a few days 
he was obliged to discontinue this application, as it occasioned a 
great deal of pain, and several parts of the recent cicatrice had fallen 
anew into a state of ulceration ; baths and emollients were therefore 
returned to. As soon as the inflammation had subsided, the ulcer- 
ated surfaces were touched with a pencil dipped in the acidulous 
nitrate of mercury; three applications of the caustic were made, and 
seemed to have produced a good effect, when the patient absconded 
from the hospital. 1 

Case CXLVII. — Serpiginous and phagedenic syphilitic ulcer eroding 
the face for three years, cured by the tisane de Feltz, and SedilloVs 
pills. A man, fifty-one years of age, with a horrible ulcer on the face, 
which it had eroded in different directions, entered the Hopital de la 
Charite, on the 20th of Nov., 1833. This man, of a good constitution, 
had never had any venereal complaint but once, a gonorrhoea, nearly 
twenty years since, and I have no reason to doubt the truth of this 
statement, as he himself informed me voluntarily of the former exist- 
ence of the gonorrhoea. There were no traces of cicatrices on the 
genital organs. Three years ago he had had eruptions and ulcers on 
the face, which were considered as syphilitic, and treated with the 
bichloride of mercury. The use of this medicine was discontinued 
immediately after the disappearance of the symptoms, which were not 
long of reappearing. A renewed anti-venereal course again put them 
to flight ; but the patient being of an irresolute and impatient dispo- 
sition, did not continue the treatment sufficiently long, and the disease 
reappeared for the third time. This want of success on one hand, a 
feeling of shame on the other, and the depression of spirits, occasioned 
by a disease which obliged him to quit his business, and live apart 
from every one, had so much affected his mind, that he resolved to 
enter the Hopital de la Charite, to make a last attempt to get rid of 
his infirmity. He was at this time in the following state : the whole 
of the right side of the nose, from the root to the corresponding ala, 
was in great part destroyed, and was covered with a brownish scab, 
flattened and indented on the surface, from under the edges of which, 
when it was pressed upon, a purulent sanies exuded. A similar scab 
which also covered a deep ulcer, extended from the lower part of the 
one first mentioned, towards the chin, following the direction of the 
zygomatic arch ; the cheek on the outside of this band was evidently 
swelled, and presented several analogous incrustations, and some 
ulcers which had accidentally lost their scabs. 

The upper lip was swollen, and presented several fissures towards 
the angle of the mouth, besides an ulcer on the right side. The lower 
lip, swelled in like manner, and drawn to the right side by cicatrices 
in the form of cords, very similar to those which are often observed 
after burns, was turned inside out, so that the saliva flowed from the 

1 This woman constantly denied the syphilitic origin of the ulcer under which she 
laboured, although it had every one of the external characters of the serpiginous 
syphilitic sore. M. Devergie has given a plate of a remarkable instance of this kind 
of ulcer. (PI. 106.) 



SYPHILIDA. 



317 



rnouth whilst the patient was speaking. In spite of all this mischief, 
the parts were but little painful, except during mastication ; the patient 
had no fever ; but he slept badly, and was in such a state of despond- 
ency as to entertain very slender hopes of recovery. 

Cataplasms, for two or three days, and warm baths, in which the 
patient immersed his head also, detached the incrustations, and we 
now saw, that under these there existed deep sulcated ulcers with hard 
edges, and gray or yellowish-coloured bottoms, which poured out a 
sanious secretion in sufficient quantity to form fresh scabs in two or 
three days after the fall of the first. This patient was ordered to have 
the tisane de Feltz and the pills of Sedillot, in doses of three a day. 
After the fall of the scabs, calomel was upon one occasion blown over 
the surface of the sores, which were subsequently cauterized very 
superficially with the acid nitrate of mercury. A progressive ameliora- 
tion in the state of the parts affected, was very speedily perceptible. 
A few sulphur baths were subsequently administered with the view of 
strengthening the constitution, and there were but two ulcers remain- 
ing, when, on the 30th December, erysipelas made its appearance on 
the face, after an attack of fever. The tisane de Feltz and the mer- 
curial pills were replaced by lemonade ; the erysipelas terminated by 
resolution at the end of five days ; and on the eighth day, the date at 
which desquamation commenced, the ulcers were found completely 
cicatrized. The patient was discharged well'on the 4th of January, 
1834. 

I saw this patient eight months afterwards, his health had gone on 
constantly improving, and the cicatrice was solid and of good appear- 
ance. 

Case CXLVIII. — Serpiginous syphilide characterized by ulcers in 
the form of Cs ; rapid recovery under the use of the pills of Sedillot 
ajid tisane de Feltz. — M. * * *, twenty-three years of age, was ad- 
mitted the 18th of November, 1834, into the HSpital de la Charite, 
where he had already been successfully treated, four years previously, 
for a serpiginous ulcer on the right leg. 

For several months past, several ulcers resembling a good deal the 
form of the letter C, had formed on the outer and posterior part of 
the elbow-joint of the right arm; these by coalescing gave rise to a 
large irregular ring, which covered the skin of the lower third of the 
outer part of the arm, and the upper third of the outer part of the 
forearm. The concavities of these ulcerated arcs were turned towards 
the interior of the ring, with one exception, however, for there was 
an arc which surrounded with great exactness, the half of the olecra- 
nal region. These ulcers formed a deep furrow, irregularly circular 
in its shape, of a grayish or yellowish colour, covered in part with 
incrustations of a darkish brown, not very prominent, and strongly 
adherent to the parts beneath; the edges of the ulcerated arcs were 
sharply cut, as if the skin and cellular membrane had been deeply 
chiseled, or taken away with a pinking-tool shaped like the letter C. 
The exterior edge of these ulcerated sulci was in general broader, 
more raised, and more sensible than the inner edge. On the follow- 
ing days, we could perceive that it was always by the outer edge, and 
not by its extremities, that the ulcer spread ; a circumstance which 
distinguished these from serpiginous ulcers in general. At a sub- 
sequent period, the work of cicatrization was found to commence 
with the inner edge, and to advance gradually towards the outer 
one until it was complete. The interior edge of one of the ulcers 
was covered with warty excrescences when the patient entered the 
hospital. 

The skin which was circumscribed by this ulcerated ring, was of a 
purplish-red colour, and in various places exhibited traces of old cica- 
trices. The elbow-joint was swelled and painful ; the limb which 
was kept in an habitual state of flexion, could not be completely 
extended, and motion of every kind was attended with pain. The 
incrustations having been removed by means of emollient cataplasms, 
the definite chiseled appearance of the ulcers struck us still more than 
before. In other respects, the health of the patient was pretty good, 
and he was immediately put upon a course of tisane de Feltz, and 
three of Sedillot's pills daily. Farther, the whole of the ulcers, except 
one, which was touched with a solution of the acid nitrate of mercury, 
were dressed with mercurial cerate ; the elbow-joint, enveloped in an 
emollient cataplasm, was fomented every morning in a decoction of 
marsh-mallows. Under the influence of this treatment, which occa- 
80 



sioned neither salivation nor any derangement whatever in the health 
of the patient, all the ulcers, with the exception of the one which had 
been cauterized, got well so rapidly, that the cicatrization was com- 
plete on the 4th of December. The ulcer which had been cauterized, 
was then dressed with mercurial ointment, and by the 11th of Decem- 
ber, it was also skin-whole. The motions of the elbow-joint mean 
time, had become as free as those of the opposite extremity. 

The patient having requested his discharge, shortly after the entire 
disappearance of the symptoms, I recommended him to continue the 
treatment, by taking the pills of Sedillot for some weeks longer, (a) 

(a) Case of virulent outbreak of psoriasis. Treatment of the pri- 
mary sores had not been mercurial. Mercury required to repel this 
attack. Other forms of cutaneous disease and subsequent outbreaks of 
psoriasis in the same case, yielded to the iodide of potassium. — [By 
Herbert Mayo, in Med. Gaz., 1839.] 

" A middle-aged person had been exposed to infection more than 
eight weeks before, when he discovered a sore upon the inner prepuce, 
near the glans. He showed it to a surgeon, who assured him that it 
was not venereal, and gave him an astringent lotion to dry it up. Ten 
days afterwards, which had been spent in considerable exercise and 
traveling, the sore presented the following appearance : — It was 
covered with dark adherent secretion, and the adjacent part of the 
prepuce was swollen and red. The sore was about half an inch in 
diameter, circular, one half on the body of the penis, the other on the 
prepuce, as it appeared when the latter was drawn back. At the 
bottom, the sore looked as if disposed to spread, by the sloughing of 
the cellular texture between the integuments and penis. It was not 
attended with pain. An ointment containing Peruvian balsam was 
applied on lint to the sore, an aperient given, and decoction of sar- 
saparilla, with four grains of iodide of potassium, ordered to be taken 
twice a day. In four or five days the sore had become clean, and had 
begun to granulate, when I discovered accidentally, the patient having 
no suspicion of its existence, another smaller sore on the opposite side 
of the inner prepuce. It was circular, without hardness, very slightly 
excavated, with a definite raised edge; the surface soft, vascular, and 
all but granulating. The same dressing was applied to it, and, like 
the first, it became a healing sore, and both were going on to cicatrize 
(which they did in three weeks, neither leaving hardness), when, in 
ten days from the commencement of the use of the iodide, syphilitic 
psoriais broke out on the glans penis, on the scrotum, on the pubes, 
abdomen, and loins. The dose of the iodide was increased, but the 
eruption advanced, and, appearing upon the head and face, threat- 
ened considerable temporary disfigurement. At the same time, it 
seemed so little controlled by the means employed, that I thought it 
necessary to recommend a course of mercury. The gums were affected 
in three or four days, and the spots upon the forehead became sta- 
tionary. The course of mercury was pursued for five weeks : by that 
time the spots had everywhere disappeared ; but those on the fore- 
head had left broad, yellow, circular stains, which only slowly wore 
out during the half year following. The character of these spots had 
been this: at first the upper part of the forehead looked mottled at 
half a dozen points near the roots of the hair ; then distinct circular 
spots, of a faint red, were seen, a quarter of an inch in diameter ; 
they were slightly raised and convex ; as they enlarged they became 
less elevated, and of a darker colour — a browner shade of red ; and 
thin scales of cuticle began to separate from them. In ten days from 
the termination of the course of mercury, the integument at the inner 
part of one eyebrow and one ala of the nose, became thickened, 
swollen, and red, assuming such an appearance as precedes syphilitic 
ulceration of those parts. The iodide of potassium was then given 
for three weeks, first in ten grain doses, and finally half a drachm, three 
times a day. In four or five days from the commencement of this 
medicine, the redness and swelling of the integuments had begun to 
decline. A week had scarcely elapsed from the discontinuance of 
the iodide, when a new eruption appeared ; spots broke out on the 
face and forehead, spreading with a red or elevated edge, leaving the 
centre paler: For this the iodide was recommenced, and, as it did 
not act as quickly as before, five grains of Plummer's pill were given 
every night in addition. On this attack receding, the throat became 
troublesome ; the tonsils had already been swollen and excoriated, but 



MB 



AMBUSTIO. 



AMBUSTIO.— BURN. 

983. Under the general title of bums, are usually designated all the 
b produced by the action of caloric on our organs, and in par- 
ir on the skin. 

■ rding to the degree of their intensity, burns of the skin are 
vri/.ed by the occurrence of erythematous spots, by the presence 
of phlyctens, blebs or blisters, and by the occurrence of eschars. 
1.— The erythematous burn {the first degree of bum, Dupuytren), is 
terized by vivid redness of the skin, which disappears under 
pressure. This burn is accompanied with acute scalding or smarting 
sensations, and some slight swelling of the parts implicated. These 
local symptoms may only continue for a few hours or be prolonged for 
several days; in the latter case, the epidermis is usually detached in 
the shape of small squamae. When these superficial burns are limited 
to small districts of the skin, they do not occasion any derangement 
in the principal functions; when they are very extensive, they are 
liable to be accompanied by restlessness, loss of sleep, delirium, and 
are sometimes even fatal in their consequences. Burns of the de- 
scription under review may be produced by exposure to the intense 
heat of the sun, on the hands, face, head or neck ; they are some- 
times also occasioned in a slow and gradual manner on the legs and 
thighs of the aged, who, during winter, expose these parts much 
to the heat of the fire ; they occur, too, among women who are in the 



now an angry superficial ulceration, with a yellow edge, spread over 
the soft palate : this gave way at once to a gargle of decoction of bark 
with half a grain of corrosive sublimate to the ounce. Next a papu- 
lar eruption appeared upon the forehead and face, and afterwards pso- 
riasis at several recurrences; but these have gone away each time 
upon a week or fortnight's course of the iodide, and since the first 
outbreak the attacks have been progressively milder. During the 
whole period, the patient's general health has been unaffected." 

The following case by Mr. Mayo, exemplifies the most virulent 
lepra. — Cure by iodide of potassium. 

" John O'Shaughnessy, in the autumn of 1828, had a primary ulcer 
and bubo, for which he took mercury. Before long leprous eruption 
and ulceration of the throat followed. He was admitted into Mid- 
dlesex Hospital in January, 1830, with several large leprous spots on 
his limbs and body; a large ulcer on the instep, another on the 
shoulder. He took liq. potassa?, with sarsaparilla, and the ulcer on 
the instep healed. But lepra broke out universally. The patches 
became covered with a great thickness of papery scales, the skin 
beneath which felt thickened : the scales became a crust, and falling 
off disclosed an ulcer. There were many of these ulcers on the limbs 
and body ; the forehead and face were covered with them. The lips, 
the ake of the nose, the eyebrows, were equally involved in ulcerated 
blotches. The patient suffered from burning heat of the body and 
face, and the ulceration of the lips produced ptyalism. The bones 
were not affected, but there was pain on moving the joints of the 
legs, and a small depot of serous matter formed in the right calf. 
Every remedy was now tried in succession, and all did temporary but 
very transient good, except nitric acid with bark, and mercury: these 
medicines made him worse. Having had him under my care a year, 
and the disease being unsubdued, I then ordered (Dec, 1830) at M. 
Magendie's suggestion, who happened to see the patient, a sixth of a 
grain of iodine, with ten grains of the iodide of potassium, three times 
a day. The good effects of the remedy were apparent after a few days : 
the skin became less red and heated, several of the crusts separated, 
and the ulcers put on a healthy appearance. In a month the patient 
had made a great amendment. But now the amendment ceased. The 
iodide was, therefore, discontinued ; upon which the patient became 
worse. After a fortnight he resumed the medicine, with the same 
advantage as on first taking it. In a month the disease became again 
stationary. He then discontinued the iodide, to resume its use in a 
fortnight. By these means in five months he recovered his strength 
and health ; but a few blotches would occasionally appear, upon which 
he again had recourse to the iodide. Afterwards a very severe relapse 
took place, of which he was cured in the Lock by the same medicines. 
When I last saw him he had been quite well for some years." 



habit of using chaufrettes. 1 These superficial burns (epluiides igncales, 
Alibert), present themselves in these cases under the form of spots of 
reddish brown, and are constantly without any feeling of heat or 
smarting. 

M. Briquet has frequently examined the skin of women of the 
lower class, whose thighs presented these kinds of ephelis, and found 
that they were occasioned by a vascular net-work, consisting of en- 
larged arteries and veins, surrounded by cellular membrane filled with 
blood. 

2. The vesicated or bullous burn (the second degree of burn, Du- 
puytren), is a more intense form of this affection of the skin. The 
blisters or bullae which characterize it, appear almost immediately 
after the action of the heated substance, particularly when this hap- 
pens to be a liquid. Fresh blisters of different sizes afterwards form 
successively in the vicinity of those first produced, and these become 
more voluminous in proportion as the inflammation increases and 
spreads around them, which it does rapidly : the skin is red and 
tense ; the subcutaneous cellular membrane is swelled ; the heat and 
pain are more intense than in erythematous burns. The serum con- 
tained in the vesicles and bulla? is of a pale-yellow colour, or slightly 
turbid ; as soon as they break the epidermis shrivels, and is thrown 
off, when a false membrane is sometimes exposed, covering the sur- 
face of the inflamed reticular body. A new epidermis is not long of 
replacing that which has been destroyed, when the burn is not very 
extensive, and is treated by appropriate means; but when, after the 
fall of the epidermis, the excoriated parts inflame and ulcerate, a 
discharge of sanguinolent serum is established ; suppuration goes on 
for a long time, and a cure is rarely obtained without cicatrices. 

3. The gangrenous burn (third and fourth degrees, Dupuytren), is 
characterized by mortification of a part or of the whole of the thick- 
ness of the skin; by the destruction of the subcutaneous cellular 
substance, and the death of the tissues still more deeply situated. 
The least serious degree of this species of burn is almost always an- 
nounced by the presence of superficial grayish or yellowish-coloured 
and insensible spots. At the moment of the accident, nothing more 
is sometimes observed in this degree of burn than an erythematous 
redness of the skin, or the formation of a few phlyctena? ; after the 
lapse of three or four days, however, superficial eschars make their 
appearance, and sores are also subsequently formed which interest 
the surface, or even the whole thickness of the corion, without any 
excessive amount of inflammation having occurred to account fortius 
unfortunate result. Complete insensibility, hardness, and a shriveled 
horny appearance, joined to a yellow or grayish colour, announce the 
conversion of the entire thickness of the dermis into an eschar. Phlyc- 
tenae or blebs are usually observed immediately around the eschars, 
and at a greater distance there is a broad band of erythematous in- 
flammation which is the seat of severe and burning pain. 

At the end of eight or nine days, seldom sooner, and very fre- 
quently later, a line of separation begins to be established between 
the dead and the living parts. Suppuration becomes abundant, and 
the discharge is mixed with shreds of sphacelated cellular mem- 
brane ; the whole of the part injured has now a gangrenous and foetid 
odour. 

When the burn is very severe and extensive, the inflammation is 
apt to run high, to extend to a great distance around ; and by its excess, 
to cause the mortification of the parts it implicates. 

984. Burns of trifling extent, whether they be superficial or extend 
more deeply, are rarely complicated by general morbid phenomena; 
but whenever a considerable district of the skin is implicated, burns 
are accompanied by ardent thirst and extreme heat of surface ; the 
pulse becomes hard and frequent ; the urine scanty and high coloured, 
&c. When nearly the whole surface of the body is burned, the patient 
invariably dies within a few days, often within a few hours after the 
accident; 2 the pulse is then small and frequent; the extremities cold ; 
delirium and convulsions supervene ; a cold sweat spreads over the 
trunk and face ; the features shrink, &c. Patients who escape these 
first violent and imminently dangerous symptoms, frequently succumb, 

1 Earthen pans of burning charcoal which the lower order of females in France 
place under their petticoats during the winter. — Tr. 

2 Serrurier. Brulure suivie de mort au bout de 12 heures. (Rev. Medic, Noverc- 
bre, 1830, p. 249.) 



AMBUSTIO. 



319 



after extensive burns, under consecutive phlegmasia? of the pulmonary 
and gastro-intestinal mucous membranes, (a) 

Several of these patients have even been seen to sink at the moment 
when the injuries they had received were nearly, or even completely, 
cicatrized. 

985. Exclusive of the injuries of the skin, which we have described, 
the bodies of persons who have died from the effects of severe burns, 
have sometimes exhibited sanguinolent and purulent effusions into the 
articulations of the extremities which had been the seat of the injury; 
occasionally congestion of the vessels of the brain, and now and then 
manifest traces of inflammation in the serous membranes, but much 
more frequently in the gastro-intestinal mucous membrane also occur. 

986. Causes. — Solid bodies occasion burns which are so much the 
more severe, in proportion as these have been applied at a higher 
temperature, as they are more dense in their composition, and better 
conductors of caloric, and as their action, whether mediate or imme- 
diate, has been continued for a longer period of time. Some sub- 
stances, which burn rapidly, and which melt while in a state of ignition, 
such as phosphorus, sulphur, the resins, &c, produce burns that are 
both very extensive, and that penetrate deeply in an extremely short 
space of time. All liquids do not burn with equal violence. Those 
which require a very high temperature to make them boil, and which 
have a great tendency to stick to the skin, such as soup, oil, pitch, 
tallow, &c, are the most dangerous. The burns occasioned by alco- 
hol, aether, or by the explosion of gunpowder, &c, are often very ex- 
tensive, but generally superficial, in consequence of which they are 
less formidable. 

Lastly. — Under the title of spontaneous burning or spontaneous com- 
bustion, certain effects or changes have been spoken of, analogous to 
those occasioned by the agency of caloric. The mode in which 
these spontaneous combustions take place is very little known, even 
at the present day. 

987. Diagnosis. — The erythematous spots, blisters and eschars 
produced by burns, differ in the cause which produces them, from 
the spots of erythema?, the bulla? of pemphigus, and the eschars of 
the skin observed in other diseases. 

In some circumstances, nevertheless, the diagnosis may continue 
uncertain for a time ; such was the case with a rheumatic patient, 
for whom I had prescribed vapour baths in the Hopital de la Charite, 
and who presented an eruption in the form of a collar round the neck, 
consisting of oval spots, from an inch to an inch and a half in dia- 
meter, the surface of which was covered with irregular bulla?, which 
were succeeded, at the end of some days, by superficial eschars of a 
yellowish-white colour. This man being questioned several times as 
to the cause of this eruption, continued to assure us that he was com- 
pletely ignorant of it ; and we only learned, some days afterwards, on 
seeing the eschars, and pressing him anew with questions, that whilst 
seated in the vapour bath he had experienced a considerable degree 
of heat about the neck, but no sensation of burning. This last cir- 
cumstance, strengthened by the appearance and progress of the in- 
flammation, determined us at length as to its cause and nature ; 
although, I repeat, the patient had not experienced the sensation of 
burning. 

Burns ought also to be distinguished from those red patches, vesi- 
cations and eschars which are produced by the application of the 
liquor ammonia?, more or less diluted, to the skin. 

Finally, the redness produced by sinapisms, the bulla? or vesica- 
tions, caused by blisters, the grayish and black eschars engendered 
by the application of caustics of different kinds, and the concentrated 
sulphuric acid, those of a yellow colour which result from the action 
of nitric acid, and those of a blue cast, which are sometimes observed 
upon the hands of washerwomen who burn themselves with compo- 
sition blue, have each appearances peculiar to themselves, and are 
distinguished by these as well as separated by their causes from ordi- 
nary burns. 

988. The prognosis in cases of burns, is unfavourable in propor- 

(a) Of the latter, the duodenum is more especially the seat of lesion. 
Mr. Curling (Med. Chir. Transact., vol. vii., and Bull. Med. Science, 
1843), gives ten cases of this complication with burns. The change 
was of an ulcerative character. 



tion to the extent and depth of the injury. Burns are most dangerous 
in children, the aged, and persons of very irritable constitution. 
Those of the parietes of the abdomen and thorax, and of the face, 
are more dangerous than those of the limbs and extremities ; never- 
theless, burns of the hands and feet have been occasionally known to 
be followed by tetanus. 

In burns the extent of injury which the skin has sustained, and the 
amount of alteration undergone by the subjacent tissues, cannot be 
precisely ascertained until the inflammation has reached its height, 
and the eschars begin to separate: even then the extent of injury 
done to the skin itself is ascertained with much more certainty than 
that which the subcutaneous cellular membrane has suffered. 

989. Treatment.— Erythematous burns ought to be treated from 
the moment of the accident, by the application of cold or iced water, 
and by compression. Immediately after the accident, the injured 
part should, if possible, be plunged into cold or iced water, and then 
covered with compresses dipped in it and kept continually moistened, 
over which a roller is to be pretty firmly applied. 

In cases of very extensive superficial burns, the action of the cold 
water may be confined to those points where the scalding heat is 
most severely felt, whilst the other parts are dressed with a mixture 
of two parts of white of egg and one of oil. When the pain is very 
intense, a little of the extract of hyoscyamus (baume tranquille) may 
be added to the mixture. 

990. In burns accompanied with vesications, when the clothes still 
adhere to the injured parts, they must be slit open and carefully re- 
moved, in order not to tear the epidermis, raised by the effusion of 
serum beneath it. 

The part shoula be plunged into cold water in order to appease 
the scalding and smarting sensations, and if it cannot be kept con- 
veniently immersed for any length of time, after being covered with 
a poultice of grated raw potatoes, it should be bound up with a 
bandage dipped in iced infusion of althea-root. The pain and inflam- 
mation should be allowed to subside in some degree before the vesi- 
cations are opened ; one or more small punctures may then be made 
at their extremities, but the epidermis is by no means to be removed, 
as by its presence it protects the tender surface of the skin from the 
action of the air. If the surface of the corion some days after the 
serum has been evacuated begins to pour out a purulent secretion, 
which escapes with difficulty, the epidermis must be removed. 
Should the suppuration prove very copious, dressings spread with 
saturnine or Turner's cerate may be applied to the excoriated skin, 
and a quantity of lint or tow laid over all to absorb the pus. When 
the ulcerated surfaces are very extensive, saturnine topical applica- 
tions must be employed with circumspection, to avoid the danger 
incidental to the absorption of lead into the system. 

Carded cotton has been employed successfully in the treatment of 
burns, quantities being applied layer after layer till a stratum is 
formed sufficiently thick to render the injured parts insensible to pres- 
sure from without. This dressing ought not to be repeated until there 
is a very considerable discharge with or without the formation and 
detachment of eschars. The silky tufts of the typha, employed in 
the same manner, have also produced the best effects. 

It is in this description of burn that Fernelius recommended the 
part affected to be exposed to the heat of the fire, ignis, ipse hie 
ipsius aleociterium, and that others have advised the part to be im- 
mersed in water as hot as it can be borne. 

Sydenham, in the same circumstances, recommended the applica- 
tion of spirits of wine, or of painter's varnish. 

Precisely similar measures are required in the local treatment of 
gangrenous burns, during their earlier stages; such measures become 
necessary subsequently as tend to bring about the separation of the 
eschars. 

When the toes and fingers have been burnt to such a degree as to 
occasion disorganization throughout their whole thickness, it is often 
necessary to divide certain ligamentous connections or shreds of ten- 
dons which continue to unite them to the parts whose vitality has not 
been destroyed. 

When a portion of a limb has been disorganized, amputation must 
be deferred till the symptoms, immediately consequent on the injury, 
have been subdued. The operation rarely succeeds when extensive 



320 



AMBUSTIO. 



surfaces besides have suffered. Amputation may also become neces- 
sary when after, and in consequence of, the separation of the eschars, 
the interior of a large articulation is exposed, or when the ulcers 
which reaoh are so extensive and irregular that a cure is not to be 
ted. 

The cicatrization of wounds consequent on burns, does not always 
proceed regularly from the circumference towards the centre ; this 
process sometimes commences far from the edges in several separate 
points at once. In every case it is of the greatest consequence to see 
that the cicatrice be kept of the same or as nearly as may be of the 
Mine extent as the skin destroyed, in order that, after the cure is 
complete, the parts may preserve their natural direction, and the 
freedom of their motions unimpaired. Tents of different kinds, 
eanuke, &x., will serve to prevent the contraction of the natural 
openings, as of the ears, nostrils, &c; and contiguous parts are kept 
separate by compresses and dressings appropriately applied. When 
the fingers are burnt they should be fixed on a splint in the form of 
the hand, and kept easily separated from one another: splints of the 
requisite form, and secured with proper bandages, will prevent any 
undue and unnatural contraction of the extremities, the faulty inclina- 
tion of the head, the dragging of the lower jaw towards the breast, 
&c. In order to obtain a smooth and uniform cicatrice, the granula- 
tions when too luxuriant must be touched with lunar caustic ; but in 
spite of every precaution that can be taken, the cicatrice will always 
appear depressed, and will always adhere to the subjacent parts when 
the burn has been deep. 

In burns accompanied with vesications, and sphacelus, when the 
discharge becomes very profuse, it is advisable to — dress the wounds 
at least twice and sometimes even three times in the course .of the 
day, care being taken only to expose the different inflamed regions 
in succession ; the many-tailed bandage, therefore, is generally to be 
preferred to the circular roller. 

991. The plan adopted by M. Lisfranc, in the treatment of burns, 
is peculiar: after having opened the phlyctense, or blisters, he re- 
moves the epidermis from their surface, and then covers the inflamed 
parts with a soft pledget of perforated linen rag, spread with cerate, 
over which he applies a compress of lint, dipped in a solution of 
chloride of lime ; and directs the dressings to be sprinkled at inter- 
vals with this liquid, so as to be kept constantly wet with it. The 
solution of the chloride of lime, employed by M. Lisfranc, in general 
indicates three degrees of M. Gay Lussac's chlorometer. If this 
application fails to occasion some slight degree of pain at the moment 
of its use, or if in subsequent stages, the cicatrization advances slowly, 
M. Lisfranc increases the activity of the solution, by raising it two or 
even three degrees in strength. If, on the other hand, the contact 
of the chloride of lime produces severe pain which continues unabated 
for some time after the dressing has been applied, and if white albu- 
minous deposits occur upon the surface of the inflamed skin, a solu- 
tion of inferior strength must be used. The action of this application, 
we are assured, has always appeared to be extremely beneficial. 

992. The general symptoms that immediately follow a severe burn, 
particularly the shock received by the nervous system, and the irregu- 
lar and prolonged shivering fits with which patients are often seized, 
as also those inflammatory attacks of the digestive organs, which so 
frequently supervene, are successfully combated by the exhibition of 
opium. Burns which are merely superficial, and of small extent, are 
seldom accompanied by such symptoms, and do not generally require 
any change of regimen or any peculiar system of internal treatment. 
In extensive burns, however, rigorous abstinence must be enforced, 
and soothing beverages, anodyne emulsions, &c, prescribed ; general 
bleeding, and the application of leeches to the head or epigastric 
region, according as the inflammation of the skin appears to have re- 
acted on the brain or the stomach, are further very constantly indicated 
in these cases. Very full diet under any circumstances is improper, 
and will be found to delay the healing of the wounds. 

993. \\ hen the trunk is the seat of a burn of considerable extent, 
the slightest motion is extremely painful. It is advisable in such 
cases to place the patient on a bed which admits of the linen and 
bedding being changed, and a proper vessel for receiving urine and 
fecal matter beinsr got under him, without any exertion on his part or 
his feeling himself obliged to move in the slightest degree. 



Burns with gunpowder are almost always followed by indelible 
black or bluish stains. Turner mentions a case in which he was so 
fortunate as to prevent this stain from occurring by scraping the sur- 
face of the burn, and afterwards applying a blister and red precipitate 
to the blackened skin. 

994. The indurated bands or cords, formed by the cicatrices of 
burns, when of no great thickness, may sometimes be so much re- 
laxed that they can gradually be stretched and finally made to dis- 
appear almost entirely, by means of oily embrocations, mucilaginous 
or oleaginous fomentations, &c, or by the repeated use of the douche, 
and the enforcement of gentle motions ; but when these cords are very 
rigid and of considerable thickness, they must be divided to their 
base, provided they contain no tendons, and the edges of the wound 
maintained forcibly apart, until complete cicatrization has taken 
place. (a) 



(a) A great number and variety of applications have been used and 
are recommended for burns. The author, in the text, says nothing of 
the stimulating practice, as far, at least, as regards dressing. M. Miiller 
(Principles of Surgery), concludes an admirable chapter on " Burns 
and Scalds," with the following judicious remarks: — "Some strenu- 
ously advise stimulating applications from the beginning; and a 
theory has been made to suit the practice. Neither seem to merit 
approval. Alcoholic applications may sometimes prove service- 
able, in a scalded but unbroken skin, by the cold which the eva- 
poration produces ; and, in the severe injuries, any stimulant, at first 
increasing the pain, may afterwards be said to deaden it by accele- 
rating and aggravating the inflammatory action, so as speedily to over- 
come the impaired vitality, and convert all into one slough. But 
such is not wise and prudent surgery. Let stimulants both internally 
and externally, be retained in their proper time and place ; and these 
will be found in the second, sixth, and ninth indications of cure." 
The references here are ; 1. To the case in which a burn or scald in- 
volves a large part of the surface, and in which the continuous use of 
cold cannot with propriety be had recourse to ; a warm solution of 
opium or other anodyne is preferable ; and if the duration and degree 
of slough be excessive, heat must be applied to the external surface 
generally, and warm drinks used internally. 2. After granulation is 
established water-dressing is applied, not hot, but tepid, as a mere 
detergent and protective ; but when the sore manifests deficient action, 
then may we have recourse to various stimulating dressings. 3. To 
maintain the powers of the system is an important indication after the 
suppurative process is begun and the constitution is irritable and en- 
feebled. " This is done by attention to air, exercise and clothing ; 
by generous diet ; and by the use of tonics and stimuli — of the latter, 
the cantharides is often the most efficient form." 

In the first or erythematic stage of a burn, or even in the second or 
vesicating, after the application of cold until the pain is subdued or 
removed, well carded cotton or cotton-wadding, is to be applied over 
the part, so as to exclude the air and to prevent any friction by 
clothes, &c. The same purpose will be answered by a layer of some 
bland adherent substance, such as will not irritate the raw or injured 
surface, and yet will effectually exclude the air, as soap, gum or 
varnish. The gum is preferable, as in the case of contused wounds. 
Or, the part may be dusted with flour ; but when vesication is ex- 
pected, this is an objectionable form of protection, inasmuch as the 
serum bakes it into crusts, which crack, loosen, and are apt to irritate in- 
juriously. A popular dressing is, equal parts of lime-water and lamp-oil, 
or, as less unpleasant, if not quite so bland, olive-oil. The cerate of 
the acetate of lead and ointment of the carbonate are soothing appli- 
cations. Warm vinegar has been found serviceable. 

In severe burns, where there is loss of skin, and ulceration is begun, 
ointment of chloride of lime or lint moistened with the fluid chloride 
of soda, is one of the best, if not the best application, to produce healthy 
granulations and to prevent deforming contractions. It is in this 
stage that other stimulants, such as the salts of zinc, copper, silver, 
&c, are occasionally serviceable. Tincture of iodine and the com- 
pound solution have been recommended in some instances. 

Throughout the whole period great attention must be paid to the 
state of the constitution and particularly to the lungs and gastro-duo- 
denal surface. Blood-letting, antimony, calomel, and opium, will, in 



PERNIO. 



321 



Historical Notices and particular Cases. 

995. Fabricius Hildanus 1 has given a good description of burns, of 
which he distinguishes three kinds. Turner 2 has left a useful chapter 
on burns, and has reported two cases of cure which deserve to be 
consulted ; he made great use of the cerate which still bears his name. 
Parkinson 3 has recommended the application of spirits of wine, already 
prescribed by Sydenham. Sir James Earle 4 has shown the advantages 
of cold applications, early advised by Rhazes and Avicenna. For the 
last twenty years M. Dupuytren 5 has annually delivered several clini- 
cal lectures of the highest interest on this subject. Anderson's 6 paper 
may be consulted on the employment of carded cotton dressings, and 
that of M. Vignal on the treatment of burns by the application of the 
down of the typha ; 7 Dr. Christison's observations on the distinction 
between burns that have happened during life and those that have 
taken place after death 3 are deserving of particular attention in several 
points of view. For information on the means of remedying the de- 
formity so often induced by the contraction of the cicatrices of burns, 9 
the work of Dr. John Thomson, 10 remarkable for the justness of its 
practical precepts and its scientific character, the later paper of Mr. 
James, 11 and the two lectures of Mr. H. Earle 12 may be particularly 
referred to. The surgical lectures of Abernethy also deserve to be 
consulted on this point. 13 

Several cases of burns of the skin detailed by Moulinie, 14 Lisfranc, 15 
Bretonneau, Velpeau, 16 Borot de Belloy, 17 &c, will be read with 
advantage; they illustrate the several peculiarities presented by these 
accidents, at the same time that they present the readerwith instances 
of the practical application of the different methods of treatment I 
have mentioned. The very interesting observations of Mr. Marshall 
on scalds or burns of the pharynx and larynx; 18 those of M. Lair 19 on 
the combustion of the human body ; and some singular facts, open, 
however, to suspicion, on the subject of spontaneous combustion, 20 
ought equally to be consulted. 

succession, be required in some cases in which inflammatory excitement 
runs high. After this period has passed, tonics and nutritive stimu- 
lants will be proper. For the means by which extreme deformities 
from burns are removed and new parts substituted for the excised 
contractions, the reader is referred to works on Surgery, and particu- 
larly to Velpeau's Operative Surgery, Townsend's Translation. 

' Fabricius Hildanus. De ambustionibus, quae oleo et aqua fervida, ferro candente, 
pulvere tormentario, fuimine et quavis alia materia ignita fiunt. Basil, 1607, 8vo. et 
in Op. om. 

2 Turner. A Treatise of Diseases incident to the skin, p. 369, 8vo. Lond., 1736. 

3 Parkinson (Thomas). On the application of spirit of wine to burns and scalds 
(Memoirs of the Medic. Society of London, 1799, t. v. p. 62). 

* Earle (James). Obs. on the cure of the curved spine ... .Also an essay on the 
means of lessening the effects of fire on the human body, 8vo. London, 1799. 

5 Lecons orales de clinique chirurgic, t. i. 

6 Glasgow Med. Journal. May, 1828. 

7 Vignal (E. T.). Essai sur la briilure et son traitement par l'usage du poil du 
typho. Paris, 1833, 8vo. 

8 Rev. medic, 2 serie, t. iii., p. 289. Arch, gener. de med., t. xxvi., p. 240. 

9 Sabatier. Med., operat. edit.de M. Sanson, t. i. p. 506. — Larrey. Traitement des 
adherences suites de brulures. (Journ. Hebd., t. v. p. 30.) — Paillard. Sur les cica- 
trices de chaque espece de degre de briilure. (Journ. Hebd., t. viii. p. 163.) 

10 J. Thomson. Lectures on Inflammation, p. 585. Edinb., 1813. 
" James (Med. Chir. Trans., v. xiii. 1825). 

12 Earle (H.). Two Lectures on Burns, 8vo. London, 1834. 

13 Abernethy (J.). Lectures on the Theory and Practice of Surgery, 8vo. London, 
1830. 

(To the above references, the essays of Kentish on Burns, 8vo., Newcast., 1798, 
London, 1800, and Dickinson's remarks, deserve to be added. TV.) 

14 Moulinie. Diss, sur les brulures. Paris, 1812. 
13 Lisfranc. Revue medic. Juin, 1826. 

•6 Bretonneau (L.). De l'utilite de la compression dans les inflammations idiopa- 
thiques de la peau. In-4. Paris, 1815. — Velpeau. Memoire sur l'emploi du bandage 
compfessif dans le traitement de 1'erysipele phlegmoneux, de la brulure, etc. (Arch. 
gener.de med. Paris, juillet, 1820.) 

17 Borot de Belloy. Observ. clinique sur le traitement de quelques maladies. In-4. 
Paris. 

18 Marshall. Obs. sur les brulures, etc. Rev. med., t. ix. p. 309. 

19 Lair (P. A.). Essai sur les combustions humaines. In- 12. Paris, 1800. 

20 Arch. gen. de med. In-8. Paris, t. x. p. ii. 



PERNIO— CHILBLAIN. 



Vocab. — Chilblain, Pernio. 



997. Under the title of Chilblain, I designate collectively all the 
affections of the skin and subjacent tissues w T hich are produced by 
the action of cold. These occur under three forms of progressive 
gravity; characterized in the first instance by an erythematous swell- 
ing, in the second by the formation of the phlyctenae with or without 
excoriations, and in the third by the occurrence of gangrene. The 
two first stages only are usually comprehended under the name of 
chilblain. 

998. Symptoms. — Chilblains attack those parts especially which arc 
most remote from the centre of the circulation, such as the feet, hands, 
ears, and tip of the nose. 

1st. In the most simple case, erythematous chilblain, the disease is 
characterized by a simple redness of the skin, accompanied with a 
troublesome feeling of pruritus, and a slight tumefaction of the sub- 
cutaneous cellular tissue. 

The affection commonly makes its appearance slowly after the action 
of cold. The skin becomes pale at first, and afterwards assumes a 
red tinge, accompanied w r ith swelling, and sensations of tingling and 
of numbness and stiffness in the parts affected, which increase in a 
remarkable manner, when these are exposed to the action of heat. 
Under the influence of the same cause, the swelling increases, and 
the redness of the skin acquires a livid and leaden cast. 

If neglected, this first degree of chilblain is sometimes followed by 
chaps, and the other symptoms which characterize the bullous stage 
of the affection. 

2d. This last is a severer species or degree of chilblain. The blebs 
or phlyctenae most frequently appear on the palmar surface of the last 
phalanges of the fingers, the plantar surface of those of the toes, or 
over the hind part of the heel, and are flattened, and filled with a 
reddish sanguinolent serum. The skin on which they are evolved. 
has a livid or bluish-red appearance. If the disease is neglected, the 
epidermis is detached, and leaves exposed, grayish excoriations, of a 
mingled pallid and sanguinolent aspect, which are the seat of con- 
siderable pain. These excoriations are irregular in their shapes, and 
are occasionally observed of considerable depth and extent. Exposed 
to cold and moisture, and rubbed and pressed upon by the clothes, 
these excoriations are apt to chap, and to ulcerate, when they dis- 
charge an ichorous pus ; they occasionally even become gangrenous 
in one or more points of their surface. The cicatrization of these 
sores is always obtained with great difficulty, particularly during the 
winter season. 

3d. Finally, when the action of the cold has penetrated more 
deeply, the parts affected become cold, insensible, motionless, and 
assume a livid hue, — gangrenous chilblain ; the cold sometimes causes 
a kind of mortification. During the winter of 1812, I attended a 
Spanish prisoner, both of whose feet, in a slate of sphacelus from 
exposure to cold, had acquired a woody hardness. When patients 
survive these local congelations, a line of demarkation is by and by 
established between the mortified and living parts ; when the former 
are not detached within a reasonable period of time, it becomes 
necessary to remove them with the knife. 

999. Erythematous and bullous chilblains of the hands and feet do 
not usually occasion any disturbance in the exercise of the principal 
functions. Gangrenous chilblains, on the contrary, are frequently 
accompanied by very serious morbid phenomena, particularly if the 
action of the cold has been deep and of long duration, viz. : rigors, 
paleness of the surface, rigidity and numbness of the body generally, 
diminution of sensation, of the power of motion and of the tempera- 
ture, slowness of the circulation, precordial anxiety, and stupor fol- 
lowed by extinction of life. 

1000. Causes. — Chilblains, in general, only prevail extensively to- 
wards the end of autumn and during the winter ; they are particular! y 
apt to attack washerwomen, hatters, dyers, &c, and weak, lymphatic, 
scrofulous children, over-tenderly brought up, whose skin is fine and 
delicate, or the children of the poor who, again, are not sufficiently 
protected against the inclemencies of the weather. They are most 






ANEMIA. 



frequently observed in temperate climates, and generally during cold 
or damp weather, and after sudden transitions from frost to thaw. 
M. Larre) relates that during the three or four days which preceded 
the battle of Eylau, the weather was extremely cold, the thermometer 
sunk so low as fifty-four degrees below zero. Not one of the 
French soldiers who had' remained in the snow during this intense 
old, ( xperienced any pain in the hands or feet. During the night of 
the 9th of February, there was a fall of sleet, and the thermometer rose 
i ral degrees above the freezing point. From this moment many 
of those who had been exposed to the severe cold, began to complain 
of acute pains in the feet, and of numbness, and a sensation of heavi- 
ness, and tingling in the extremities. In some, the parts affected were 
but little altered in size or colour. In others a slight degree of red- 
ness made its appearance about the roots of the toes, and over the 
upper part of the foot. In many, however, the toes lost all sensation, 
and power of motion, becoming cold, and soon afterwards black, hard, 
and lifeless. 

1001. Diagnosis. — The erythematous inflammation, and the puffing 
of the subcutaneous cellular membrane, the phlyctense, chaps and 
Fissures, the ulcerations, gangrene, &c, that occur in consequence of 
chilblains, differ in their mode of development and the succession of 
their phenomena, from analogous lesions produced by .other causes; 
to discover the characters which distinguish chilblains from burns, 
and erysipelas, it is therefore enough to study them comparatively 
under these two points of view. 

1002. Prognosis. — Erythematous and bullous chilblains, whether 
with or without fissures, are affections less dangerous than troublesome. 
In scrofulous subjects they are very rebellious to every kind of treat- 
ment. Sphacelation of the fingers and toes is to be apprehended when 
these parts, by exposure to intense cold, lose their sensibility, when they 
have a shrunk and withered appearance, and when they assume a purple 
or livid hue. 

1003. Treatment. — The preservative treatment of chilblains consists 
in avoiding sudden transitions from cold to heat ; in protecting the 
parts liable to be affected with them, from the influence of cold and 
moisture, and better still when this can be done with propriety, in 
gradually hardening the hands and feet and inuring them to the cold. 
1'he extremities should above all things be defended from moisture, 
.ind when they have accidentally been wetted with very cold water, 
and very considerable pain is complained of, they ought to be simply 
dried and covered, and allowed to get warm of themselves, without 
being exposed to the immediate action of heat. 

Frictions with snow frequently repeated, lotions with salt and water, 
wine, camphorated spirits of wine, or any alcoholic fluid, tincture of 
Benzoin, &c; or what is perhaps preferable to any of these, a solution 
of alum in water, in the proportion of one ounce to a pint, the artificial 
sulphureous water-bath, and the disuse of gloves lined with fur, and 
of woolen stockings, which defend the hands and feet too completely 
for a time from the action of the external temperature, are powerful 
preservatives against chilblains. 

When the disease is characterized by a simple redness of the skin, 
and slight swelling of the subcutaneous cellular membrane, the parts 
affected must be bathed several times a day with a decoction of althea- 
root and poppy-heads, and the hands and feet enveloped at night in 
eompresses soaked in goulard water. 

Emollient and narcotic cataplasms, sprinkled w r ith a solution of the 
acetate of lead, are useful applications to chilblains, which are accom- 
panied with phlyctenae, violent pain, and much swelling. The livid 
and fungous-looking sores lhat follow in these cases, require to be 
subsequently touched with the nitrate of silver, and dressed with soft 
pledgets, spread with saturnine cerate, which, being covered with 
compresses dipped in any mild astringent and discutient wash, the 
whole is to be supported by a firm roller, (a) 

The parts affected must now be carefully protected from cold and 
damp ; these measures generally prove sufficient to accomplish the 
cure of chilblains rapidly. 

Gangrene may be prevented in parts which have been exposed for a 
length of time to very severe cold, by rubbing them with snow, or by 



(a) The chlorides of lime and soda are excellent applications in these 
cases. 



bathing them with icy cold w r atcr in the first instance, and using every 
precaution, only to allow the temperature to rise very gradually. 
When the circulation appears to be in some measure re-established, the 
parts affected may be fomented with cold spirit lotion, and wrapped in 
dry flannel, the patient being, mean time, made to take some warm and 
gently stimulating drink. 

When gangrene has taken place, all we can do, is to wait until its 
extent is indicated by a circle of inflammation, and a line of separation 
begins to be established between the living and dead parts ; this once 
formed, we may decide whether we shall allow the sphacelated parts 
to separate of themselves, or perform amputation. 

Historical Notices. 

1004. Celsus 1 has given a very accurate description of chilblains. 
Ploucquet 2 mentions several dissertations on this disease, which I 
have not been able to consult. Dr. J. Thomson 3 has studied the 
effects of cold on the human body with particular care, and has given 
the details of many experiments made on animals, which prove that 
limbs which have been frozen, whose fluids have been fairly con- 
gealed, are incapable of being restored to life. M. Lisfranc 4 has 
lately recommended compresses dipped in a solution of chloride of 
lime, to be applied over the ordinary dressings applied to the sores 
that follow chilblains. 

The history of gangrenous chilblains, or of the gangrene which is 
produced by congelation, has been given, with all its details, in more 
than one of our recent systems of surgery, as well as in several excel- 
lent inaugural dissertations. 5 



ANEMIA. 

1005. A general morbid paleness of the skin and gums, joined to a 
state of habitual debility, without any lack of colour in the hair, uvea, 
or choroid coat, is sometimes observed in young females, affected with 
amenorrhcea or dysmenorrhea. This state is familiarly known by the 
name of chlorosis. 6 In males, also, but much more rarely, a peculiar 
pallor or sallowness of skin has occasionally been observed, independ- 
ently of anterior hemorrhage, intermittent fever, a cancerous diathe- 
sis, &c, but merely connected with a weakly state of the constitution 
generally. 

These general anemice, 7 or bloodless states of the body, may depend 
on various causes ; their history is still incomplete, and I limit myself 
in this place to simply mentioning these phenomena. 

I have observed the hands and feet of many individuals, in all 
respects in very good health, become suddenly extremely pale and 
very cold, as if they had been plunged in icy cold water. This spe- 
cies of local anemia evidently occurs without any lesion of the arte- 
ries of the extremities, and is sometimes altogether independent of 
the temperature of the atmosphere, for I have seen it happen during 
summer, and have known it continue for several days without derange- 
ment of the principal functions. 

1 Fiunt etiam ex frigore hiberno ulcera, maxima in pueris, et prascipue pedibus et 
digitis eorum,non nunquam etiam in manibus. Rubor cum infiammatione mediocris 
est ..interdum pustulae oriuntur, deinde exulceratio, dolor autem modicus. Prurigo 
major est; non nunquam humor exit, sed non multus, qui referre vel pus vel saniem 
videtur. (Celsus. De re medica, lib. v. sect, xxviii. § 6.) 

2 Ploucquet. Litteratura medica digesta. — Art. Pernio. — Aymes (J. P. C A.). 
Diss, sur les engelures, 4to. Montpellier, 1813. 

3 J. Thomson. Traite medico-chirurgical de rinflammation. Traduction de MM. 
Jourdan et Boisseau, in-8. Paris, 1827, p. 638. 

< Lisfranc. Obs. d'engelures traitees et gueries par la chlorure de chaux. (Revue 
medic, 1826, t. i. p. 210.) 

5 Houin (F.). Expose sur le congelation. Paris, 1813.— Stockly. Sur la gangrene 
par congelation. Paris, 1813. 

6 De\sormeaux. Art. chlorose, Diet, de med., en 21 vol. 

7 Halle Obs. sommaire sur une maladie qu'on peat appeler anemie (Journ. de 
Med. et Chirurg. de Corvisart, t. ix. p. 3). — Elliotson. Anemie et ictere (Gaz. Med. 
4to. Paris, 1833, p. 83).— Journ. des progres, t. i. p. 269.— Valat. Coup-d'ocil sur les 
maladies des ouvriers des mines. (Bulletin gener. de Therapeulique, 1834, t. vii. p. 
185.) 



SANGUINEOUS CONGESTIONS— HEMORRHAGIC. 



323 



SANGUINEOUS CONGESTIONS. 

1006. Several of the sanguine congestions which are observed on 
the surface of the body, depend on an impeded or retarded venous 
circulation. Such are those which may be produced at pleasure by 
the application of a tight ligature round any of the limbs ; of the same 
description are those also which occur in the feet and in the extremi- 
ties, in diseases of the heart, in the asphyxia of new-born infants, 
&c. The sanguine congestions which appear over the cheek bones 
in pneumonia, and the livid blotches which are observed on the pos- 
terior parts of the trunk, at the moment of dissolution, or after death, 
are in like manner attributable to impeded venous circulation. 

It is well known that these livid blotches (maculce morientium) are 
chiefly found occurring in those parts on which the body has lain 
during dissolution, or after death, and that they are sometimes ob- 
served to extend over the whole posterior surface of the body and 
limbs. Their bluish tint is in general not so deep as that of ecchy- 
moses. 

When the skin of the regions thus marked is incised, it is found 
gorged with dark blood. It is sometimes even possible to cause these 
livid marks to disappear, by giving the body, at the time of dissolution, 
or immediately after death, a position different from that in which they 
had been formed. 

Congestions, again, which are occasionally preceded by morbid pale- 
ness, appear to be owing to an anormal influence of the system; such 
is blushing or the redness of the face which is caused by emotions of 
various kinds, and that which is observed in the second stage of inter- 
mittent fever. 

Whatever the cause of sanguine congestion of the skin, whether 
the afflux of blood be transient and accidental, intermittent or con- 
tinuous, it is distinguished from every form of exanthematous inflam- 
mation by the latter being constantly accompanied with morbid heat, 
or followed by furfuraceous desquamation of the cuticle. 

Sanguine congestions of the skin are not in themselves of a serious 
nature, but they are often symptomatic of highly dangerous affections 
of the heart, lungs, &c. Congestions do not require any treatment 
other than that proper for the diseases which produce them. 

In persons labouring under contraction of the auriculo-ventricular 
orifices of the heart, or of the pulmonary orifice of the right ventricle, 
under congenital or accidental communications of the right cavities 
with the left, or with the principal arterial trunks, &c, a peculiar san- 
guineous injection of the skin, and mucous membranes, is observed; 
these present a livid bluish tint, and the state is known by the name 
of cyanosis. 1 It is distinguished from other congestions by its causes, 
its generality, its continuance, and by a more or less marked disturb- 
ance in the functions of respiration and circulation. 



HEMORRHAGIC 

1007. The diseases in which blood is deposited on the surface of 
the skin, within its substance, or in the cellular membrane underneath 
it, have received different denominations, according as the extravasa- 
tions are altogether local (ecchymosis, thrombus), or general (purpura), 
or phenomena superadded to some other affection more or less serious 
in its nature (petechial typhus, scurvy). Further, those effusions of 
blood which are occasionally observed from the surface of the skin, 
when accidentally deprived of epidermis, and even when still covered 
with the cuticle in new-born infants, have been designated by the 
name of der motor rhagice. 

' M. Gintrac (Observations et recherches sur la cyanose, in 8vo., Paris, 1825), has 
published a very good monograph of cyanosis ; and has collected and compared a 
great number of facts for the purpose of determining the organic conditions, which 
may give rise to this phenomenon. M. Louis (De la communication des cavitees 
ganche du coeur, Memoires d'Anatomie Pathologique, in 8vo., Paris, 1826), and 
Messrs. Bertin and Bouillaud, (Traite des maladies du coeur et des gros vaisseaux, 
8vc, Paris, 1824,) have made some observations on this disease which deserve to be 
consulted. 



Petechia are minute red or violet-coloured spots formed by small 
quantities of blood deposited within the substance of the skin. The 
name of ecchymoses has been given to spots of a larger size ; these are 
generally of a ruddy violet-colour, often livid and sometimes quite 
black; they are commonly of a deeper hue in the middle than in their 
circumference, and they vary in extent from a diameter of a few lines 
to one of several inches. These two varieties of spots are to be 
observed in all cutaneous haemorrhagiee, whatever their causes and 
characters. 

The sanguineous infiltrations which take place in scurvy and in 
petechial typhus, 2 as well as those which occur incidentally in certain 
diseases of the skin, in severe erysipelas, in malignant scarlatina, and 
in the eczema rubrum of the inferior extremities, can only be studied 
in connection with these diseases. The ecchymosis traumatica, or 
ecchymosis which occurs in consequence of a blow, &c, is described 
in all treatises of surgery. 



Vocab. Art. Purpura, Hsemorrhcea, Heemacelinosis, Land Scurvy, fyc. 

1008. I comprehend under the general name of purpura, several 
diseases whose common and generic character is to manifest them- 
selves internally by hemorrhage, and on the external surface of the 
body by petechiae or ecchymoses, independently of outward violence. 

This group comprises two species, which are very distinct from 
each other in their progress, and in the symptoms associated with 
the common hemorrhagic phenomena which characterize them; viz., 
purpura sinefebre, and purpura febrilis. 

Purpura sinefebre itself comprehends three varieties (purpura sim- 
plex, purpura urticans, purpura hemorrhagica), to which purpura 
senilis, and purpura cachectica, must be added as sub-varieties. Pur- 
pura febrilis may present the external and hemorrhagic characteristics 
according to which the varieties of purpura apyretica have been esta- 
blished. The disease which has been described under the title of 
febris hemorrhagica must be associated with febrile purpura. 

1009. Purpura simplex. This disease almost always commences 
independently of any known causes, and without marked derange- 
ment of the principal functions. Some patients, nevertheless, com- 
plain of lassitude and dejection some days before the appearance of 
the spots. These are generally true petechiae, sometimes intermixed 
with ecchymoses ; in some very rare cases ecchymoses only are to be 
distinguished on the exterior of the body. 

1010. When the eruption is petechial 3 only, the disease may pre- 
sent a considerable variety of appearances according to the number 
of the spots, as they are disseminated over nearly the whole surface 
of the body, or limited to a certain number of regions, and as the 
petechiae have all been evolved at once, so as almost everywhere to 
present the same hue, or as they have appeared successively, during 
the course of several days, when they present a mixture of recent 
and old spots, and vary in colour, from a reddish-brown to a clear 
yellow. 

In ordinary cases, the petechiae show themselves principally on the 

2 Petechiae frequently supervene in typhus between the second and tenth day. 
According to the report of Messrs. Raickern and Bianchi.out of a hundred and ninety- 
four subjects attacked with typhus at Volterra, in 1817, a hundred and fifty-six ex- 
hibited petechias. In typhus, the petechias generally show themselves on the lateral 
parts of the neck, on the shoulders, thighs, and especially on the interior of the fore- 
arms from the elbows to the wrists. True petechias are rarely observed at Paris in 
typhus fevers — (dothinenterites) — they supervene more frequently in variola and 
scarlatina. They are sometimes observed with ecchymoses in those animals, into 
whose veins putrid animal matters have been injected. 

3 Sauvages describes simple petechial purpura, under the title of phcenigmus pete- 
chials: "Estexortus macularum purpurearum inuniversacute — sinepruritu, tumore, 
aliociue symptomate. DifTert a publicum morsu quod in maculis phcenigmi non sit 
punctures vestigium, ut in pulicum, apum morsibus,quos delet cataplasma ex farina, 
aceto et oxymelite. Hunc affectum vidi aliquoties in pueris ob calorem sestivum 
enasci sine ulla notabili functionum Isesione, et potu refrigerante et dein levi cathar- 
lico adhibito, inter paucos dies evanescere. Illust. vero, Professor Haguenot similem 
observavit in tribus mulieribus, quas quidem ille morbus defaedabat, sed aliunde nul- 
latenus molestabat, quique intra aliquot dies sponte recessit (Sauvages, Nos. Meth . 
t. ii. pp. 594-95).— Voyez.: Acta phys. med. nat. cur., 1757, p. 386.— Cusson. Diss, 
de purpura, 1762. Monspel. (Purpura a pyre ta).— Parry. Edinb. Med. and Surg. 
Journ., vol. vii. — Bree. Medic, and Physic. Journ., vol. xxi. 



324 



HEMORRHAGIC. 



legs; a great number are sometimes seen upon the face, which, at a 
certain distance, appears pricked with blackish and yellowish points, 
a> it it had been bitten by a host of fleas. In this case the conjunc- 
tiva' arc apt to exhibit a number of ecchymoses. 

I'll • distinguishing character of petechia?, which are, as has been 
said, formed by a very small quantity of blood shed into the substance 
of the skin, is tbat they undergo no change of colour under the pres- 
sure of the finger. In this, consequently, they differ from other small 
red or rose-coloured spots observed in typhus and typhoid fevers, which 
are immediately effaced by pressure, and return when it is removed. 
The greater number of these petechias are not quite so large as a flea- 
bite ; for the latter, besides the small ecchymosis produced by the 
suction of the insect, is surrounded by a narrow pink areola, capable 
of being obliterated by pressure, which is not observed in the spots 
of purpura. Some spots, of larger dimensions, and even proper ec- 
chymoses, are often interspersed among the ordinary petechias. These 
petechia? and ecchymoses are developed without local heat or pain, 
or any implication of the principal functions ; children affected with 
them continue their play, and persons of more advanced age do not 
cease, in general, to occupy themselves with their ordinary affairs ; 
the pulse remains undisturbed, and the digestion, respiration, excre- 
tions, and nervous functions, continue to be performed as in a state of 
health. 

Shortly after its formation, each petechia undergoes a change of 
colour ; from a reddish brown it passes through various intermediate 
shades to a yellow ; and, unless where there is a cachectic state of the 
constitution, the blood which has formed it is generally reabsorbed in 
the course of a fortnight. This reabsorption almost always proceeds 
from the circumference towards the centre of the spots ; I have, how- 
ever, seen it take place in a contrary direction, so that the spots, in 
the last stages of their duration, assumed the appearance of little yel- 
low rings or arcs. These spots are not prominent, except in those 
very rare cases in which the blood is not only shed into the skin, 
in the form of a dark point, but where a minute drop of the fluid is 
■effused beneath the epidermis, which it raises ; this little eminence, 
of the size of a pin's head, dries up into a small dark crust. 

1011. When the eruption of petechias is considerable, they occa- 
sionally appear collected in different places into irregular clusters. 
This disposition is very rare. Finally, in a few very rare cases, a 
kind of marbling, of a light violet colour, like the eruption in rubeola 
nigra, is observed disseminated among the petechias. 

1012. The petechial eruptions which characterize this form of pur- 
pura simplex, of infinitely more frequent occurrence than the other 
eruptions of the same nature, are not accompanied by epistaxis, hasma- 
temesis, hasmoptysis, nor by any other internal hemorrhage ; they are, 
however, pretty frequently intermingled with real ecchymoses of the 
skin and subcutaneous cellular membrane. 

1013. There are even cases in which purpura simplex is charac- 
terized by considerable numbers of ecchymoses disseminated over the 
body and limbs, on which very few or no petechias are to be seen. 
When the blood is thus more widely effused into the substance of the 
s/cin, it is almost always over the dorsal surface of the feet and hands, 
and on the internal aspects of the limbs that the broader spots are en- 
countered. These never exhibit any thing like regularity of shape, and 
sometimes bear no slight resemblance to the marks left by the strokes 
of a whip, or violent bruises. In the intervals between the ecchymoses 
the skin preserves its natural colour, temperature and sensibility. The 
colour of these spots, which is a dark or livid blue, remains stationary 
for several days, and fades more slowly than that of the subcutaneous 
ecchymoses. They are sometimes succeeded by an exfoliation of the 
epidermis, particularly when a certain quantity of sanguinolent serum 
has been effused under it, so as partially to detach it ; this happens to 
such an extent in some cases that the skin appears beset with a number 
of sanguinolent bulla? or phlyctenee. 

1014. When the blood is effused into the subcutaneous and inter- 
muscular membraiie, the skin commonly presents a number of broad and 
slightly prominent spots, dark in the middle and of a greenish-yellow 
towards the circumference. These spots are little, if at all, painful ; 
but when the blood has been shed in large quantities into the subcu- 
taneous cellular substance of the lower extremities, as sometimes 
happens, more especially in purpura hasmorrhagica, the tumefaction 



and tension of the parts may be so considerable as to produce a rather 
intense degree of pain. In this case, the entire skin of (lie inner aspect 
of the leg is of a greenish-yellow hue, which only disappears with 
extreme slowness. A sort of cedematous swelling has been observed 
to occur on the back of the hand in certain cases of purpura simplex, 
characterized by similar ecchymoses. 

In purpura simplex, the petechias and ecchymoses sometimes return 
suddenly in a single night, just as the disappearance of a first eruption 
seemed to indicate the complete re-establishment of the health. These 
hemorrhagic phenomena may be repeated at periods so little remote 
from one another, that each succeeding attack appears like that 
which has gone before it ; some of the spots are then yellow or nearly 
effaced ; others, very recently evolved, are of a reddish-brown ; while 
others of intermediate standing are of a paler red. It often happens 
too, shortly after an apparent cure has been accomplished, that a new 
eruption shows itself; so that the duration of purpura simplex can 
never be predicted ; it varies from a few weeks to several months. 

1015. There is a last variety of purpura simplex in which the extra- 
vasation of the blood is preceded by the formation of reddish oval or 
circular-shaped spots, prominent and accompanied by smarting or 
tingling sensations similar to, but much less decided than, those of 
urticaria (purpura urticans). 1 These little spots, usually of the size 
of a lentil, sink at the end of two or three days to the level of the sur- 
rounding skin ; their colour, which was pink at first, becomes at the 
same time deeper and livid. New spots appear while the first are 
going off. They appear most frequently upon the legs, and sometimes 
in other regions of the body, intermixed with true petechias ; the lower 
extremities in these cases are often cedematous ; or they become 
affected with a sensation of stiffness or heaviness. The eruption is 
generally of a month's duration, but may continue beyond that term. 

Purpura urticans can only be distinguished from hemorrhagic urti- 
caria, i. e., urticaria in which a little blood is effused into the wheals, 
when numbers of true petechias are found interspersed among the 
larger raised spots. Cases of urticaria have been met with, which 
were followed by an attack of purpura sometimes of a pretty severe 
character. 

The spots of purpura urticans are broader than those of petechial 
purpura ; but are not so extensive as the ecchymoses of purpura hemor- 
rhagica, which are besides more irregular in their outline. The spots 
of purpura urticans sometimes exist on the skin without being accom- 
panied with true petechias and without primary ecchymoses ; but there 
are cases in which these three appearances are found united in the 
same individual. 

When purpura simplex shows itself under the form of ecchymoses, 
it is generally a more serious disease than when it appears under the 
petechial form. Purpura urticans is the least important of all the forms 
of purpura. 

1016. Purpura hemorrhagica (morbus maculosus Werlhofii). This 
species of purpura is of a much more serious nature than the species 
first described. It is sometimes preceded for several weeks by a sen- 
sation of lassitude and debility, by pains in the limbs, &c; but it 
often makes its attack suddenly 2 upon persons apparently in the enjoy- 
ment of good health. 

Purpura hemorrhagica is characterized by the same external appear- 
ances as purpura simplex, sometimes by petechias, often by ecchy- 
moses, still more frequently by both of these hemorrhagic forms at the 
same time, but very rarely by an actual dermatorrhagia. 3 In the ma- 

1 Macmichael has seen a case of purpura which appears to have been preceded 
by an intermittent urticaria, for six or eight months, and which was cured by means 
of purgative medicines. Lond. Med. Gazette, vol. ii. p. 90. A case of purpura urti- 
cans has been inserted in the Edinb. Med. and Surg. Journ., vol. xii. p. 243. Bate- 
man, Reports on the Diseases of London, 8vo. London, 1819, p. 181. 

2 Joannes Dolasus speaks of a child : " Cujus omne corpus, absque dolore, febre 
aut lassitudine pragressa, subito una cum facie, labiis, et lingua, ubi mane adsurge- 
ret, numerosissimis maculis lividis et nigerrimis obsitum fuit," etc. (Ephem. Nat. 
Cur., Dec. ii. ann. iv. obs. 118.) Zwinger (Act. Nat. Cur., vol. ii. obs. 79), P. G. 
Werlhof (Commerc. liter. Norimberg, ann. 1735, Hebd. 7 et 2) have reported analo- 
gous facts. Sauvages mentions this disease under the title of Stomacace universalis. 
(Nosol. Meth., t. ii. p. 296.) 

3 I have not observed this transudation of blood through the skin. It is asserted 
that in the majority of cases, the skin from the surface of which the blood flows, is 
not sensibly injured. Nevertheless, in a case reported by Doctor Whytt, the end of a 
finger whence the blood flowed was painful, and exhibited a red spot. Ploucquet 
(Art. Hoematidrosis, sudor cruentus) mentions several authors who have observed 



PURPURA. 



325 



jority of cases the ecchymoses appear before the petechia?. The body 
has been seen to become covered with livid spots similar to those that 
follow bruises ; in children actual thrombus occasionally forms under 
the hairy scalp, and the blood has even been seen exuding from be- 
hind the ears and the vertex, and the eruption of such extent as to 
cover nearly the whole of the skin. The disposition to hemorrhage is 
so great in some patients that the mere act of feeling their pulse, the 
pressure of a bleeding fillet, or that occasioned by the weight of the 
body in sitting or lying down, is sufficient to produce actual ecchy- 
moses. In these cases the slightest punctures, the most trifling in- 
juries that merely graze the skin, are always followed by afar greater 
amount of hemorrhage than usual ; blood also occasionally flows 
copiously from the surface of blisters, issues, ulcers, &c, in such sub- 
jects. The number of petechia? and ecchymoses in purpura haemor- 
rhagica is likewise almost always more considerable than in purpura 
simplex ; and they recur with more promptitude and intensity, and 
continue longer than in the latter. 

But the essential or distinguishing feature of purpura Jiemorrhagica 
consists in the hemorrhage from the viscera or internal membranes, 
which invariably precedes, accompanies or follows the ecchymoses or 
effusions of blood into the skin or subcutaneous cellular membrane. 
The disease is always complicated with epistaxis, intestinal hemor- 
hage, haemoptysis, haematemesis, heematuria, and, in females, with 
metrorrhagia. 

Of all internal hemorrhages, epistaxis is that which occurs most 
frequently, particularly in children ; metrorrhagia in females, and pul- 
monary and intestinal hemorrhage are common in adults. Several 
of these varieties of hemorrhage often occur simultaneously, or they 
alternate at different times in the same patient, (a) 

1017. The general characters of the disease, which are always 
striking, are modified by diversity in the local symptoms, and, indeed, 
these vary themselves, according as the hemorrhage occurs from 
organs of greater or less relative importance in the economy, as the 
blood lost is small in quantity or very large, as the flux is frequently 
repeated or occurs at distant intervals, or as the hemorrhage takes 
place from one point in succession or from several simultaneously. 

1st. Purpura hemorrhagica with epistaxis 1 is the most common of all 
the varieties. Bateman has seen it accompanied by heematemesis and 
followed by death, from sheer loss of blood. 

2d. Purpura hemorrhagica with hemorrhage of the throat, or only 
of the amygdalae* is rather a rare variety ; sometimes the whole fauces 
appear of a deep red and the blood issues from every part ; after the 
hemorrhage has ceased, the parts appear dark. In one case in 
which there existed but an inconsiderable number of petechia? on the 
skin I have seen purpura complicated with angina membranacea ; this 
complication has even been observed under an epidemic form. 3 

3d. Purpura hemorrhagica, with hemorrhage from the mouth and 
gums, 4 is often accompanied by epistaxis 5 and hematemesis. 6 The 
gums are livid, spongy, and the blood exudes from their free edge ; 

(«) Dr. Huston (North Amer. Med. fy Surg. Jour., vol. ii.), gives 
an account of a case of purpura occurring in an infant forty-eight 
hours after birth. A few hours afterwards there was a discharge 
from the vagina resembling the menstrual flux in its colour, want of 
coagulability and in its being accompanied by mucus. This dis- 
charge continued at intervals until the time of death, which took 
place on the eighth day after birth. When the vaginal discharge 
ceased, the patient was tormented with spasms. 

these blood-sweats or hemorrhages through the skin. Fournier cites two examples 
of the kind. Art. cas rares. (Diet, des Scien. Med.) 

1 Latour (Hist. Phil, et med. des hemorrhagies, 8vo. Paris, 1828, t. ii. p. 192, obs. 
612). — Rogerson (Med. and Phys. Journ., vol. xlii. — With hematemesis). — Medic. 
Repository, vol. vi. 

2 Buxton (Medic. Repository, vol. xix.). 

3 Read. Histoire de l'esquinancie gangreneuse petechiale qui a regne dans le vil- 
lage de Moivron, Metz. 12mo. 1777. 

4 Nicholl (Medic. Repository, vol. xvi.). — Latham (Lond. Medic. Gazette, v. i. p. 
544.) Watson [Lond. Med. Gazette, v. vii. p. 128, 1830]. 

5 Harty. [Edinb. Med. and Surg. Journ., vol. ix.]. — Duncan [Med. and Surg. 
Journ., No. 21]. — Planchon. [Journ.de med.de Paris, annee 1770.] [Two cases.] 

8 Harty (Edinb. Med. and Surg. Journ., vol. ix.). 

82 



the tongue is livid and blackish, 7 bleeding and fungous in appearance, 
and twice its natural size; the inner surface of the cheeks presents 
some blackish and soft patches, and the palate is covered with 
blackish spots. Children have been seen to die in a single night 
after excessive hemorrhage from the mouth or nose ; but they more 
commonly sink from the effects of bleeding, which, though less 
abundant at any one time, has recurred frequently during several 
weeks. The epithelium is sometimes raised on the tongue, palate, 
inside of the cheeks, lips, &c, in consequence of ecchymoses. It 
then forms irregular phlyctena? or bullae filled with blackish blood ; by 
and by the epithelium bursts, and the blood flows from the surface of 
the excoriation; the mucous membrane often ulcerates more deeply, 
and hemorrhage to a greater amount is apt to take place. 

4th. Purpura with hemorrhage from the stomach is sometimes 
accompanied with pain in the left hypochondrium, and an increase in 
the size of the spleen : symptoms which have been more particularly 
observed in individuals who have been attacked with purpura after 
having suffered from intermittent fever. 

5th. Patients more frequently pass blood by stool; the blood is 
rarely pure, and of a bright colour ; it is often a blackish-looking 
matter, of a sooty colour : this variety of purpura is less serious than 
the preceding one. 

6th. When the blood flows by the urinary passages, 8 the urine is 
tinged with the blood, or the fluid is passed unmixed, partially coagu- 
lated, and sometimes in considerable quantities, without even the 
urinous odour. Blackall 9 has found the urine coagulable by heat, or 
nitric acid in four cases of purpura without haematuria ; all the patients 
had the legs slightly infiltrated with serum. In one case of purpura 
hemorrhagica, with febrile symptoms, Doctor Coombes remarked, 
that the urine which was very coagulable in the height of the disease, 
becomes less so after blood-letting, and abundant loss of blood ; these 
evacuations of blood were of evident advantage, and when the cure 
was effected, the urine ceased to be coagulable. 

7th. In purpura with hemorrhage from the uterus, the vagina, 10 or the 
pudenda 11 patients often experience pains in the loins. These hemor- 
rhages of the uterus are almost always serious ; I have seen a case in 
which the bleeding was mistaken for a miscarriage, and the patient 
died. It very rarely happens that such hemorrhages are salutary, 
or critical ; nevertheless Bateman met with a woman affected with 
purpura simplex, who recovered after an attack of uterine hemor- 
rhage. 

8th. When hemorrhage takes place from the lungs, 12 patients have 
fits of coughing, spit blood or bloody matter, and feel great pain in 
the praecordia and chest. Duncan and Bateman have seen the descrip- 
tion of hemorrhage under review prove rapidly fatal. 

9th. Finally there are cases in which hemorrhage occurs success- 
ively, and in a few days from the nasal fossae, from the mouth, from 
the lungs, from the stomach, the intestines, 13 &c; in some cases the 
bleeding recurs at particular hours, in others there is a slow and almost 
continual exudation of blood. 

If hemorrhage recurs frequently or proves very abundant, from 
whatever channel it may flow, the lower limbs become cedematous, 
the face pale, and the body generally assumes a livid and yellowish 
hue ; the petechia? and the ecchymoses, greater in number, have a 
deep brown tint, the blood becomes more and more serous, the 
extremities cold, the patient experiences weakness, the pulse becomes 
small and frequent ; nervous symptoms, sometimes convulsive move- 
ments, trembling of the whole body, and fainting fits occur ; and if 
the hemorrhage is repeated, the patient dies ex-sanguine, unless febrile 
symptoms supervene and give rise to some other form of fatal ter- 
mination. In fact, after a certain number of attacks of hemorrhage, 

7 Harty, loc. cit. 

s Rogerson (Med. and Physic. Journ., vol. xlii.). G. Johnson (Med. and Surg. 
Journ., No. 72). Harty (Edinb. Med. and Surg. Journ., v. xxxiv. p. 57). 

9 Blackall (John). Obs. on the nature and cure of dropsies, 3d edit. Lond. 1818, 
p. 123, ch. viii. Cases resembling land-scurvy. 

'o Case of purpura hsemorrhagica with remarks. (Edinb. Med. and Surg. Journ., 
vol. xvii. p. 83.) 

" Pretty. Med. and Physic. Journ., vol. xlix. 

12 Kift. Edinb. Med. and Surg. Journ., v. xxvii. p. 71. — Planchon. Journ. de med. 
Paris, ann. 1770 (two cases). 

" Latour. (Ouv. cite. torn. ii. p. 180. Case from Horst.) — Ibid. t. ii. p. 20. Obs. 
621. — Ibid. t. ii. p. 498. Case of Leroy erroneously quoted as a case of scorbutus. 



326 



HEMORRHAGIC. 



an acute fever, with symptoms of a typhoid character, sometimes comes 
on, and patients frequently sink on or about the twelfth day. 1 

1018. Purpura febrUis. This description of purpura may be spo- 
radic or epidemic ; 2 its ordinary duration is from two to three weeks. 
Purpura f brills attacks persons of all ages, and of every variety of 
constitution. 

A feeling of great lassitude and depression, shivering fits, of longer 
or shorter duration, followed by heat, pains in the back and limbs, 
headache, and oppression, sometimes a sensation of great heat over 
the whole of the body, nausea, retching, quickness of the pulse, and 
other febrile symptoms, are the precursors of the petechia? or ecchy- 
moses. They appear from the third to the sixth day, sometimes with- 
out hemorrhage from the mucous membranes, or the viscera (purpura 
febrilis simplex). 

Frequently, in purpura febrilis, after the initiatory fever, the erup- 
tion of petechia} is preceded by exanthematous spots, 3 analogous to 
those of urticaria febrilis. The skin, already red, is then covered 
with petechia; of a purple colour, the dimensions of which vary from 
that of the head of a very small pin to that of the tip of the little finger. 
These last are slightly prominent. 

1019. Purpura febrilis may appear under the form of ecchymoses . 
M. Ollivierd'Angers 4 observed a curious case of this kind in an infant, 
three years of age, which he gave me an opportunity of seeing, in 
whom the cutaneous ecchymoses made their appearance on the limbs 
at the same time that these became cedematous. The skin was hot 
and painful ; the pulse from 120 to 130 in a minute ; the child experi- 
enced pain in the abdomen ; the pressure of a garter, or of the finger, 
was sufficient to produce an ecchymosis. This child was cured after 
a month's illness. 

1020. In purpura febrilis, after the primary fever, hemorrhages 
occasionally occur from one or other of the different passages of the 
body, at the same time that petechia? and ecchymoses are formed in 
the skin, and subcutaneous cellular tissue (purpura febrilis hemor- 
rhagica). 5 In some patients the urine is highly tinged with blood ; 
the pulse, small and contracted, in the first instance, sometimes ac- 

• Duncan, jun. (case of purpura hemorrhagica, Edinb. Med. and Surg. Journ., 
vol. xviii. p. 405). 

1 Lordat observed in the prison at Montpellier, a hemorrhagic petechial fever 
which appeared in the spring of the year 1800, lasted five months, reappeared towards 
the middle of September, 1804, and continued till the month of January, 1808. This 
description of fever attacked nearly one half of all the women who were confined 
there, and no more than two men. It began by a shivering fit, followed with intense 
fever and depression, pain in the head, acute suffering in the epigastrium, redness of 
the face, white tongue, scanty and scalding urine, "constipated bowels, &c. This 
state continued for three days; on the fourth, the fever abated, and an eruption of 
petechia: took place on the neck, breast, upper part of the arms, trunk, &c. After 
the eruption had appeared, the fever and the hemorrhage, which was generally from 
the nose and the uterus, subsided at the same time; towards the ninth day the spots 
usually disappeared. After several days of apparent convalescence, a relapse often 
occurred, and these relapses were sometimes repeated: no one died. Some women, 
after several relapses, became decidedly scorbutic. Latour (op. cit. p. 170). Van- 
dermonde, Journ. de Med., t. vi. p. 339, maladie voir d'une espece parliculiere, has re- 
corded a remarkable case of purpura febrilis. We must assimilate to these cases the 
accounts we have of a disease observed among deserters who were brought by forced 
marches to a place of confinement, and whose bodies became covered with petechiae 
and ecchymoses, and in whom nothing succeeded in stopping the nasal and intestinal 
hemorrhages. (Latour, op. cit. t. ii. p. 469.) See a case of Sporlius, ciled by Fabri- 
cius Hildanus (obs. chir. cent. vi.). Th. Schwenck, Sang. Hist., p. 130. 

» During the summer of 1797, Latour saw at the Hotel Dieu of Orleans, a great 
number of reapers, the whole of whose bodies, after great lassitude in the limbs, 
irregular shivering fits, and vertigo, became redder and hotter than usual, whilst the 
head was heavy and painful, the pulse very full, and the bealingof the carotid arteries 
extremely violent; the tongue was at the same time red and dry, the thirst urgent, the 
urine scanty, the bowels relaxed, the breathing occasionally interrupted by sighing, 
&c. On the second and third days of the attack, exanthematous patches appeared 
over the skin, which looked as if it had been whipped with nettles. Towards the fifth 
or sixth day innumerable brown and black petechioe, of a lenticular shape, appeared 
in the middle of the exanthematous blotches ; the fever commonly subsided about the 
lourteemh or fifteenth day, and always before the one and twentieth, and the petechiee 
vanished, becoming yellowish, like ecchymoses, as they declined; the disease was not 
p ' n , 1 '^' endenc 'es. Latour (Hist. Philosoph. et med. des hemorrhagies, vol. ii. 8vo. 
hp™,rh •' t0m ' , 11- P> 172, and Se q u ent) relates another case of this species of 
■rrhagic nettle-rash, which after beginning with delirium, and other serious 




ii^^ou^ma^freas.m^'^F^^ SP u° n,an6 d ' ecch y™ses cutanee avec cedeme 
n u.ous-cuiane et gastro-entente. (Archives gener. de Med t xv d 206 1 

r) ^^rZv^llt h --"^a%etech,a.i.-Memo V r a P bil Cli'ntc. fasc. 
i.)> relates uiree remarkable cases of purpura febrilis h^mnrrhamV, 



purpura febrilis haemorrhagica. 



quires more strength and softness after a first hemorrhage; but upon 
further loss of blood, all the symptoms which I have mentioned in 
treating of purpura /Hemorrhagica non-febrilis, may occur. 

Purpura febrilis may present, from the commencement, very serious 
symptoms, and terminate, in a few days, in death, when blood is c\- 
travasated, in large quantity, into the tissue of the lungs or substance of 
the brain.' 5 

1021. We must assimilate a species of hemorrhagic fever 7 to pur- 
p\ira febrilis, inasmuch as it only differs from purpura febrilis haemor- 
rhagica, by the absence of ecchymoses and petechia. In this fever 
after symptoms of a more or less violent character, hemorrhages from 
the nose, mouth, intestines, urinary passages, &c, take place. These 
general hemorrhages are sometimes not accompanied with fever in the 
beginning, but it generally appears after an interval of a few days. 

These general hemorrhages have been seen to alternate with deter- 
minations of blood to particular organs, as the tonsils, &c. 

1022. Purpura senilis. Under this name, Bateman has described 
a variety which he has only observed in old women, and in which 
ecchymoses, of a very deep-red brown colour, irregular in their form 
and dimensions, appeared principally along the outsides of the fore- 
arms. Each of these spots lasted only from ten to twelve days; but 
in one case, Bateman saw them return at different times, during the 
space of ten years, all the while, without any particular derangement 
of the health occurring. I have myself, several times, observed simi- 
lar spots on the same parts, and on the backs of the hands of elderly 
people of both sexes. I ought to add, that in all these cases, this 
description of ecchymosis lasted much longer than in those mentioned 
by Bateman, generally longer than a month. The spots were of the 
colour of wine lees, and bore a pretty strong resemblance to particu- 
lar ngevi ; they did not disappear upon pressure. 

This ecchymosis senilis must not be confounded with true purpura 
which may also attack the aged. 3 

1023. Certain eruptions of petechiae and ecchymoses may be re- 
garded as marking states approaching to purpura senilis, which is 
sometimes seen in individuals labouring under enteritis, chronic 
peritonitis or other serious diseases, followed by the cachectic consti- 
tution. As for the ecchymoses and petechias, which appear on the 
lower limbs of patients, affected with asthma, or diseases of the heart 
and in dropsy, the sanguineous infiltrations are probably the effect 
of two causes: an impediment to the venous circulation, and some 
modification of the blood. 9 

6 Zacutus Lusitanus speaks of a patient whose whole body was livid, and who, 
during two days, was in a general bloody sweat, and became covered before deaih 
with a perfectly black* eruption. In another place, he relates that several persons, 
who had been cupped in this disease, bled so profusely that it was impossible to 
stop the hemorrhage by any means, so that they all died. [Praxis medica miranda, 
obs. 41,42.] 

7 M. Littre showed me a young man who for several days had laboured under 
haemoptysis, and hemorrhage from the nose, intestines and urinary passages [Gazette 
medic, de Paris, 1833, p. 263]. Petrus Poterius, (obs. et curat, insig. cent. iii. 60,) 
has published a similar case. Morgagni states, that in the year 1200,a great number 
of men died in Etruria and Romagnia.in twenty-four hours, in consequence of allow 
of blood from the nostrils. [De sedib. et caus. morbor. Epist.] 

8 Latour, op. cit. t. xi. p. 27. 

9 The patient Pierre, sixty-nine years of age, had been for several months at the 
Hopital de la Pitie, when he was attacked on the 6th Feb. 1826, without any apparent 
cause, with pain in the epigastrium, diarrhoea, and loss of appetite; the tongue was 
red and dry, the thirst great, the pulse weak, and not frequent. These symptoms 
were met by abstinence, demulcent drinks, and emollient poultices applied to the 
abdomen; the symptoms continued, and the patient sank more and more. On the 
23d, the tongue was dry and brown, the pulse slow and weak; large ecchymoses ap- 
peared on the inside of the lower limbs, and he died the 7th Feb., 1826.— Secto cada- 
veris, thirty-six hours after death. On the right leg towards the anterior and inner 
surface of the tibia, the skin appeared livid, and below it was a large ecchymosis, six 
inches long and three inches broad. Black blood was exlravasated into the subcuta- 
neous cellular tissue, with which it maybe said to have been combined ; similar sub- 
cutaneous ecchymosis had taken place in the sub-aponeurotic cellular tissue of the 
leg; the subcutaneous cellular tissue of the whole of the outside of this leg was 
infiltrated in the same manner with black blood. This infiltration was much more con- 
siderable than would have been imagined from the external appearance of the limb. 
There were no ecchymoses in the cellular tissue of the sole of the foot: but it was 
bathed in a reddish serum. The vena saphena contained very little blood. There 
were ecchymoses in the tibialis posticus, and similar sanguineous infiltrations in the 
subcutaneous cellular tissue of the outside and inside of the thigh. Some were also 
discovered under the crural aponeurosis, and in the cellular tissue between the rectus 
femoris, and the triceps; the lower left limb presented similar alterations, and was 
surrounded under the skin with an infiltration of black blood. The right arm pre- 
sented subcutaneous, sub-aponeurotic, and inter-muscular ecchymoses. The left 
arm did not present any. Thorax. A great quantity of adipose tissue, deposited 



PURPURA. 



327 



1024. Purpura sinefebre is more frequently complicated with rupia 
than with any other eruption. Purpura febrilis and the hemorrhagic 

fever occasionally appear in the course of several acute diseases, and 
particularly during small-pox. 1 Purpura may complicate jaundice 2 
and peritonitis (Watson). I have seen it occur in the course of a 
fatal case of internal strangulation of the small intestines, and in 
several other diseases very different in their nature from purpura. 

1025. Anatomical observations. — Cutaneous and subcutaneous 
ecchymoses and petechia?, observed in purpura, neither increase nor 
decrease at the instant of dissolution. In dissecting the skin after 
death, the petechias and ecchymoses are found not to be all similarly 
situated. Some are very superficial and on the surface of the skin, 
others occupy the internal areola? of the dermis, and the larger and 
deeper are seated in the subcutaneous cellular tissue. All these 
spots are formed by the effusion of blood which is coagulated in the 
largest and blackest, and fluid in the smaller ones. The vascular 
ramifications in the neighbourhood of the small effusions are not 
more developed than in their natural state; the blood is easily re- 
moved by the aid of washing or maceration. 

The mucous membranes of the mouth, stomach, and intestines 
present in some point or other, petechia? and ecchymoses similar to 
those of the skin. The exterior surface of the lungs generally pre- 
sents a certain number of ecchymoses, which are rendered particularly 
distinct, as in the spaces between them ; the colour of the lungs is 
natural. Beneath the ecchymoses, the tissue of these organs is of a 
reddish-brown colour, homogeneous texture, harder than the healthy 
part which surrounds it, and presents a small circumscribed infiltra- 
tion from which black blood is easily forced out by pressure, a cha- 
racter altogether analogous to the haemoptic or apoplectic dispositions 
described by Laennec. The same description of ecchymosis is some- 
times found between the mesenteric laminae, under the peritoneum, 
pleura, pericardium, &c. Positive effusions of blood have been seen 
also into the membranes of the brain, and sanguineous infiltrations 
into the diplo? of the broad bones, and into the medullary membranes 
of the long bones. 3 When patients have sunk after profuse or 
repeated hemorrhages, the heart only contains sanguineous serum 
without clots ; the arteries and veins present no peculiar or regular 
alteration, and the same may be said with regard to the other organs, 
which may present accidental, but not characteristic lesions. 

1026. Askow, having analyzed the blood of patients affected with 
purpura, affirms that it is in no way different from that of a healthy 
person ; Johnston, however, has seen it remain fluid, not separating 
into serum and coagulum, although there was some appearance of 
coagulable lymph. In a case seen by Duncan, the blood, in flowing 
from the vein, had a most extraordinary appearance ; he compares it 
to arterial blood mixed with water ; it was half transparent, and of a 
bright red colour. The blood coagulated very slowly, and the coagu- 
lum was not very firm; the serum did not separate, and the coagulum 
had the appearance of a shaking jelly, through which the red globules, 
which had fallen to the bottom, could be perceived. The red colour- 
ing matter was in smaller proportion than in ordinary blood, probably 
from the frequent recurrence of the hemorrhage. There was no trace 
of coagulable lymph. At the commencement of purpura Iwemorrhagica 

between the muscular tissue and the pericardium, surrounded the heart, particularly 
the right ventricle ; the organ was small in size. The mucous membrane of the 
larynx and trachea was of a livid red colour; the lungs were healthy and crepitating; 
the abdominal and thoracic aorta was ossified in parts along its whole extent. This 
artery contained a large fibrinous clot. The thoracic and abdominal vena cava con- 
tained no blood ; a number of small lymphatic inflamed glands were perceived in 
the neighbourhood of the aorta ; the sub-peritoneal cellular tissue and the epiploons 
were loaded with fat. The peritoneum was healthy; the mucous membrane of the 
stomach was covered with numerous blood-vessels; deep red-coloured spots were 
found on the duodenum; the rest of the intestines did not present any alteration. 
The urinary and biliary organs, and the spleen were healthy ; the psoas and iliacus 
muscles were deeply ecchymosed, and loaded with black blood; the muscles of the 
body and of the face did not present any particular appearance ; the articulations 
were healthy ; the brain appeared loaded with transparent serum ; the cerebral sinuses 
contained fibrinous concretions. 

1 Haller speaks of an epidemic small-pox in which the patients, at the moment the 
eruption appeared, experienced pains in the back, and haemoptysis: petechias and 
ecchymoses appearing at the same time among the pustules. [Opuscul. Patholog., 
obs. 44.] 

2 Dr. Elliotson has related two cases of this complication ; one was successfully 
treated with calomel in doses of 12 grains, and half an ounce of castor oil repeated 
for several days; the other terminated in death. 

3 Journ. complem. des sc. med., t. xxxvi. p. 434. 



sinefebre, I have never been able to discover any thing in the blood 
that differed from the natural state ; after repeated hemorrhage, it only 
became more serous. In purpura febrilis, I have several times seen the 
blood present a well-marked bufly coat. 

1027. Causes. — The mode of formation of the ecchymoses and 
petechia? in purpura, is still unknown.- The vessels in which the 
blood circulates, having been found unaffected, and no obstacle to its 
flow being discoverable, it has been supposed that the transudation 
of the blood was owing to a change in its composition, to a greater 
tenuity of its molecules, &c. Others have supposed that the blood 
flowed from the dilated pores of the capillary arteries and veins, whose 
sensibility was increased or diminished, or the sides of which had 
given way, &c. 

The disease, not of very frequent occurrence, attacks all ages ; but 
more frequently appears before puberty. I have particularly noticed 
it in children of weakly constitution, ill fed, kept at sedentary occu- 
pations, inhabiting low and damp places, or in women of a nervous 
temperament, and of great mental susceptibility. Purpura sometimes 
occurs, without any appreciable cause, among the higher classes of 
society, and in persons apparently of the finest constitutions ; it appears 
that it may be hereditary. 4 

1028. Diagnosis. — Ecchymoses produced by external violence, and 
certain extravasations of blood 5 into the subcutaneous and intermus- 
cular cellular tissue of fractured limbs, the consolidation of which 
they either retard or prevent, must be distinguished from purpura 
simplex. Nor must this disease be confounded with the petechia? or 
ecchymoses which sometimes appear on the lower limbs after standing 
for a considerable length of time, or in consequence of a mechanical 
obstacle to the return of the blood. 6 

Purpura ye6n7?'s and hemorrhagic fever may easily be distinguished 
from scorbutis, which is a chronic affection. Purpura sinefebre can- 
not be confounded with scorbutus, when the hemorrhage occurs from 
any other passages than the mouth, if the gums are healthy, &c. ; but 
it appears to me to be almost impossible to distinguish chronic hemor- 
rhagic purpura, in which the blood flows from swelled gums, and the 
insides of the cheeks, from true scurvy. To be satisfied of this posi- 
tion, no more is required than to consult the account which Poupart 
and Thibaut have published of an epidemic scorbutus, which attacked 
great numbers of the patients in the Hotel Dieu. 7 Still in scorbutus the 
gums are swelled, softened, and, as it were, putrefied ; whereas, in pur- 
pura, they are simply the seat of true hemorrhage, and do not generally 
present any of these appearances. 

The alteration of the gums is much more extensive in scorbutus, 
where it is most commonly preceded by swelling and inflammatory 
redness, as it is followed by the loosening and loss of the teeth. 3 
Scorbutus has further been most frequently observed on ship-board, in 
prisons and in besieged fortresses. 

In yellow fever, as in purpura hemorrhagica, spontaneous hemor- 
rhage, blackish bloody evacuations and vomiting, sanguineous infiltra- 
tion into the muscles, into the cellular substance under the skin, into 
its substance, or over its surface, occur ; but yellow fever differs from 
purpura in its cause, and the severity of its symptoms, of which pro- 
fuse hemorrhage is never one of the most alarming. 

4 Davis's Edin. Med. and Surg. Journ., t. xxvi. p. 291. 

6 Cloquet (Jules). Du scorbut qui se manifeste d'une maniere locale pendant le 
traitement des fractures. (Archiv. gener. de medic, t. i. p. 470.) 

6 Pringle having bled a person labouring under jail fever, petechias appeared, 
during the time of bleeding, on the forearm, below the ligature, and in no other part. 
(Vide Latour, op. cit. t. ii. p. 345.) I attended in 1829, at the Hopital Saint Antoine, 
a man in whom, after death, the right iliac vein was found filled with fibrinous clots 
of recent formation. There had appeared during life, a serous infiltration of the 
whole of the right leg. This infiltration, which was very considerable, happened 
about thirty hours before death, and was accompanied after eighteen hours by a con- 
siderable development of petechiae and ecchymoses which appeared only on the infil- 
trated parts. 

7 Poupart (Memoires de l'Academie des Sciences de Paris, 1699). 

8 Escarbot has left us a description of an epidemic scorbutus with which Cartier's 
fleet was affected on a voyage of discovery to Canada in 1535. " Et a aucuns leur 
devenaient les jambes toutes sursies de gouttelettes de sang comme pourpre, puis 
montoit ladicte maladie aux hanches, aux cuisses et espaules, aux bras et au col, et 
a tous venoit la bouche si infectee et pourrye par les gencyves, que toute la chair en 
tomboit jusqu' a la racine des dents lesquelles tomboient presque toutes, et tellement 
sesprint ladicte maladie a trois navires, qu'a la my-febvrier, de cent dix hommes que 
nous estions, il n'y en avoit pas dix sains." Les navigations, etc, faites par les 
Francais es-Indes Occidentales. Paris, 1618. 



328 



HEMORRHAGIC. 



The same observation applies io small-pox, measles, scarlatina, 
typhus, severe hospital or jail fever, 1 and the plague, diseases all of 
which are sometimes accompanied with petechia? and ecchymoses. 
But the morbid miasmata or poisons which produce these different 
diseases, L'ive them peculiar characters and distinguishing features, 
which the mere community of a single serious phenomenon, that of 
hemorrhage, will not permit us to overlook or to misunderstand. 

1:029. Prognosis. — Purpura hemorrhagica, ■which shows itself by 
ecchymoses on the skin, is, generally speaking, a more serious disease 
than that which appears by petechia-, and this latter form is of a more 
dangerous nature than purpura simplex. l?ur\niT<iJebrilis and hemor- 
rhagic lever are generally less serious than those forms of hemorrhagic 
purpura which commence without fever, but become febrile after 
hemorrhage has recurred several times. A small, hard, and very fre- 
quent pulse (from 130 to 140 a minute) is often a precursory sign of 
a renewal of the hemorrhage or of other serious symptoms. 

Ecchymoses on the nose are often the forerunners of profuse he- 
morrhage from the nose or the nasal fossa? ; palpitations or pulsations 
of the epigastrium are indicative of hrematemesis ; oppression about 
the chest, and cough often precede haemoptysis. 

1030. Treatment. — The treatment varies with the varieties, the 
forms, and the periods of this disease. Purpura simplex sine fehre 
sometimes gets well spontaneously after lasting several weeks, when 
the petechial eruption is not very considerable. Antiscorbutic medi- 
cines — infusion of wild radish, antiscorbutic wine and syrup — are ap- 
plicable in the greatest number of cases, and are beneficial above all 
to individuals of a pallid complexion and of weakly constitution. 

Purpura hemorrhagica sine fehre should be treated by acidulated 
drinks, chalybeates, the decoction and extract of rhatania, sometimes 
by the acidulated decoction of cinchona, and often by lotions, cold 
ablution and aspersion, if the hemorrhage is very profuse, and if, as 
is usually the case, there is no indication that the loss of blood is 
necessary or supplementary to some other evacuation. At this period 
and under such circumstances, blood-letting is rarely advisable, unless 
the pulse be strong and full ; haemoptysis, hematuria, and bleeding 
from the uterus, sometimes render it necessary to have recourse to the 
detraction of blood ; but when, after several attacks of hemorrhage, 
the primary symptoms remain or reappear, bleeding ceases to be 
applicable, even with a hard and frequent pulse, (a) In this case 
purgatives become very useful, and have been particularly recom- 
mended by Storck, Burserius, and a great many able practitioners. 
Some prefer cathartic vegetable, others mercurial purgatives. 2 Oil of 
turpentine 3 combined with calomel, with castor-oil or syrup of senna, 
has been mentioned as a good form of laxative ; I generally make use 
of jalap combined with calomel, (b) 

When purpura occurs where the individual is already affected with 
intermittent fever," if the petechia; and ecchymoses have appeared 

(a) Dr. Elliotson and Dr. Latham give cases of successful results 
after blood-letting, followed by purgatives. Aware of the different 
states of the system associated with purpura, we should have recourse 
to treatment correspondingly various. As a general rule, neither vene- 
section nor the early use of tonics is advisable. Purgatives, mild 
salines, with the other parts of an antiphlogistic regimen, are preferable. 

(6) Acetate of lead and opium, and sulphate of quinine and calo- 
mel (Dr. Wright— JV. Y. Med. # Surg. Jour., vol. i., p. 456), have 
been found to succeed in some cases. 

' Latour says, that a great number of deserters died at the Hospital of Orleans in 
1806 and 1807, of a violent fever, sinking in some cases whilst vomiting quantities of 
blackish and fetid blood, in others in consequence of a nasal or intestinal hemorrhage 
so profuse that it only ceased with dea'.h. Several of these patients were covered 
with black and violet-colouied petechia ; others had the whole surface of the nose 
only as black as charcoal. 

2 Harty (W.). On the efficacy of mercurial purgatives in purpura. Edinb. Med. 
and Surg. Journ., vol. xxiv. p. 57. 

3 Whitlock Nichol. Obs. on the treatment of purpura hasmorrhagica. Edinb. 
Med. and Surg. Journ., vol. xviii. p. 540. Magee, Jos., (case of purpura hemorrhagica 
.successfully treated with spirit of turpentine, Edinb. Med. and Surg. Journ., vol. xxiv. 
1835, p. 307,) appears to me to have used both scammony and turpentine in too 
large doses. 

« I had a man twenty-seven years of age under my charge in 1829, at the Hopital 
de la Charite, who had been long ill with quartan ague,and for the last six weeks had 
been passing blood in his stools, without pain, upon whose belly and lower limbs 
petechia? had appeared at the same time. The fever quickly yielded to the adminis- 



during the attack, sulphate of quinia, by preventing the return of the 
fit, often renders all other remedies unnecessary. 

If purpura occurs after privations of all kinds, more generous and 
wholesome food, composed of rich soups, boiled and roast meats, wine, 
jellies, and good wine mixed with water for drink, contribute materially 
to the cure. 

1031. Each variety of hemorrhage which occurs in purpura, further 
requires a different mode of treatment. 

1st. Ecchymoses and petechia? should be treated by stimulating spi- 
rituous lotions or lotions of the chloride of lime. The limbs may also 
be wrapped in rollers dipped in cold vinegar and water. 

2dly. In cases of frequent or very profuse epistaxis, cold lotions 
applied to the head and between the shoulders, astringent lotions, 
mustard foot-baths, and above all, plugging the nostrils, should be made 
use of. 

3dly. Dry cupping in different parts of the body has often proved 
very serviceable in haemoptysis. 

4thly. Lotions and styptic injections, ice, and cold applications to 
the epigastrium, are useful in uterine hemorrhages. 

5thly. Cold water strongly acidulated with vinegar, injections of a 
strong acidulated decoction of gall-nuts, ice enclosed in a bladder 
and applied to the belly, should be made use of in intestinal hemor- 
rhages. 

6thly. Hemorrhages which take place from the surface of issues, 
blisters and ulcers, may be arrested by compression and styptic lotions; 
and, finally, other hemorrhages are to be treated by similar means, 
and according to the general principles that are applicable under other 
circumstances. 

1032. The antiphlogistic treatment generally, — low diet, &c, is 
usually applicable in purpura febrilis and hemorrhagic fever. The 
temperature of the body and of the outward air should be kept very 
moderate. Cold water, whey, and slightly acidulated mucilaginous 
drinks are the best means we possess for reducing fever ; if the first 
febrile symptoms are of a serious nature, if the hemorrhages which 
have taken place have not been very profuse, and, as a still stronger 
reason, if the pulse be strong and full, bleeding should be had recourse 
to once and again, should it appear to be indicated. 5 Bleeding from 
the foot is particularly recommended in epistaxis, and bleeding from 
the arm in haemoptysis, haematemesis, metrorrhcea, &c. When purpura 
has been preceded by amenorrhcea or dysmenorrhea, the application 
of leeches to the genital organs is preferable to bleeding from a vein. 
Immediately after bleeding, purgatives are extremely useful ; a bolus 
of rhubarb and calomel, and of jalap and calomel, with whey for drink, 
may be prescribed immediately, and followed up by the use of injec- 
tions of oil of turpentine. 6 The symptoms have sometimes been known 
to disappear after salivation, and hypercatharsis occasioned by large 
doses of calomel. To conclude, bleeding and purgatives are the prin- 
cipal remedies in purpura febrilis and hemorrhagic fever. 

1033. Ecchymoses occurring in the aged, require nothing more 
than simple local measures, the use of spirituous and tonic lotions, &c. 
Petechia? and ecchymoses occurring in persons of cachectic constitu- 
tions are the results and indications of serious and deeply-seated 
diseases towards which the whole attention of the practitioner should 
be directed. 



Historical JYotices and particular Cases. 

1034. Hippocrates 7 describes a species of disease of the spleen with 
fetid odour of the mouth, swelling of the gums, and large bleeding 
ulcers of legs, which seems rather to be scurvy than purpura. Celsus 8 
repeats this passage almost literally and makes further mention of 
hemorrhages of the nose and other parts. The ancients speak of uni- 
versal hemorrhages, not only proceeding from all the principal orifices 

tration of sulphate of quinine, when the petechia? disappeared and did not return. I 
have quoted, after Stoll, in the first edition of this work, a case of purpura complicated 
with intermittent fever, which terminated in death. Stoll. Ratio medendi. Pars 
prima, p. 110, 8vo. Parisiis, 1787. 

5 Parry. On the utility of vaenesection in purpura. Edinb. Med. and Surg. Journ., 
vol. vi. p. 7. 

6 Belcher. Revue medic, 1825, t. ii. p. 461. 

7 De intern, affectionibus. Sect. v. p. 55S. 

8 Celsus. De re medica, lib. ii. sect. 7, p. 52. 



PURPURA. 



329 



of the body, but even through all the pores of the skin, and which 
they attribute to the bite of the serpent hmnorrhois. 1 

Riviere or Riverius 2 had distinguished purpura from the petechia 
which are observed in malignant fevers, long before Werholf 3 devoted 
some lines to the description of this disease in the celebrated Nurem- 
berg collection. Graff-* published, in 1775, the first inaugural disser- 
tation on this affection, the history of which has since been rendered 
more complete by the researches" of Behrens, 5 Car. Strack, 6 Adair, 7 
Berenger, 8 J. G. Acrel, 9 Osthoff, 10 Havinga, 11 Willan, 12 Bateman, 18 
Pickel, 11 Groeser, 15 Gauthier-Bellefonds, ,6 Pierquin, 17 Brachet, 18 Four- 
neaux, 19 A. Keller, 20 Conradi, 21 and several others. 

Case CXLIX. — Purpura /Hemorrhagica; nasal hemorrhage, numerous 
spots upon the skin ; death ; petechias in the cerebral substance, on the 
heart, and lungs; collection of blood in the substance of the liver. — 
Joseph Roullier, thirty-two years of age, a porter, had been extremely 
subject to attacks of epistaxis for two years. About three months ago 
he had been admitted into the hospital Cochin. At that time he was 
very much debilitated by a copious bleeding from the nose which had 
continued for a fortnight; he had, moreover, small red spots upon the 
skin. At the end of a fortnight the bleeding at the nose had ceased, 
and the patient being better, he was discharged on the breaking out 
of the epidemic cholera ; he remained about a fortnight after leaving 
the hospital without any fresh attack of hemorrhage ; subsequently 
to that period, however, he rarely passed four days without one ; he 
did not the less continue at his work, although his strength diminished 
daily. The pituitary membrane still continued the only part towards 
which the hemorrhagic effort was directed; the patient had never 
had haemoptysis, nor had he ever voided blood in his stools. He pre- 
sented himself for admission at the hopital de la Charite on the 26th 
October, 1833. For eight days previously he had been continually 
losing blood, and his debilitated state had obliged him to give up 
work. The following is the state which he presented the day after 
his admission: — Considerable paleness of the face ; the nasal cavities 
continue to discharge drops of blood, excessively liquid and serous, 
and slightly inclined to a pink colour. The hemorrhage is, however, 
rather diminished since yesterday, compresses steeped in vinegar 
having been applied to the face since the patient's admission into the 
hospital. The tongue and lips are pale ; the gums, perfectly healthy 
and firm, as in the normal state, are blanched ; the appetite is pretty 
good ; the patient asks for food ; there is no nausea ; the stomach is 
perfectly healthy. The alvine evacuations are natural, occur regu- 
larly, and present no appearance of blood. The chest, after careful 
examination, is found to be in the most normal state. The pulse is 
quick, giving a hundred pulsations in a minute. The chest, neck, 
arms, and legs, are covered with a multitude of deep red spots, scat- 
tered here and there in an irregular manner. These spots, which are 
regularly rounded, are for the most part a line in diameter ; on some 

' Lucan has drawn an appalling picture of these symptoms. (Pharsal, lib. ix. v. 
810.) Several naturalists have doubted the existence of the hsemorrhois. 

2 "Et interdum erumpere soleant (maculae purpureas) in mulieribus mensium 
suppressionem patientibus, et in nonnullis pueris ob luem quandam sanguinis ebul- 
litionem, nulla tamen apparente febre, quod nobis in utrisque non raro videre licuit." 
Lazari Riverii Praxeos medicae, 12mo. Ludg., 1674, t. ii. p. 630. Cent., obs. to 21. 

» Werlhof. Commer. Norimb. ad rei Medic, et Scient. Natural, incrementum 
Institut., 1745. 

* Graff (Eberh. Gott.). Diss, de petech. sine febre, 4to. Gotting., 1775. 

5 Behrens. Diss. Epist. de morbo maculoso haemorrhagico, etc. Recus. in Werl- 
hofii. Op. Coll. a Wichmann, p. 615. 

s Strack (Car.). Obs. med. de morbo cum petechiis. Caroliruhae, 1766. 

7 Adair (J. B. in.). Diss. med. de hasmorrhoea petechiali. Edinb., 1789. 

' Berenger (J. G.). Diss, de haemorrhceft petechiali. Halse, 1792. 

9 Acrel (J. G.). Diss, de haemorrhoea. Resp. Ca. Zetterstroem. Upsal, 1797. 

10 Osthoff. Diss, de morbo maculoso. Duisburg, 1798. 

11 Havinga. Diss, de morbo maculoso Werlhofii, 4to. Groning., 1799. 

12 Willan (R.). Reports on the diseases in London, 1801. 

13 Bateman. Diss, de haemorrh. petechiali, 8vo. Edinb., 1801. 

14 Pickel. Diss, de morbo maculoso. Wirceburg, 1802. 

15 J. Groeser. Diss, de morbo maculoso hasmorrhagico. Heidelberg, 1803. 

16 Gauthier-Bellefonds. Dissert, sur la maladie tachetee de Werlhof. Strasbourg 
1811. 

17 Pierquin (V.). Recherches sur I'hemacelinose, 4to. Montpellier, 1821. 

18 Brachet. Mem. sur la maladie tachetee de Werlhof. (Revue med., t. vii. p. 83. 
Paris, 1822.) 

"9 Fourneaux. Obs. sur quelques humorrhagies cutanees et sous-cutanees, etc., 
4to. Paris, 1826. 
» Keller. Abhandl. Qber die Blutfleckenkrankheit. Wurzburg, 1826. 
41 Diss, de morbo maculoso haemorrhagico Werlhofii. Gottingae, 1829. 

83 



points they are isolated, in others they are united by twos and threes, 
and in several places are more closely connected, being clustered in 
large numbers, so as to form patches of various dimensions, which at 
first sight resemble ecchymoses. The greater number of these spots 
are of a deep red, others present a paler russet colour, and others 
have a slightly yellowish tinge like an ecchymosis that has almost 
entirely disappeared. On examining attentively such of these spots 
as are thus in process of resolution, it is easy to perceive that they 
fade from the centre towards the circumference, as they leave at length 
a thin marginal ring. The arms and thighs exhibit only a few de- 
tached spots, scattered here and there. The ehest and abdomen, on 
the contrary, present a much greater number; the spots, indeed, are 
confluent over these two regions, and in some places form continuous 
patches of ecchymosis. (Decoction of bark with acid ; half a drachm 
of extract of rhatany in pills). 

28th. The nasal hemorrhage diminished; the general condition the 
same as yesterday; the intellect of the patient is observed to be slightly 
affected. 

29th. Fresh epistaxis, which is very copious: the blood flowing 
from the nasal cavities is very serous; face extremely pale, pulse very 
weak; vomiting in the morning, the patient drowsy; the spots upon 
the skin neither larger nor more numerous than on the preceding day; 
{acidulated decoction of bark, as before; draught, with decoction of 
rhatany, and eighteen grains of alum; a lump of ice to melt in the 
mouth; compresses dipped in vinegar to the face; sinapisms to the feet.) 

30th. Extreme paleness ; continued hemorrhage, but less copious ; 
drowsiness ; the patient talks incoherently on being waked from sleep, 
and exhibits a considerable degree of excitement ; pulse very weak. 
The spots had faded considerably; on the arms and thighs they have 
disappeared ; but are still to be found on the breast and belly, though 
paler than before. These spots still continue to fade from the centre 
to the circumference, thus forming little rings, which become effaced 
gradually. (Acidulated decoction of bark ; four ounces of Malaga 
wine; draught, with a decoction of rhatany, and eighteen grains of 
alum; compresses dipped in vinegar and water.) On the following 
days, nothing occurred worthy of remark; the bowels began to act; 
the patient was less depressed. 

3d of November. — The old spots have almost entirely disappeared, 
and no fresh ones have been thrown out; the face still rather pale; 
the patient feels much better; the pulse is stronger than on the pre- 
ceding days ; it is easy to trace in the spots which yet remain, all the 
various shades of colour through which they pass before they disap- 
pear. (Acidulated decoction of bark and Malaga xoine, fyc, as before ; 
quarter diet.) 

5th. Fresh nasal hemorrhage, but not copious; the face pale; the 
pulse Aveak and quick; the skin does not, however, exhibit any new 
spots; and it is with difficulty that a few small discoloured rings, the 
remains of the brown spots which the skin formerly presented, can 
still be perceived ; the chest and digestive organs do not appear to 
be affected ; the patient talks much, but does not seem anxious about 
his situation ; (mucilaginous draught, with sixty drops of the essential 
oil of turpentine ; mucilaginous lemonade ; mustard bath to the feet ; 
compresses, wrung out of vinegar and water, to the nose and forehead.) 
Nothing new on the following days; the hemorrhage stopped com- 
pletely; the patient is still pale and weak; he attempted to rise, but 
felt giddy, and nearly fainted. 

9th of November. — The spots on the skin have completely disap- 
peared. The patient has expectorated several times ; the mucus, 
which appears to come from the posterior nares, is slightly tinged 
with blood, but there is no actual hemorrhage. The dose of turpen- 
tine is increased to a drachm ; the patient has half diet, which he eats. 

10th. Fresh nasal hemorrhage. 

11th. The hemorrhage continues; the blood is very liquid and 
pink-coloured. The patient is extremely pale and feeble; the pulse 
weak and quick; tongue white; no derangement of the digestive 
organs, nor of the chest ; the patient is drowsy, retains all his facul- 
ties; in other respects there is nothing remarkable. With regard to 
the skin, the old spots have completely disappeared, and no new ones 
have shown themselves. (Acidulated decoction of bark; wine and 
vmter for drink; four ounces of Malaga wine; sinapisms ; compresses 
wrung out of vinegar and water.) 



330 



HEMORRHAGIC. 



12th. The dehilky is ; the nasal cavities continue to dis- 

,i small quantity of blood of a very pale colour, which does 
not coagulate, and is entirely serous; the face, lips, and tongue, are 
blanched; the patient complains of his chest; the respiration is em- 
sed ; with the stethoscope, the respiratory murmur can be heard, 
but it is feeble and indistinct ; the chest generally sounds satisfactorily ; 
lie pulse is very weak and quick. (Acidulated decoction of bark; 
wine anil water, 6>"c, as before.) The bleeding from the nose continued 
\i t\ slowly; the patient became gradually weaker and w-eaker; and 
after sinking into a tranquil kind of delirium, he died in the course of 
the day. 

Sectio cadaveris thirty Jiours after death. — There is nothing remark- 
able in the external appearance. Head. — The arachnoid membrane 
is rather thickened ; the sub-arachnoid cellular tissue is infiltrated 
with serum. The cortical substance of the brain is pale, and very 
moist ; in one point of the anterior convolutions, there is a small 
bloody effusion, of the size of a large pin's head. The white sub- 
stance presents a great number of petechiae, disposed in patches here 
and there. These red points are surrounded by a small gray circle ; 
in another point there is a second effusion, of the size of a common 
pea. Chest. — The right lung is affected with a kind of ecchymosis 
towards its base; the pleura which covers it presents numerous 
petechiae. The pulmonary tissue is highly cedematous; on being in- 
cised, numerous points of sanguineous suffusion appear on the surface 
of the cut. Towards the posterior parts of the lower lobe, there is a 
point where the pulmonary tissue, apparantly indurated, is infiltrated 
with blood. The left lung does not present any petechiae on its ex- 
ternal surface ; it is not very crepitating, but loaded with fluid, and 
also presents a great many extravasated points of blood. The heart 
is of the ordinary size ; numerous petechiae appear on the anterior 
surface of the right ventricle; on die left ventricle they are rare; the 
posterior aspect of the auricle is very thickly beset ; the cavities of 
the heart contain a very small quantity of fluid blood ; the aorta also 
contains a small quantity of blood, which is excessively pale and 
serous, and a fibrous clot of small size, entirely colourless. Abdo- 
men. — The stomach is softened about the great cul-de-sac. Its mucous 
membrane presents a great number of small reddish points, resem- 
bling petechiae. The remainder of the alimentary canal does not 
offer any thing remarkable. Towards the extremity of the small intes- 
tines, a very decided follicular eruption is perceived, precisely analo- 
gous to that which is met with in cholera, although our patient had 
presented no symptom of the kind, not having even had liquid stools 
towards the close of his life. The liver presents internally a circum- 
scribed collection of blood, a sort of apopletic cell, the size of a small 
hazelnut ; throughout the remainder of its extent, the substance of 
the liver is pale and bloodless. The spleen presents externally a 
great number of small pink spots. The other organs contained in 
the abdomen have nothing remarkable in their appearance, (a) 

(a) " Purpura hemorrhagica in an infant three weeks old. Dr. Post 
gives (JV. Y. Jour, of Med. # Surg., vol. i, p. 222), the following 
description of a post-mortem examination of this case : 

" On the 25th Feb. 1839, I was invited by Dr. B. B. Coit, to ex- 
amine the body of an infant three weeks old. There had been 
hemorrhage during the first and second days of its life, from the sides 
of the umbilical cord, which had been checked by the application of 
powdered galls, and by pressure. It had then exhibited purple spots, 
apparently formed by the extravasation of blood, beneath the skin in dif- 
ferent parts of the body ; these spots were an inch or more in diameter. 
The evacuations from the bow r els continued for eight or ten days of a 
black colour, and of a tar-like consistence. Small doses of calomel 
were then administered, and the evacuations began to assume a 
healthy appearance. The ecchymosed spots then began to fade 
away, and no new ones made their appearance. But about the 10th 
day, a fluctuating tumour began to form about the posterior part of 
the occipital ridge, which continued to increase during a period of 
ten days, when it had acquired about the size of a hen's egg, and 
was very tense, and seemed to cause much irritation. The tumour 
was opened with a lancet, and black fluid blood flowed from it. On 
the following day, the child died. 

"The following appearances were found on examination: body 



Case CL. — Purpura hcemor rhag-ica preceding small-pox. — F. C, 
Sorel, three years and nine months old, admitted into the Hospice 

not emaciated ; surface extremely pale ;■ ecchymosed spots in several 
places beneath the skin, scarcely perceptible on its external surface, 
but very distinct on the internal surface ; there was a fluid tumour at 
the posterior part of the occipital ridge, containing a soft coagulum of 
blood ; this sac was found beneath the periosteum and the bone ; 
small quantities of bloody fluid were found beneath the arachnoid 
membrane on the surface of the pia mater ; bloody serum and small 
quantities of coagulated blood in the ventricles of the brain ; cineri- 
tious substance of the brain of a pure white colour, so that I could 
not, in any situation in which I examined it by broad day-light, dis- 
tinguish it from the medullary substance ; lungs remarkably pale ; 
cavities of heart empty; stomach and intestines very pale and dis- 
tended with gas ; liver of about the usual size and consistence, but 
of a yellowish-brown colour, without any shade of red." 

" Purpura subsequent to eczema mercuriale. — Mr. Adams said that 
with the permission of the Society he would communicate a case of 
purpura which had occurred in the Jervis Street Hospital, where the 
notes of it had been taken by the late Dr. Coulter. The appearances, 
at different periods of the progress of the case, were accurately deli- 
neated, in the four drawings on the table. The subject of the case 
had been affected with syphilis six weeks before his admission into 
the hospital, and had used mercury pretty freely ; he became affected 
with eczema mercuriale. After the tenth rubbing in of the mercu- 
rial ointment, small, very minute vesicles appeared. Some of these 
dried up ; others discharged a fluid which excoriated the parts about 
the scrotum, a circumstance formerly observed by Pearson, and de- 
scribed in his work: dyspnoea and cough supervened. On the 
seventh or eighth day after his admission into the hospital, the dys- 
pnoea became more oppressive ; there were rigors, and afterwards 
bleeding from the gums, and from the fissures about the scrotum : 
during several subsequent days, ecchymoses appeared on different 
parts of the body, and in all these there was a great disposition to 
slough : there were ecchymosed spots on the lips, which rapidly 
sloughed : about the sacrum, in the same manner, sloughs formed, 
and from the sloughs there were bleedings : he died on the 16th day. 
The body was carefully examined after death : there were no hemor- 
rhagic petechiae within the cranium, nor on the surface of the heart ; 
the lungs, anteriorly, were very anaemic and white — posteriorly they 
were congested ; the mucous coat of the stomach and intestinal canal 
was ecchymosed. 

" Mr. Adams considered that purpura was rather a symptom of 
peculiar debility than a disease itself. In proof of this, he mentioned 
a case of pemphigus gangraenosus, in which purpuric spots appeared 
on the skin, and in a case of cancrum oris they had been observed 
towards the close of the disease. It was well known that they 
appeared in scarlatina maligna, in plague, and in some other diseases. 
Indeed, purpura corresponded very much to the descriptions which 
authors give of the land scurvy." — Proceedings of Path. Society of 
Dublin, in Dublin Journ. of Med. Science, vol. xxiv. 

Purpura hcemor rhagica— fatal. — William Hunt, aet. 45, admitted 
into the Westminster Hospital, January 13th, under Dr. Bright. On 
the elbows, down the course of the spine, inside of the thighs, and 
generally over the legs, the purple maculae are dispersed : in some 
places the patches are so large as to seem like the result of bruises. 
The colour is most decided in the centre of each spot, and gradually 
fades towards the margin. The pulse is 84, feeble ; tongue clean ; 
bowels torpid, motions clay-coloured ; urine scanty and high-coloured, 
depositing a sediment like carmine. The man has a sallow com- 
plexion ; the white of the eye is tinted gamboge. There is no ten- 
derness in the hypochondrium. The abdomen is tense over fluid. 
The legs are cedematous. 

" Hunt is an old soldier ; he served in Spain and at Walcheren. At 
this last place he had the well-known epidemic. Being an habitual 
drunkard, he was exposed, about six weeks before admission into 
this hospital, to cold, whilst in a state of inebriation. When he came 
to himself, he had pain in the right hypochondrium and throughout 
the muscles of the body ; these symptoms gradually evanesced, and 
were succeeded by dropsy of the belly and legs. Cotemporaneously 



PURPURA. 



331 



des Enfans Maladies on the 19th of August, 1825, had enjoyed per- 
fect health till within two months of the above date, when measles 
made its appearance, without, however, presenting any thing unfa- 
vourable in its character. During the last fortnight, the patient has 
had a slight cough, and the skin has been burning; but she has made 
no complaint, although evidently dull and listless ; for six days she 
has experienced great difficulty of breathing ;' in the evening of the 
9th and following day, she complained of pain in the epigastrium 
{four leeches applied) ; on the 11th the difficulty of breathing increased 
(blood taken from the arm; gum water); no improvement; the 12th, 
an eruption of purple spots over the whole body, which still continue 

an attack of haemoptysis occurred. About a week before he showed 
himself at the hospital, the petechia? just described made their appear- 
ance. Ordered the following medicines : — 

R. Ext. Coloc. Comp. gr. x., h3c nocte et pro re nata sumend. 
R. Pulv. Rheei, gr. iij ; Pulv. Cinchonas gj. M. fiat pulv. ter die 

sumendus. 
Decoct. Cinchona? et Acid. Nitric. 6tis horis. 

" January 14th. — The abdomen is still tense ; water not increased ; 
bowels confined. 

Rep. Pulv. 

"15th.' — The petechiae unaltered ; copious rosaceous deposit falls 
from the urine ; anasarcous swelling of the legs diminished. 

" 16th. — Fresh petechiae have appeared on the calves of the legs. 
The older petechiae are of a paler colour ; the cedema has diminished ; 
abdomen still tense ; urine of a dark madder colour, depositing the 
purpurate .of ammonia. During the day considerable hemorrhage 
took place from the lungs. Calomel and squill pills to betaken daily, 
and cream of tartar solution to be drunk ad libitum. 

" 17th. — The purple spots have diminished as regards intensity of 
colour. Epistaxis took place to some extent this morning. The 
bowels torpid. To take a dose of spirit of turpentine, qualified with 
oil of peppermint. 

" 18th. — Complains of some pain in the left side, increased on 
coughing. The purpura has appeared in some fresh places. The 
bowels are freely open. 

" 20th. — Bowels again torpid, the maculae spreading generally over 
the back. Urine increased in quantity, but of the same madder-like 
colour, and still depositing the purpurates. 

" 23d. — The patient much harassed by cough. The sputa consist 
of mucus, floating in a greenish fluid. The yellowness of the eye 
has remained undiminished. The urine has increased to three pints 
daily. To be purged with jalap and calomel. 

" 24th. — Abdomen less tense. The maculation diminishing in 
colour and extent ; urine clearer and more lightly coloured. 

" 25th. — This morning about nine o'clock sudden hemorrhage 
from the mouth occurred. It proceeded apparently both from sto- 
mach and lungs. The blood was of a bright vermilion hue, and 
streaked with dark lines. The face of the patient is contracted. Pulse 
very weak. Laudanum and dilute mineral acid is administered in 
proper doses. 

" 10 a. m. — The hemorrhage returned in ten minutes after the exhi- 
bition of the draught, to the extent of nearly a quart. No pulse was 
perceptible at the wrist. A glass of wine given. The hemorrhage 
remained uncontrolled, and the patient died at half-past ten o'clock. 

" Sectio cadaveris thirty-six hours after death. — The entire body 
was dotted with petechiae, and all the surface was of a yellowish tint ; 
the lungs were slightly oedematous, but in other respects healthy. 
The mucous surface of the stomach, and small intestines throughout, 
covered with blood ; this membrane, when sponged, was of a red 
colour, and infiltrated with blood. The liver was granular, and ad- 
herent by membranous bands to the adjacent viscera. The gall-blad- 
der distended with bile ; the cystic duct thickened, and almost im- 
pervious. The contents of the gall-bladder consisted apparently of 
blood mixed with cystic bile of a sweet mawkish taste ; staining red 
rather than yellow. The surface of the gall-bladder was ecchymosed ; 
all the other viscera were sound, except the musculi recti abdominis, 
which were completely infiltrated with blood." 



to-day, the 14th; the variolous eruption was not remarked till the 
13th." The following is a description of the patient's state at the 
time of her admission : The variolous pustules, in inconsiderable 
numbers, are small, blanched, shriveled, and centrally depressed. 
On the surface of the skin, and particularly on the forehead, upper 
eyelids, back, and posterior aspect of the limbs, a number of spots 
are observed, irregularly scattered, rounded, and well defined, but 
not prominent ; some, of a bright purple colour, are about the size of 
a lentil; others, of larger size, are of a deep violet hue. The lips 
and nostrils are covered with a dark sanguinolent incrustation. It is 
impossible to examine the inside of the mouth, so as to ascertain the 
state of the gums. The orifice made in the vein of the arm, three days 
ago, is still open, and discharged a little very serous blood this morn- 
ing. The pulse is very languid ; the extremities cold. The child 
retains its consciousness, notwithstanding the extreme depression ; 
(sinapisms.) Death at three o'clock in the afternoon. Sectio cada- 
veris at eleven o'clock on the morning of the 15th. External ap- 
pearance. Cadaverous stiffness of the inferior members ; none of the 
superior. The colour of the skin, and of the spots, is precisely the 
same as during life. On incising the skin, it is easy to perceive that 
all the spots do not penetrate to the same depth ; some are very super- 
ficial, and situated directly under the epidermis ; others occupy the 
areolae of the corion ; finally, there are some (and these are the largest 
and deepest), whose seat is entirely in the subcutaneous cellular mem- 
brane. All these spots are formed by extravasations of blood, coagu- 
lated in the larger and darker kind, and liquid in those of smaller size. 
Examined with the assistance of a powerful glass, the vascular rami- 
fications in the neighbourhood of these ecchymoses and petechia, are 
not observed to be more developed than in the ordinary state. If, 
after laying bare one of these effusions, a stream of water is directed 
upon it, the blood is soon washed away. A piece of skin, put into 
water to macerate, did not present any appearance of spots on the 
following day. There are no ecchymoses in the deeper strata of the 
cellular membrane generally; the right arm, however, where the 
puncture made in a recent venesection, still continues open, is the 
seat of an universal sanguineous infiltration, to which its tumefaction 
and livid appearance are owing. The veins and arteries of this ex- 
tremity, traced into their most minute ramifications, do not present 
any visible alteration ; the median cephalic vein, on which the opera- 
tion of bleeding was performed, does not even exhibit any redness 
on the edges of the orifice; its walls are thin and transparent, and 
its external membrane is smooth and grayish, as in the healthy state. 
There is no ecchymosis into the substance of the scalp. Limpid serum, 
in small quantity, appears on the surface of the cerebral hemispheres ; 
the subarachnoid vessels are empty; the cortical substance is pale ; 
the medullary substance firm; the superior longitudinal sinus empty; 
the sinuses of the base of the cranium are filled with a liquid ver- 
milion-coloured blood; traces still remain of a slight sanguinolent 
effusion, converted into dark incrustations, upon the lips and nostrils. 
The tongue and gums are pale and blanched ; the palate is violet- 
coloured ; the epiglottis swelled, as well as the edges of the glottis ; 
the latter are covered with a very thin false membrane ; the tracheal 
and bronchial mucous membranes are apparently healthy. The ex- 
ternal surface of the lungs presents a great number of bright red cir- 
cumscribed points, and several ecchymoses of a deeper colour; one 
of these, on the summit of the left lobe, is four lines in diameter ; 
there are three smaller ones on the lower part of the same lobe, which 
also presents another, much more extensive, at its base. These spots 
are the more striking, on account of the lungs retaining their natural 
grayish colour. On examining the spots, they are found to correspond 
to a kind of dense circumscribed nucleus, which, on being cut across, 
presents a reddish-brown, homogeneous, granular tissue, in which 
the blood appears as if combined with the proper substance of the 
lungs. The parenchyma of both lungs contains several formations 
of the same kind, circumscribed in like manner, and situated in the 
midst of a perfectly crepitating tissue, from which, when incised, a 
quantity of blood, mixed with serum, escapes. Several of the glandu- 
lar bodies of the bifurcation of the bronchi are red and enlarged. The 
pulmonary artery at its origin, and the right ventricle and right auricle 
of the heart, present three lenticular ecchymoses of a bright red, 
approaching to the natural colour of these parts, and another violet- 



332 



HEMORRHAGIC. 



coloured one, nearly of the size of a sixpence, with irregular edges, 
situated on the posterior aspect of the apex of the heart. These 
effusions are situated entirely in the subserous membrane, and do not 
extend to the muscular tissue of the heart. A sanguineous suffusion, 
two inches in breadth, exists under the pericardium on the right side. 
The substance and cavities of the heart as in the healthy state; the 
internal membrane of the aorta and pulmonary vessels perfectly healthy. 
The stomach appears contracted ; its mucous membrane very much 
wrinkled, particularly in the direction of the great curve, and beset 
with numbers of small red points, of a vermilion tint, like the pricks 
of a pin. Within three inches of the pylorus, there is a lenticular soft- 
ened spot, of a dark-yellow colour, limited to the thickness of the 
mucous membrane, under which there is a small ecchymosis of the 
same size ; the duodenum presents, for the space of an inch, from the 
pylorus, a number of small petechial spots, closely set together like 
those of the skin ; they are far fewer in number towards the lower por- 
tion of this division of the intestines. The mucous membrane of the 
small intestines is of the natural dirty gray colour; the glands of Peyer 
are slightly developed ; the ileum contains green, flaky, muco-bilious 
matter. From the ileo-ccecal valve, the great intestines present a 
general violet red colour, which increases in intensity towards the 
sigmoid flexure of the colon ; they are covered by an infinite number 
of red points ; some, which are white in the middle, appear to be 
follicles; others are very small ecchymoses, which, towards the com- 
mencement of the colon, follow the circular folds of that intestine ; in 
this situation they are covered with a grayish secretion, and are much 
less numerous than in the transverse and descending colon. Nume- 
rous trichocephala in the ccecum and its vermiform appendix, which 
is rather red ; the fecal matter contained in the large intestines firmly 
moulded ; mesenteric glands, of small size, intensely red, brownish 
in their centres. Some purple marblings are observed on the liver, 
but no spots ; spleen small and healthy ; kidneys pale ; bladder con- 
tracted and healthy. 

Case CLI. — Pulmonary tubercles, chronic pneumonia and peritonitis ; 
purpura characterized by epistaxis, subcutaneous, submucous, subpleural 
effusions of blood, &c. Ferd. Helene, seven years of age, of a very 
feeble constitution, was admitted into the " Hopital des Enfans," on 
the 14th of March, 1825. He had been a long time ill, was subject 
to diarrhoea and colic, and the belly was distended and painful. For 
the last four or five days the cough had increased, the fever was 
higher, and the thirst more intense. At the time of entering the hos- 
pital, this patient was labouring under chronic pneumonia and perito- 
nitis. In spite of the active measures immediately employed, the 
patient continued to suffer from frequent cough, constant diarrhoea, and 
intense fever. 

After being about twenty or twenty-five days in the hospital, the 
respiration became very laborious and short ; the respiratory murmur 
was scarcely to be heard on the left side, and posteriorly to the right 
it could not be perceived at all. A blister applied a few days previously 
to the right side of the chest, became gangrenous, and was surrounded 
by erysipelatous inflammation of the most vivid red. At the same 
time a number of small violet-coloured circumscribed spots, were re- 
marked on the upper and lower extremities, some circular, others 
oblong, and about a line, or something less in diameter. The patient 
had had several attacks of epistaxis ; his pulse was very weak, the 
extremities were cold; (mucilaginous decoction of bark; lavement of the 
same.) The patient died in the course of the day. Sectio cadaveris. — 
Externally, a number of dark purple spots were observed on both fore- 
arms, some the size of flea-bites, others of grains of millet. There 
were also several on the legs and thighs, but these were much less 
dark in colour, and smaller in size. On cutting into, and dissecting 
off the skin of the forearms, hands, thighs and legs, we perceived that 
the subcutaneous cellular membrane was much injected, and very red, 
and presented a number of small sanguineous effusions, corresponding 
to the spots upon the skin, though none of these small ecchymoses 
were seated in the tissue of that membrane. The lymphatic glands 
of the armpit were injected and swelled. The subcutaneous veins of 
the extremities were pale and void of blood ; externally they were 
white ; the muscles were healthy. Respiratory organs.— Larynx, 
trachea and bronchi in a healthy state ; inter-bronchial ganglions tu- 
bercular, softened in the centre, and very voluminous ; agglomeration 



of tubercular ganglions in front of the trachea. Right lung. — Upper 
lobe healthy, crepitating, spotted internally by an infinite number of 
small ecchymoses ; middle lobe hepatized, anil filled with pus, which 
flows out when the part is compressed ; several hepatized points in the 
inferior lobe ; two cavities in its centre, of the size of a hazelnut 
containing yellow pus. Left lung. — Superior and inferior lobes cre- 
pitating, but filled with a much greater number of ecchymoses than 
the right lung. On several points the surface of both lungs presents 
spots analogous to those observed upon the skin ; subpleural ecchy- 
moses. Some miliary tubercles were found in the lungs. Digestive 
organs. — The mucous membrane of the mouth is pale. Several small 
submucous (similar to the subcutaneous) ecchymoses are remarked at 
the root of the tongue. Pharynx and oesophagus healthy ; stomach 
healthy. The mucous membrane of the large and small intestines 
presents a few spots not much injected. The liver and spleen are 
healthy. The peritoneum is thickened at all points, and its folds 
adhere together. A number of small whitish tubercles, some of which 
are soft, occur at intervals between the layers of the epiploa. The 
great epiploon adheres throughout its whole extent to the abdominal 
parietes ; all the intestines are agglutinated, and it is very difficult to 
separate them. The mesenteric glands are swelled and purple-coloured. 
Urinary organs, healthy. Nervous system. — The membranes of the 
brain are in a healthy state, the cerebral substance is of the natural 
consistence ; there is very little serum in the ventricles; the cerebellum 
is perfectly healthy. 

Case CLII. — Inflammation of the mouth ; amygdalae with pseudo- 
membranous deposits. Purpura hemorrhagica. A pale and delicate 
girl had been in bad health for a long time ; she was in a very feeble 
condition, when red, livid spots made their appearance on her body ; 
the amygdala? at the same time became covered with dark spots, and 
a species of false membrane, of a black colour, and rather pulpy con- 
sistence. This young person had hemorrhage also from the mouth 
and nose. The dark hue of the amygdala? gave reason to suspect her 
of being affected with gangrenous angina ; the left tonsil was scarified, 
and the right touched with hydrochloric acid and water in equal pro- 
portions. The abdomen was not painful; the respiration was unaffected. 
On the evening of the 23d July, 1829, the skin was hot, burning, dry; 
the pulse quick and weak ; the face swelled, particularly in the lower 
part, and the region under the jaw. This swelling was owing rather 
to a sort of ceclematous puffing than to inflammation ; the skin was 
straw-coloured ; lymphatic glands could be felt under the swollen 
angles of the jaw, more to the right than the left. The lips were 
swelled, thick, and glossy, particularly the lower one, the mucous 
membrane of which, from its origin to the gums, was black and 
swelled. In the same situation a salient spot of the size of half a 
crown was observed, the centre of which was of a darker colour than 
the circumference. This prominent spot was formed by a kind of 
false membrane which could be removed with forceps without causing 
pain, excepting at the middle of the patch. This false membrane, of 
a grayish or dirty white colour, extended over the gums, diminishing 
in thickness, and less and less adherent to the parts beneath : it was 
easily removed piece-meal. On each side of the mouth, a dark, 
irregular skinny substance w T as observed attached to the gums by one 
extremity. These false membranes did not emit the offensive gan- 
grenous odour. Beneath them, the tissue of the gums was red, and 
glossy, like, the mucous membrane of the lip. The colour was not 
very bright. On the false membrane being removed, blood was seen 
to flow from the surface of the lip, and to coagulate in a short time 
afterwards. The teeth were white, and not loosened ; and the false 
membrane insinuated itself between several of them ; the upper lip 
was swelled in like manner, and also presented some dark points ; 
the tongue was covered with a dark thick mucus. The patient was 
unable to open her jaws ; a purulent, ropy liquid which had nothing 
of the gangrenous odour, flowed from her mouth. Over the whole 
surface of her body were scattered red, livid spots of the size of a 
lentil, which could not be effaced by the pressure of the finger; there 
were also many others of smaller size which appeared of more recent 
formation. Draught with pulvis cinchona ; drink acidulated with muri- 
atic acid ; astringent gargle. Died at one o'clock in the morning of 
the 24th. Autopsy eighteen hours after death. The skin presented 
here and there spots of a deep colour, formed by the effusion of blood 



MORBID SECRETION OF THE SKIN. 



333 



into the substance of the skin only. There were none in the subcu- 
taneous cellular membrane. The tongue, right amygdala, and gums, 
were covered by a thick, black, false membrane, which was removed 
without difficulty ; the tissue of the amygdala was yellow, and soft, 
internally it was black ; there were a kind of flaky filaments on its 
surface. The left amygdala was swelled in like manner ; its tissue 
was yellow; the neighbouring cellular membrane was black; the 
amygdalae did not emit the gangrenous odour. The epiglottis and 
glosso-epiglottic ligaments, presented black spots under the mucous 
membrane ; there was an effusion of dark blood into its substance ; 
the glands of the neck on both sides were swelled, without being the 
seat of any effusion ; the nasal cavities did not contain blood. 

The larynx, the trachea and bronchi were healthy ; the lungs pre- 
sented several black spots on their surface, varying in size, but never 
exceeding the dimensions of a sixpence ; they were evidently owing 
to blood deposited underneath the pleura, and infiltrated superficially 
into the tissue of the lungs. The lungs were crepitating, except at 
their base, where they were loaded with fluid. The whole surface of 
the heart, more particularly in front, and more on the left ventricle 
than elsewhere, as well as under the serous membrane, presented 
purple spots of the size of a pin's head, in very close contact. The 
pleura under the third and fourth ribs, near the sternum, presented a 
considerable patch tinged with effused blood. 

The stomach, rather livid, presented a small dotted patch; its 
mucous membrane presented the natural thickness and consistence. 
The intestines, liver, and spleen were healthy. The upper part of the 
right kidney was a little spotted with black under its proper mem- 
brane ; the left was pale and less consistent. The uterus and bladder 
were healthy. 

On the dura mater was found a large, red irregular patch, formed 
by blood deposited under the arachnoid membrane ; on the side of the 
left lobe of the brain, between the arachnoid, and the pia mater, a 
slight sanguine infiltration ; the corpus striatum, and corpus callosum 
presented a dotted appearance. A similar infiltration was remarked 
in the whole of the right lobe; the same disposition in the left lobe 
of the cerebellum. The muscles were red and healthy; the cellular 
tissue exhibited no traces of extravasation. 

Case CLIII. — Purpura hemorrhagica febrilis ; petechias and ecchy- 
moses, preceded by a kind of erysipelatous attack, fyc. — Madame Robert, 
70 years of age, a washerwoman, of a sanguine temperament, with a 
coarse, ruddy skin. This woman inhabits a healthy lodging, lives 
well, leads a very regular life, and has not suffered from illness for a 
great many years. She began to be affected with headache in the 
beginning of May, and afterwards by general indisposition, and itching 
of the lower extremities, which swelled slightly. Some days after- 
wards the face looked puffed, and she became a patient in the hopital 
de la Charite on the 31st of May, 1834. Both cheeks were swelled, 
tense and red as in erysipelas, and strewed with specks of a darker 
red, the size of a lentil, and not to be effaced by the pressure of the 
finger. These dark ecchymotic specks were also discovered on the 
nose and eyebrows ; the eyelids were infiltrated with black blood, as 
well as the lobe of the right ear, which was mottled like marble. 
There was also a large black ecchymosis under the chin, but without 
any elevation of the epidermis. The body only presented two or three 
black spots on its posterior surface ; both the superior and inferior 
extremities were swelled, hard, and covered with large black patches, 
the epidermis of which was raised by a sero-sanguineous liquid, and 
surrounded by a pink areola. These patches existed principally on 
the dorsal aspect of the forearms, and on the anterior surface of the 
thighs. On the latter there was also a hemorrhagic petechial dotting, 
particularly on the right thigh. The palms of the hands and soles of 
the feet were livid or black, swelled and slightly cedematous ; an effu- 
sion of blood had taken place under the corion, and even into its outer 
surface but without any detachment of the epidermis; the patient 
complained much of pricking sensations in these parts. 

All the spots had existed for six days. The lips were swelled. The 
gums were without any appearance of redness, and did not bleed. 
The patient had had no epistaxis, haemoptysis, or hsematemesis ; neither 
had she ever remarked blood in her stools or urine. The tongue was 
moist and natural in colour. There was no sensible derangement of 
the functions of digestion. The respiration was free; there was no 
84 



cough. The sound of the chest on percussion, however, was some- 
what dull ; and the respiratory murmur in one particular spot of the 
posterior surface of the left lung was only heard very indistinctly. 
The patient was feverish (the pulse eighty-eight per minute). The 
temperature of the skin was higher than natural. The beat of the heart 
was regular ; near its apex a single sound could alone be distinguished ; 
the bellows sound (bruit de soufflet) at the base of the organ ; the 
same bellows sound was heard synchronous with the first sound of 
the heart; the second sound was natural. Under the sternum and 
near its right margin both sounds of the heart were heard as in a state 
of health. The cerebral functions were intact. [Sherbet of sulphuric 
acid for drink ; half an ounce of Epsom salts.) The bowels acted 
once during the day. On the following morning, the 1st of June, a 
great number of new hemorrhagic patches made their appearance on 
the limbs ; they were purple, irregularly circular, and formed by san- 
guineous serum effused under the raised epidermis; some pain in the 
throat was complained of; the pulse was very full and hard; the skin 
hot; (half an ounce of Epsom salts, drink as before, decoction of rhata- 
ny acidulated with nitric acid); tormina, and several stools in the 
course of the day. On the 2d the tumefaction of the cheeks and 
limbs had diminished a little ; that of the hands only still continued 
as before ; but fresh hemorrhagic spots had been thrown out upon the 
limbs, principally in the line of extension. The pulse continued full, 
the skin hot; the pain in the throat was not abated. Drink as before ; 
venesectio. Little blood was obtained, the swelling of the arm having 
rendered the operation difficult. 

On the 3d the fever continued; the left lung gave a dull sound on 
percussion ; posteriorly, a slight bellows sound was heard ; the ex- 
pectoration was mucous without any mixture of blood ; (the same 
drink; fifteen leeches to the epigastrium). The leeches drew little 
blood, yet gave relief; the spots of the forearm disappeared from the 
centre towards the circumference, as in lichen circumscriptus haemor- 
rhagicus ; the fever had abated ; (the same drink ; leeches to the anus.) 
On the 5th the amendment continued; the swelling of the extremities 
subsided ; the sanguinolent fluid effused beneath the epidermis, had 
either escaped or been absorbed ; the epidermis had become dry on 
some of the patches ; and the violet red of the skin had faded into a 
yellow: the redness and tumefaction of the face had diminished greatly; 
the pain in the throat had ceased; a little cough still remained. 

On the 6th, the internal surface of the epidermis raised by the san- 
guineous serum was observed to be covered by a reddish coating, 
while the surface of the dermis retained its natural colour. The dark 
or yellow discoloration of those patches the epidermis of which had 
not been raised, continued to disappear from the centre towards the 
circumference, which assumed a jagged appearance. The same 
drink was continued through the following days ; the spots from purple 
became yellow, and they afterwards disappeared completely. The 
swelling of the extremities subsided, but the cough and mucous 
wheezing or rattle in the left lung continued. There was still some 
expectoration. These trifling symptoms ceased some days after- 
wards, and the health was improving, when the hands became 
swollen afresh, but without any new hemorrhagic spots. A few 
doses of rhubarb put all to rights again, and the patient was in good 
health when she was discharged from the hospital. Auscultation of 
the heart gave the same results as when the patient was admitted. 
At no stage of the disease did the urine, treated with nitric acid, let 
fall any albuminous precipitate. 



MORBID SECRETIONS OF THE SKIN. 

1035. Exclusive of the formation of the epidermis, two species of 
extrinsic secretion occur in the skin, namely the cutaneous perspira- 
tion, and the follicular secretion. These secretions are liable to be 
modified by different diseases. 



334 



MORBID SECRETIONS. 



PERSPIRATION. 



Vocab. Art. Ephidrosis, Dysodia. 



1036. The study of the cutaneous perspiration as a symptom of 
various diseases, cannot be separated from the history of these com- 
plaints themselves, particularly in a therapeutical point of view : the 
sweating that accompanies intermittent fever yields to the action of 
cinchona, that which attends phthisis to white agaric, 1 &c. But there 
are ephidroses or profuse sweats, which appear independently of any 
other lesion, and which must therefore be considered as peculiar 
affections. 

1037. M. Dupont 2 has published an account of a curious case of a 
chronic general ephidrosis, which lasted upwards of six years. The 
woman who was thus affected became pregnant during this time, and 
was happily delivered of an infant which she nursed herself. This 
ephidrosis, which, according to him, was independent of any other 
affection, after having been fruitlessly combatted by various remedies, 
yielded at last to extract of aconite, given at first in doses of half a 
<;rain, and gradually raised till sixteen grains a day were taken. 
Hartmann 3 cites the singular fact of a woman who, during pregnancy, 
perspired only on the right side of her body. 

1038. Instances of excessive habitual cutaneous exhalation from 
the axillae and feet, without any appreciable alteration in the texture 
of the skin or other organs, are more frequent. A man twenty-nine 
years of age, presented himself at the hopital de la Charite to consult 
me with regard to an habitual ephidrosis of the feet, with which he 
had been affected for nearly four years. This exhalation was more 
copious in the right than in the left foot. From time to time he ex- 
perienced, particularly during the night, transient pain in the right 
heel, similar to what might have been produced by the introduction 
of the point of a nail into the skin. The soles of the feet were 
slightly red, and looked macerated, as though they had been immersed 
for a long time in hot water. This appearance of the skin was 
less remarkable in the left than in the right foot. The patient assured 
me that the perspiration from the feet was equally profuse in winter 
as in summer, and that he was obliged to change his stockings three 
or four times a day. This man, who was of a sanguine-bilious tem- 
perament, and robust constitution, was not affected with any other 
disease of the skin. Foot-baths of cold Bareges water were re- 
commended, and used with success in abating the ephidrosis com- 
plained of. 

These profuse, and often fetid ephidroses of the feet 4 sometimes 
continue to a very advanced period of life. They are more copious 
and emit a more disagreeable smell during the heats of summer, and 
after the person affected has walked far. The sudden suppression of 
these ephidroses is liable to be followed by colicky pains of the bow- 
els, toothache, various affections of a nervous character, and other 
bad effects. 

I had a man about forty years of age under my care in the hopital 
de la Charite, who, after the suppression of an habitual ephidrosis of 
the feet, so copious that the soles always looked white, and as if they 
had been macerated, became subject to headache; and I am at the 
present time attending a young man who has been attacked with 
chronic pleurisy, in consequence of the suppression of an habitual 
ephidrosis of the same parts. 

Ephidrosis of the feet requires that the stockings should be fre- 
quently changed. When it occurs among persons of vigorous con- 
stitution, it may be rendered more endurable by the use of sul- 
phureous foot-baths. Should the diminution or suppression of this 
secretion be attended with injurious effects, the secretion may be re- 
stored by covering the feet with worsted stockings and oil-silk overalls. 

1 Bisson (L.). De l'emploi de l'agaric blanc contre les sueurs dans la phthisie 
pulmonaire. Paris, 8vo. 1832. 

2 Dupont. Hist, d'une sueur chronique, etc. (Journal General de Medecine. 
1907, t. xxx. p. 33.) 

3 Hartmann. Diss, de sudore unius lateris, 4to. Halae, 1751. Consult farther: 
Marcel. Donat. p. 91.— Haller, Elem. Physiol., 4to. t. v. p. 48. 

* Von Bilchuer. Diss, de sudoris pedum in primis habitualis noxia suppressione. 
Hals, 1762.— Paullmi. Observ. Physic. Medic, cent, ii., obs. 78: Francofurti, 1704. 
—Vide similar cases in the Ephem. nat. cur. dec. ii. ann. ii. obs. 34.— Ann. iii. obs. 27. 
Ann. vi. app. p. 4.— Dec. iii. ann. i. app. p. 125.— Ann. ix. et x. obs. 96. 



1039. The perspiration, by being changed in its composition, may 
acquire a sour or rancid odour, or a smell very similar to that of musk. 
I had a woman, under my care in the Hopital de la Charite, affected 
with chronic peritonitis, and who, some time before her death, exhaled 
a very decided odour of musk; the pupil who called my attention to 
this circumstance, had observed the smell for several days, while 
dressing the patient who had been blistered, but thought it owino- to 
a bag of musk put purposely into the bed to overpower other bad 
smells ; the woman, however, assured us, that she had no description 
of perfume about her, and I satisfied myself that no musk had been 
brought to her from without, and that her linen, which was frequently 
changed, was not impregnated with any perfume before being deliv- 
ered to her from the laundry of the hospital. The odour of musk, 
the existence of which was fully ascertained by myself and several 
physicians, and which was very perceptible on the arms and other 
regions of the body, did not become more powerful from rubbing. — 
After continuing for about eight days, the smell became fainter, and 
nearly vanished the evening before the patient's death. Speranza 5 
relates a similar case. Schmit has inserted in the Ephemerides Na- 
turae Curiosorum, an account of a journeyman saddler, three and 
twenty years of age, of rather robust constitution, whose hands ex- 
haled a smell of sulphur so powerful and penetrating as very soon to 
infect any room in which he happened to be. I was once consulted 
by a valet-de-chambre who could never keep a place in consequence 
of the unpleasant odour he left behind him in the rooms which he had 
been occupied in cleaning. There have been instances of individu- 
als who, to obtain their discharge from military service, have simu- 
lated these offensive perspirations, by rubbing their axillae with the 
animal oil of dippel, assafcetida, a piece of much decayed cheese, 
putrid fish, &c. 

1040. Finally, the colour of the cutaneous respiration may also be 
modified by changes in its composition. Instances are recorded of 
green, 6 black, 7 blue, 8 and yellow, 9 perspirations, &c. Not having 
myself met with any thing of the kind, I merely refer to the works 
in which mention is made of such cases. With regard to the urinous 
perspiration observed among persons suffering from retention of urine, 
I do not think this a proper place for making any farther mention of 
the circumstance. 



MORBID SECRETION OF THE EPIDERMIS. 

1041. The secretion of the epidermis is modified under a great 
variety of circumstances; it is active and very abundant in the squa- 
mous inflammations generally; it is remarkable, though unaccom- 
panied with desquamation in ichthyosis ; it is thrown out in greater 
quantity on those parts of the skin which are habitually exposed to 
repeated pressure, as on the palms of the hands, and soles of the feet, 
where it occasions callosities, bunions, and corns, above the knee in 
shoemakers, on the elbows of paper stainers, and on the instep of the 
persons who polish oaken floors, &c, in all of whom it causes appear- 
ances very similar to what is seen in ichthyosis. Finally, the epider- 
mis is sometimes observed to be secreted in excess after the use of 
blisters, in the neighbourhood of the cicatrices of ulcers, and of certain 
cutaneous eruptions, being in some instances characterized by increased 
thickness of the membrane, in others by its constant renewal and ex- 
foliation. The skin, on the termination of certain acute diseases, is 
also known to renew its epidermis several times successively, this 
covering being detached in many instances in almost insensible furfurse. 

It is necessary to distinguish the furfuraceous desquamation which 
very commonly takes place from the skin of the aged, from exfoliations 

s Speranza. Obs. d'odeur aromatique exhalee par la peau et l'avant-bras (arch, 
gen. de med., t. xxx. p. 399). 

s Borellus. Hist, et obs. med. physic, cent. ii. obs. 54.— Paullini., cent. l. obs. 38. 

' Bartholinus. (Acta. Hafn. i. obs. 70.)— Ephem. nat. cur. dec. i. ann. ii. obs. 19. 

8 Conradi. Blue perspiration of one half of the scrotum. Handbuch der Pathol. 
Anat. p. 292.— Lemery. Hist, de l'Acad. des Sciences, 1701.— Fontenelle, sur les 
sueurs bleues (Journ. de chimie medicale, torn. i. p. 330). 

» Ephem. Nat. Cur. dec. i. ann. vi. et vii. obs. 78. 



NEUROSES OF THE SKIN. 



335 



of the kind under consideration, as well as from that of the squamous 
inflammations generally, and particularly of pityriasis. 

New-born infants from three to five days old, almost always present 
an exfoliation of the epidermis. 1 In fact, some days after birth, the 
epidermis loses its elasticity, becomes dry, brittle, and less firmly 
attached to the skin ; it then cracks, and by and by is detached in 
various modes according to the region. Thus, from the folds of skin 
about the articulations, from the groins, popliteal regions, &c, it is 
thrown off' in linear shreds ; from the chest, soles of the feet, and 
sometimes from the abdomen, the desquamation takes place in large 
flakes ; finally, from the sternum, cheeks, between the shoulders, &c, 
the epidermis is detached in small furfuraceous scales. The skin of 
the parts which have recently exfoliated is red, and inflames with the 
greatest readiness ; the epidermis is soon restored in its normal state, 
excepting in the folds of the skin, which continue for some time to 
secrete a mucous matter. 

This exfoliation of the epidermis has been known to occur twice 
conspicuously in the same infant ; in other cases the desquamation is 
often almost imperceptible. 

The duration of these exfoliations varies from one to two months, 
but they may extend to a longer period, and become very considerable 
in children which have fallen into a state of marasmus. The epider- 
mic exfoliation of new-born infants, requires no peculiar medical 
treatment. The skin has only to be kept clean and dry. 



NEUROSES OF THE SKIN. 



1042. The sensibility of the skin may be diminished (anaesthesia), 
or augmented (hyperesthesia), or vitiated. 

1043. Anaesthesia; of the skin may be either local or general; the 
former are sometimes strictly limited to the parts supplied by the 
branches of a single nervous trunk : at the hopital de la Chante, I 
have met with three cases of paralysis of the skin of one side of the 
face, evidently depending on a lesion of the fifth pair of nerves. The 
first 'case was that of a young woman suffering from a disease of the 
heart, who, during her stay in the hospital, without any known cause, 
lost all sensation in the right side of the face, the power of seeing 
with the right eye, that of smelling with the right nostril, and that of 
tasting with the right half of the tongue. These serious symptoms 
were completely subdued by bleeding, cupping over the mastoid pro- 
cesses, and perpetual blisters applied to the forehead and cheek. 
Another case was that of an elderly woman labouring under dropsy 
with albuminous urine, and having a tumour deeply seated in the left 
temporal cavity. She was simultaneously affected with insensibility 
of the corresponding cheek, loss of smell and taste, and also with 
paralysis of the muscles of the face of the same side, and of the 
rectus externus muscle of the right eye. After death, I ascertained, 
that the anaesthesia was owing to an alteration of the plexus of the 
fifth pair of nerves, which had become red, and adhered strongly to 
the dura mater and neighbouring parts, particularly to the nerve of 
the sixth pair. There was also a tumour deeply seated in the zygo- 
matic fossa, which compressed the neighbouring parts. The left lobe 
of the cerebellum near its peduncle, was yellowish, and rather soft; 
and its membranes, which presented granulations, adhered to its 
surface. The third case was that of a man, and was altogether 
similar to the first as far as the phenomena accompanying it went, but 
it was not successfully treated. _ 

1044. Under other circumstances, anaesthesia has been seen to affect 
various portions of the surface of the skin, receiving branches of nerves 
from several different sources. In other cases, the anaesthesia has ap- 
peared to be limited to certain branches of a single nerve, the phe- 
nomenon not extending to other ramifications of the same trunk. I 
remember to have been consulted by a man, the whole of the skin of 
whose right thigh, from the hip to the knee, was so insensible that it 

1 This exfoliation has been particularly studied by Orfila and Thierry ; and by 
Billard in his Traite- des maladies des enians nouveau-nes et a la mamelle, p. 32. 
Paris, 1828. 



could be pierced with needles, without his experiencing an; pain. 
Rubbing the part with nettles produced the appearance of n*ca*»j 
but without smarting or itching. Finally, anaesthesia has been obse v ed 
to be limited to a portion of the trunk, to a leg, a hand, &c; and, as 
in the preceding cases, without the motion of the regions affected 
being implicated. Among these local anaesthesia, there is another 
which I have only observed in a single instance ; it was a case ot 
paralysis of the skin of the belly, in a man labouring under colica 
pictonum. I communicated a curious case to Mr. O'Brien, which he 
has inserted in his inaugural dissertation ; this was anaesthesia of the 
skin of the arm, produced by the presence of a clot of blood in the 
brachial artery, which had occasioned a cessation of the radial pulse, 
and a diminution of the temperature of the arm during life. In seve- 
ral cases of o-anorene, accompanied with the formation of clots in the 
principal artery of a limb, I have observed diminution of temperature, 
and absolute insensibility of the skin, without there being any appre- 
ciable change in its outward appearance. 

1045. Insensibility of the skin may sometimes be general, or ex- 
tend to almost all the regions of the body, without being attended with 
any evident affection of the organs of motion. But more frequently 
anesthesia of one or more regions of the body, is symptomatic ot 
important lesions of the brain or spinal marrow, 2 and coincides with 
paralysis of the motive powers ; at the same time, it must be observed 
that, in the case of cerebral hemorrhage, with loss of sensation and 
motion, it is not unusual to find sensation return, even when paralysis 
of motion continues, (a) 

Historical Notices and particular Cases. 

1046. Galen 3 having remarked the loss of sensation in a man who 
had had a fall on the neck and upper part of the back, gave the name 
of avalodtjola to this paralysis of sensation. Ferdinandus 4 mentions 



(a) Anaesthesia of the skin may, as M. Andral justly remarks, 
(Cours de Pathologie, 4rc.,) be present without any other symptom 
of disorder of the nervous centres, and also without any perceptible 
lesion of these parts. He instances, under this last category, the case 
of a woman, fifty-six years old, in whom there was complete insensi- 
bility of both hands and both feet. This disorder came on after 
sleeping in the sun ; the skin was covered with a phlyctenoid erup- 
tion. So great was the cutaneous insensibility, that this woman fre- 
quently burned her toes without knowing it. 

Still more anomalous cases are those in which, at irregular dis- 
tances, there occur disseminated insensible spots, of a circular form. 
Anaesthesia may result from lead poisoning. The proportion of 
cases of this disorder, to those of paralysis of motion, recorded by 
M. Tanquerel, ( Traite des Maladies de Plomb ou Saturnines,) was 19 
to 50. In seven of the former, the insensibility was confined to the 
skin. In one of these was superficial anaesthesia, with hyperesthe- 
sia, or exalted sensibility of the parts beneath, and paralysis of the 
corresponding muscles. . 

The loss of sensation, from lead poisoning, is always limited in its 
extent — being sometimes confined to certain parts of the abdomen, 
or of the chest or neck, and sometimes occupying the limbs. It may 
be complete or partial— frequently shifting its place, or varying in 
extent. Sometimes the attack is preceded by slight numbness, but 
more commonly it reaches its maximum with great rapidity. 

The treatment of cutaneous anaesthesia will vary according to its 
presumed cause. If it depend on lesion of a nervous centre, recourse 
will be had to purgatives, and cutaneous revulsives, such as friction, 
irritating liniments, blisters, &c, either to the part or to the spinal 
column. Strychnia is represented to be a medicine of considerable 
power. Sulphureous baths and douches, and electricity, are also 
among the therapeutical means resorted to in cutaneous anaesthesia. 

2 Consult: Lallemand. Rech. Anatomico-pathologiques sur l'encephale, 8vo-. 
Paris 1826-1834. — Rostan. Rech. sur le ramollissement du cerveau, seconde edit. 
8vo. ' Paris, 1823. — Ollivier (d'Angers). De la moelle epini&re et de ses maladies, 
8vo. Paris, 1823.— Serres. Anatomie compare du cerveau, 2 vols. 8vo. Paris, 
1826. 

3 Galenus. De locis affectis. 

* Ferdinandi (E.). Centum historian, sive observaliones et casus media, etc. 
Venetiis, fol. 1 612. Historia 46. 



336 



NEUROSES OF THE SKIN. 



the ease of a young man, twenty-four years of age, who, after having 
seized with insensibility of the whole body (the head excepted), 
was cured by purgatives, and other remedies. A remarkable example 
of anaesthesia occurs in the Ephemerides JWdurce Curiosorum. 1 Thomas 
Bartholin 9 cites the case of a young man who had lost the senses of 
m1 feeling; and that of a young girl who could allow the skin 
of her forehead to be pricked, and that of her neck to be burned, 
without experiencing any pain. Laraothe 3 mentions a case of insen- 
sibility of the hands and feet, in consequence of a kick from a horse 
in the head, without any external wound. In the Mhnoires deVAca- 
dhnie des Sciences, for the year 1743, we read an account of a soldier 
who, after having accidentally lost all kind of sensation in his left 
arm, continued to go through the whole of the manual exercise with 
the same facility as ever. It is known, also, that La Condamine was 
able to use his hands for many years after they had entirely lost their 
sensation. Finally, many observations on, and cases of, anaesthesia 
published by Daniel, 4 Hebreard, 5 Alexander Reid, 6 John Yelloly, 7 and 
and Mathacus, which are all cited by O'Brien, 8 who has detailed nume- 
rous very interesting additional cases in his inaugural dissertation, 
may be consulted with advantage. 

Case CLIV. — Paralysis of the skin of the leftside of the trunk, with- 
out afection of the muscles. George Pilavoine, forty-three years of age, 
a eartwright, was admitted into the Hopital de la Pitie on the 16th of 
January, 1827. Languid temperament; apoplectic constitution; a 
little above the middle size ; stoutly built; short neck; face red and 
injected. For the last three days, total loss of sensation in the sHn 
of the left side of the trunk. This paralysis extends from the left 
mammary region to the haunch, and from the vertebras to the linea 
alba. 

Throughout this whole extent the skin is insensible ; it may be 
pinched or punctured without the patient being even aware that he is 
touched. The paralysis is not quite so complete in those parts of the 
integument that are in connection with the healthy skin. Even the 
parts most completely paralyzed, do not present any perceptible altera- 
tion in their colour or texture. The subjacent muscles of the trunk, 
as well as those of the other regions of the body, possess all their 
powers unimpaired. The patient is free from fever, and makes no 
complaint except of slight headache. The pulse is strong and full. 

This patient informed us that, five years previously, he had occa- 
sionally experienced, on going to bed, an involuntary.spasmodic con- 
traction of all the muscles of the back part of the body, which de- 
prived him of the power of changing his position or of speaking ; 
and that, on these occasions, he had scarcely time to give warning to 
his wife who, by dragging him from his bed, always succeeded in 
arousing him from the kind of benumbedness into which he had fallen. 
He then walked about the room, and afterwards returned to his bed, 
little fatigued by the attack, which was sometimes preceded by sen- 
sations of pricking, and confusion of head. These attacks recurred 
for a period of two years, particularly during the spring, when they 
happened almost once a fortnight, and sometimes even twice in the 
same day. Besides these attacks, he was also subject to headaches, 
for which he used to get bled. These headaches had become less 
frequent, when, about four months ago, while he was at work, he was 
seized with a violent attack of giddiness, fell upon a wheel, and 
received a wound of considerable size upon the right side of his fore- 
head, for which he became a patient during two months in the Hotel 
Dieu. Since that period, the right eye has continued inflamed, the 
headache has returned, and after three attacks of benumbedness, 
similar to those with which he had already been affected, the patient 
became affected with the paralysis of the skin of the trunk, of which 
mention has been made. (V. S. ad Sxii. ; low diet; lemonade.) 18th 

Nat Cur. Ephem. ann. iii. obs. 251, p. 390. De perfecta anaesthesia, per totam 
corporis peripheriam. 

2 Bartholini (Th.). Hist. Anat. Medic, rar. cent. iv. hist. 82. (Sensus abolitus.) 

3 Lamothe (Guil. Mauquest de) Traite complet. de chirurg., etc. Paris, 1722, 3 
vols. 12mo. Obs. 168. 

* Journ. general de med., torn. lxi. 1817, p. 161. 

5 Bullet, des Sc. med., vol. i. 1807. 

' Bdinb. Med. and Surg. Journ., vol. xxxi. p. 292. 

' Medico-Chirurgical Transactions, vol. iii. 

8 O'Brien. Be 1'anesthesie, 4to. Paris, 1833. Conmltez en ontre: Zukowski. 
Diss, de anaesthesia. \ ilnm, 1802.— Lesauvage. Hemiplegie du sentiment sans 
U sioo du mouvement. [Bull, des sc. medic, de Ferussac, t. xix. p. 198.1 



and 19th. The insensibility of the skin continues; the headache has 
left him; tingling in the whole of the left side of the body, and in 
both of the thighs, which are affected with involuntary convulsive 
motions. 20th and 21st. Same state, but the twitching* of the thighs 
occur more rarely. 22d. (V. S. ad 3xvi.; water gruel; aret. mor- 
place, one-sixth gr.) 23d and 25th. The same insensibility of the 
skin of the trunk ; but the muscular twitchings of the thighs have 
ceased. The right eye is more highly inflamed {eight leeches to the right 
temple) ; it became less painful afterwards. 25th. The skin of the 
left side of the trunk is somewhat more sensible ; the sensation seems 
to return from the circumference of the part affected towards its cen- 
tre. The eye is again inflamed and painful. A seton in the nape of 
the neck, a plaster of antimon. tartaris. to the paralyzed district. 
Feb. 1st. The plaster had scarcely produced any irritation of the 
skin. The paralysis was now gradually abating ; on the 7th the pa- 
tient was still under treatment. 

Case CLV. — Insensibility of the skin of the whole body without im- 
plication of the power of voluntary motion. A. A. Barbier, aged 60, 
a worker in marble, became a patient in the hopital St. Antoine, on 
the 9th May, 1829. This man had been bitten severely in the arm, 
three years before, by a dog which was not mad, and he still con- 
tinued to speak of this accident ; the attack of the animal having 
evidently frightened him greatly. Every time he saw a dog, indeed, 
his limbs trembled, and he occasionally even suffered a convulsive 
attack, with foaming at the mouth, which lasted for an hour and a half. 
These attacks occurred at least once a month, and sometimes oftener. 
Since the date of this fright he has also been subject to headache, 
and is occasionally seized with involuntary fits of laughing like a 
child or a paralytic person ; these laughing fits often precede the epi- 
leptic attacks. He has lost his memory and often talks incoherently 
in the intervals between the fits. He has been bled several times at 
the periods of the epileptic attacks, but this does not seem to have 
done any good. On the 19th of May, this man's intellectual powers 
were evidently very much affected ; his senses were dull ; he was 
almost deaf; his tongue when thrust out trembled ; he had two small 
wounds on the head ; one above the left eyebrow, the other on the 
hairy scalp, occasioned by a fall on his entrance into the hospital. 
Here he was bled once. Several days afterwards a great degree of 
insensibility of the skin of the whole body was observed. This was 
greatest in amount over the arms, less over the legs, abdomen and 
thorax. If the attention of the patient were otherwise engaged, he 
might be pricked with a pin, and pinched without his appearing to 
know any thing about it. He moved the limbs freely, making no 
complaint of weakness in any of them. The pulse was full; he had 
no headache ; no uneasiness in the chest or abdomen. ( V. S. on the 
26th of May.) The blood was buffy ; but it was serous. The alvine 
and urinary discharges are natural, and preceded by the usual sensa- 
tions announcing a call. 

On the 29th, the soles of the feet were less insensible than any 
other part of the body. The scalp was completely void of sensation. 
On the 6th of June the anaesthesia was cured, and the patient tran- 
quilized on the subject of the bite he had received, left the hospital 
well satisfied. 

1047. Hyperesthesia, 9 or exaltation of the sensibility of the skin, is a 
phenomenon observed in the current of several nervous diseases, and 
especially in connection with inflammatory affections of the spinal cord. 
The sensibility of the skin is also perverted or exalted to a great ex- 
tent in urticaria, in prurigo, and in several other cutaneous eruptions. 
But I have here only to make mention of those cases in which the 
sensibility of the skin is increased without any apparent change in its 
outward appearance, in its thickness, &c. 

I have occasionally observed the skin affected with pruritus of a 
very violent description, without being the seat of papulae or any 
other form of eruption, in patients labouring under chronic diseases 
of the liver, complicated or not with icterus. We also know that in 
certain of the prurigos to which the aged are subject, the pruritus 
attains such a degree of intensity that patients tear themselves with 
the fury of madness or despair, and afterwards tremble almost con- 
vulsively from head to foot, without there being more than a very 

9 Chomel. Sensibilite exageree des t<:gumens des membres inferieurs. Gazette 
Med. de Paris, 1831, p. 140. 



LEUCOPATHIA. 



337 



small number of papulae, the presence of which Is altogether inade- 
quate to account either for the violence of the pruritus or for its con- 
tinuance after their destruction. It is with justice that those cases of 
pruritus, which are independent of papular eruptions, have been sepa- 
rated from those that are connected with the presence of these affec- 
tions. '(a) 



ALTERATIONS IN THE COLOUR OF THE SKIN. 

[disordered chromatogenous functions of the dermis. — E. Wil- 
son, maculae. — Willan.] (b) 

1048. Besides the morbid tints occasioned by inflammatory affec- 
tions of its tissues, and hsemorrhagic effusions into its substance, the 



(a) " Anesthesia of the trigeminus nerve. — A woman, 42 years of 
age, had the misfortune to fall and strike the back of the head on the 
edge of a stair. A year afterwards the catamenia ceased altogether, 
and from this time she began to suffer from frequent attacks of most 
violent sneezing. No unusual appearance could be detected in the 
nostrils ; and it was therefore suspected that there was an irritation of 
the fifth pair of nerves in the cranial cavity. Along the course of the 
first and second divisions of the trigeminus there was no loss of sensi- 
bility ; but the third division was decidedly anesthetic. 

" The left half of the under lip, both on its inner and outer surface, 
and the left half of the chin, were quite insensible, even when pricked 
deeply with a needle : the inner portion of the muscle of the corre- 
sponding ear and of the meatus auditorius were equally dead to all 
impressions. The teguments of the left temple near the hair, and also 
the entire left half of the tongue, were perfectly insensible alike to 
injury and to changes of temperature : this side of the tongue, too, had 
lost its sense of taste. But when the skin of the temple near the fore- 
head w^as pricked, the patient immediately complained — in conse- 
quence of this part being supplied with twigs from the frontalis nerve. 
On the right side all the corresponding parts were quite sensible ; and 
even in the left eyelids the other sensory nerves retained their integ- 
rity, both as respected sensation and power of motion. The organic 
and nutritive functions of all the parts, which were insensible, were 
not at all impaired. The patient eventually died of dropsy. 

''Dissection. — At various points on the surface of the brain there 
was an exudation of lymph ; and on the lower surface of the posterior 
lobe the cerebral substance was found in a state of ramollissement, to 
the extent of an inch or so. The third, or submaxillary branch of the 
trigeminus pair on this (the left) side, where it entered the foramen 
ovale, appeared to be enveloped with a red vascular network, com- 
posed partly of fibres and partly of transparent vesicles. On close 
inspection, it seemed to be either an exudation on, or an hypertro- 
phied state of, the neurilemma: the substance of the nerve itself was 
swollen, of a yellowish colour, and somewhat harder than it usually 
is. But it was only that portion of the third branch which arises 
from the Gasserian ganglion, that was so altered. The motory portion 
on the inner side was unchanged, and coalesced with the larger divi- 
sion beyond the diseased point. The various twigs to the pterygoid 
and buccinator muscles, to the temple, the tongue, and the lower jaw, 
were throughout in a normal condition, as well as the third branch of 
the right trigeminus, and also the glosso-pharyngeal on both sides." — 
Med. Chir. Rev., 1841 — from Medicinische Jahrbucher, t. xxix. 

(b) The disorders of the Chromatogenous Functions are divided 
by Mr. E. Wilson into : 1. Augmentation of pigment, which includes 
nigrities, pigmentary naevi and moles ; 2. Diminution of pigment, or 
leucopathia, albinismus and vitiligo ; 3. Morbid alterations of pigment, 
embracing ephelis or sunburn, lentigo or freckles, chloasma or liver 
spot and melasma ; and 4. Chemical discoloration of the dermis ; as 
in the oxide of silver stains. 

1 J.Wilson. A Familiar Treatise of cutaneous diseases: Sense of itching without 
eruption, p. 147. London, 8vo. 1814. 

85 



skin of the human body is subject to various alterations in its colour.- 
Some of these depend on a deficient supply or diminished secretion 
of the pigmentary matter (albinismus leucopathie) : others upon an ad- 
ventitious or accidental accessive deposit of the ordinary pigmentum 
(nigrities, ephelis, lentigo), or of an unusual colouring matter (chloasma, 
melasma, pigmentary ncevi) ; a third class is owing to the introduction 
of foreign substances into the tissue of the skin (icterus, artificial 
stains, the slate tint that follows the use of the nitrate of diver). 



leucopathia. [diminution of pigment.] 
Vocab. Albinismus, Leucopathia. 

1048. General or partial, congenital or accidental colourless states 
of the skin, arising from absence or deficiency of the pigmentum, and 
of the colouring matter of the hair, are designated under the name of 
leucopathia or albinism. 

1049. In general congenital leucopathia (albinismus), the skin is 
usually of a dull white, which has been compared to the colour of 
milk, and sometimes of an extremely pale-yellowish tint. The hair 
of albinos is smooth, silky, generally straight and flowing, but some- 
times crisp like that of negroes ; it is of a peculiar white colour, like 
cotton or bleached silk, and different from the snowy whiteness which 
age produces, and from the golden yellow tint of light hair. The 
eyebrows, the beard, and the hair of the pubes, are equally blanched ; 
the rest of the skin is covered with a down of extreme whiteness and 
softness. The iris is almost always of a light blue or pale rose colour, 
and the pupil of a decidedly red hue, which arises from the absence 
of pigmentary matter in the choroid membrane and uvea. 

Albinos are generally of weakly constitution, middling stature, and 
limited intelligence, although some examples to the contrary have been 
quoted. The great sensibility of the eye does not allow them to go 
out in the middle of the day with comfort, unless the weather be 
cloudy ; they are then constantly winking, and the pupil contracts 
and dilates, oscillating continually. The edges of the eyelids are 
often covered with glutinous exudation, and tears run from their eyes 
when exposed to the light of the sun. The moral constitution of 
albinos is in relation with the general weakness of their organization. 

1050. General accidental leucopathia has never been observed ex- 
cept among negroes. Whites, after long confinement in places from 
which light is excluded, undergo a blanching which must not be con- 
founded with albinism. 

1051. Partial leucopathia may be congenital; negroes who are 
affected with it, and who are known by the name of piebald negroes. 
present on different parts of the body, white spots, of various shapes 
and sizes. In the Museum of Natural History of Paris, there is a 
portrait of a young piebald negro, whose skin in the colourless parts 
was of a pale rose colour instead of the usual dead white. When 
these spots are on the hairy scalp, the hairs -growing from them are 
also colourless. These cases of partial congenital deficiency of colour 
in the skin have never been observed among whites. 

1052. Both blacks and whites may be accidentally affected with 
similar partial colourless states of the skin, the extent of the patches 
augmenting progressively. 

1 have often remarked, that these colourless patches, wherever they 
appeared, occurred simultaneously with considerable depositions of 
pigmentary matter within the skin of some other region or of the 
neighbourhood of the white spots. A young girl in the Hopital Saint 
Antoine had spots of lentigo on the face, and leucopathie patches on 
the neck and body, which had only appeared within a few months. I 
have observed accidental local albinism in all parts of the body, but 
more frequently on the genital organs and in their immediate neigh- 
bourhood than elsewhere. 

1053. Not having had opportunities of making anatomical researches 
into the state of the skin affected with general or partial leucopathia, 
I shall confine myself to stating, that the whiteness of the skin is attri- 
buted to the absence of pigmentary matter. In the body of an albino 
who died in the hospital at Milan in 1783, the absence of the uvea 

2 Bose. De mutato per morbum colore corporis humani. Leipsic, 4to. 1758. 



338 



LEUCOPATHIA. 



and of the colon; Ii of the choroid membrane was ascertained ; 

neither coul pigmentary matter be detected on the ex- 

1 surface ot" the dermis. 

105 t. Causes. — Except in cases of an hereditary nature, the etiology 
ipathia is very obscure ; it is generally attributed to weakness ; 
.:s ia all the races of the human kind, in all parts of the globe, 
and among a great many animals. 

The children of an albino and a person of colour are generally 
mulattos, but sometimes albinos. Although albinos are more common 
in Africa, still they have also been met with in other southern latitudes 
inhabited by blacks, in the isthmus of Darien, in Brazil, in Sumatra, 
in New Guinea, ice.; and even in Europe among whites, in Den- 
mark, England, France, Switzerland, &c. 

Accidental partial leucopathia, like the blanching of the hair which 
occurs independently of age, is most generally the consequence of 
some mental emotion. I was very recently consulted at the hopital 
de la Charite by a man thirty years of age, who, upon the loss of 
what was to him a considerable sum of money, became affected with 
partial leucopathia, characterized by white, milky spots, disseminated 
over the body and limbs, with partial blanching of the hair, whiskers 
and eyelashes. 

1055. Diagnosis. — General leucopathia differs from chlorosis in the 
int being of a more dead white, and the latter disease not being 

ipanied with blanching of the hair or of the uvea and choroid 
membrane ; the paleness of the skin in leucopathia results from the 
absence of the pigmentary matter, while in chlorosis the pale hue of 
the integuments would seem to depend in a great measure upon the 
small quantity of blood distributed to them. 

At a period when the diseases of the skin were little studied, some 
analogy was supposed to exist between the state of this tissue covered 
with the white squamae of lepra and leucopathia ; but at the present 
day the idea of associating alterations so different in their natures is 
impossible. Partial leucopathia, which has also been described under 
the name of ephelis alba, is very different from every other description 
of colourless state of the integuments. Certain colourless states of 
the skin, however, occasioned by slight, but long-continued pressure, 
particularly those which are sometimes seen below the pads of the 
bandages worn by persons effected with hernia, bear some analogy to 
partial and accidental leucopathia. 

1056. Treatment. — General congenital leucopathia has been very 
little studied in a therapeutic point of view; this congenital malforma- 
tion is generally looked upon as incurable. In partial and accidental 
absence of colour of the skin, if the patches are in the face, and it is 

wish of the patient, attempts may be made to promote the secretion 
of the*pigment, by exciting the blanched patches with flying blisters 
or stimulating liniments. 

Historical Notices and particular Cases. 

1057. Lecat, 1 Buffon, 2 Buzzi, (Fr.), 3 and Blumenbaeh,' 1 were the 
first who instituted inquiries of any importance into the subject of 

teral albinism. A great number of new cases have been published 
lately. 5 

Observations on accidental partial leucopathia are more rare. Seve- 
ral affections in which the colour of the skin is changed are indicated 

' Lecal. Traite de la couleur de la peau [humain, 8vo. Amsterdam, 1765, 3d 
part; de la metamorphose des negres en blanc, etc. 

2 Buflon. Sur les blafards et les negres blanes. Hist. Nat. Gen. et particuliere, 
etc. Suppl. t. iv. pp. 5.55-578, ed. Sonnini, t. xx. pp. 336-37-7. 

3 Buzzi (Fr.). Dissertazione storico-anatomica sopra une varieta particolare di 

ii blanchi eliofobi, 4to. Milan, 1784. 

* Blumenbaeh (J. Fr.). De generis humani varietate nativa. Ed. 3d., Gotting., 

1795, 8vo. — Trad, en francais par Fred. Chardel, sous ce titre : De l'unite du genre 

:ain et de ses varietes, etc. Paris, 1804, 8vo., p. 271. — De oculis leuceelhiopum 

i idis motu commentalio. (Comment, soc. reg. sc. Gotting., vol. vii. pp. 29-62. 1 

pi., 1784.) 

» Sachs (G. T. L.). Historia naturalis duorum Leucoethiopnm, aucloris ipsius et 

mis ejus. Sulzbach, 1812, 8vo.— Mansfield. Reflexions sur la leucopathie, con- 

mme le resuhat d'un letardement de developpement. Journ. complem. des 

. ! es. torn. xv. pp. 250-53;;.— Etwas iiber Hemmungsbiklungen in Allge- 

ueinen, und fortijesetzie L'ntersuchungen ober die Eeukopathie (Mechel's Archiv. 

Anatomie und PI. :. j, pp . 96-104). — Rennes. Leucozoonie (Arch. 

. t. xxvk p. 3711.— Geoffroy Saint-Hilaire (Isidore) De l'Albinisme 

et particuliere des anomalies de reorganisation chez l'hommeet chez les 

ainmaux, etc., etc. Paris, 1832, t. i. pp. 293-323). 



under the name of vitiligo ; r and although the description of \nx>; 
bears considerable analogy to that of partial leucopathia, many transla- 
tors and critics have been led, from a passage in Hippocrates ( Prorrhct. 
lib. 11, ad finem), to imagine that under this name the ancients meant 
to indicate a very serious disease, to wit, elephantiasis anaeth 
the Greek or Jewish leprosy; 

Hamilton, Bree, &c, have reported cases of accidental partial leu- 
copathia. 7 M. Alibert has lately described leucopathia under the 
name of achroma. 

Case CLVI. — General congenital leucopathia in a negress. A white 
negress, born in Dominica, in 1759, of black parents, has all the fea- 
tures of a negro ; the hair, eyebrows, and eyelashes are also those of 
her race in all except the colour ; the hair is of a very short woolly kind, 
and slightly coloured; the eyebrows, as well as the eyelashes, are of a 
more golden hue ; the general appearance of the skin is a dull white, 
with a slight pink tint on the cheeks, lips and nose, which becomes 
deeper under the influence of mental emotions ; the skin of the face 
is slightly spotted over the cheeks by small marks of a violet hue, 
similar to that of the complexion in a fresh-coloured aged European; 
the edges of the eyelids are long, and the external angles slope up- 
wards ; the eyelids themselves are very narrow, and the parts over 
them are raised ; the iris is gray, with an orange-coloured tint towards 
the crystalline lens ; the eyes are in continual involuntary and irregu- 
lar motion ; the sight is weak without being short ; the light of the 
sun, that of a fine day, or even of a torch is distressing. But this girl 
neither sees better, nor later than others, as the day declines. The 
breasts seemed very large for this young woman's age ; she is of the 
ordinary height and rather well made, except that the right shoulder 
is somewhat larger than the other ; the hands are large, the feet strong 
and also very large; the little toes are broad, the skin appears rather 
wrinkled, and upon the arm there are several freckles; her voice is- 
sweet like that of negresses generally ; she has the odour of the race 
also, but her skin is less soft than it is commonly in blacks. — (Joimi. 
Physique de VAbbe Rosier, 1777.) 

Case CLVII. — General congenital leucopathia in a white. I went, in 
March, 1827, to the Hopital de Bicetre, to see a man named Roche, an 
albino, better known in the hospital by the name of the white rabbit. 
This man, then forty-three years of age, at first sight had the appear- 
ance of an aged person : the hair, eyebrows, eyelashes, eyelids, beard, 
&c, are of a milky white ; the uvea is very little coloured, and tra- 
versed with small red and gray streaks ; the pupil is as red as blood. 
The skin is nearly of the tint peculiar to persons of a very fine skin, 
and without the dull white colour generally seen in albinos. The 
mucous membranes of the eyelids, the tongue and the genital organs 
are not at all blanched, but of the same red tint as among well-con- 
stituted Europeans. The nails are of the usual form and size. The 
eyes of this man are very sensible to light ; his eyelids are generally- 
half closed, and he winks continually. The muscles of the limbs and 
body are pretty well developed ; his intellectual faculties are limited ; 
he understands the questions which are put to him, but his short or 
monosyllabic replies are comprehended with difficulty. He articu- 
lates badly, almost like a person affected with chorea or a congenital 
cleft of the palate. Roche was sent to Bicetre at nine years of age, 
in 1793, on account of his very limited understanding. _ The organs 
of generation are well developed, and the principal functions regular. 
A man engaged in the hospital, and who had known the parents of 
this albino, informed me that they never had any other children, and 
that the mother, according to the vulgar notion, attributed the defec- 
tive constitution of her son, to her having been alarmed, during her 
pregnancy, at the sight of a large white cat. This woman was a na- 
tive of Picardy, and of a dark complexion ; the father was of Auvergne, 
and of good constitution. 

Case CLVIII. — General congenital leucopathia in a white? We 
have had this year, 1809, at Paris, two individuals, brother and sister, 
the one ten, the other twenty years of age, born in the Bourbonnais, 

e Celsus (A. Corn.). De re medica, 18mo. Paris, 1823, lib. v. sect, xviii. 

» Hamilton (M. R.). Cas de leucopathie accidentelle chez un negre (Arch, gener. 
de med., mat, 1827.) — Bree. Obs. de decoloration de la peau et des polls. Arch. 
gener.de med.,mai, 1828.— Bissel. Sur un changeraent de couleursurvenu a la peau 
d'un Americain. Journ. univers. des sc. mod., t. xii. 

s Gauluer (G. A.). Recherches sur l'organisation de la peau de l'homme, etc., 
870. p. 7 1-. Pans, 1819. 



NIGRITIES. 



339 



whose skin was of a dead white, without apparent vitality, and like 
wax. The hair of these individuals was soft, very long, and of a 
whiteness equal to that of the skin; the iris was reddish; the eyes 
appeared distressed by the bright daylight, and both the eyes and the 
eyelids were in almost constant and involuntary motion." The skin 
was soft and flabby; the muscles very small. Both of these indivi- 
duals were alike apathetic and dejected. 

We know two other children, the one eight, the other ten years of 
age, who are affected in the same way ; they have soft fair hair, which 
becomes whiter as they grow older. They are born of perfectly 
healthy parents ; their brothers are not similarly affected. 

Case CLIX. — Congenital leucopathia ; the iris blue, the pupil red, 
skin of a pinky white. Louisa de Brun, three years of age, was born 
in Paris, an albiness; the mother has hair of the very lightest kind; 
the father's hair is of a light brown colour. This child has always 
enjoyed good health, is lively and pretty, talks a great deal, and has 
never shown any symptoms of idiocy; her hair is of a brilliant white, 
almost colourless, of the usual strength, straight and not woolly. Her 
byes are in constant motion. The iris is of a blue colour, the pupil 
red, the eyebrows very thin, short and extremely white; the eye- 
lashes, particularly those on the upper eyelid, are long; the skin is 
white, with a slight rose tint. This child has only eighteen teeth; 
the two upper small incisors are wanting; she has two fistulous sores 
in the left leg and is affected with eczema of the hairy scalp and ears. 

The mother of this child informed me that she had another daughter 
fifteen years of age, also born an albiness, whose hair was now of the 
very fairest description. 

Case CLX. — Lentigo of the trunk from childhood, leucopathic spots, 
and reddish-brown hue of the skin in their vicinity, of one yearns stand- 
ing. Thirion, a porter, forty-six years of age, had several kinds of 
spots on the skin. Some {lentigo) reddish, lenticular and very super- 
ficial, had existed in great numbers on the upper part of the chest 
and back, since childhood. Other spots of a dull white colour, super- 
ficial, irregular, and mostly circular, were very numerous on the skin 
of the back shoulders and chest; in fact, the skin of the chest, upper 
extremities, back, posterior parts of the neck, and of the loins and 
sides, was of a reddish-brown hue, while that of the buttocks, and 
the posterior aspects of the upper extremities, was of the usual white. 
The dull white spots mingled with the pervading brown hue of the 
skin, gave a remarkable marbled appearance to the back of the body, 
shoulders, calves of the legs, &c. These white patches had only 
appeared within a year; they followed an eruption of blebs, accom- 
panied with itching. Thirion declares that six months ago, the skin 
was white, and that it had only assumed the reddish-brown appear- 
ance it now presents since that time. The spots of lentigo only had 
existed since childhood. 

Case CLXI. — Congenital partial leucopathia in a black. Artaud 
informs us, that he had seen a mulatto, nineteen months old, who 
had a tuft of white hair on the top of the head, a little to the right; 
there was also in the centre of the sinciput another white tuft, two 
inches broad, and in the middle of the forehead, a white band run- 
ning obliquely to the eyebrows, ivhich were half white. Between- the 
pectoral muscles and the umbilicus, there was a white star with seven 
cusps upon the skin ; the right heel was white, and there was a white 
spot on the vagina, &c. [Mem., sur Us albinos, Journ. de Physique, 
t. xxxv.) 

Case CLXII. — Accidental general leucopathia in a black. One of 
Colonel Filcomb's negroes, having been burnt in several parts of the 
body, in stirring a boiler of sugar, the new skin which was formed 
over the burnt parts became white, and the whiteness gradually 
spread over the other parts of the body, until he became as white as 
an European. The new skin was so tender as to blister when exposed 
to the sun. The master, astonished at this change in the colour of 
his negro, had him dressed like his white servants. (Histoire des 
Voyages, t. xv. p. 614.) 

Case CLXIII. — Accidental partial leucopathia in a black. Franck, 
born in Virginia, in 1758, forty years of age, of a robust constitution, 
and enjoying excellent health, cook to Colonel Barnes, had in her 
youth as black a skin as the most swarthy African; about twenty 
years ago, however, she remarked that the skin, in connection with 
the nails, began to whiten; the same change took place afterwards 



around the raouth, and this phenomenon continued by degrees to 
spread over the body until the whole of the skin had partaken more 
or less in this singular change. Four-fifths of the surface of the body 
are now actually white, smooth, clear and transparent, and all that 
remains black is losing that colour by degrees ; the neck and the back 
along the vertebral corumn are the parts which are darkest; the head, 
face, breast, abdomen, arms, legs, and thighs are almost entirely 
white; the private parts and axillae are A'ariegated black and white ; 
where the skin of these parts is white, it is covered with white hairs, 
where black, it is beset with black hairs. The face and neck become 
inflamed if she is excited to anger or is under the influence of shame. 
When she has been long exposed to the heat of the fire, red spots 
appear on the parts which have become white. This woman has 
never suffered the least inconvenience from this change ; no stoppage 
of the catamenia ever occurred, except during pregnancy; she has 
never had any disease of the skin, nor made use of any topical appli- 
cation, which could have accomplished the change which has taken 
place equally on the parts sheltered from the fire, as upon those 
exposed to it. Perspiration takes place most naturally, and as freely 
from the white as the black parts of the skin ; a blister was applied to 
the arm but did not rise. Philos. Trans., vol. 51. 

Case CLXIV. — Accidental partial leucopathia in a white. Charles 
Ferron, hackney coachman, sixty years of age, exhibited several spots 
on the skin as white as snow, and which are rather symmetrically dis- 
posed. On the groins they are broad, extend irregularly, and blend 
with each other. Three-fourths of the penis, and of the scrotum, the 
skin of the upper and inner parts of the thighs in contact with the 
scrotum, a portion of the outer aspects of both thighs, the lumbar and 
dorsal regions, and that of the linea alba, over an extent of surface 
twelve inches in length by about three in breadth, also present this 
snow white appearance, which forms a strong contrast with the natural 
brownish colour of the skin in other parts. In places where the skin 
is white the hairs are white also. On several parts in the neighbour- 
hood of those which are blanched, small white spots are seen at the 
roots of the hairs ; some of these are broader than others, and appear 
by spreading to have formed the larger white spots. Although this 
man has been engaged during thirty-five years in an occupation in 
which of course he has been subject to great exposure, he has never 
had any serious illness ; neither has he ever laboured under skin dis- 
ease of any kind ; he is in short a very healthy subject. The blanch- 
ing process began in the spring, at the age of forty-five, and advanced 
slowly. The spring and summer have always been the seasons most 
favourable to this change of colour, which took place without pruritus 
or pain. Various means have been had recourse to, but ineffectually, 
to restore the colour of the skin and stop the progress of the alteration. 
Since he attained the age of puberty he has had a considerable tuft of 
1 hair on the ridge of the nose. (Gauthier, op. cit., p. 76.) 



NIGRITIES. [AUGMENTATION OF PIGMENT.] 

1058. The skin of the European, white in childhood, of a brown 
hue in manhood among the inhabitants of the South, sometimes acci- 
dentally assumes upon some particular district, or over the whole sur- 
face of the body, a black hue, similar to that of the negro or mulatto 

(nigrities). 

1059. Local nigrities is most frequently observed on the genital 
organs. It is not uncommon to see the scrotum and the skin of the 
penis of adults or full-grown men, almost entirely black, so as to form 
a strong contrast with that of the pubes, and of the upper parts of the 
thighs. Haller 1 met with a woman in whom the pubic region was 
as black as that of a negress. 

The nipples of nurses while suckling, are very often of a deep black 
colour which disappears after weaning. The skin of the face may 
present a like phenomenon. A lady r says Lecat, 2 about thirty years 
of age, became pregnant; about the seventh month, the forehead as- 
sumed a dusky hue, of the colour of iron rust; by degrees the whole 
face became entirely black, except the eyes and the edges of the lips, 
which retained their natural colour. This hue was deeper on some 

1 Haller. Element. Physiolog., I. v. p. 18. 

2 Lecat. Traite de la peau humaine. Amsterdam, 8vo., 17C5, p. 13G. 



340 



NIGRITIES. 



dara than on otters. This lady, being naturally of a very fair corn- 
had tie appearance of an alabaster figure with a black marble 
head. Her hair, too, was naturally exceedingly dark, but the part of it 
which grew from the dark-coloured skin appeared coarser, and filled 
with a blacker sap than the rest, to the height of about a line or two 
above its roots. She did not suffer from headache; the appetite was 
good ; the face, after becoming black, was very tender to the touch ; 
the black colour disappeared two days after her accouchement with a 
profuse perspiration, by which the sheets were stained black; the 
child was of the natural colour. In the following pregnancy, and even 
in a third, the same phenomenon reappeared in the course of the 
seventh month ; in the eighth month it disappeared, but during the 
ninth this lady became subject to convulsions of which she had an 
attack each day. 

1060. I have seen several cases in which the tongue became black; 
the colouring matter, of a bluish-black, is generally deposited on the 
edges of the organ, in small close spots, from Avhence it gradually ex- 
tends over its upper surface. The tongue is otherwise perfectly 
healthy. It is necessary to distinguish these pigmentary discolora- 
tions from the artificial blackening, produced by food or medicine, 
and from those which the reaction of two substances, the one contain- 
ing tannin, the other iron, might produce on being taken into the 
mouth at the same time, or shortly after each other. 1 

1061. General congenital nigrities has perhaps never been seen. 
A case is related 2 of a woman who, like her husband, was of the 
white race, being delivered of a black child, in consequence of the 
portrait of an Ethiopian having been accidentally before her eyes at 
the time this child was conceived. P. Albrecht 3 speaks of a woman 
who, at the latter end of her pregnancy, was much burned, andburied 
for a time under the ruins of a house, which had been on fire, and 
who a month after, gave birth to a child whose skin was as black as 
that of an Ethiopian. M. I. Geoffroy Saint Hilaire, who mentions 
these two cases, adds with reason that the first seems susceptible of 
another interpretation, and that the second is incredible. 

1062. On the other hand the existence of accidental nigrities 
rests on well-established facts. M. Chomel 4 quotes a case of a very 
apathetic old soldier, whose skin, without any appreciable cause, be- 
came as black in some parts as that of a negro, and of a yellowish- 
brown in others. Goodwin 5 relates a case of an old maiden lady, 
whose complexion, up to the age of one and twenty, was of the ordi- 
nary whiteness, but who then gradually became as black as an Afri- 
can. M. Rostan 6 has published a case of a woman, seventy years of 
age, who became as black as a negress in a single night, after great 
mental agitation. Wells has also published a case of accidental ni- 
grities. 7 I have myself met with two cases of this kind. 

1063. This accidental blackening of the skin, more frequently 
seen in women than in men, and occasioned by a deposition of 
pigmentary matter on the outward surface of the dermis, must be dis- 
tinguished from the more or less dark brown or yellowish hue, which 
the skin assumes in old age ; nor must it be confounded either with 
the ecchymoses which appear in purpura, sometimes to a great ex- 
tent, with the blackish-green tint which appears in certain forms of 
icterus, nor with the superficial blackness which the sulphuret of 
mercury produces, &c. 

General nigrities differs from melasma, in this latter disease being 
accompanied with considerable desquamation of the skin. 

1064. The black and partial discolorations of the skin, as well as 
the yellow tints it sometimes assumes during pregnancy, commonly 
disappear after delivery. General nigrities rarely disappears either 
spontaneously, or through the influence of therapeutic agents. Chlo- 
rine baths make the skin yellow, instead of whitening it. 

1 Rumsey (Nath.). Remarkable blackness of the tongue. (London Med. Gaz., 
vol. vii. p. 245.) 

2 I have not been able to find this remark in Hippocrates to whom it has been 
attributed. Hoyer (Acta medico-physic, t. iv. 381), quotes two analogous instances. 

s Ephem. Nat. Cur. dec. ii. ann. 6 (1C87). Obs. xii. 

« Bulletin de la Faculte de Medecine de Paris, 1814, No. 6. 

* Goodwin, cit. by Renauldin, Art. Decoloration, Dictionnaire des Sciences Medi- 
cates. 

« Bulletin de la Faculte de Medecine, 1817, Nos. 9 and 10, t. iv. p. 524. Nouveau 
Journal de medecine, mai, 1819. 

• Wells ( W. B.). An account of a female of the white race of mankind, part of 
whose skin resembles that of a negro, 8vo. 



Cask CLXV. — General nigrities. Renaud, a sailor, sixty-three years 
of age, was admitted into the hopital de la Charite on the 28th of .Au- 
gust, 1827. This man, whose parents were healthy, had never had 
more than two diseases of the skin : the small-pox at ten years of 
a°"e, and scabies at seventeen. Being drafted into the military ser- 
vice, he bore the fatigues attached to it for sixteen years, without his 
health being in the least degree impaired. He was engaged in the 
Spanish and Flemish wars. In Flanders, he was attacked with in- 
termittent fever, which lasted for a year. The skin became of a sal- 
low-yellowish colour, as is generally the case after this disease ; and 
notwithstanding the immense quantity of quinine which was admi- 
nistered, the cure was only effected by his return to his native country. 
Since this period, the skin had resumed its natural colour. After 
having obtained his discharge, this man married a woman who had 
always enjoyed good health, and who was of a strong constitution ; 
he now indulged in eating a great deal, but never committed any 
excess in spirituous liquors. On the 7th of July last, he perceived 
that his skin, which had always been white, had assumed a darker 
appearance approaching to a yellow. This change began on the inner 
aspects of the extremities, and extended progressively over the whole 
surface except that of the face, which only presented the bronzed 
appearance occasioned by the heat of the sun. At the end of six 
weeks this dark colour had become general over the trunk and limbs. 
Renaud then perceived that small solid elevations of the same colour 
as the skin, were forming on the body, the itchiness and smarting of 
which were so violent as to disturb his sleep. These papulae covered 
the shoulders, the upper parts of the chest, and the posterior aspects 
of the limbs, without extending over the belly or buttocks. This 
eruption lasted three weeks. Laceration of the papulae from scratching 
was followed by the effusion of a small spot of blood, which coagu- 
lated, and formed a minute black and circular scab ; this was readily 
removed, and left a white cicatrice a little depressed behind it. A 
fortnight after the appearance of these papulae, a perspiration broke 
out over the whole body, which lasted for two whole weeks ; far from 
relieving the patient, this only rendered the smarting and itching more 
violent. The skin from that time, has gone on acquiring more and 
more the appearance of that of a mulatto, becoming darker and darker 
every day. The skin of those parts which are least exposed to 
the air is of a bronze colour, exactly similar to that of mulattos. The 
face is much lighter than the rest of the body and of a reddish-yel- 
low hue. The conjunctive and the sclerotic coats are of their usual 
whiteness ; the nose, lips and cheeks are not deeper than the rest of 
the face ; the lips are white as in elderly people. The external mu- 
cous membranes have generally their natural tint. The whole of the 
skin of the neck is bronzed, deepening gradually in colour from the 
upper to the lower part, and passing from a dark yellow to a black 
bronze colour ; it is, however, lighter in front, where it is habitually 
exposed to the air. The chest, of a pure bronze colour somewhat 
deeper than the anterior part of the abdomen, is covered with small 
white circular cicatrices, from two-thirds of a line to a line in diame- 
ter, which are evidently consecutive to the papulae of prurigo. On 
the skin of the back, which is of a dark brown, white lines or linear 
cicatrices are also seen, the results of the excoriations produced by 
scratching ; the arms are of a darker brown than the chest, particu- 
larly on the outsides ; they are of a deep yellow on the insides, and 
literally covered, particularly on the upper part, with an immense 
number of irregular cicatrices. The back of the hand is dark, but 
less so than the outside of the arm ; the palm is nearly of the natural 
colour ; the nails of both hands and feet are of a clear yellow ; the 
colour deepens continually from the lower towards the upper part of 
the thighs, so that the posterior part of the pelvis is almost black. 
The skin is shining like that of negroes, and soft to the touch, with- 
out being moist from perspiration. The hair which grows on the 
outsides of the legs and arms, and is scantier than it was at the 
beginning of this affection, seems harsher and blacker, and to have 
acquired a disposition to curl ; the hair of the head has become of a 
deep black ; on the breast there are several white spots. 

The pulsation of the heart, and the arterial pulse, are strong, regu- 
lar, and slow ; the radial arteries, which are very large, are tortuous. 
The veins of the legs have been for a long time very prominent. On 
the 30th of August a blister was applied to the left arm, which rose 



EPHELIS. 



341 



in the ordinary manner. The external surface of the dermis was of 
a yellowish-red, and appeared to be the seat of the accidental dis- 
coloration of the skin. The epidermis did not differ from that of 
whites generally, except that its internal surface appeared in some 
points of a yellowish-white. The blister was kept open for four days. 
A new epidermis was then allowed to form on the surface, and the 
skin assumed very nearly the same appearance which it presents in 
whites, after the application of cantharides, the colouring matter 
having very probably been discharged with the serum and pus. 1st, 
2d, and 3d of September, lotions of chloride of lime were applied, 
but produced no effect on the skin. From the 14th to the 20th, sul- 
phureous water baths, and after the 20th, simple tepid baths were 
administered. On the 22d, the patient appeared less black ; the backs 
of the hands resembled copper which had been long exposed to the 
air ; the anterior parts of the neck, breast, and abdomen, the inneT 
part of the extremities, and the other regions, which were of a deeper 
colour, changed from brown to bronze. Since this time the state of 
the skin has not undergone any change, and the principal functions 
have experienced no derangement. 

Fourcroy (Systhne des connaissances chimiques, t. ix. p. 259), as- 
sures us that a negro, after having placed his foot in a solution of 
chlorine in water, and held it there for some time, drew it out bleached 
and almost white. He adds, that the skin did not resume its black 
hue for several days. 

; Beddoes (Considerations on the Medicinal Use of the Factitious 
Airs, &c), having stated that he had made a similar experiment on the 
hands of a negro, I myself tried the effects of this agent in the case 
just related. A pint of water, saturated with chlorine, w r as poured 
into an arm-bath, and the right hand and forearm were immersed in 
it for twenty minutes. This bath occasioned slight smarting, and con- 
siderable redness of the skin. The parts immersed appeared less 
black when removed ; the hairs of the forearm were yellowish and 
brittle. During the day the arm became red and very hot. Two 
days afterwards, this erythematous inflammation had subsided, but it 
was followed by slight desquamation, attended with this peculiarity, 
that the detachment of the epidermis was accompanied in some places 
with the removal of the colouring matter of the skin. I afterwards 
tried general chlorine baths, by which the skin was rendered yellow- 
ish, but was not restored to its natural colour. 

Case CLXVI. — Nigrities after weaning and amenorrhcea, in a wo- 
man of a choleric disposition. C * *, thirty years of age, a laundress, 
of a very violent disposition, born at Mezieres, of French and white 
parents, had several times suffered from nervous attacks, after fits of 
passion. After having suckled her infant a year, she weaned it in 
the month of May last, and made use of a variety of drinks to carry 
off" the milk. Since that time she has continued weak ; she entered 
the Hopital de la Charite the first time with pains of the abdomen, 
which were treated with anodynes. She was admitted again on the 
29th of August, 1834. She had menstruated for the first time at the 
age of nineteen, married, and became the mother of two children, 
but the catamenia had not appeared since her last confinement, upon 
which occasion she informed me that she had been very ill for six 
weeks. 

The skin of this woman, who, in every other respect — in the form 
of her cranium, the colour of her hair, &c. — has the appearance of an 
European, was of a generally blackish hue, like that of a mulatto. 
She assured me that this change of colour had only taken place since 
the weaning of her last child, had occurred very suddenly after an 
attack of illness which she had then experienced, and had gone on 
increasing in intensity so long as she continued very ill. Since then 
it had diminished a little. The black colour is almost uniformly 
diffused over the whole surface of the body except under the knees 
where it ceases suddenly ; the lower limbs are much less deeply tinged 
than the other regions ; the colour is rather deeper on the outsides 
than on the insides of the extremities. It is darker over the joints in 
the sense of extension. The lips and lower eyelids are particularly 
black. On the left side of the lower lip there is a small irregular spot 
about the size of a sixpence, considerably lighter than the integu- 
ments around it. On the left arm, where a blister had been applied 
five months since, and kept open for twelve days, there is a spot 
which is much darker than the surrounding skin. The w r hole surface 
86 



of the skin is not of equal blackness ; some places are of a much 
lighter shade than others. The conjunctiva? have undergone very little 
change of colour. This woman has blue eyes, and lank hair ; her 
nails have never become either black or yellow. She says she has 
suffered lately from attacks of intermittent fever. She was affected 
with amenorrhcea accompanied with derangement of the digestive 
functions, characterized by loss of appetite, difficulty and slowness of 
digestion, but without either abdominal pains, thirst, or redness of the 
tongue. The heart beats regularly, the breathing is natural, the sleep 
is disturbed. I tried in vain to bring about a return of the catemenia 
by the application of leeches to the genital organs, and by strengthen- 
ing the constitution with the use, alternately, of the tepid and sulphu- 
reous water bath. This very unmanageable and passionate woman 
quitted the hospital in almost the same state in which she had entered 
it, and without any appreciable alteration in the morbid colour of the 
skin. 



Vocab. Ephelis, Freckle. 

1065. Following the example of Lorry, and of Peter and Joseph 
Frank, I have made use of the word ephelis in its literal acceptation, 
so well indicated by Blanchardus and Castelli, employing it to desig- 
nate the brown spots produced by the action of the rays of the sun on 
the skin. They are often few in number, broad, irregular and of a 
deep brown, (Ephelis umbrosa, J. P. Frank,) sometimes small, circu- 
lar and very numerous, and of a deep yellow, approaching to lentigo 
in form and colour (EpJielis lentigo, P. Frank). They always appear 
in the spring or during the heats of summer, upon the face, neck, 
upper part of the thorax, and hands, particularly among children and 
individuals who have a very fine skin. Our gentlewomen make use 
of veils to prevent these spots. Some carry their solicitude so far as 
to wash their hands and face in a mixture of white of egg and water ; 
others, to restore the colour of the skin when covered with freckles, to 
its natural colour, bathe it with cream, whey, a variety of distilled 
and aromatic waters, &c. These marks generally disappear on the 
approach of winter. 

1066. Dr. J. Davy 1 has made several experiments to ascertain the 
mode in which tliis discoloration of the skin occurs upon exposure to 
the rays of the sun. In order to determine the nature of the change 
which takes place in this case, and in seeking to discover the uses of 
the change itself, he has ascertained that among Europeans, when any 
part of the surface of the skin is exposed for the first time to the burn- 
ing sun of hot climates, slight erythematous inflammation takes place ; 
the epidermis is subsequently detached in large scales, and is replaced 
by a new one of a very light brown hue, but which becomes much 
darker after several successive desquamations. A similar change is 
frequently known to follow the inflammation produced by a blister. 
This alteration in the colour of the skin, nevertheless, often happens 
without any previous perceptible inflammation ; and then occurs after 
long exposure to a strong diffused light. The change of colour does 
not take place in the epidermis, but is attached to the surface of the 
dermis, upon which a quantity of brown colouring matter is deposited. 
This substance is chemically the same as the black pigmentary matter 
of the eye, and like it, resists a low red heat, without decomposition. 
The effect of the change of colour wdiich the skin undergoes, is to pro- 
tect it against the farther action of the burning rays of the sun. The 
results of Dr. Davy's experiments on this point are in accordance 
with the conclusions which Sir E. Home 2 has drawn from his inquiries 
on the same subject. When the skin has once acquired the brown 
colour, exposure to the rays of the sun may still occasion some slight 
smarting and a trifling increase in the temperature, but desquamation 
does not generally take place. From analogy, the name of ephelis 
ignealis is given to the brown or yellow spots which are seen on the 

1 Transact, of the Med. Chir. Soc. of Edin., v. iii. p. 89. Extract, in Arch. gen. de 
med., t. xviii. p. 89. 

2 Home (Eyerard). Sur la couleur noire du reseau muqueux de la peau des 
negres, considered comme servant a la preserver de Taction trop vive des rayons 
solaires. Extrait. Archiv. gener. de med., t. i. pp. 90-92. Phil. Trans., 1821. 






LENTIGO— CHLOASMA. 



inner parts of (he legs and thighs of females who are in the habit of 
warming them over pans of lighted charcoal. 



LENTIGO. 



Vocab. Art. Freckle, Lentigo. 



1067. Lentigo, 1 more generally known under the name of freckle, 
is characterized by the presence of yellowish, not prominent, and 
circular-shaped spots. These occur both scattered and in clusters, 
especially on the face, breast and arms. The spots are of a lighter or 
darker yellow hue, and as has been said, do not rise above the level 
of the skin. Appearing from the period of infancy, without any 
appreciable cause, these spots are generally seen on persons with very 
light, or reddish brown, or bright red hair; they sometimes continue 
to°an advanced period of life, but usually decline towards the_ age of 
puberty. The epidermis does not present any inequality over the 
stained parts. These spots are not accompanied either with tingling 
sensations or itchiness, but they abstract powerfully from the whiteness 
and brilliancy of the skin, which no topical application will restore. 
They sometimes disappear at indefinite periods, in consequence of 
the modifications produced by age in the structure or condition of the 
skin. The spots of lentigo differ from those of ephelis, in their per- 
manence ; the latter appear on the face, hands and other exposed parts 
of the body during summer, and disappear or become paler in the winter; 
the stains of lentigo, again, are lasting. Farther, ephelis, appears 
indiscriminately in all children, and in almost all adults who are ex- 
posed to the heat of the sun, while the spots of lentigo are more par- 
ticularly observed in persons whose hair is red or very light, whose 
eyes are of a pale blue, and whose skin exhales a very unpleasant 
odour. 

1068. When pieces of skin covered with these pigmentary spots 
are put to macerate, the colouring matter almost always remains firmly 
adherent to the dermis, when the epidermis has been detached from it. 

Lentigo is never made the subject of medical treatment. " Pene 
ineptiae sunt, curare varos et lenticulas et ephelidas ; sed eripi tamen 
f.rniinis cura cultus sui non potest." — Celsus. Dere medicd, lib. vi., 
sect. v. 



CHLOASMA. LIVER-SPOT. 
Vocab. Art. Pityriasis versicolor, Maculae hepalicas. 

1069. Chloasma is characterized by one or more accidental spots 
or patches, from the size of a millet seed to that of the palm of the 
hand ; they are dry, generally without pruritus, and of a pale or 
brownish-yellow colour; they are almost always developed on the 
trunk, sometimes on the face and neck, but very rarely on the extremi- 
ties. 

1070. Symptoms. The colour of the spots of chloasma may, in 
some cases, be compared to the pale yellow of the withered leaves of 
certain trees, in others to the deep yellow of rhubarb or saffron ; in 
other instances, but very rarely, these spots are of so deep a colour 
that they approach the description of stain which I shall afterwards 
treat of, under the name of melasma. The form and size of these 
spots are subject to great variety : some are several inches in diameter, 
whilst others are scarcely a few lines long. Others, still smaller, of 
the size of the papulae of lichen simplex, are generally scattered over 
the anterior parts of the chest and abdomen, and are to be distinguished 
by their yellowish or greenish colour. In some individuals, these 
spots, at first single, multiply, enlarge and unite into larger or smaller 
clusters, so as to give the skin a very remarkable appearance. A 
certain number of these maculae, very analogous to those of ephelis, 
do not rise above the surface of the skin which surrounds them, and 
are not the seat of any apparent exfoliation. Spots of chloasma are 
more particularly observed among persons whose skins are fine and 
delicate, and among pregnant women (the Maculae gravidarum of 
certain authors). The stained parts are at other times slightly pro- 

' Foreslus. Obs. chir. lib. v. ob. iv: De lentigine et panao faicei. 



minent ; their surface becomes the seat of an itchiness which is 
increased by heat and exercise, or the use of strong liquors. The 
epidermis afterwards cracks over the surface of the spots, and is 
detached in small furfuraceous lamellae (chloasma ps&ttdo-porrigo, 
Frank; pityriasis versicolor, Willan); and even when these spots do 
not appear at all squamous to the eye, the altered epidermis may often 
be detached by scratching them with the nail or rubbing them with a 
dry cloth, and the true skin left exposed, which then appears impreg- 
nated or overlaid with colouring matter, of a greenish-yellow. The 
epidermis scales off with particular ease after several sulphureous 
water baths have been taken. When patients leave these baths, the 
spots, instead of presenting the ordinary saffron or yellow appearance, 
are of a reddish colour which bears some analogy to that of lichen 
simplex. Sometimes, also, during summer, or at the beginning of 
spring, the yellow spots of chloasma extend, become itchy, and 
acquire, temporarily, a fiery tint. I have observed this change more 
particularly among women who had one or more spots of chloasma 
between the breasts. 

The duration of the spots of chloasma is very variable ; they are 
most frequently evolved without any known cause, and generally last 
for several years, if not treated appropriately. The skin of females 
is. more frequently affected with them than that of men; they are 
rarely seen among children. Women who are affected with them 
often observe that the colour becomes deeper at the period of men- 
struation ; in this case the spots appear and disappear without any 
visible desquamation of the cuticle taking place. Several patholo- 
gists have designated under the name of chloasma gravidarum or 
chloasma amenorrhceica, similar spots which appear during pregnancy 
or on the suppression of the catamenia. 

1071. Pieces of integument, covered with the spots of chloasma, 
have been left to become putrid in the open air, and in maceration ; 
the epidermis, when detached from the former, did not remove the 
colouring matter ; it remained on the external surface of the dermis, 
under the appearance of a brownish, blackish or grayish layer, which 
was easily removed with the back of the scalpel. The colouring 
matter of the pieces subjected to maceration, was divided between 
the epidermis and dermis, on the surface of which it appeared in the 
form of a blackish or grayish liquid matter, stagnant in the small fur- 
rows, and disposed in layers of unequal thickness. On the surface 
of the dermis there was observed besides, a band of a blackish colour, 
deeply situated, which could not be detached with the scalpel with- 
out implicating the tissue of the true skin. 

1072. Causes. — These spots (macula hepatim) often appear in in- 
dividuals otherwise in perfect health. Patients suffering from chronic 
affections of the stomach and lungs are also liable to them. In spite 
of the vulgar opinion which attributes these spots to disease of the 
liver, it is notorious that they rarely accompany affections of this 
organ. 

The mode in which these spots of chloasma are produced is almost 
unknown ; although a marked analogy between the colour of par- 
ticular spots, and those which follow the application of blisters, may 
lead us to suppose that the former, as well as the latter, are preceded 
by a morbid accumulation of blood in the discoloured parts. 

1073. Diagnosis. — Hepatic spots cannot be confounded with any 
other morbid discoloration of the skin ; ephelis differs from them in 
situation, colour, and above all, in its cause ; lentigo in its form, its 
continuance, its red colour, and its commonly accompanying hair of 
a similar tint. Naevi, of the colour of milk coffee, are, in the par- 
ticular of colour, singularly like some spots of chloasma, but differ 
from these in other respects, inasmuch as they are congenital, lasting, 
and their surface is never either furfuraceous or itchy, like that of the 
patches of chloasma. 

1074. Treatment.— The spots of chloasma, which often appear in 
women a few days after conception, frequently disappear at the end 
of the first month of pregnancy, along with the troublesome symp- 
toms which announced this state ; but they have been known to con- 
tinue during the whole period of utero-gestation, and even for some 
time after delivery. In this last case, and whenever these spots exist 
independently of all other affections, they must be treated by sulphu- 
reous water-baths, administered every other day, a remedy under 
which they almost always disappear in the course of a fortnight, or 



MELASMA. 



343 



of a month at the longest. This means is greatly preferable to various 
other remedies which have been recommended, such as acid washes, 
the application to the parts affected of embrocations and liniments of 
camphor, borax, the lauro-cerasus, &c. I ought to remark that, after 
the administration of a sulphureous bath, the spots of chloasma often 
appear of a very deep red, which lasts during several hours. I have 
seen liver spots vanish after an attack of measles. When the cure 
has been effected by sulphureous baths, or any other means, it is not 
uncommon for chloasma to reappear the following year, particularly 
in the spring. 

Chloasma is in general easily subdued by the use of sulphureous 
baths. Nevertheless, I have seen several cases of a variety of this 
affection, which is almost incurable, but which is happily of no real 
consequence. Almost the whole surface of the body was covered 
with large spots of a dirty yellow colour, neither itchy nor furfura- 
ceous, some of which it would have been impossible to cover with 
the palms of both hands joined together. In these rare cases, small 
streaks only, or isolated points of healthy skin, were seen between 
the spots. Several of the patients thus affected, had been sent to 
various watering-places, but this without avail in so far as the affec- 
tion of the skin was concerned, and almost always with temporary 
injury to their general health. These yellow discolorations of the 
skin resemble meladermia in their rebelliousness to treatment and 
their continuance. 

When patches of chloasma exist at the same time with an affection 
of any of the internal organs, as of the intestines, the uterus, &c. ; or, 
when they appear after the cure, or decline of the more active symp- 
toms of these affections, many practitioners object to treating them 
by the sulphureous bath, lest any disease which should occur acci- 
dentally afterwards might be attributed to their cure. This alarm, 
however, though it may not always be prudent to oppose it, does 
not appear to be justified by any well-authenticated case. 

Historical Notices and particular Cases. 

1075. Hippocrates has designated under the name of f^xt? not only 
the spots which are produced by the heat of the sun, but those also 
which sometimes appear on the faces of pregnant women. 1 Senner- 
tus 2 has given a very good description of liver spots, and has quoted 
and praised that of Solenander. At various later periods, these spots 
have been described by Lorry 3 under the name of maculae biliosce; by 
Willan and Bateman, under that of pityriasis versicolor; by M. Ali- 
bert under that of ephelides hepatiqties, and by P. Frank, under the 
title of chloasma. Some cases of this disease are to be found in the 
medical journals. 4 

Case CLXVII. — Liver spots on different parts of the body, cured by 
the use of sulphureous baths. A girl, eighteen years of age, of a 
bilious and sanguine temperament, had observed, for the space of 
about a year, some brownish-yellow coloured spots on almost all 
parts of her body. When I saw them, these spots occupied more 
particularly the anterior and posterior parts of the trunk. These were 
of different forms and sizes, extending in some places to between four 
and five inches in diameter. The greatest number of them were 
accompanied with no morbid sensation. Others were itchy, and their 
surfaces appeared covered in parts with small furfuraceous squamae. 
A careful examination of the thorax and abdomen detected no organic 
lesion in either of these cavities ; the general health of the girl was 
good. The spots disappeared after the use of five and twenty sul- 
phureous baths. 

Case CLXVIII. — Spots of chloasma on the trunk and limbs. D * * *, 
five and twenty years of age, was attacked with chloasma in the 
month of February, 1824. The spots first showed themselves on the 
neck, and from that extended over the other regions of the body. 
On the 7th of May, 1826, the whole posterior part of the trunk was 

' "Quae utero gerant in facie maculam habent, quam tfnKiv vocant." Hippoc. Op. 

mpi «<})0(i»v — UtfX yuvaixiim. 

* Sennert. Opera, t. iii. lib. v. part iii. sect. i. cap. vii. De maculis a Germanicis 
epaticis dictis. 

3 Lorry. De morbis cutaneis, introductio. p. 91. 

* Obs. de pityriasis versicolor. Journ. Hebdom., t. viii. p. 45. — Obs. d'Ephelides 
hopatiqnes gurries par la methode ectrotique. Journ. Hebd., t. iv. p. 264. — Avantages 
du borax. Journ. de chim. medic, t. ii. p. 591. 



covered with brownish-yellow spots, running into each other; they 
were all of the same colour except in some few places in front of the 
neck and chest, and especially between the mammae where the skin 
appeared whitish, and from which desquamation had taken place. 
The spots were fewer in number on the belly, but increased again on 
the thighs where they were very deep in colour and confluent. There 
were none on the legs and very few on the upper extremities, except 
above the elbow where they were more numerous. The face was 
free from them, with the exception of two on the right side of the 
forehead. On all the parts affected, this young woman experienced 
great itchiness and a tingling sensation which were excessive when 
she was not in motion. Her general health was good and all the 
functions regular. 

These spots disappeared in the course of six weeks after the use of 
thirty-three sulphureous baths, without any implication of the general 
health. 

Case CLXIX. — Spots of chloasma on the trunk and scrotum. M***, 
forty years of age of a sanguine temperament, consulted me on the 
11th of June, 1821, for chloasma which appeared in several parts of 
the body. On the skin of the neck and shoulders, and on the poste- 
rior and anterior parts of the trunk, there were many superficial spots 
of a brownish-yellow hue which did not change colour on pressure ; 
they had a fimbriated appearance in some places, in others, by being 
disposed in small circular spots, they gave the skin a marbled appear- 
ance. Their edges were well defined, not shaded off into the sur- 
rounding skin, and so close together on the upper part of the trunk, 
that it was scarcely possible to distinguish the natural colour of the 
skin ; they became fewer in number on the lower part, so that the 
hypogastrium and loins were almost entirely free from them. In the 
spaces between these spots the skin retained its natural colour. Any 
thing that accelerated the circulation, and produced an increase of 
heat or perspiration, was sure to create a violent itchiness in the spots 
of chloasma. The patient could not then be prevented from scratch- 
ing himself violently, and the spots were soon afterwards affected with 
furfuraceous desquamation. The skin of the scrotum and of the 
upper and inner parts of the thighs was of a yellowish-brown hue, 
similar to that of the other spots, from which, indeed, it did not differ 
in outward appearance, save in being habitually affected with a pretty 
abundant furfuraceous desquamation. 

During the heats of summer these spots became exceedingly itchy. 
During the past year, a great number of them had disappeared after 
some sulphureous water douches which the patient had taken at Aix. 
After the use of forty sulphureous baths they disappeared entirely 
without there being any necessity for having recourse to other forms 
of treatment. 



Vocab. Art. Melasma, Pityriasis nigri. 

1076. Under the title of melasma I designate an accidental and 
temporary blackish discoloration of the skin, and particularly of the 
epidermis occurring in one or more parts of the body, and almost al- 
ways followed by furfuraceous desquamation. This disease has been 
observed by Willan in children born in the Indies and brought to 
England. Lorry 5 and M. Alibert describe it as a peculiar species of 
discoloration of the skin, under the name of ephelide scorbutique. 
This morbid alteration in the colour of the skin, so frequently met with 
in those affected with pellagra, appeared among a certain number of 
individuals of both sexes and of all ages in the epidemic of Paris of 
1828. 

The variety of this affection observed by Willan in children (pity- 
riasis nigra, Willan), began by a partial eruption of papulae, and 
ended in slight furfuraceous desquamation from, and blackish dis- 
coloration of, the skin. This disease sometimes affects only the half 
of a limb, as the arm or the leg, sometimes only the fingers or the 

s Alia macularum species datur quas, quasi pulvere nigro cutis foret conspersa, 
earn deturpant, et srepius diarrhoea solvuntur, aut vacuatione quavis, e. g., sudoribus;' 
tales in muliere gravida vidi quae partu solutas sunt, cam per dolorum atrociam 
sudoribus ilia deflueret. Lorry. De morbis cutaneis— Introductio. p. 91. 



344 



PIGMENTARY REVI. 



toes. M. Alibort 1 relates three cases, one of which is a very remark- 
able instance of melasma : the skin of a beggar became as black as 
: a chimney Bweeper, and the surface in many parts rough and 
granular. A similar alteration of the skin has occasionally been 
observed incases of pellagra (see Pellagra). In the epidemic of 
Paris, in 1828, the epidermis became thickened in a great number of 
principally at the extremities of the fingers and toes, and the 
skin of these parts, as also that of the chest, and abdomen particularly, 
frequently assumed a blackish hue, as though it had been coloured with 
soot. This colour sometimes extended regularly over a larger or 
smaller portion of the body ; or it appeared in the form of isolated 
patches, at different distances from each other. The epidermis thus 
discoloured, became dry and rough, and then cracked and was de- 
tached from the skin, which appeared of the natural colour beneath 
it, and was speedily covered afresh with healthy cuticle. 2 

There is a morbid discoloration of the skin observed in South 
America, which may be assimilated to melasma (see Pinta). 

Case CLXX. — Melasma observed during the epidemic of Paris, in 
an individual in whom no symptoms of this epidemic had appeared. 
Gerard, three and thirty years of age, a sawyer, entered the Hopital 
Saint Antoine the 27th of September, 1828. Born of healthy parents, 
his father having been fair, his mother dark, this man was of ordinary 
complexion, the skin naturally rather brown, and the hair black. In 
the month of July last he experienced great lassitude, and complained 
of pains in his limbs, which were independent of the fatigues of his 
occupation. These pains were accompanied with dry cough and 
some oppression of chest. Leeches were applied to the epigastrium, 
and demulcent drinks prescribed. He also experienced great itchi- 
ness over the trunk and limbs. He was relieved by bleeding ; but 
the oppression of chest not having entirely subsided, he entered the 
hospital. We were struck with the force and irregularity of the beat 
of the heart ; the face was swollen. The patient was bled twice, 
after which the palpitation and puffiness of the face subsided. 

On the day of his entrance, all were struck on uncovering the pa- 
tient with the black hue of the skin of the belly and trunk ; the pa- 
tient seemed equally astonished himself, and assured us that the skin, 
though always naturally brown, was very different from the state in 
which it then appeared. This hue continued. On the 30th of Sep- 
tember, no morbid discoloration had taken place on the skin of the 
face ; the skin of the neck and of the anterior and posterior parts of 
the thorax, was brown and smooth like that of a mulatto. The ante- 
rior part of the abdomen presented a very peculiar appearance : the 
epidermis was detached in small plates about the size of a silver 
threepence ; these plates were positively black both on their internal 
and external surface, but appeared much blacker on the skin than 
after they were detached ; when examined between the eye and the 
light, they were of a grayish hue. On the parts from which the 
cuticular lamellae were ready to be detached, the skin was already 
provided with a new epidermis, not nearly so black as the preceding 
one, and almost of the same colour as the skin of a mulatto. The 
skin of the scrotum and upper parts of the thighs, was as black as 
that of a negro, but was not smooth and shining as it is in blacks ; 
desquamation was in fact going on in several places from its surface. 
After the coloured epidermis had fallen off, the skin assumed a brown 
hue. The patient left the hospital in a fortnight from the time of his 
entrance ; he now suffered no inconvenience from palpitations, and 
after taking a few tepid baths the skin resumed its natural colour. 



PIGMENTARY N^EVI. 

1077. Under the title of ncevi 3 are designated those congenital 
alterations of the colour or texture of the skin, which are generally 
permanent and confined to one part of the body. Although these 

1 Precis thoor. et prat, sur les malad. de la peau, t. i. p. 400. Plate xxvii. bis of 
his loho work gives a faithful representation of this alteration. 

* Kuhn. Epidemie reguante a Paris. Bull, des sc. med. de Ferussac, t. v. p. 
252. ' 

3 Haller. Element, physiolog., 4to. t. viii. p. 129.— Jacquin (Ch.). Memoire et 
observations sur les marques ou taches de naissance. (Journal general de medicine, 
de chirurgie, etc., torn, xliii. 8vo. Paris, 1812.) 



na-vi are of very various appearance, they may all be classed under 
three heads: the one comprises congenital anomalies of tie 
mucosum, in which the colouring matter of the skin is contained ; 
another vascular formations and hypertrophies ; and a third various 
congenital tumours formed by the cutaneous and subcutaneous tissues 
hypertrophied. These two last species of mevi will be treated of 
hereafter. 

1078. Congenital affections of the pigmentary membrane, which 
were generally spoken of by the ancients under the name of spili. 
present an endless variety in regard to number, form, size, colour, lVc. 
Those yellowish congenital spots which in colour are so singularly 
like the patches of chloasma, but which differ from them in generally 
resisting the curative means to which they yield, may be designated 
under the name of nsevus chloasma. A young woman, twenty-eight 
years of age, had a slightly oval-shaped spot, of a brownish-yellow 
colour, and nearly of the size of a five-shilling piece, on the right 
side of the fore part of the neck ; this spot was exactly like those stains 
which I have designated under the name of chloasma. In conformity 
with the vulgar notion, this young woman attributed the existence of 
this spot to a longing which her mother had had during her pregnancy 
for cafe au lait. These congenital spots are also sometimes seen of a 
lighter or darker brown or black colour (ncevus niger). A young 
man had on the inner and upper part of the right thigh, a black con- 
genital spot, not prominent, of about two inches in diameter, the 
edges of which were irregular and as if scolloped ; the hairs which 
grew on the surface of this spot, presented a slight enlargement towards 
their roots. 

Gaultier 4 mentions congenital and bronzed spots of the skin. A 
man, forty years of age, calling himself Joseph Galart, born in Switzer- 
land, attracted the attention of the curious, by exhibiting himself under 
the name of the living angel. He presented the following appear- 
ance : the skin of the whole posterior part of the trunk, from the nape 
of the neck to the loins, is of a bronze colour. This colour extends 
over the shoulders and the sides of the neck. This part is covered 
wdth hairs, of great fineness and growing very thick ; the skin of the 
rest of the body is of the usual whiteness. Those parts are darkest 
which are most thickly covered with hair; on the back there is a 
space of an inch in diameter, which has preserved its whiteness, and 
where the hairs are fewer in number, darker at their bases, and sur- 
rounded by a very small black circle ; the hair is thinner on the sides 
of the neck; there are a great many individual hairs surrounded by 
circles of colouring matter ; but there are also many which present 
nothing of this coloured areola. In some places the general dark 
colour of the skin blends with the areola surrounding the roots of the 
hair, so that one uniform brown surface results. In many places the 
brown colour changes into black. The pupil of the eye is very black, 
the iris brown. This man is of a very unstable character, extremely 
undecided in all his undertakings ; he has a lively but silly expression 
of countenance. A distinct smell of mice, with a mixture of a gar- 
licky odour, is emitted from those parts where the excessive secretion 
of the colouring matter takes place. In these places the heat is also 
greater than natural. To conclude, I recollect having seen at the 
Bureau Central des Hopitaux, a young man, whose eyelids, and adja- 
cent parts of the cheeks, were of a bluish tint, similar to that which 
is produced on the skin by the explosion of gunpowder. Still more 
recently, I met, among the out-patients of the Hopital de la Charite, 
with a man, on the outer side of whose legs there was a congenital 
spot, which at first sight might have been taken for an ecchymosis. 
A cbild was also brought thither to me, who had a grayish-black spot 
in the region of the loins, the colour of which resembled that which 
is produced by spreading a thin stratum of mercurial ointment upon 
the skin. 

1079. Pigmentary naevi are sometimes covered with hair, the strength 
and colour of which are very different ; it is, however, most generally 
brown and short. Some of these congenital pigmentary spots fade in 
intensity of colour after birth ; others continue through life, without 
spreading either in breadth or in depth. These congenital alterations 
are removable with the knife, the use of caustics, and the repeated 
application of certain irritating solutions which inflame the skin ; but 

* Gaultier (G. A.). Recherches sur l'org. de la peau, etc., p. 66, 8vo. Pari', 809. 



BLUE COLOUR OF THE SKIN— YELLOW COLOUR OF THE SKIN. 



345 



these various means leave cicatrices almost as disagreeable in appear- 
ance as the spots themselves. 



BLUE COLOUR OF THE SKIN. 

1080. Billard 1 has published a very extraordinary case of blue dis- 
coloration of the skin, which ought probably to be assimilated with the 
blue sweats that have been described. " Victorine Rufland, sixteen 
years old, and of a good height for her years, presented on the neck, 
face, and upper part of the chest, a beautiful blue tint of the skin, 
principally spread over the forehead, the alae nasi, and round about 
the mouth. When these parts were rubbed with a white towel, the 
blue colouring matter was detached from the integument, and stained 
the towel, leaving the skin white. This girl's lips were red ; she was 
pretty stout ; the pulse was regular and natural ; the strength and appe- 
tite like those of a person in health. The only morbid symptom was 
a dry cough, but without mucous rattle, and without any deficiency of 
sound of the chest, and without alteration of the natural beat of the 
heart ; the catamenia had never failed. She had been engaged as a 
laundress for the last two years ; from the time she began this occupa- 
tion, she had perceived a blueness round her eyes, which disappeared, 
however, on going into the air. This phenomenon reappeared, more 
particularly when the irons were heated by a very bright charcoal fire, 
or when she worked in a hot and confined place. This discoloration, 
however, made no progress until the month of May last, when the 
whole forehead and face became so blue, as to attract the attention of 
those who met the patient. The dry cough, of which I spoke, came 
on ; the catamenia became more abundant than usual, and she was 
seized with spitting and afterwards with vomiting of blood : still the 
regularity of the catamenia was never interrupted. The patient was 
bled several times, and had a blister applied to the arm, but all with- 
out any improvement. When I first saw this girl, I looked upon her 
as affected with cyanosis, depending upon organic disease of the heart; 
but as the colouring matter was secreted on the surface of the skin, 
which was left colourless when it was wiped off, I soon came to the 
conclusion that the cutaneous secretion only was diseased. This diag- 
nosis established, I now felt myself embarrassed as to the indications 
to be fulfilled. Still I ventured to advise medicines which, by their 
direct action on the skin, might perhaps bring about a favourable 
modification in its functions. I therefore prescribed six grains of 
sublimed sulphur, and a pint of decoction of sarsaparilla made with 
half an ounce of the root every day. Far from being useful, this 
course, which was continued for twelve days, only occasioned profuse 
perspiration, a material diminution in the quantity of urine excreted, 
and a considerable increase of the blue discoloration. The forehead, 
face, neck, breast and belly now became shaded with azure blue, 
which spread like clouds, and appeared deeper or paler according as 
the subcutaneous circulation was accelerated or retarded ; when, for 
example, the patient should have blushed, the face became blue instead 
of red. The changes exhibited were positively like the sudden transi- 
tions from one shade to another, presented by the chameleon. It is 
proper to observe that the face and forepart of the trunk, the shoulders, 
the arms, and a portion of the thighs, were alone coloured ; the poste- 
rior part of the trunk, the axillae, and the calves of the legs were in 
their natural state. The linen of the patient was stained blue. The 
sclerotic coats of the eyes, the nails, the skin of the head, and the ex- 
ternal ear preserved their usual colour. The mucous membrane of 
the mouth was a little pale, the tongue almost always loaded. No 
febrile symptoms appeared. I saw the patient again at the distance of 
a fortnight from the time of my first visit ; the different parts of the 
body which I have described were then of a deep blue colour. The 
cough was more violent ; there was, however, no fever ; but for six 
days the urine had been scanty, and for the last three, the patient had 
not passed a single drop. She did not, however, experience any of 
the inconveniences that usually accompany a retention of urine, such 
as distension of the abdomen, pain in the hypogastric region, swelling 
of the legs, &c. From the absence of these symptoms, it was easy to 

3 Billard [C.]. Mem. sur un cas particulier de cyanopathie cutanee ou coloration 
bleue de la peau, causee par une alteration de la transpiration. [Arch, gener. de 
med., t. xxvi. p. 453.]— Gazette med. Paris, 1831, p 399. 
87 ] 



perceive that if the patient did not make water, it was only because 
there was none secreted ; on the other hand, the blue colouring matter 
had become more abundant, and profuse perspirations took place each 
night. Thus the skin seemed to supply the place or to perform the 
function of the kidney. Spitting of blood had occurred some days 
previously, for which she had again been bled. The blood did not 
present any peculiarity of appearance. By means of a little oil, I ob- 
tained a considerable quantity of the blue colouring matter, which I 
had only been able to collect with great difficulty, and in small quan- 
tity by using plain water or vinegar and water. I sent it to M. Cadet, 
the distinguished chemist, who, from several experiments, concluded 
that this blue matter did not partake of the properties of the cyanour- 
ine, which M. Braconnet found in the blue urine of a patient, and that 
it was not composed of cyanogen, neither was it one of its compounds 
with iron. 

Having found that an alkaline solution was the most innocent of 
all the reagents capable of neutralizing this colouring matter, I pre- 
scribed the bicarbonate of soda in an infusion of orange leaves, in 
doses of six grains a day, then of twelve, and finally of eighteen, 
progressively. At the end of twelve days, the skin of the trunk and 
limbs had become quite white ; a light blue tint only remained round 
the eyes, about the alas nasi, and over the forehead ; the urine had 
become more copious, and was passed with greater ease, and the 
perspirations had diminished in quantity. During the following 
month the blue colour continued to diminish. In the whole of this 
time the patient had taken an ounce of bicarbonate of soda ; the 
urine, which had previously been very acid, became in nowise alka- 
line ; the perspiration was less acid than usual. This patient is at 
present in a very satisfactory state ; the face is only slightly disco- 
loured ; but this colour increases with exposure to heat, any agitation 
of mind, fatigue of body, and towards the time that the catamenia 
appear. At this period, too, the cough increases, and she spits and 
vomits a certain quantity of blood, as in haematemesis. She has been 
bled in the arm ; and the blood subjected to chemical analysis, pre- 
sented no peculiar feature. The patient has nevertheless vomited 
blood, which contained a sufficiency of blue colouring matter to stain 
the sides of the vessel. She says, also, that in bleeding from the nose, 
she has seen blue drops among the drops of blood. Unfortunately, 
these matters were not preserved. 



YELLOW COLOUR OF THE SKIN. 



1081. Morbid yellowish tints of the skin occur much more fre- 
quently than the preceding ones, and are almost alw T ays connected 
with serious diseases, of which, indeed, they generally constitute an 
unimportant symptom ; it will be enough to mention these very briefly. 

Icterus is the most common of these discolorations ; although 
depending, in a great number of cases, on disease of the liver, and 
mechanical obstacles to the proper course of the bile, yet it some- 
times exists without any apparent lesion of the biliary ducts, of the 
liver itself, or of any other organ which might affect the passage of 
the bile into the intestines (icterus spasmodicus, &c). The discolor- 
ation in icterus varies from a pale lemon colour to a greenish-yellow, 
to a dark or brownish-yellow, and even to a green. This discolor- 
ation, more or less general, and always deeper in some parts than in 
others, appears at first on the conjunctivae, the temples, the forehead, 
round the mouth, on the hands, breast, &c. The superior surface of 
the tongue seldom becomes yellow, but this tint is often observed on 
the inferior surface. The urine that is passed is of a deep yellow, 
and stains linen of a saffron hue. This yellow tint of the skin in 
icterus diminishes sensibly after death. 

The kind of icterus to which new-born infants are subject 1 seems 
to differ essentially from common jaundice. Two or three days after 
birth, when the child is still very red, a yellowish shade is perceived 
over the skin, very light at first, but which increases by deo-rees. In- 
stead of becoming white under the pressure of the finger, the skin 
assumes a yellow tint, and returns to the red colour when pressure 
is discontinued ; at a later period the skin becomes very distinctly 
yellow. 

' Billard, op. cit., p. 643. 






ARTIFICIAL DISCOLORATIONS OF THE SKIN— SLATE COLOUR OF THE SKIN. 



The yellowish appearance of the skin in the yellow fever, seems to 
depend, according to Desmoulins, 1 upon a kind of bloody effusion, or 
rather upon a very slight and diffuse ecchyraosis of the skin and sub- 
cutaneous cellular tissue. 

A yellow tint often appears in cases in which pus is absorbed into 
-tern, even when the liver is not affected. 

A similar yellow tint is sometimes seen in cases of pneumonia of a 
bad description. 

The skin assumes a straw-coloured tint in intermitting fevers of long 
duration, and presents an earthy and yellowish hue in the cancerous 
diathesis. 



ARTIFICIAL DISCOLORATIONS OF THE SKIN. 

1082. Independently of the various morbid discolorations of the 
skii\, which I have either just described or mentioned, there are 
others which are produced artificially, either by the direct introduction 
of certain colouring matters into the tissue of the skin (tattooing, the 
black or blue discoloration occasioned by the explosion of gunpowder, 
&c), or by the introduction into the system of certain substances, 
which give the exterior of the body a peculiar adventitious colour 
(tfi£ slate colour produced by the internal use of nitrate of silver). 

Slate colour of the Skin produced by the internal use of JVitrate of Silver. 

1083. The nitrate of silver, which has now for a considerable number 
of years been employed internally in the treatment of various nervous 
diseases and more particularly of epilepsy, sometimes produces a slate 
colour of the skin, something similar to that of the mulatto, and one 
which occasionally becomes even nearly black. 

1084. This alteration of the pigment appears to have been observed 
for the first time by Swediaur. 

A Protestant clergyman, says he, of the neighbourhood of Hamburg, 
affected with obstruction of the liver, took, by the advice of an empiric, 
a solution of nitrate of silver. Having continued the use of this remedy 
for several months, the skin insensibly changed its colour, and became 
at last almost entirely black. This colour lasted for several years, and 
then began to diminish. 2 J. A. Albers, of Bremen, in 1801, prescribed 
nitrate of silver to a woman, thirty years of age, subject to epilepsy. 
This woman being much relieved by this remedy, continued to use it 
for three years and a half. Towards the end of the last year, being 
pregnant, the skin, particularly of the face, neck, and hands, became of 
a bluish colour ; the sclerotic coats were also coloured in the same 
manner. The blue tint of the integuments was afterwards observed 
to increase on the approach of the menstrual periods ; the colour of 
the blood was quite natural ; the health of this woman was in no way 
affected ; notwithstanding the application of different remedies, the skin 
continued to retain its deep blue colour. 3 Struck by the singularity 
of this phenomenon, Albers addressed himself to other practitioners, 
inquiring if they had observed any thing of the kind. Reimar, of 
Hamburg, wrote to tell him that he had seen two cases. Professor 
Rudolphi informed him that similar results had been observed by a 
physician in Griefeswalde. Doctor Schleiden, and Doctor Chaufepie, 
of Hamburg, sent the particulars of three new cases of the discolo- 
ration of the integuments in question. Doctor Roget, of London, 
having prescribed nitrate of silver to a young lady affected with 
epilepsy, and continued it for four or five months, perceived, some 
time after the use of the medicine had been discontinued, that the 
tongue and fauces had assumed a blackish-brown hue. At the end of 
some months a dusky-coloured circle appeared round the eyes, and the 
same tint spread successively over different parts of the body. This 
alteration of colour was permanent; it underwent no change at the 
time of menstruation. 4 Three similar cases have been detailed by M. 
Butini, 5 in his Dissertation on the internal use of the preparations of 



' Desmoulins. In Journ. de physiol. exper. Juillet, 1823. 

- Fourcroy. Medecine eclairee, t. p. 342. 

' Med. Chir. Trans., t. vii. p. 284. 

s Butini. De usu interno, pnepar. argent. Genevas, 1815. 



« Ibid., p. 290. 



silver. Professor Sementini has mentioned this change in the colour 
of the skin, in a work on the same subject. M. Planche, 6 in an ana- 
lysis of this work, relates that in the year 1817, he saw a woman, 
seventy years of age, in Guy's Hospital, London, whose whole body 
was of a deep violet or livid colour, the effect of a course of nitrate 
of silver. I have myself observed this change in the colour of the 
skin in four persons subject to epilepsy who had been treated with the 
nitrate of silver. 

C * * *, formerly a soldier, twenty-nine years of age, entered the 
hospital of St. Louis, in the month of January, 1816, labouring under 
epilepsy. At this period the fits were violent and frequent. Since 
1811, they had occurred in the most unequivocal form, after a shock 
which C * * * had received at the battle of Wagram, where he was 
struck down senseless by a cannon ball, which tore away his knapsack 
from his back. It is very possible, however, that the origin of this 
disease might date from an earlier period, as the patient had for several 
years experienced a constant pain in the frontal and supra-orbitary 
region, which he compared to the vibrations of the arm of a balance 
within his head. Shortly after his entrance into the hospital of St. 
Louis, nitrate of silver was prescribed for him. The dose, consisting 
of half a grain, at first, was progressively increased to eight grains a 
day. C * * * took the shower bath at the same time, and the head 
was kept constantly bathed with cold water. The use of the nitrate 
of silver, interrupted from time to time, was continued for about three 
years. The fits became less frequent and not so violent, but did not 
entirely disappear. The digestion of the patient became exceedingly 
bad, and for a year there were unequivocal symptoms of gastro-intes- 
tinal inflammation. The tongue was constantly dry and loaded. 
Some months after he had commenced taking the nitrate of silver 
internally, C * * * perceived that his skin had assumed a bronze hue. 
At the end of the course which it was considered necessary he should 
undergo, this morbid discoloration had increased to such an extent, 
that at first sight the patient was always taken for a mulatto. The 
coppery hue has always been deeper on the face than on any other 
part of the body. For several years it has gradually decreased, and 
the patient assures us that now (March 8th, 1827) the colour is not 
half so dark as it was in 1819 and 1820. It has remained deeper on 
the face and body than elsewhere, and the skin now presents a livid 
appearance similar to that of workers in copper. This hue is not so 
apparent on the legs and thighs, hands, and forearms. The con- 
junctiva is bright and of a very light coppery yellow ; the mucous 
membranes of the lips and penis are sallow, the nails and hair have 
not experienced any change. Two or three small cicatrices have 
remained white, and have not participated in the general change of 
colour of the skin. 

1085. I have seen two other persons affected with epilepsy who 
had been unsuccessfully treated with the nitrate of silver, whose skin 
also assumed this bronzed appearance. In one of them, R * **, this 
morbid discoloration was very dark, particularly on the face and 
hands ; it was less so on the parts which are not constantly exposed to 
the light and air. This patient had several cicatrices which have 
acquired the same hue as the skin. The mucous membrane of the 
tongue, and the conjunctiva, are changed in the same manner as the 
integuments ; the nails and hair have not undergone any alteration. 

1086. M. Lelut has ascertained in two cases that the mucous mem- 
brane of the stomach and intestines presented a similar hue to that of 
the skin ; he gives the following summary of his observations : 7 

1st. The discoloration has not extended to the osseous, the muscu- 
lar nor the serous tissues, nor to the substance of the encephalon, of 
the liver, &c. The mucous membrane of the lungs seemed also to 
have escaped it. Perhaps some gray spots on the inner membrane 
of the aorta, were the effects of the medicine. 

2d. The skin, and the mucous membrane of the digestive organs, 
were the only tissues which were evidently affected. The corion is 
the special seat of the discoloration ; through the whole extent of the 
two integuments, this alone is uniformly discoloured. The epidermis 
and corpus mucosum, do not necessarily participate in this discolora- 
tion, as they were only affected in the hands and face ; and as in the 

6 Planche. Journ. de Pharm., fevrier, 1622. 

7 Coloration bronzee des tegumenschez un epileptique,produitepar l'usage interne 
du nitrate d'argent. [Journal Hebdomadaire de medecine, t. vi. p. 305.] 



ARTIFICIAL STAINING OF THE SKIN. 



347 



sub-diaphragmatic portion of the mucous membrane of the digestive 
organs, there is neither epidermis nor corpus mucosum. 

3d. The action of the air, and that of the light and heat of the sun, 
are not necessary conditions of this discoloration, as the mucous mem- 
brane of the digestive organs was bronzed through its whole extent. 
They seem, nevertheless, to favour the development of the preterna- 
tural hue, since it was much deeper on the face and hands than else- 
where, and as it was only over these parts that the two epidermic 
layers were affected. 

4th. The colour which the internal use of nitrate of silver gives to 
the integuments, is influenced in its intensity, as well as the natural 
colour of the skin, by the state of the circulation, and the other vital 
actions ; in fact, after these actions have ceased, it loses half its in- 
tensity. 

1087. Mr. Brande 1 assures us that he found oxide of silver in the 
skin and other organs, in a case in which all the tissues were said to 
have acquired a livid hue. 

1088. The change caused by the nitrate of silver in the colour of 
the skin, cannot be confounded with any other alteration in the pig- 
mentary matter ; it is even very distinct from the black discoloration 
produced on the integuments by the action of lunar caustic. 

1089. The slate colour of the skin, produced by the continued 
action of nitrate of silver, has not as yet yielded to any of the means 
employed with a view to remove it. It generally fades in intensity 
after lasting for some years ; but I do not know whether it ever 
entirely disappears. Perhaps stimulating baths might aid in removing 
the morbid discoloration in question. Mr. Badeley 2 found that the 
inflamed skin resumed its natural colour after the application of a 
blister. M. Lombard, 3 after making a number of experiments on the 
administration of nitrate of silver internally, in cases of epilepsy and 
other nervous diseases, thinks it advisable, when the state of the 
patient admits of the practice, to suspend the use of the remedy from 
time to time, in order to prevent the slaty discoloration of the integu- 
ments from taking place. 

Case CLXXI.— Slate-colour of the skin and of the mucous mem- 
brane of the stomach and intestines, produced by nitrate of silver. — 
Jacques-Auguste, twenty-eight years of age, subject to epilepsy, 
after having undergone a course of nitrate silver of about thirteen 
months' duration, observed, some time afterwards (in 1822), slate- 
coloured patches forming on different parts of his skin, and extending 
progressively over the whole of his body. Having been received 
into the Bic^tre, this man died there on the 18th of April, 1827. 
On opening the body, three cancerous tumours, with destruction of 
the cerebral convolutions in each of the lobes of the left hemisphere 
of the brain, were discovered as probable causes of death. A simi- 
lar tumour was also found in the anterior lobe of the right cerebral 
hemisphere, and pleuro-pneumonia of both lungs. M. Lelut examined 
the integuments with much care, and ascertained the following facts : 
All the external integument was of a gray slate-colour, of moderate 
intensity. This hue, which was nearly the same in all parts of the 
skin, did not prevent the vascular colour of the cheeks from being 
distinguished. The edges of the lips, their internal surface, the inside 
of the cheeks, and both sides of the tongue, presented an exactly simi- 
lar hue; the internal surface of the whole alimentary canal was of the 
same colour as the skin, and the upper opening of the gastro-pulmo- 
nary membrane. In the stomach this tint was extremely deep; it was 
not mixed with any violet-coloured marblings, depending on vascular 
patches or striae ; it was uniform over the whole extent of the viscera. 
In both the small and great intestines it was a little clearer, but still 
very appreciable ; it was uniform as in the stomach, and slight traces 
only of vascular ramifications were discovered in the whole extent 
of the alimentary canal. Before being subjected to the action of boil- 
ing water, the epidermis generally, and the epithelium of the lips and 
tongue, were exactly similar to the same tissues in individuals whose 
skin has not been coloured with the nitrate of silver. The colour, 
both of the outer and inner tegument, resided in the corion, and did 

1 Quarterly Journal of Science, 1830. 

2 Badely. On the eflects of nitrate of silver on the complexion. (Med. Lhir. 
Trans., torn, vii.) . 

s Lombard. Emploi du nitrate d'argent it L'intcrieur. (Gaz. Med. de Pans, 1833, 
p. 487.) 



not extend beyond it to the subcutaneous cellular membrane. After 
having been boiled in water, the cuticle and epithelium, both in their 
deeper and more superficial component parts (corpus mucosum vel 
reticulaire, and cuticle, properly so called), were perfectly colour- 
less and white. The corion of the skin, and of the mucous mem- 
brane, alone preserved their slate-colour. The mucous, membranes 
of the alimentary passages, freed from their epithelium, and the mu- 
cous layer supplied by the mucus they secrete, preserved the slate 
colour which they presented at first, after being boiled in water, 
another proof that the seat of this peculiar tint was the corion. The 
cellular and adipose cellular membrane, the muscles, tendons, apo- 
neuroses, nerves, vessels, and bones, in different parts of the body, 
presented the same hue as corresponding parts examined in two 
individuals, one aged, the other young, who had never taken nitrate 
of silver. Maceration in simple cold water for several days made 
no difference in the depth of the slate tint of the pieces of skin thus 
treated. The cuticle of the skin, the epithelium of the tongue, and 
the mucous body were colourless ; the peculiar tint in question resided 
entirely in the corion, both of the external and internal tegumentary 
envelop. 



ARTIFICIAL STAINING OF THE SKIN. 

1090. Harrold informs us' that he had seen a man who became 
uniformly black by taking sulphur during a mercurial course ; a kind 
of iEthiops mineral appeared to have formed on the surface of the 
body. Dr. Rigby also tells us 5 that he has known a patient, labour- 
ing under syphilis, complicated with scabies, who was ordered to rub 
in mercurial ointment, after having been treated with the unguentum 
sulphuris, become as black as an iEthiop. This phenomenon, which 
is easily imagined, disappeared very speedily after the disuse of the 
medicines named. I have myself seen a kind of black scurf formed 
on the surface of the skin of workmen employed in the manufacture 
of white lead, whom, having become affected with paralysis of the 
extremities, from the action of this poison, I had ordered to take the 
sulphureous water-bath. 

M. Chevalier 6 was once consulted by a young woman as to the 
means of getting rid of a great number of black stains upon her face : 
he discovered that these were produced by a solution of nitrate of 
silver, designated Eau de Perse, which this damsel used to dye her 
hair. 

1091. Various substances applied to the surface of the skin stain 
it of different colours. The females of our great cities especially, are, 
many of them, in the habit of using rouge, with a view to restore the 
brillancy of the complexion, when wrinkles and the lapse of years 
begin to abate its colour and freshness. The women of Greenland 
rub their faces with white and yellow ; those of Nova Zembla streak 
their foreheads and chins with blue ; the Japanese dye their lips and 
eyebrows with the same colour; the old inhabitants of the Canaries 
painted their bodies red, green and yellow ; the ancient Britons pre- 
ferred blue for this purpose ; the negroes of the kingdom of Juida 
(Guinea) paint their persons red [and the female savages of London 
and Paris still bedaub themselves with rose pink and pearl white]. 7 

1092. The study of these strange practices, and the discussion of 
several other species of artificial maculation of the skin, are almost 
foreign to the object of this work. Pare informs us that in his day 
lazy mendicants used to rub their faces and persons with a mixture 
of wood soot and water, to simulate jaundice ; the deception was 
readily detected by examining into the white of the eye and applying 
a wet towel to the skin. Many have also attempted to simulate 
icterus by staining their skin with a strong infusion of rhubarb, of the 
curcuma or chelidonium. 8 _ 

1093. Motion, friction, and the action of the perspiration, speedily 
rub off or alter colouring matters applied to the skin ; to fix them 

4 Meckel's Archiv. 

s The Lond. Medic. Repository, April, 1817.— Bibliotheque medicale, t. lx. p. 408. 

« Lancette Franchise, fol. Paris, t. x. 167. 

i Consultez sur ces colorations artificielles de la peau, Cadet de Gassicourt, Art. 
fard. Diet, des scienc. med. 

« Jaunisse simulee avec la ch£lidoine. Journal general de medecine, t. xiii. p. 
341. 



348 



HYPERTROPHIC. 



permanently the art of tattooing has been invented; this custom 
(aims extensively over the face of the globe. The colouring matter 
appears to be inserted into linear incisions of considerable depth in 
man; cases; although in some of the tattooed heads preserved in our 
museums, the skin appears without cicatrices, but chiseled as if the 
lines had at least been retouched after the death of the individual. 

1094. In Europe the practice of tattooing is unknown, save among 
our sailors, and the lazy soldiers confined to garrison duty. After 
having drawn with a pen and ink the letters or designs they mean 
to imprint upon their skin, these tracings are thickly pricked with 
needles, and colouring matter is then rubbed into the punctures. The 
only mischief that ever follows this practice is the occasional excite- 
ment of a kind of phlegmonous erysipelas. 

1095. The stains thus produced by the insertion of indigo, curcu- 
ma, red lead, finely pulverized charcoal, &c, are indelible like those 
that follow burns with gunpowder. They cannot be removed by 
blisters, nor any other form of topical application, unless they act so 
energetically as to destroy the corion at the same time, in the sub- 
stance of which the colouring matters which cause them are fixed. 

1096. After having macerated several pieces of tattooed skin, I 
found that the epidermis was not coloured any more than that of the 
unchanged parts of the skin ; that the colouring matter was deposited 
underneath it, and at various depths from the surface of the corion, 
as the needles had been forced more or less deeply ; and finally that 
the tattooed corion was firmer and harder than that which was in 
its natural state. 



HYPERTROPHIC. 

1097. The papilla? of the skin and the epidermis, the vascular rete, 
occasionally the entire substance of the skin, and even the subcuta- 
neous tissues themselves, now and then occur of unusual thickness. 
This state may be either congenital or adventitious. 

Hypertrophy of the Papilla; and Epidermis. 

1098. The papillae of the skin occasionally present themselves of 
unusual dimensions, and the cuticle which covers them almost invari- 
ably then undergoes very remarkable modifications. I shall, by and 
by, detail a case of congenital extraordinary development of the 
papillae, which, projecting like fringe, became covered with an almost 
cartilaginous epidermis. Ulcers on the legs, chronic eczema, impetigo 
Jigurata, and particularly blisters 1 — (§ 311) — are occasionally accom- 
panied or followed by an unusual development; of the papilla? ; these 
become particularly apparent when the part affected is plunged in 
water, and look mammillated and uneven, like the pile of coarse 
plush or velvet. The skin in these cases is habitually covered with 
scales, sometimes micaceous in appearance, generally brown and 
rough, and easily rubbed off. By maceration the cuticle can be re- 
moved entirely; this part is then found to consist of several lamina?, 
the innermost of which adheres to the points that correspond to the 
hypertrophied papilla?. It occasionally becomes necessary to remove 
the callous and nipple-like granulations which the papilla? form in 
some cases, with the flat scissors. 

Excessive development of the papilla? and epidermis is besides one 
of the principal characters of several other diseases. 

1099. To this hypertrophy of the papilla? of the skin observed after 
blisters, must be assimilated the affection which Mr. Hawkins de- 
scribes under the title of warty tumours of cicatrices, 2 which appear 
on the surface of old cicatrices succeeding wounds of very dissimilar 
kinds, and several years after the date of the original injuries. These 
growths make their appearance on the cicatrice in the shape of a small 
wart or warty tumour, covered with a thin epidermis, and dry in the 

' Baier (Ferdin. Jacob). De verrucis post vesicatorium recens application subor- 
ns. Nova acta Acad. IN at. Curios., vol. ii. p. 298. 

^L" 3 ^,'" 5, L0nd> Med " GaZeUe ' Decem Wl833._Gazette medicale de Paris, 
J 834, p. 71. , ' 



first instance, but which soon becomes moist and the seat of partial 
ulcers, like the warts of mucous membranes, and which finally secrete 
a thin, sharp, half-purulent looking matter. At this time there is no 
complaint made either of pain or inconvenience of any kind. In its 
second stage the tumour grows more rapidly, and the resemblance to 
a wart is lost to a certain extent ; a more solid substance arises from 
the diseased integument, whilst around the original excrescence new 
warty formations go on making their appearance, which in their turn 
undergo changes similar to those that have been already mentioned. 
The excrescence is extremely vascular, and bleeds when touched ■ a 
probe can generally be pushed through its irregular tissue ; some- 
times, however, it is of such solidity as to resist the blunt end of 
the probe. This kind of excrescence is best removed with the 
knife. 



ICHTHYOSIS. 

Vocab. Ichthyosis, Fish-skin disease [Porcupine disease]. 

1100. Ichthyosis is characterized by a morbid development of 
the papilla? and thickening of the epidermic lamella? ; these often 
assume the form of small irregular compartments, which have been 
compared to the scales of fish. The affection may be almost quite 
general, or it may be confined to a single region, (a) 

1101. Symptoms. — When ichthyosis is general, it is always in 
those places in which the skin is naturally thick, and the epidermis 
rough, as around the great articulations, on the anterior and external 
parts of the lower extremities, in front of the patella, over the ole- 
cranon, &c, that the altered epidermis becomes thickest. Every- 
where else the adventitious layer which it forms over the surface of 
the skin is much thinner ; it is commonly entirely wanting on the pre- 
puce, eyelids, groins, axilla?, &c. ; in a word, in every place where 
the skin is soft and of great delicacy. This morbid development of 
the cuticle is also very rarely seen on the palms of the hands and soles 
of the feet, and when it does appear there, it is always to a less extent 
than in the regions mentioned as its principal seats. 

At the period of birth, congenital ichthyosis is usually but little ap- 
parent. Yet in the anatomical collection of Berlin, there is a foetal 
monster preserved, the whole surface of whose body is covered with 
a thick layer of epidermis. The skin is also several lines in thick- 
ness ; the cuticle presents numerous fissures, and forms a covering 
like a coat of mail to the body. This singular case has been particu- 
larly described by M. Steinhausen. 3 

The skin of those infants, who are by and by to become the subjects 
of ichthyosis, instead of being smooth and soft as usual, appears sal- 
low, dry, and like shagreen. The affection is proclaimed with cha- 
racters less equivocal during the course of the two first months of 
existence. The cuticle in some places becomes rough, sallow, of a 
grayish colour, and to the touch conveys a sensation similar to what 
is communicated by the skin of the aged in many cases. An altera- 
tion of the epidermis to this extent may continue during a whole life- 
time without going farther ; or it may increase with the progress of 
years until it becomes excessive. 

Ichthyosis may occur several months after birth, with more decided 
characters. After having passed by different intermediate degrees of 
thickening, the epidermis at length appears divided into small irre- 
gular compartments, the appearance of which is certainly more analo- 
gous to that presented by the legs of fowls than to that of the scales 
of serpents, although Alibert has designated the variety of ichthyosis 
under review by the title of ichthyose nacrce serpentine. 

When ichthyosis shows itself with characters still more decided, it 
appears upon the extremities, especially in the sense of their exten- 
sion, under the guise of a thick epidermic layer, which has been 
likened by some pathologists to the bark of certain trees. In this, as 
in the two first varieties, the epidermis appears composed of numbers 



(a) Ichthyosis is divided by Mr. E. Wilson into I. simplex ; I. cor- 
nea; I. spuria. 

5 Steinhausen. De singulariepidermidis deformatione, Berlin — Gazette medicale, 
1831, torn ii. p. 10. 



ICHTHYOSIS. 



349 



of small compartments, very irregular in their shapes, not imbricated, 
not more than from two to three lines in diameter, generally broad in 
proportion as they are thin, and of a grayish or sallow hue. In some 
rare cases they are shining and in some sort opalescent ; more fre- 
quently they are of a deep brown colour ; the surface is then so rough 
that the hand passed over it experiences a sensation similar to that 
which is felt when a fde, or shagreen, or the skin of certain fishes is 
handled (Ichth. nacrte cyprine, Alib.). These squamae maybe de- 
tached without causing any pain, if we except the largest, which 
always seem to adhere more strongly, and which, when removed, 
occasion at least an unpleasant sensation. In every case, when they 
are detached, whether by friction or in any other manner, they are 
speedily reproduced with the same characters as before. 

1102. There is a fourth variety of ichthyosis, extremely rare, but 
very remarkable. Individuals have been seen whose skins were co- 
vered with numerous small and prominent appendages, which could 
not be taken away without pain, or the subsequent exudation of a 
reddish or sanguinolent fluid. These appendages are often whitish 
internally, though black on the surface. One of the most remark- 
able cases of this singular alteration of the skin, occurred in a man, 
a native of Suffolk, who exhibited himself about the year 1710, and 
was known under the name of the porcupine man. The whole sur- 
face of this individual's body, except the face, the palms of the hands, 
and the soles of the feet, was covered with small excrescences in the 
form of prickles. These appendages were of a reddish-brown colour, 
and so hard and elastic, that they rustled and made a noise when the 
hand was passed over the surface. They had appeared two months 
after birth, and fell off every winter to reappear with the summer. 
The. man was, in other respects, in very good health ; he had six 
children, all of whom were covered with excrescences like himself; 
the hand of one of these children has been figured by Edwards in 
his Gleanings; 1 the hand of the father may be found represented in 
the 59th volume of the Philosophical Transactions, (a) 

This race of porcupine men has been mentioned by several writers, 
the accounts being taken from the well-known family of the name 
of Lambert. The whole of the males of this family have the body 
covered with spines. Two brothers, members of it, were examined 
by Geoffroy St. Hilaire, one aged twenty-two, the other fourteen. The 
body of the elder, except the head and palms of the soles, was entirely 
covered with spines ; the younger was naked in several places, particu- 
larly over the breast; but a number of brown spots showed that with 
age he would probably become as completely covered as his brother. 
The spines on the back of the hand were extremely thick, and might 
have been compared, as far as the diameter was concerned, to the quills 
of the porcupine ; those which surrounded the nipple bore a greater 
resemblance to squama? ; they formed long narrow laminae, very nu- 
merous, closely set, and implanted vertically into the skin. This 
thickening of the epidermis and hair was the effect of a morbid dis- 
position, which was transmitted hereditarily, but only from father to 
son; the daughters not being affected. Five generations could be 
reckoned which had been affected in the manner described. 2 

Local and accidental ichthyosis constitutes a fifth variety very dis- 
tinct from the preceding species, which, in its mode of development, 
bears the greatest analogy to that of corns ; of this nature is the 
ichthyosis evolved on the anterior and lower part of the thighs in 
shoemakers, in those places upon which the last rests, whilst they are 
going on with their work, and especially when they are driving nails 
into the soles of shoes ; of this nature is the scabrous formation which 
occurs on the elbows of paper stainers, on the surface of the outer 
ankle in tailors, &c. I have also observed a morbid development 
of the papilla? of the tongue, in a man in all respects in very good 
health, which I regarded as precisely similar in its nature to local 
ichthyosis of the skin. 

It is not uncommon for the skin, in subjects affected with ichthy- 
osis, to cast off the adventitious epidermic formations, characteristic 

(a) See, also, for a notice of this family, Lawrence's Lectures on 
Physiology, &c, sect, ii, chap. vii. 

i Gleanin<?sof Natural History. London, vol. i. 1758; ii. 1760; iii. 1764, 4to., pi. 212. 
2 Bulletins des Sciences par la Societe philomathique, No. 67, p. 146, an. ii. de la 
Ri'publique. 

88 



of the different varieties of the general disease, during the summer 
season ; these are, however, constantly reproduced on the approach 
of autumn. This kind of desquamation has also been observed at 
other seasons. The skin, divested of its squama?, shows no signs ot 
inflammation ; whether the epidermis have been removed by the in- 
fluence of the seasons, or by the action of the vapour bath, or any 
other external application, its colour is natural, only the shallow fur- 
rows which occur on its surface are more remarkable than usual. 
The cutaneous exhalation and follicular secretion appear to be entirely 
suppressed, or, at least, are inappreciable. 

Ichthyosis is not accompanied with pruritus, nor with any other 
morbid sensation. Neither does it seem to have any kind of unfa- 
vourable influence on the general constitution ; I have met with 
several individuals labouring under the first and third varieties of the 
disease, who enjoyed the most perfect health, and were very robust. 
In these individuals it is probable that the pulmonary exhalation and 
urinary secretion supplied the place of the defective cutaneous per- 
spiration; which, however, is sometimes seen to be very copious in 
the palms of the hands and soles of the feet. 

Individuals labouring under ichthyosis are liable to be attacked with 
acute inflammation of the skin. I have given the case of a young man, 
twenty-three years of age, affected with congenital ichthyosis who died 
of small-pox. 3 The porcupine man, seen by Baker, also contracted 
small-pox ; his skin was temporarily freed from the squamae, but these 
reappeared before long. I have also seen ichthyosis modified by the 
occurrence of an internal disease ; during its course the squama? became 
thinner, the surface less dry and rough, &c, but the ichthyosis re- 
covered all its original characters as soon as the disease which had 
accidentally complicated it, had subsided. 

1103. Anatomical observations. — I have tried the effect of macera- 
tion upon portions of the skin of individuals who had laboured under 
ichthyosis. The small compartments of which the epidermic layer con- 
sists, and which give the malady its principal external characters, are 
readily detached under the form of a grayish or blackish membrane, 
impregnated with pigmentary matter in the porcupine species, little or 
not at all coloured in the other varieties of the affection. These small 
compartments do not overlap each other like the scales of a fish ; the 
title ichthyosis, taken in its literal signification, would lead to an erro- 
neous anatomical idea. Tilesius made a few experiments on the nature 
of the thick black superficial epidermic layer, which was detached in 
squama? from the bodies of the brothers Lambert. Buniva has since 
assured us that the squama? were nothing more than gelatin, become 
hard and solid from its combination with a certain quantity of phosphate 
and carbonate of lime. M. Delvaux has discovered that it also con- 
tains a little carbonate of iron and traces of silica ; consequently that 
the squama? of ichthyosis supplied the same chemical principles as the 
nails, the hair and the epidermic productions generally. I have myself 
demonstrated experimentally that this substance possessed physically 
and chemically the same properties as the epidermis. Dr. M. Good, 4 
who designates it improperly by the title of incrustation, supposes it 
to be formed by cutaneous secretions containing an excess of calcare 
ous matter. Under the first epidermic layer in ichthyosis, which is 
commonly coloured by pigmentary matter, a second is found of a dirty 
white or grayish hue. 

The lines or furrows which the corion presents on its outer surface 
are much more decided in ichthyosis than in the standard condition. 
The papillary eminences, which are also much more remarkable than 
on the healthy skin are sometimes extremely large ; it is indeed to 
the hypertrophy of these that Tilesius ascribes the production of the 
epidermic spines in the porcupine men. I have ascertained the occur- 
rence of this hypertrophy in the four first varieties of ichthyosis. This 
excess of development of the epidermic layers recalls an analogous 
circumstance already observed in a great number of simple cutaneous 
warty productions. 

Tilesius informs us, that in the brothers Lambert, the cutaneous 
follicles were obstructed, and full of a thick substance. These organs 
were but little apparent, and in many places imperceptible, in the great 
majority of the subjects affected with ichthyosis, whom I have examined. 
The hair and hair bulbs were found remarkably enlarged in a particular 
case, the history of which is given by Dr. Martin. To conclude, the 
3 Case LXV, p. 161. * Study of Medicine, vol. iv. p. 591. 



350 



HYPERTROPHIC. 



corioo lias alw a\ s appeared to me to be thicker, harder and more dense 
than it is in the natural state. 

[n the small number of cases in which opportunities have been found 

snining the bodies of individuals affected with ichthyosis, who 

i some accidental intercurrent disease, a variety of organic 

res, differing both in kind and situation have been observed, which 

appeared in nowise connected either with the development or the ex- 

istence of this affection of the skin. 

1104. Causes. — General ichthyosis is by no means a very rare dis- 
ease, at least in France. I have myself seen above forty cases of the 
kind. It is known to be transmitted through several successive gene- 
rations. The history of the Lambert family, which has been given by 
Geoffrey St. Hilaire, Tilesius and Buniva, aflbrds a remarkable instance 
of the affection being only transmitted to the males. Ichthyosis is 
seldom developed accidentally long after the period of birth. The 
whole of the male children of the same father and mother, who were 
themselves free from such an affection, have been seen labouring 
under ichthyosis. Such was the case of the brothers, Brayer, born in 
the department of Cantal. One of them, John, who became a patient at 
the H&pital de la Charite, in 1827, assured me that his brother, thirty- 
seven years of age, was like himself affected with ichthyosis, although 
neither his father nor his mother had ever been the subjects of a 
similar affection, of which his three sisters also presented no indica- 
tion. 

Some pathologists have ascribed the development of ichthyosis to 
moral affections of the mother during pregnancy ; this cause, however, 
is very problematical. I was once consulted on account of three little 
boys affected with congenital ichthyosis, born of healthy and well- 
formed parents ; and the mother assured me that she had never been 
better than during her three pregnancies, in none of which had she 
suffered any thing like mental disquietude or alarm. Neither climate, 
nor mode of life, nor temperature appears to exercise a marked influ- 
ence on the production of this disease. It does not appear to be 
endemical in Hayti, in Paraguay, nor among the inhabitants of the sea 
coasts or banks of rivers who live much upon fish, as it has been 
stated to be on insufficient authority. 

Women are known to be much more rarely affected wdth ichthyosis 
than men. 

1105. Diagnosis. — Ichthyosis bears but a remote and slight resem- 
blance to the squamous inflammations. Willan and Bateman, and 
several other pathologists, certainly did wrong in uniting these affec- 
tions into a single group. Ichthyosis almost invariably makes its 
appearance in the course of the first months of existence, and con- 
tinues during the whole of after life. It is not accompanied either with 
morbid heat or pruritus, or, in a word, with any other symptom 
observed in inflammation of the skin, (a) In lepra, psoriasis and 
pityriasis, the production of squama? is constantly preceded by redness 
of the skin, which can be readily made apparent by divesting the 
integument of the epidermic scales and furfura? deposited on its sur- 
face. In confluent and inveterate lichens, the skin may become 
rough, brownish, and covered with an infinity of minute scales some- 
what similar in appearance to those of slight and partial ichthyosis ; 
but this state is accompanied with pruritus of the most insupportable 
description, and is preceded by an eruption of papulae. The simul- 
taneous existence, or the ulterior evolution of papula? on some neigh- 
bouring point of the skin already covered with furfurae, will always 
suffice to dissipate any doubt which might be entertained of the true 
nature of these obscure cases. Local ichthyosis is no less distinct 
from the squamous and furfuraceous states which the skin presents 
around old ulcers, or after chronic and long-standing eczemas. 

We know that from the second to the fifth, and sometimes the 
tenth day after birth, the skin of the new-born infant throws off its 
epidermis, (b) This epidermic exfoliation, which has been particu- 

(a) On this assertion Mr. Plumbe (p. 318, op. cit.) remarks — 
" There is always — always irritation — present, showing itself in some 
form or other." 

(b) A thick layer (smegma) of deadened epidermis, or rather con- 
sisting of sebaceous matter and soft and flexible lamella?, invests the 
body of the infant at birth. This is soon detached, in zones and 
patches, at different times within a few days from birth. 



larly studied by Billard, 1 can never be confounded with ichthyosis ; 
for independently of other circumstances, it does not continue longer 
than a limited period. The skin of the aged is also occasionally 
affected with an epidermic exfoliation, which differs from the slightest 
known form of ichthyosis in the absence of all thickening of the 
cuticle about the knees and elbows, a condition the existence of 
which is invariable in the latter affection. 

It were useless here to particularize the numerous characters 
which distinguish ichthyosis from all kinds of horny productions of 
the skin, and from pellagra ; these having been either already men- 
tioned, or being about to be noticed. But I think it necessary to 
solicit attention to a mistake which must be readily fallen into, see- 
ing that two excellent observers have committed it. Bateman has 
given a figure in his atlas under the title of ichthyosis of the face, 2 of 
a case which is certainly one of ceruminous or sebaceous dej)osit from 
diseased action of the follicles; and Dr. A. T. Thomson has detailed 
a case of the same description under the same erroneous title. 3 In 
this affection of the follicles, however, which I was the first to notice 
particularly, the part of the integument affected becomes at first, as it 
were, unctuous or oily ; the secretion of the sebaceous follicles then 
increases ; the fluid thrown out upon the surface acquires additional 
consistency, and finally forms a kind of squamous crust or layer of 
greater or smaller extent. Soft at first, and adhering but slightly, it 
by and by acquires hardness, and then cannot be removed without 
occasioning very considerable pain. The skin under this sebaceous 
deposit is of a vivid red ; the orifices of the follicles appear dilated, 
and sometimes distended with concrete sebaceous matter, (c) 

1106. Prognosis and treatment. — Congenital ichthyosis often dis- 
appears for a time in consequence of acute inflammation of the skin. 
Local or accidental ichthyosis is often successfully treated by means 
of flying blisters, or topical stimulants. In two cases, in which this 
chronic alteration of the skin was limited to the legs, Mr. Plumbe 
succeeded in curing the affection by strapping the affected parts tightly 
with adhesive plaster, and applying a long roller kept constantly 
moistened with cold water. The straps were removed every fourth 
or fifth day, and brought away with them the accidental epidermic 
lamina with which they were in contact. The skin under this treat- 
ment gradually recovered its natural texture and appearance. 4 

Patients have been recommended to pick off the squamae with their 
nails whilst they were seated in a warm bath, or to get rid of them 
by rubbing the surface with a flannel cloth or coarse towel after 
coming out of a simple or sulphureous tepid water bath (Bateman). 
I have always found that though the hardened cuticle could be 
readily removed in this way, it was constantly reproduced after the 
lapse of a few days. Dr. A. T. Thomson has made the same remark. 

In general ichthyosis emollient applications continued for a long 
time, gentle frictions, mucilaginous and soothing fomentations, tepid 
baths frequently repeated, or alternated with the watery vapour or 
the alkaline bath, used with such discretion as to cause no disturb- 
ance in the performance of the principal functions, are usefully em- 
ployed in clearing the skin from the squama? that cover it, and in 
keeping it in a state as near as possible to that which characterizes 
the healthy integument. 

Bateman tried, but fruitlessly, the effect of plasters of different 
kinds, and a great variety of stimulating lotions and topical applica- 
tions in general ichthyosis. Mr. Coulson 5 appears to have been more 
successful: — W. Scott, aged eight years, was brought to him on the 
13th of July, 1832, having laboured under ichthyosis for several 
years, the arms and legs being the parts principally affected, but the 
skin of the breast and back being also brown, dirty looking and 

(c) One might be led to infer from this confident critique on Drs. 
Bateman and Thomson, that ichthyosis of the face is hardly ever met 
with. This would be a great mistake. I see from time to time a 
case of congenital origin in which the whole face is implicated. 

' Traite des maladies des enfans nouveau-nes et a la mamelle, 8vo. Paris, 1823 
p. 32. 

2 Delineations of Cutaneous Diseases, 4to. London, 1817, pi. xviii. 

3 Bateman, Synopsis, 7th edit. 8vo. London, 1829, p. 8. These cases are quoted 
in a note to § 1187 of this work. — Tr. 

* Plumbe on the Diseases of the Skin, p. 334. 
5 Coulson, in Med. Gaz., vol. x. p, 718. 



ICHTHYOSIS. 



351 



rugous. No internal medicines were employed, but the parts princi- 
pally affected were bathed twice a day with a wash of the corrosive 
sublimate. The skin, although improved in appearance, soon became 
stiff and tense, and at the end of a week, a liniment consisting of half 
an ounce of the nitrate of mercury, and an ounce of olive oil, with 
which the parts were anointed thrice a day, was substituted for the 
sublimate wash. Under this liniment the scales, as they are denomi- 
nated, soon disappeared, but the brown colour of the skin still continued. 

I have not succeeded in curing a single case of hereditary ichthyosis 
of some extent. Happily this congenital affection of the skin is unac- 
companied by every thing like important symptoms, and is in itself, 
indeed, of no consequence. It is not true that individuals affected 
with it die early from pulmonary consumption, or are worn out by 
colliquative diarrhoea. 

Willan recommended tar as an excellent medicine in ichthyosis. 
He prescribed this substance in doses of from half an ounce to an 
ounce daily during several months, and assures us that by this means 
he succeeded not only in freeing the skin from its thickened epider- 
mic covering, but imparted such pliancy and softness to the mem- 
brane, as prevented the recurrence of the affection. Bateman also 
gives the case of a lady who took, for a considerable time, from two 
drachms to half an ounce of pitch daily, and tells us that not only 
did this remedy produce the best effects on the state of the skin, but 
that her general health improved immensely under its use. 

Bateman further informs us, that a young girl who laboured under 
a slight squamous affection, particularly of the scalp, the shoulders and 
the arms, got well under the use of the arsenical solution. In two other 
cases, however, the same preparation was tried without advantage. 

Under the objectionable title of Greek leprosy, Turner describes a 
case of ichthyosis which was advantageously modified by the exhi- 
bition of antimonial, mercurial, and several other medicines. 1 

I must also add that Dr. Elliotson, having been consulted on behalf 
of two brothers labouring under ichthyosis, was so fortunate as to 
cure one of them by means of oleaginous applications, and the admi- 
nistration of pitch internally. He prescribed, he informs us, a warm 
bath every day, and desired the patient to anoint himself on coming 
out of it with oil, treating him like an ancient Roman; twice a day, 
besides, the whole of the body was rubbed with sweet oil. Pitch 
was also prescribed internally at the same time, at first in quantities 
of ten grains a-day, the dose being gradually increased until at last 
ten scruples were taken three times every day. The patient who had 
laboured under ichthyosis for four years, soon .derived the most 
marked benefit from the treatment ; the skin became less rugous, and 
on the 13th of January, — the patient was admitted into the hospital 
on the 2d of December, — he w r as perfectly well, the skin being as 
supple as that of a young female, and softer than the doctor's own. 
On his discharge he had a plentiful supply of oil and pitch. From 
the beginning the patient had been clothed in flannel, and advised 
never to wipe the surface of his body after having anointed himself 
with oil. On the contrary he was directed, during the whole period 
of his stay in the hospital, to wear the same flannel shirt, drawers and 
stockings, so that his skin was kept constantly impregnated with oil. 
The pitch had no appreciable effect on the organs of digestion ; the 
motions were the same as they had been before its administration ; 
neither was there any pitch mixed with the evacuations, which had 
no smell of this substance. The chief difficulty experienced was to 
induce the patient to swallow so many pills ; but he got into the way 
at last of taking down twenty at a time. A good plan, Dr. Elliotson 
informs us, of taking pitch pills is to make the patient chew a piece 
of biscuit till it becomes a soft pulp, with which a number of pills 
being mixed, the whole is swallowed readily. 

Dr. Elliotson was further informed by a gentleman, that a lady of 
his acquaintance, who had laboured under ichthyosis, and was attended 
by Dr. Willan, had taken an ounce of pitch daily with the same success 
as the patient whose case has just been quoted. Dr. E. also knew 
of another case, treated by Willan, which got well under the use of 
pitch taken in the same doses. 2 

Willan and Bateman do not tell us, whether the cures they effected 
were accomplished rapidly ; had they been so, these authors would 

1 Turner on Diseases incident to the Skin, 5th edit., p. 30. 

2 London Med. Gaz., vol. vii. p. 636. 



probably have mentioned the circumstance. The doses of pitch pre- 
scribed by Dr. Elliotson were much larger than those ordered by 
W T illan. "The warm bath seemed to have had little or no share in the 
cure of Dr. Elliotson's patient. Having rubbed off the thickened 
cuticle of his legs, he complained that the baths caused these parts to 
smart, and they were given up after ten days' trial. It is very pos- 
sible that the use of the oil hastened the cure. This point deserves 
to be made the subject of further inquiries. 

Several trials which I have myself made, particularly of pitch inter- 
nally, have not been followed by the beneficial results obtained by the 
practitioners quoted; whether it was that the cases were more severe, 
that the pitch was not prescribed in doses large enough, or continued 
for a sufficient length of time, I know not. I have nevertheless ordered 
half an ounce daily for more than a month. 

Dr. A. T. Thomson reports his having cured a woman attacked with 
an affection of the skin of the face, which he entitles ichthyosis, by the 
use of a decoction of the roots of the rumex acutus ; but in reading 
over the account of this case, I am satisfied that the patient was not 
affected with true ichthyosis, but with a disease of the sebaceous fol- 
licles. (a) 

Historical JVotices and particular Cases. 

1107. Panaroli, 3 Van der Weil, J Marc. Donatus, s Schenckius, 6 
Willan, 7 Alibert, 8 Janin de St. Just, 9 Ansiaux, 10 Chiappa, 11 &c.,have 
given the details of numerous cases from which information may be 
acquired in regard to the several varieties of ichthyosis. Among the 

(a) The eruption always returned a short time after the decoction was 
discontinued ; and hence, believing the return to depend on habit, Dr. 
Thomson blistered the face with cantharides plaster, immediately after 
the eruption was again cleaned off, and the cure became permanent. 
(Thomson's Bateman, p. 81.) Subsequently (in Cyclop. Pr act. Med.), 
Dr. T. recommends the rumex obtusifolius . 

Mr. E. Wilson [op. cit.) sums up briefly the treatment as follows : — 
" The indications to be fulfilled in the treatment of ichthyosis are 
two-fold ; firstly, the removal of the abnormal production ; and 
secondly, the prevention of its reproduction. The first of these indi- 
cations may be effected, without much difficulty, by employing the 
well-known powers of soda in the dissolution of albumen. Warm 
baths containing the subcarbonate of soda will speedily soften and 
then dissolve the hardened epidermis. The second indication calls 
for the use of measures which are calculated to modify the state of 
the system. For this purpose, alteratives should be used, both 
externally and internally, with the intention of exciting a different 
action in the cutaneous textures. Some stimulating application, such 
as a liniment, or ointment of croton oil, in the proportion of a drachm 
to the ounce, should be rubbed into the skin, with a view to excite 
and keep up the capillary activity; while the liquor potassse, the 
hydriodate of potash, or, as a last resource, the liquor arsenicalis, 
should be administered internally, (a) Willan, Bateman, and Elliot- 
son, have recommended the use of pitch, taken internally, in doses 
of an ounce, daily ; creosote is an elegant substitute for this remedy. 
Ichthyosis cornea may be treated with local stimulants, in addition to 
the constitutional management. The nitrate of silver, in solution, 
may be used beneficially in this form. The spurious form of the 
disease, particularly when it affects the lower extremities, requires 
the use of well-adjusted bandages. These, with some slight stimu- 
lant, will frequently remove the disposition to recurrence of the 
epidermic formation." 

(a) Plumbe assures us that both pitch and arsenic have failed in 
his hands. 

3 Panaroli. Ialralogismorum.seu medicinalium observationem pentecostae quinque 
etc.; Romae, 1652, 4to. Pentecost, v. obs. 9. 

4 Van der Wiel. Obs. rarior., cent. 1 et 2, 8vo. Leidae, cent. 2, obs. 35. 

5 M. Donati. De historia medica mirabili opus, etc., lib. 1 and 3. Mantua? 4to. 

s Schenck. Obs. med. rarior., p. 699.— Vater. Programma de cuticula pueri XV. 
annorum cutis rhinoncerotis aut corticis arboris instar incrassata. Vitemb. 1732. 
i Willan. On Cutaneous Diseases, 4to. Art. Ichthyosis. 

8 Alibert. Dermatoses, 8vo. Art. Ichthyose. 

9 Janin de Saint-Just. Journ. compl. des sc. med., t. v. p. 220. 

10 Ansiaux. Bulletin des sc. med. de Ferussac, t. xv. p. 289. 

11 Chiappa. Revue med., 1829, mars, p. 385. 



352 



HYPERTROPHIC. 



most serious cas< ird, however, are undoubtedly those of the 

brothers Lambert, of which Tilesius' and Ibiniva 2 have each' pub- 
lished very accurate details. Dr. Martin 1 has lately described a very 
remarkable variety of ichthyosis in which the skin was covered with 
Strong hairs like the bristles of B boar. Follet 1 and Joulhia 5 have 
also described two varieties of ichthyosis in their inaugural dissertations. 

Case CLXXII. — Ichthyosis over part of the legs and feet ; erysipelas 
of the l>i't leg; death from perforation of the heart. Lanautte, aged 
seventy-seven, entered the bdpita] de la Charite, on the 23d of March, 
on account of an cedematous erysipelas of the left leg. For the 
last two years, this old man has suffered habitually with swelled legs 
towards evening, and for a year past has complained of pains in his 
limbs, which he attributes to the dampness of -the room in which he 
lives. In 1825, he wounded his right leg, which did not get well till 
it had been eight months under treatment. At this present date, 24th 
April, 1832, the patient is in the following state. 

The left leg is affected with ichthyosis, and with an cedematous ery- 
sipelas, and is covered with several phlyctena?. The ichthyosis only 
extends over the lower third of the outer and posterior part of the legs, 
and a portion of the dorsum of the foot. It is characterized by small 
epidermic lamella-, from one to two lines in diameter, and from half a 
line to a line in thickness, rising above the level of the healthy skin 
towards the circumference of the patch, of an irregular quadrilateral 
shape, slightly adherent to the skin, and separated from one another 
by slight furrows. 

The erysipelas is characterized by a great increase in the heat of the 
skin, and a violet-red colour of its surface: the inflammation reaches 
as high as the knee on the inside, not higher than the level of its upper 
third on the outside. The colour is so deep in some places that it 
seems to be produced by a deposition of blood within the substance 
of the skin ; for it cannot be made to disappear with pressure. Several 
bulla? or phlyctena? are scattered over the parts most violently affected. 
Some of these of considerable size are isolated ; others smaller are 
crowded and confluent. Several superficial sores are also observed on 
different parts of the limb, probably consequent on excoriated phlyc- 
tena?. The surface of these presents different appearances according 
to their date. The subcutaneous cellular membrane is cedematous ; 
the skin pits on pressure, and preserves the print of the finger. 

The right leg is unaffected with inflammation. On the dorsum of 
the great toe, however, there is an erythematous spot. The lower 
part of this leg is affected with ichthyosis like the left. 

There is an ecchymosed spot on the back of the left hand. The 
patient is besides affected with inguinal reducible hernia. He is 
exhausted with diarrhoea and complains greatly of thirst ; the tongue 
is covered with thick mucus. The pulse is febrile in its beat. 
[Bandage to the legs ; simple dressings ; eight leeches to the inferior and 
inner part of the left thigh; mucilaginous drink.) 

April 25th. The puffing and redness of the left leg have declined ; 
but the patient is in a state of collapse, and is comatose. He died 
next day. Sectio cadaveris. The integument of the left leg presents 
the same violet-red colour it possessed during life. The skin of the 
lower third of the outer aspects of both legs, and that of the dorsal 
surface of the feet, is covered with a grayish epidermic layer, three or 
four times thicker than the healthy cuticle, divided into an infinity of 
small compartments, mostly of a quadrilateral shape, under which the 
layer of epidermis was discovered which was continuous with that of 
the healthy skin towards the circumference of the altered patch. 
The dermis of this patch was thicker, denser, and presented deeper 
furrows or lines than those of the healthy skin. The nails of the feet 
were long and thick. The subcutaneous cellular tissue of the inflamed 
leg was loaded with serum, and felt firmer under the scalpel than 
healthy cellular substance. The vena saphena was not inflamed; the 

1 Tilesius. Ausfuhrliche Beschreibung and Abbildung der beyden sogenanten 
StacheUchweinmenschen aus der bekannten englischen Familie Lambert. fol. Alten- 
bourg, 1802. 

2 M. Buniva. Particularity les plus remarquables de deux corn-ecailleux nommes 
Jean et Lichard Lambert, observes a Turin en fevrier et mars de l'an 1809, fig. 
M m. de 1 Acad. imp. de Sciences, lettres et beaux-arts de Turin, 4to. Several ad- 
ditional observations on the same family may be found in the Lond. Med. and Surg. 
Journ., bept., 1834. ° 

' ^',r jn C £. L ° - !V ' e r dical and Chirurg. Transactions, vol. ix. part 1, p. 153. 
* Follet. Diss, sur I Ichthyose cornee. Paris, 1815, p. 280. 
'Joulhia. Diss, sur 1'Ichthyose nacree. Paris 1819. 



subcutaneous bursa mucosa of the left knee was red, injected, and 
contained a little yellow purulent matter. Head. The brain was 
healthy; there were about three spoonfuls of serum in each ventricle. 
Thorax. The lungs were loaded with blood posteriorly, and pre- 
sented a number of blackish marblings anteriorly. The pericardium 
contained about six ounces of sanguinolent serum, or rather of fluid 
serous blood. At the base of the heart near the left auricle a fibrinous 
clot was discovered, the broad extremity of which was free, and 
floating in the cavity of the pericardium, whilst the other was impacted 
in the tissue of the auricle. This coagulum having been detached by 
means of a jet of water, we discovered a small opening in the auricle, 
into which a grooved director could be readily passed; the instru- 
ment penetrated a kind of sub-pericardial pouch filled with clots of 
blood. After washing away this blood, we found two small openings 
into the left ventricle near the attachment of the mitral valvfc which 
was ossified ; the blood seemed, therefore, to have made its way from 
the left ventricle into the substance of the auricle, and from this into 
the pericardium. The substance of the heart was ecchymosed, and 
infiltrated with blood around the seat of the effusion. The substance 
of the heart elsewhere was of a tawny yellow colour, and tore with 
ease. There were also various other morbid appearances about the 
heart. Abdomen. The lower part of the oesophagus was slightly- 
injected. The liver was altered, as was the spleen also. The kid- 
neys appeared simply injected. The urinary bladder presented a 
remarkable alteration ; a great number of fine filaments arose from 
the inner surface of this organ, and floated free within its cavity, so 
that the part, especially when laid in water, bore a pretty strong resem- 
blance to one of those large powder puffs which were formerly in use 
for powdering the hair. The preparation is preserved in the collec- 
tion of the Ecole de Medecine. I very lately met with a second 
instance of the same organic alteration ; the filaments, however, were 
less numerous, and not so long as in the case I have just mentioned ; 
they were also intermingled with vesicles from one to two lines in 
diameter, adhering to the inner surface of the bladder, and consisting 
of a single extremely thin and pellucid envelop, containing a watery 
and colourless fluid. 

Case CLXXIII. — General ichthyosis. Palliative treatment. A 
wagoner, thirty years of age, had been affected with ichthyosis from 
his infancy. The affection was especially remarkable on the lower 
extremities, particularly in the sense of extension, and in the neigh- 
bourhood of the knees. In these situations the skin was covered 
with small thickened squama?, of a blackish colour, and so rough that 
the appearance presented was altogether very similar to that of the 
bark of a tree. The trunk and superior extremities were covered 
with a cuticle which was evidently much thicker and drier than in the 
healthy state, and which was detached in the form of furfuraceous 
squama;. This alteration did not extend to the skin of the face. The 
principal functions were performed with perfect regularity. The 
patient was directed to take the vapour and simple tepid water bath 
alternately. The squama? disseminated over the surface of the body 
became, under this treatment, thinner and fewer. This palliative treat- 
ment had already been successful on two different occasions. 



VERRUCJE. WARTS. 



Vocab. Verruca, M T art. 



1108. Warts are small elevations produced by hypertrophy of the 
papilla?, and occasionally of the whole of the different component lay- 
ers of the skin, (a) There are two species of warts : 

1st. Some, commonly evolved upon the hands, (verruca vulgaris,) 
are small eminences, from a line, or less, to two lines in diameter, 
rising to the height of from half a line to a line above the general 
level of the skin, rough, and almost insensible on their surface. 
When one of these warts is cut vertically across in the dead body, 
the epidermic lamina? of the skin form a covering of various thick- 
ness over the exterior of the wart; the corion itself rises to the sur- 

(a) Meynier of Orleans advances the opinion that warts in man are 
gym nosporanges. 



VERRUCOUS N.EVUS. 



353 



face of the wart in the shape of a little tuft, enveloped by the cuticle 
which dives down between each of the papillary eminences. Small 
blood-vessels, in the form of red strife, accompany these prolongations 
of the corion ; to conclude, small blackish points are frequently ob- 
served in the substance of warts. 

1109. 2dly. Instead of small isolated eminences, warty bands are 
occasionally observed on the surface of the skin. These are com- 
monly reddish, or of the colour of the skin, and are formed by small 
prolongations of the dermis, and of the papilla?, which arise from the 
particular part of the skin affected under the form of a kind of coarse 
plush or shag. It is frequently difficult to decide whether these are 
syphilitic or not (§922). M. Rennes 1 met, in the person of a con- 
script, with a very remarkable instance of this variety of wart ; a band 
of agglomerated warts, from eight lines to an inch in breadth, ex- 
tended from the upper and anterior part of the right side of the 
breast, underneath the clavicle, along the arm and forearm of the 
same side, till it reached the carpus, where it increased considerably 
in breadth, and finally overspread the whole palm of the hand. 

1110. Warts occur at all ages ; but they are certainly more frequent 
in childhood and youth than in old age. M. Marc saw a woman whose 
face and fingers became covered with warts, after an apoplectic attack. 
Habitual irritation seems to provoke their development on the hands ; 
they are therefore most commonly seen among individuals who handle 
hard substances, who are negligent of proper cleanliness, and whose 
hands are exposed to great variations of temperature. Turner was of 
opinion that they were more common than usual among persons who 
milked, and had the charge of cows. Some individuals appear to have 
a kind of predisposition to warts, which return after they have been 
destroyed, in spite of every regard to cleanliness. It has been said that 
the blood which flows from a wounded wart is liable to cause the for- 
mation of others on the parts it touches. M. Cruveilhier informs us 
that M. Brunei showed him a band of warts upon the back of the hand, 
assuring him that they had sprung up in the line of the stream of blood 
which had followed the removal of one of these productions. I have 
tried repeatedly to inoculate warts in this manner, but the operation 
has never succeeded. 

1111. Common warts must not be confounded with several small 
appendages of the skin which have been denominated pediculated 
warts, nor with those small lenticular hypertrophies of the corion 
without thickening of the cuticle, which are occasionally met with on 
the skin of the back of the hands, and which have also been desig- 
nated under the name of warts. 

Warts differ from syphilitic excrescences ; the latter, preceded or 
accompanied by various symptoms of syphilitic infection, are situated 
especially on the genital organs, on the chin and face generally, and 
frequently disappear under the influence of the preparations of mer- 
cury, the deuto-chloride of gold and soda, &c. Vascular excrescences 
are of various shades of red, and pour out an infinitely larger quantity 
of blood, when punctured or excised, than warts. Cancerous tubercles 
of the nose and face differ from warts in the characters already par- 
ticularly pointed out (§751). Chimney-sweeper's cancer, however, 
begins with^ a species of wart, (§ 761,) and many cases of warts on 
different parts of the body degenerating into cancer are mentioned. 2 

1112. Warts often disappear spontaneously; they are easily re- 
moved as well as destroyed ; but in either case are apt to be repro- 
duced. Some warts may be tied with a fine silk thread or horse- 
hair ; when their bases are very broad they may be removed with a 
knife or flat curved scissors ; or they may be destroyed by means of 
caustic applications. When warts are excised they ought to be bathed 
in warm soapy water for half an hour ; they are then to be removed 
by very thin layers at a time until the blood begins to spring, when 
their surface is to be rubbed over with nitrate of silver. When 
active caustic substances are employed to destroy warts, such as the 
nitric acid, they must first be surrounded with a piece of diachylon 
plaster, to preserve the healthy skin from the action of the escharotic. 

1113. We have been recommended to rub warts with a piece of 
moistened sal-ammoniac twice a-day ; and this salt, though it acts 
slowly, destroys almost all warts that are not of extraordinary hard- 

1 Arch. gen. de med., t. xxvi. p. 350. 

2 Saviard. Obs. chirurg.— Ephem. Nat. Car. dec. ii. an. vii. Obs. 224, Misc. Nat. 
Cur. dec. ii. an. viii. p. 546 ; dec. ii. an. v. 1686, p. 271. 

89 



ness, without exciting either inflammation or pain. The acrid juices 
of the chilidonium raajus, of the euphorbia, juniperus sabina, ficus 
indica, &c, have been celebrated for removing warts in the same 
manner. 

All these topical applications, however, destroy warts less speedily, 
and less certainly than nitric acid. Lorry tells us, 3 that in the early 
part of his life, he saw a practitioner order asses' milk to a crop of 
warts of the face, and that this application removed them, to his great 
amazement. The same author informs us, that an unstimulating 
regimen, the tepid bath, and a milk diet should be prescribed for 
those young people who, without any assignable cause, are affected 
with great numbers of warts upon the face and other regions of the 
body. (a) 

Historical Notices and particular Cases. 

1114. The description of warts left us by the older writers, are by 
no means free from obscurity. 4 The acrochordon appears to corre- 
spond to our pediculated warts ; the myrmecia to the common sessile 
wart, and the thymus to excrescences. 

Warts have not engaged any great share of the attention of medical 
men. 5 



VERRUCOUS NiEVUS. 

1115. Dr. A. T. Thomson 6 has given two instances of warty nsevus. 
One of these, which is figured in his Atlas, occurred in a young man, 
twenty-five years of age, in the enjoyment of good health, the skin of 
the right side of whose breast, from the nipple to the clavicle, over an 
extent of about eight inches, that of the axilla of the same side, and 
that of the inner aspect of the arm and forearm, presented a band, 
nearly two inches in breadth, of congenital papillary eminences, which 
had grown with extreme rapidity during the last four months. These 
papilliform eminences, simple or ramified, elastic, of a reddish colour, 
fungoid, and with narrow bases, were so much crowded together that 
they stuck out quite straight from the skin. The majority were four 
lines in length, and nearly three-quarters of a line in diameter. When 
they were cut they bled profusely. They were habitually moistened 
with a colourless exudation of so unpleasant an odour, that this alone 
had induced the young man to seek for medical assistance. When 
divided, the cuticle was dense and cartilaginous-looking, and was 
without difficulty detached from a kind of internal vascular nucleus. 
The appearance of this papillary naevus, however, was not alike in the 
different regions which it occupied: on the chest the papillae, larger 
and redder, were traversed by furrows parallel to the clavicle, at the 
bottoms of which the white skin could be seen. Along the arm the 
excrescences looked like longitudinal spines. On the inner and lower 
part of the forearm, the nsevus extended into the palm of the hand, 
and even along the inner part of the ring and little finger. In these 
latter situations the appearance of the formation was notably altered ; 
the skin, indeed, only looked somewhat thickened, and the cuticle in- 
durated. Each of the papillae was separately cauterized with concen- 
trated nitric acid ; they were all thrown off in the course of about six 
weeks, and the young man got completely rid of his infirmity. 

(a) " Warty formations on the skin are not unfrequently of a malig- 
nant kind, in the aged ; and are most commonly situated on the face. 
The wart is of an angry and irritable character, and soon degenerates 
into the cancerous ulcer, surrounded by more or less of the carcino- 
matous deposit. The remedy is, free removal by excision, if possible, 
before open degeneracy has been fully established. All warts of the 
face, indeed, should be removed, at whatever age, and however 
simple their nature may seem to be; they all being most prone, if not 
certain, to degenerate in advancing years." — Miller's Principles of 
Surgery. 

3 Lorry. De morb. cutaneis, 4to., p. 544. 

4 Foes. CEconomia Hippocratis, Voc. dxps^opJcvi,-, /Avf/xtixtat, 66/j.ia(. 

5 Wedel (S. W.). Diss, de verrucis. Paris, 1696. Hanin (Louis). Des verrues 
et de leur traitement. (Rec. period, de la soc. de Paris, torn, xliii. p. 278.) 

e Thomson (A. T.). Atlas of delineations of cutaneous eruptions, Gr. 8vo. Lon- 
don, 1829, p. 100. 



354 



HYPERTROPHIC. 



The other case is related move briefly. It occurred in a child 

n months old. Here the papillary nrevus occupied the right 

the lip ami chin. Mr. Okes took away nearly the half of the 

lip, and a portion of the cheek affected, and by bringing the edges of 

the wound together, and retaining them in contact by means of a 

suture, a cicatrice was obtained which caused very little deformity. 1 

To these warty ixeri we must assimilate a very remarkable case of 
congenital warts met with by M. Ollivier d'Angers in a foetus at the 
full time. 2 



II0RNV PRODUCTIONS. 

1 1 16. The anomalous horny productions, often conoidal and pro- 
minent {horns), sometimes flattened (horny lamina), and of various 
sizes, occasionally observed on the surface of the skin, are formed of 
a substance very similar to that of the nails and epidermis. 

1117. Horny productions are most commonly developed on the 
and on those districts of skin which are most plentifully sup- 
plied with sebaceous follicles. The greater number of horny pro- 
ductions result from an affection of one of these follicles. Sir Astley 
Cooper has given engravings of two cases of these appendages, 
developed in the cavity of a distended follicle. 3 The simultaneous 
development of follicular tumours and of these horny appendages 
has even been observed. 

1118. Horny productions, secreted on the inner surface of the 
follicle, soft at first, soon become hard and tough ; they then rise 
above the level of the skin, and grow both in length and in thick- 
ness ; they have, occasionally been seen several inches long. 

During the early periods of their formation, and when they are still 
of small size, these horny productions are surrounded by a membrane 
which makes them appear encysted. By and by this membrane only 
envelops the base of the formation. Horny productions do not 
extend more deeply than the follicles, within the interiors of wmich 
they appear, as it were, to be set. They are consequently always 
movable, and participate in the motions which the skin receives from 
the subcutaneous muscles. The cyst, or kind of cyst, in the cavity 
of which they are implanted, is sometimes the seat of chronic inflam- 
mation, which occasionally ends in ulceration. 

1119. Horny productions are also frequently evolved on parts at- 
tacked with chronic inflammation. M. Julius Cloquet met with a large 
horny production on the forehead, which made its appearance after a 
burn. Professor Dubois had an old woman under his care in the 
Hospice de Perfectionnement, upon whose forehead there was a conoi- 
dal horn six inches and a half high by about seven inches in diameter 
at the base. There is a drawing of this patient in the collection of the 
Faculte de Medecine. A contusion or wound of the skin had preceded 
the growth of this horn. The patient complained of habitual headache, 
the intensity of which was constantly on the increase. The apex of the 
horn was solid ; its base was of a clearer colour, and much inferior 
consistency. Circular striae indicated the successive deposits of the 
matter of w T hich it consisted, and formed inequalities similar to those 
which are observed on the horns of certain ruminating animals. The 
cuticle was arranged around the base of the horn, as it is around the 
root of the nails ; it extended beyond the corion to a greater extent, 
however, namely, by several lines. Portions of the horny production 
thrown upon lighted coals burned with a smell similar to that which 
horn diffuses when burned. This production had pushed the integu- 
ments of the forehead aside, and especially downwards, to such an 
extent that the eyelids were habitually closed. The head of the 
woman diffused a fetid odour. 

1120. In a patient of the name of Aumont, who died in the HSpi- 

1 Home, in Phil. Trans., v. 81, p. 95. 

2 On the front of the thorax and abdomen, shoulders, arms, &c, of this foetus there 
were an immense number of warts, of a grayish-white colour, several of which were 
of the size of a lentil, and all pedicnlated in a greater or less degree. The larger 
were cleft to a considerable depth. They passed through the cuticle without being 
covered by it, springing from the substance of the corion and subjacent cellular 
membrane. Some of these warts presented the yellowish hue of ephelis. The 
viscera of this foetus appeared to be quite healthy. (Archiv. gen. de med., t. xxxv. 
p. 74. 

•» Cooper and Travers' Surgical Essays, vol. ii. 



tal de la Charite of a disease of the heart, I observed a squamous 
and pearly-looking production developed on the cicatrice of a gun- 
shot wound of the leg, which he had received in I80(i, when in the 
military service. The cicatrice was covered with scattered pearly 
squama 1 , bearing a strong resemblance to the scales of a carp, which 
they also equaled in size. Detached by means of warm water, or 
the tepid bath, these squamae were soon reproduced. Examined after 
death, the corion presented an arrangement similar to that of the skin 
which covers the legs and feet of fowls." 

1 121. Horny productions may appear on every region of the body. 
Of 71 cases of the kind in which M. Villeneuve was consulted, thirty- 
seven occurred in women, thirty-six in men, and three in infants. In 
nine of these cases the horns were situated on the head ; 5 in fourteen 
on the forehead, 6 and in twelve on the thigh ; 7 in the cvher cases they 
were situated three times on the temples; 8 five times on the nose; 9 
twice on the cheek; 10 once on the jaw; four times on the chest;" 
four times on the back; 12 three times on the penis and glans; 13 four 
times on the ischium; 14 twice on the knee; 15 twice on the ham ;" ! 
once on the leg, twice on the foot, and once on the hand. 17 They 
have also been seen on the back of the hand, 18 and above the ear. 10 

1122. The cases of horny degeneration of the skin of different parts 
of the body, and of monstrosity of the integument observed by Mal- 
pighi, 20 * * * * Ash, 21 Locke, 22 and Musaeus, 23 appear to form a separate 
group, and to depend on a kind of general disposition, different from 
the morbid processes, of a purely local character, which eliminate 
horny productions. 24 (a) 

(a) " The so-called horns (§ 514) sometimes met with on the head, 
and developed from the interior of a hair follicle, are nothing more 
than concretions of inspissated and altered sebaceous substance, 
modeled in shape by the interior and aperture of the follicle, and 
partially covered by the attenuated integument, which originally 
inclosed the sebaceous matter. I have seen productions of this kind 
so hard from desiccation as to resist the edge of the knife. 

" The following is a case in illustration of the sebaceous horn : — 
Louise Marino, an Italian peasant, fifty-four years of age, perceived, 
in the month of January, a small tubercle, of about the size of a millet- 
seed, imbedded in the integument of the root of her nose. The 
tubercle was attended with a trifling degree of pain and pruritus, but 
continued to grow with considerable rapidity. On the thirtieth of 
October of the same year, it had reached the length of an inch, was 
of a grayish-brown colour, had the diameter of a writing-quill, was 
grooved along its under surface, and curved like the beak of a bird 

* This case is surely one of accidental ichthyosis. It seems out of place here.— 7>. 

5 Uaklani. Mem. di Verona, t. xvi. p. 137. — Schenck. Obs. med. lib. is Cornuti, 
p. 13. 

6 Ephem. Nat. Cur. dec. iii. ann. iv. obs. 65, ann. v et vi. App. p. 148. 

i Dnmonceau. Journ. de medec, t. xiv. Carradori. Opuscol Seletti di Milano, 
vol. xx. p. 231. 

s Obs. de Vicq. d'Azyr. Mem. Soc. Roy. de Medec, p. 494, 1780. 

9 Hist, de l'Acad. Roy. des Sc. de Paris, 1772, p. 25. 

10 Borellus. Cent. i. obs. 14. 

11 Dupre. Philosoph. Transactions, n. 251. (Excrescentias cornea? ex calvaria.) 

12 Avenzoar, lib. ii. cap. v. Scaliger. Exercit. 199, No. 5, ad Cardan. Zacutus 
Lusitanus. Prax. admir., obs. 188. 

13 Horny productions of the glans have often been preceded by chronic inflamma- 
tion of this part of the prepuce, vide Caldani (Osserv. Anat. Pathol, oss. xiii. in 
memor. della Societa Italiana, t. xvi. p. i. p. 124). Richond de Brus. Obs. d'une come 
sur le gland. Arch, gener. de medecine. t. xv. p. 216; Meckel, sur les comes acciden- 
telles, Journ. compl. des sc. med., t. iv. p. 91. For horny productions of the scrotum, 
vide Wadd (William). Cases of diseased prepuce and scrotum, 4to. Lond., 1817. 

14 Rigel. Diet, des sc. medic, t. iv. p. 251. 

15 Benedictus. Histor. c. h. cap. x. p. 10. Denis. Recueil des memoires, et con- 
ferences sur les sciences, 1672. Hambourg. 

'« Borellus. Cent. iv. obs. 52. Dolceus, Epist. p. 216. Ephem. Nat. Cur. dec. i. 
ann. i. Obs. 30, etc. 

" 7 Arch, gener. de medecine, t. xxiii. p. 453. 

' ? Otto, Seltene Beobachtungen, cap. i. p. 109. Breslau, 1816. 

19 Parkinson. Memoirs of the Medic. Society of London, vol. vi. App 

2° Malpighi (De cornuum vegetatione, in Mangeti Bibl. Anat. p. 38, fol. Geneva?, 
1685), has described and represented a case of horny production observed on the 
palms and soles, with deformity of the nails, in a woman aged thirty. 

21 Ash. Philosoph. Transact., n. 176. 

22 Locke, ib. n. 230. 

21 Musaeus. De unguibus monstrosis et cornuum productione in puellicornigera. 
Kopenhagcn, 1716. 

21 Morgagni met with a horn on the prepuce, which followed the degeneration of a 
wart. (Epist. lxv. art. 2.) 



CORNS. 



355 



1123. Besides the horny productions developed in the cavities of 
the sebaceous follicles, similar formations are occasionally seen suc- 
ceeding a variety of wart. Rose Davene, aged sixty-four, of healthy 
constitution, and the mother of seven children, consulted me at the 
Bureau Central des Hopitaux on the 31st of August, on account of a 
yellowish-coloured horny production, more than two inches in length, 
the base of which was fixed upon an inflamed patch of the skin, cover- 
ing the inner surface of the thigh. In the situation which this pro- 
duction now occupied, two small spots (boutons) had appeared about 
six years ago, which had suppurated. On the seat of these a wart 
made its appearance, and by and by became covered with a horny 
top, which she had removed with a ligature ; but it soon grew again, 
and was now of the length mentioned. It was only troublesome in 
walking ; the glands of the groin were healthy. I recommended it to 
be removed, but do not know whether (his was done or not. 

1124. Voigtel, Conradi, J. F. Meckel, Otto and others, have pub- 
lished many interesting facts connected with the history of manifold 
horny productions. In the collection of the Ecole de Medecine at 
Paris, the hands and feet of an old woman, presented by Beclard, are 
preserved, which are covered with horny lamellae of different sizes. 
The backs of these parts are covered with horny productions of less 
length than those of the palms and soles. From the latter arise five 
or six excrescences, as thick as the finger, and from eight to ten inches 
in length. 

These productions are extremely friable. They demonstrate the 
analogy of the substance of proper horn to the epidermis. The mode 
of connection of these multiple horny productions with the skin, is less 
known than that of the single horns of which particular mention is 
made above (§§ 1117-1118). 

1125. The causes of horny productions are extremely obscure; 
they appear most generally to follow some chronic irritation of the 
papillae. 

1126. The form, colour, and especially the consistence and struc- 
ture of these productions, and the smell they exhale in burning, dis- 
tinguish them sufficiently from the hard, dry, and pyramidal-shaped 
incrustations, which occasionally cover syphilitic, scrofulous and 
cancerous ulcers. These horns are still more distinct from fungous 
tumours of the dura mater, from nodes of the bones, &c, with which 
they have been said occasionally to have been confounded. Bony 
appendages or spiculae of the femur, humerus, &c, similar to those 
mentioned by Cabrolius, Vicq d'Azyr and others, can never be mis- 
taken for horny productions of the skin, even though they projected 
to a considerable distance after piercing the skin. 

1127. I only know of one case which goes to prove that the spon- 
taneous fall of horny productions may be followed by a permanent 



of prey. It adhered firmly, by means of a narrow base, to the skin 
and subjacent areolar tissue. Dr. Portal removed it by incision ; the 
areolar tissue at its base, the periosteum and bone, were perfectly 
sound." 1 — Wilson (op. at.)'. 

Mr. Wilson has recently, in vol. xxvii. of the Medico- Chirurgical 
Transactions, contributed a paper, 2 setting forth the mode of produc- 
tion of horn from the skin and giving some statistics of the subject. 
He remarks: — " The sebaceous substance is secreted from the blood, 
through the urgency of the cells which contain the epithelial lining 
of the gland, as is the case probably with all the secretions of the 
body; but there is this difference between the sebaceous and other 
secretions, namely, that the former is semi-solid, while the rest are 
fluid; the solidity or density of the sebaceous matter being due to the 
great number of empty and more or less distended cells which com- 
pose the mass." 

Mr. Wilson has collected ninety cases, of which fifty-four were 
females and thirty-nine males, the sex of the remainder not mentioned. 
Forty-eight were seated on the head, four on the face, four on the 
nose, eleven on the thigh, three on the leg and foot, six on the back, 
five on the glans penis, and nine on the trunk of the body. Old age 
seems to be a predisposing cause of this affection. 

' II Filiatre, Sebezio, February, 1842. 

2 Account of a Horn developed from the Human Skin; with observations in the 
Pathology of Certain Diseases of the Sebaceous Glands. 
a A case detailed by Roots, quoted by Weslrumb. 



When it is held necessary to remove these horny productions, on 
account of the inconvenience or deformity they occasion, the knife is 
always to be preferred to every form of caustic application. After 
including the base of the formation within a circular or elliptical 
incision, it is necessary to dissect away, or to destroy, by means of 
escharotics, the follicular pouch, the warty excrescence, &c, from 
which they spring. When this precaution is neglected, or when these 
productions are simply cut across at their bases, or removed with a 
ligature, they are very apt to grow again. 

Little has yet been done in trying to subdue the particular dispo- 
sition manifested by certain individuals to have horny growths de- 
veloped upon the surface of their bodies. Fabricius Hildanus^ tells 
us that a young female, having made use of evacuants, eramena- 
gogues and the sulphureo-aluminous thermal waters of Neuham, was 
cured for a time of these horny productions with which her skin was 
covered. The combined action of simple tepid, of alkaline, and of 
vapour baths, would probably prove advantageous, if these appendages 
were found to adhere but slightly to the skin. 

Historical JYotices and particular Cases. 

1128. In alluding to a horny production springing from the sur- 
face of a wart, Morgagni remarks, with justice, that this fact confirms 
the observations of Malpighi on the part which the papilla? play in 
the formation of natural horns: "Quid (ait) aliud denique sunt ver- 
rucse nisi productae morbosaeque cutis papillae ?" 

Home and Cooper have studied the horny productions developed 
in the sebaceous follicles. I have already referred to several cases 
of horny productions, arising from extensive surfaces of the skin, 
usually after these had been affected with chronic inflammation. 
Dauxais 5 and Westrumb 6 have quoted an immense number of cases, 
in which accidental horns were evolved in men and among the lower 
animals. 



Vocab. Tytosis. 

1129. Corns are accidental circumscribed epidermic indurations, 
of a round shape and hard consistence, which are commonly evolved 
on the upper surface, or on the lateral aspects of the toes, occasion- 
ally also on the soles of the feet, especially towards the anterior ex- 
tremities of the metatarsal bones. Corns compress and irritate, and 
sometimes inflame and even pierce the subjacent skin; they have also 
been known to cause inflammation in the joints situated underneath 
them. 

1130. Causes. — The injurious pressure of tight, short, or ill-made 
shoes immediately upon the skin, or of the toes upon one another, 
are the most frequent causes of corns. 

1131. Corns are generally shaped like the head of a nail; the 
cuticle of which they consist is so much thickened, that layer after 
layer of it may be removed with a knife. In the middle of the yel- 
lowish hardened epidermis, a small point, of a white colour, may be 
perceived, which penetrates more deeply than the other parts of the 
induration. The slightest pressure over this white point occasions 
severe pain. This nucleus is sometimes surrounded by a slight ec- 
chymoses, situated in the corion. 

Corns of the lateral aspects of the toes are usually situated under 
the projections formed by the articular heads of the phalanges, upon 
which, of course, pressure acts more powerfully as well as more con- 
tinually. They are almost always moist; their centre is depressed, 
and presents a slight cavity of a grayish tint, that forms a marked 
contrast with the pearly white which the constant moisture of the feet 
gives to the thickened cuticular rim that surrounds the corn. 

1132. Bunions, callosities and indurations are names given to thick- 

« Cent 2, obs. 25. 

6 Dauxais. Des Comes. Diss, inaug. Paris, 1820. 

6 Westrumb. Sur le developpement des productions cornees. Journ. complem., 
t. xxxii. p. 331. 

Ant. Piccinelli Snll'origine e cura di quelle escrescenze impropriamente chiamate 
come umane, 4to. Bergamo, 1826, may also be consulted. 



356 



HYPERTROPHIC. 



enings of the cuticle coi (-ring the palms of the hands, soles of the feet 
nits of the toes. They do not differ from corns, save in heing 
without the central white cone, ohserved in these last, which, from 
penetrating deeply, has procured them the title of clavi pedum. Press- 
men, in printing offices, arc liable to indurations of the nature of bunions 
on certain parts of the palms of their hands, and 1o painful chaps which 
are produced by the alkaline leys used for cleaning type. Hard cu- 
ticular indurations frequently occur around the heels, on the inner 
sides of the great toes, on the inferior surface of all the others, and 
especially over the digital extremity of the first metatarsal bone. 

1133. When pieces of integument, affected with corns, are ma- 
cerated for some time, the thickened epidermic layers are seen to 
have depressed and altered the corion beneath them. The central 
nucleus, firmer and more horny than any other part, is almost always 
distinct. 

M. Blandin 1 believes that corns are always formed by a kind of 
hypertrophy of the superficial lamina cornea seu albida of the skin, 
and that the thickening of the cuticle observed at the same time is 
entirely accessory. 

1134. Corns may be prevented by wearing easy shoes. These 
are essential to persons who by their aA'ocations are required to walk 
a great deal. These individuals ought also to rub their toes with a 
little tallow, as well as to grease the ends of their stockings, and 
those points which are in contact with the projecting parts of the foot. 

The acute pain produced by corns may be appeased for some time 
at least, by cutting away the exuberant parts of these productions with 
a sharp knife. The eye of the corn may sometimes be picked out 
with the nails after soaking the foot in warm water, or softening the 
induration by the application of a soft cataplasm, or a piece of dia- 
chylon plaster, &c. Two or three operations of this kind, at the 
distance of a fortnight or three weeks from one another, occasionally 
suffice to remove the evil entirely. A blunt needle, fixed into a 
handle, is an excellent instrument for working out -these central 
nuclei. The part should afterwards be anointed with a little mutton 
suet and covered with a bit of soap or diachylon plaster. 

Plasters of soap, of mucilage, of gum ammoniacum, of galbanum, 
various unguents, the leaves of the house-leek, the pith of the rush 
used by coopers, cotton, fine linen, &c, applied around the toes, 
will all be found useful in treating corns of the feet, provided the 
sufferer at the same time reforms his boots and shoes in the essential 
point of size. It is not without great advantage either, that the 
central nuclei of corns are preserved from pressure, by being covered 
with a piece of thickish soft leather spread on one side with dia- 
chylon and pierced in its centre with a hole of a size corresponding 
to that of the nucleus to be defended. Sir A. Carlisle proposes the 
above means of dressing, continued during about six weeks, as a 
simple and very effectual plan of cure. 

Coins have also been destroyed by being rubbed with caustic 
potash, nitrate of silver, muriate of antimony, nitric acid, &c. These 
agents are attended with many inconveniences in inexperienced 
hands, and excision appears to be preferable. 

Historical Notices. 

1135. Corns were described very long ago. 2 Rousselot, 3 Lion, 4 
and Carlisle, 5 have studied them particularly in modern times. 



HYPERTROPHY OF THE VASCULAR ELEMENTS OF THE SKIN. 

1136. The vascular tissue of the skin occasionally acquires preter- 
natural enlargement. In one case the superficial veins become 
extremely apparent, ramifying in large branches in situations where 
none are usually seen (Phlebectasia) ; in another instance, but much 
more rarely, the skin presents small red spots, formed by extremely 

1 Anat. Topog. 8vo. Paris, 1826, p. 681. 

2 Celsus. De re medica, lib. v. sect, xxviii. 14. 

•J Rousselot. M.-thode certaine sur le traitement des cors. La Have, 1762. 
< Lion H7). I'reati-e upon spins pedum, with plates. London, 1802. 
s Carlisle. Obs. on the nature of corns. Medic. Facts and Observations.— Rec. 
period, de littoral, medic, etrang., t. ii. p. 142. 



delicate and almost capillary arborizations, angieetasia capillaris in a 
third set of cases, violet or purple covered stains appear upon the 
skin (mother marks) or bloody tumours, the centre or a considerable 
portion of the surface of which exhibits no vascular ramifications, at 
least wdien viewed with the naked eye, but whose circumference 
generally presents a remarkable vascular net-work, or numerous 
branches of dilated veins. 

1137. Phlebectasia, or simple dilatation of the veins, has been most 
frequently observed on the nose, in consequence of rosacea of long- 
standing, or of a preternatural enlargement of this part, somewhat 
analogous to Arabian elephantiasis in its nature. The veins occa- 
sionally acquire a very considerable size, and form very strongly 
marked bluish lines on either side of the nose. I have observed tliis 
dilatation of the veins in individuals of mature age without any other 
alteration of the nose. 

In those individuals who are affected with enlarged veins of the 
legs, the skin of the instep and inferior inner part of the leg often 
presents bluish arborizations, produced by some dilated venous 
twigs. One of the consequences of ascites, and of pregnancy, is 
occasionally a dilatation of the superficial veins of the skin as well as 
an enlargement of the principal trunks of the lower extremities. 

1138. Under the name of capillary angieetasia, I would designate 
those vascular spots or patches of various magnitudes, ramified on the 
surface, not prominent, and of a reddish or rose colour, different from 
the violet tint of the spots occasioned by dilatation of the veins. This 
variety of blood-mark maybe congenital or accidental. 

1139. Under the title of naevus araneus certain small congenital, 
reddish, arborescent spots, of the size of a sixpenny piece or less, have 
been described ; these disappear on pressure ; and very seldom occur 
singly, being frequently scattered over the whole of a limb or region 
of the body. These marks differ from certain other congenital spots 
which are occasionally observed on the forehead, the eyelids, &c, the 
uniform red tint of which has caused them to be compared to a ripe 
cherry. This last species of spot is frequently prominent. 

1140. There is a kind of red arborescent spot, of which I have 
met with but one instance, that bears a great analogy to the naBvus 
araneus. 

A woman, thirty years of age, of good constitution, who had long 
been an inhabitant of New Orleans, came to consult me on account of 
some spots of the description alluded to, which had made their appear- 
ance on one foot and on both legs about nine years previously, some 
months later on the hands and thighs, and very recently on the abdo- 
men. At first sight I took the spots she showed me for spider nsevi ; 
but the woman assured me that they were accidental, and that they 
increased every year in the spring season. The smallest of them 
could be covered with the head of a large pin ; the largest did not 
quite equal a sixpence in size ; the whole were covered with vascular 
ramifications ; but were without heat, unaffected with pruritus, and 
the seat of no desquamation of the cuticle. Neither the father nor 
mother of this person w T as affected with similar spots. She had been 
married at an early age, and had had nine children, five of whom had 
died in infancy. For the last four or five years the menstrual dis- 
charge had been scanty, and she was a good deal troubled with leu- 
corrhcea, but she enjoyed habitual good health notwithstanding this. 
In the hope of discussing the marks in question, the anti-scorbutic 
syrup, with the addition of bichloride of mercury, the Bareges baths, 
and baths with the addition of sulphate of iron, had been made use of, 
but unsuccessfully. I recommended a trial of astringent baths, and 
local styptic applications with no better success. 

In the Hopital de la Charite, I once saw a woman, on the back of 
whose foot and lower part of whose leg there was a reddish blotch, 
which disappeared under pressure, and returned immediately, and 
was evidently connected with an extraordinary development of the 
minute blood-vessels of the skin. This woman had no varices of 
the legs, and felt neither unusual heat nor itching nor smarting in the 
part affected. She had been aware of the existence of the red mark 
for a great many years. 

1141. Under the title of ?icevijlammei or port-wine marks, flat stains, 
marks or blotches of various shades of colour have long been desig- 
nated. These are sometimes of the shade of port-wine or claret, and 
sometimes of the stain produced on the skin by the raspberry or black 



VASCULAR N^VUS. 



357 



currant. They all become deeper in colour under the influence of 
those causes which accelerate the circulation, such as violent exercise, 
hot rooms, the use of strong liquors or stimulating food, affections of 
the mind, and in women the approach of the menstrual period. The 
portion of skin affected with this kind of naevus is little or not at all 
thickened or swelled. The surface of the spot is in one case smooth, 
in another more or less uneven and sometimes even shagreened and 
mammillated. The blood-vessels distributed to these congenital 
marks are occasionally of considerable size. Alibert has described 
and figured a case of naevus jlammeus under the name of ecchymome 
congenital. 

These naevi Jlammei occasionally extend from the skin to the neigh- 
bouring mucous membranes : in a man of the name of Petit Jean, who 
was received into the Hopital de la Pitie, on the 16th of November, 
1826, on account of pulmonary catarrh, one of these naevi was ob- 
served occupying the left half of the upper lip, and spreading from 
thence over the mucous membrane of the same side of the mouth. 
The temporal, malar and palpebral regions of the left side were also 
beset with irregularly circumscribed congenital spots, of the colour of 
wine lees, the skin between them being healthy. These spots did 
not rise above the level of the skin, did not disappear under pres- 
sure, and were unaffected with any unpleasant sensation. When the 
patient grazed any of these spots with the razor in shaving, he had 
always great difficulty in arresting the hemorrhage. Under the lower 
eyelid there were two small red vascular tumours about two lines apart, 
as large as grape-stones, soft, and capable of being flattened, and 
made to diminish in size with pressure. These two little tumours 
had arisen about two years previously after slight wounds. The skin 
around their bases was redder, and more evidently raised than it was 
about any of the larger spots. 

Naeviyfammei are occasionally only observed on one side of the body, 
as in the above instance. I have, however, seen a more remarkable 
one in the person of a man twenty-four years of age, the whole of the 
right side of whose body, including the right arm and leg, was covered 
with thickly set and in some places confluent spots of a vinous red 
colour. The colour of these spots did not become paler with pressure; 
but was evidently deepened under the influence of bodily exercise, 
exposure to an elevated temperature, &c. The subcutaneous veins of 
the right side generally were extremely large ; the mucous membrane 
of the right side of the mouth was also occupied by several spots of a 
ruddy violet colour. The gums of this side looked swollen and more 
vascular than usual. 

1142. These cutaneous vascular naevi left to themselves may long 
continue stationary. When they happen to become inflamed, they 
are apt to ulcerate ; and the sores that result are never healed but with 
great difficulty. E * * D * * was born with an extensive vascular 
naevus of the right forearm and hand. It did not rise sensibly above 
the level of the healthy skin that surrounded it. It was of a violet 
colour, and deepest upon the hand. Five weeks after birth this naevus 
was affected with inflammation in several places, which all gave way 
and became open ulcers. These spread gradually, became united, and 
at length occupied the whole surface of the preternatural formation. 
The extensive ulcer that now resulted discharged considerable quan- 
tities of blood and purulent matter, and only began to heal in different 
places, towards the age of five months. The hand and forearm not 
having been kept upon a horizontal split, as cicatrization advanced, 
were gradually drawn towards one another, and the cicatrice finally 
assumed the appearance of a thick hard band of the same nature as 
those that follow burns, extending from the breast along the anterior 
margin of the axilla, down the inner aspect of the arm and forearm, 
turning over the outer edge of which last, it gained the back of the 
hand, where it divided into several branches spreading downwards 
to the backs of the fingers, and upwards to the posterior and outer 
surface of the forearm, &c. The hand is consequently fixed in a state 
of extreme extension upon the forearm; this remains in a semiflexed 
position on the arm, and the arm itself cannot be brought into complete 
abduction. 

M. Sabatier once showed me a child at the breast affected with a 
cutaneous vascular naevus, situated on the inner aspect of the left 
thigh, ulcerated in several points, and presenting numbers of small 
cicatrices in others. 
90 



1143. Under the name of vascular growth of the skin I would indi- 
cate a rare and little known affection, characterized by small red per- 
sistent vascular elevations, scattered and isolated, or clustered together, 
scarcely rising above the level of the integument in the first instance, 
but subsequently attaining one or more lines in length, and then form- 
ing true excrescences. 

1144. These vascular growths, the etiology of which is extremely 
obscure, are commonly evolved on the face. Few in number and 
isolated at first, they occasionally become confluent in consequence of 
several successive eruptions. They often continue stationary during 
a long course of years ; but in some cases they become extremely nu- 
merous in a short space of time, without any appreciable cause. When 
these vascular growths are dispersed over the skin, this tissue gene- 
rally preserves its natural colour in the spaces between them ; but it 
acquires a reddish tint similar to that of naevus Jlammeus when they are 
very numerous and much crowded together. Pricked with a pin the 
vascular growths in question pour out a drop of blood ; cut into, the 
hemorrhage that follows is rather considerable. 

1145. When these vascular excrescences are situated on the extre- 
mities, they are seldom numerous ; and as they occasion neither incon- 
venience nor visible deformity, individuals affected with this slight 
alteration of the skin do not generally resort to medical assistance ; 
but when they occur in great numbers on the face, there are few who 
do not seek advice on account of the deformity which then ensues ; 
for the affection not only shows no disposition to improve, but on the 
contrary gets continually worse. 

1146. Styptic lotions, successfully employed against syphilitic ex- 
crescences, are unavailing in the description of the case at present under 
review. Vascular excrescences, as they scarcely rise above the level 
of the skin and have uniformly broad bases, cannot be attacked with 
the ligature. Excision and cauterization to be of any service must 
interest the whole thickness of the skin, in which case puckered cica- 
trices and a great deal of deformity ensue. Convinced by experience 
of the inutility of these surgical measures, I tried the effect of the 
bichloride of gold and soda, the action of which is so powerful in 
cases of syphilitic excrescences, whose organization appears every 
way as perfect as that of the vascular growths we are considering, but 
without any success. 

Case CLXXIV. — Vascular elevations and excrescences of the skin. 
Booklage, a German by birth, twenty-seven years of age, and of a 
lymphatic temperament, entered the Hopital de la Charite on the 16th 
of March, 1827, on account of a slight gastro-intestinal inflammatory 
affection, which gave way in the course of a few days to antiphlogistic 
treatment. 

This man also laboured under an extremely rare affection of the 
skin of the face, characterized by small vascular elevations and ex- 
crescences. The patient is not aware that this affection arose under 
the influence of any particular cause ; he only remembers having been 
told by his parents that it was not born with him, but made its appear- 
ance about the third year of his age. The excrescences, scattered at 
first pretty evenly over the face, by coalescing in a greater degree in 
one place than another, now form three principal bands. They are red, 
and appear completely vascular ; they shrink and become pale under 
pressure, but instantly return to their former size and colour, when 
the finger is removed. The smallest of them, of the size of a pin's 
head, scarcely rises above the level of the skin, and is of a pale rose- 
colour; the largest are globular in form, three or four lines in diame- 
ter; but several are filiform, especially such as are situated about the 
alae of the nose. Several of the excrescences grow from the free 
edges of the lips, but there are none on their inner surface nor around 
the orifice of the nostrils. On the gums of the upper jaw there are 
a number of small elevations and excrescences of the same colour as 
the general lining membrane of the mouth ; the prominent angles of 
the gums that lie between the several teeth are loose and movable. 
The forehead, ears, and eyelids are free from excrescences; the base 
of the nose is covered with them ; they become gradually fewer and 
fewer in number towards the root, where there are none. The 
skin of this member is red, as in cutaneous vascular naevi generally. 
There are no vascular excrescences on the neck, but three small cuta- 
neous appendages, two lines in length, are there perceived. On the 
back there are several appendages of the same description ; and both 






HYPERTROPHIC. 



on the upper and lower extremities there arc a few small tubercles of 
the form and magnitude of a split pea scattered about. 

On the -2d of April, 1 touched live or six excrescences situated close 
to the left side of the nose, with sulphuric acid, and a cluster of eight 
or ten others, situated on the chin, with nitric acid. Neither of these 
applications was complained of as extremely painful. 

The excrescences thus treated were detached spontaneously on the 
18th; the cicatrice was even, not at all conspicuous, and nearly of 
the colour of the skin. I therefore determined immediately to touch 
the whole of a warty-looking band, which ran transversely between 
the chin and the under lip, with the nitric acid. This application 
destroyed the excrescences, but it interested the skin through its 
whole' substance. The patient had for some time rubbed in the 
bichloride of gold and soda under the tongue, in quantities success- 
ively of a twentieth, a tenth, a fifth, a quarter, and a third of a grain, 
but without any evident influence whatever. 

Case CLXXV. — Vascular tumours and excrescences of the face. I 
was consulted for an affection similar to the last which had made its 
appearance in the spring of the year 1816, in a young man then in 
the twelfth year of his age, of a sanguine temperament and well 
formed. The red and enduring globular elevations which character- 
ized the affection, had appeared at first on the chin, and about the 
furrow which runs between the alas nasi and the face, and on the 
cheeks, especially on that of the right side. From the year 1817 to 
1826, these growths had scarcely been observed to increase either in 
number or in size. At the latter date, they were red, grew pale upon 
pressure, and bled profusely when one of them happened to be touched 
by the razor in shaving ; pressure was the only means of arresting 
the hemorrhage. 

Alcoholic and acid washes had been fruitlessly employed with a 
view of discussing these excrescences. I proposed to destroy them 
by the use of the potential cautery, but the patient having expressed 
great repugnance to this measure, I did not urge it; the disease was 
trifling in extent. 

1147. Cutaneous vascular ncevi frequently occur under the form 
of red grains or small ovoidal tumours, pediculated, or with bases 
which blend insensibly with the skin that surrounds them. This 
variety of nscvus appears at first in the guise of one or several spots 
of a rosy or red colour of varying intensity of shade, which children 
bring into the world with them. These spots are generally of trifling 
extent, and often bear a great resemblance to flea bites. They fre- 
quently continue stationary for several years, and only begin to enlarge 
in some cases about the age of puberty, or during an attack of dys- 
menorrhcea in females ; more generally, however, they extend both 
in breadth and depth from the very first, acquire a darker colour, and 
are gradually changed into red, uneven and irregularly circumscribed 
tumours, compressible and elastic, less tense when the individual 
affected with them is in a state of repose than when he cries or moves 
actively, indolent, without inflammation, and generally exhibiting 
nothing like pulsation, unless when they happen to lie over large 
arteries. These vascular tumours have been especially observed 
upon the forehead, about the root of the nose, on the eyelids, lips, 
lobe of the ear, labia majora, shoulder, and over the sternum. They 
commonly grow less rapidly than the vascular tumours of the same 
description accidentally evolved after birth. 

1148. Subcutaneous vascular neevi occur more frequently on the face 
than on other regions. The size of these tumours is diminished by 
pressure, and increases under efforts, exercise, crying, &c. ; but they 
do not pulsate, like aneurism, by anastomosis. 

1149. Congenital cutaneous and subcutaneous vascular tumours are 
characterized by a preternatural development of a point of the vas- 
cular network of the skin or subcutaneous cellular tissue. Two 
species are admitted ; erectile tumours, and varicose tumours. 

1st. Those vascular tumours which consist of erectile tissue (Du- 
pnytren), whether evolved as a consequence of a bruise or blow, or 
independently of any assignable cause, are of a reddish or brownish 
colour, and generally granular on the surface. Their base is com- 
monly broad, implanted in the skin and subcutaneous cellular tissue, 
and even penetrating between the muscles ; they communicate a pe- 
culiar jar to the hand applied to them, as if the obscure rushing of a 
fluid were felt, and dilate and contract synchronously with the dias- 



tole and systole of the heart. This pulsation is generally particularly 
obvious at their bases. Soft to the touch, when nothing irritates 
them, very slight stimuli cause them to increase remarkably, and to 
become extremely firm ; when wounded, the hemorrhage is always 
profuse, and stopped with difficulty. These vascular tumours never 
disappear spontaneously ; they tend, on the contrary, constantly to 
increase, to spread into new parts, and to disorganize these in their 
own peculiar manner. Having attained a great degree of develop- 
ment, these erectile tumours have been known to give way on the 
surface, to form the bases of enormous fungiform growths, and to give 
rise to hemorrhage so incessantly repeated and so profuse, as to cause 
the speedy death of the individual affected. 

Vascular tumours, consisting of erectile tissue, generally begin in 
the subcutaneous cellular substance of the lips, eyelids, 1 inner aspects 
of the arms and thighs, of the breasts, lobes of the ears, palms of the 
hands, 2 cheeks, &c, appearing at first in the shape of small, mov- 
able, indolent, and elastic red tumours, the progress of which is usually 
slow, if it be not accelerated by violent efforts, convulsions, and so 
on. The skin is for the most part only consecutively affected ; the 
disease finally gains the characters that have been indicated. 

Tumours of this description form well-defined masses of various 
sizes, covered occasionally with a thin fibrous envelop, presenting 
internally the appearance of a cellular or spongy cavity, consisting, 
in fact, of an inextricable plexus of mingled arteries and veins, com- 
municating by innumerable anastomoses like the capillary vessels, but 
of much larger size than these. The veins are readily injected from 
any of the surrounding branches ; injection penetrates with greater 
difficulty into the arteries. When these tumours only implicate the 
skin and subcutaneous cellular membrane, the neighbouring muscles 
are simply pushed aside without being altered in their structure. But 
the muscles very generally participate in the morbid change of struc- 
ture. The large vessels running in the vicinity of such tumours are 
generally free from alteration, (a) 

(a) JVavus, or vascular or erectile tumour, is so well and tersely 
described by Mr. Miller (Principles of Surgery), that I must introduce 
his remarks in this place. 

" The term denotes a diseased formation, in which the vascular 
tissue bears the most prominent part. There are varieties of such 
adventitious structure. 1. The capillaries of a portion of integument 
may be equably and permanently dilated ; producing discoloration, 
and but slight elevation of the affected part. Bleeding is copious 
from any breach of its surface, by ulcer, or by wound. This is one 
form of naevus, or congenital mark; an affection of no danger, and 
but little inconvenience ; which may be looked upon as rather a 
deformity than a disease. 2. The structure may consist chiefly of 
dilated veins ; not over-distended, and mere passive tubes, as in 
varix ; but retentive of tone, and energy of function ; fed by arterial 
branches, of somewhat corresponding size and activity ; yet the latter 
tissue holding but a comparatively subordinate part in the develop- 
ment of the tumour. This morbid structure is not found in the sub- 
stance of the true skin, like the preceding, but in the subjacent cellu- 
lar tissue ; of various size and prominence ; causing a doughy elastic 
swelling, of a livid hue — the venous structure appearing with tolerable 
distinctness through the superimposed integument. If breach of 
surface take place, the hemorrhage is profuse, and chiefly of the 
venous character ; capable of being arrested by pressure, without 
much difficulty. If an incision pervade the mass to any considerable 
extent, arterial branches are found spouting with much activity; still 
the main stream is dark and venous. Or the tumour may be sub- 
mucous ; as exemplified by one kind of hcemorrhoid, situated partly 
within and partly without the verge of the anus. 

" 3. The third form of swelling is composed chiefly of dilated and 
active arteries ; supplied with large tortuous veins, placed in the 
vicinity ; the principal mass consisting of the changed arterial tissue ; 
the veins not properly constituting any part of this, but being rather 
the mere conduits whereby the arterial contents are conveyed back 
into the general circulation. Also, in the neighbourhood, are to be 

: Mackenzie. On the Diseases of the Eye, 8vo. London, 1830. 
2 Rognetta. Mem. sur les tumeurs sanguines et lipomateuses de la paume de la 
main. (Gazette medicate de Paris, 5 Avril, 1834.) 



VASCULAR N^VUS. 



359 



2d. On the palms of the hands particularly, but also on other regions 
of the body, we occasionally observe soft bluish-coloured tumours, 
formed by a plexus of dilated veins. These vascular tumours di- 
minish under the influence of cold, the application of ice, and com- 
pression. They are much rarer than the species which has just been 
described. 

1150. Causes. — The causes of vascular naevi, and the mode in 
which they are formed, are little known. The vulgar opinion which 
attributes these alterations of the tissue of the skin, &c.,to the influ- 
ence of moral affections of the mother, reckons but few supporters in 
the present day. Chaussier has made the remark that nsevi were more 
frequent among those infants whose mothers were subject to chronic 
inflammation of the skin. 

The etiology of all the other varieties of accidental sanguineous 
blotches, excrescences, and tumours, is also extremely obscure. 

1151. Diagnosis. — Vascular marks, excrescences, and tumours, 
have external characters so striking, that they are not liable to be 
confounded with any other form of cutaneous affection. Cutaneous 
and subcutaneous vascular tumours differ from vascular neevi in regard 

found the feeding arteries ; originally twigs, now enlarged to trunks ; 
pulsating strongly, and obviously carrying on a plentiful and active 
supply. The mass may be subcutaneous ; constituting the true aneu- 
rism by anastomosis or erectile tumour ; varying in bulk and tension, 
according as the circulation is sluggish or excited ; compressible ; 
elastic to the touch, and indicating its tubular structure on being 
pinched or rubbed when in the flaccid state ; of a reddish hue ; in 
some parts tending to liver, but not continuously so, as in the preced- 
ing form of tumour. Or it may be submucous ; constituting the most 
frequent form of internal haemorrhoid. The structure is analogous to 
the normal erectile tissue ; but with this difference, that whereas in 
the normal, there are periods of complete repose and collapse, tension 
and fulness occurring but occasionally by local determination — in the 
morbid, there are never utter flaccidity and repose. The tumour is 
more full and tense at one time than at another ; yet at all times is 
full and active ; evincing an undulatory movement, if not actual pul- 
sation. Strictly speaking, there is no aneurism here ; but rather a 
simple exaggeration of arterial tissue and function ; no degeneration 
of coats, but simply dilatation; and yet not dilatation alone, but cor- 
responding increase of function as well. The morbid formation may 
supervene at any period of life ; but most frequently it is congenital ; 
and, growing faster than the normal structures around, claims our 
attention at an early age. The most common situations are, beneath 
the integuments of the face, head, and neck ; not unfrequently it forms 
on the hands and feet. The tumour pulsates synchronously with the 
heart's action ; but much less distinctly, and with less expansion, than 
the true aneurism ; it may be considerably diminished by equable and 
sustained pressure, resuming its wonted bulk on removal of the pres- 
sure ; a bruit is heard, dull and rough, and sometimes associated with 
a vibratory thrill. At first the skin is free ; ultimately it becomes 
involved in the morbid structure, and incorporated with the general 
mass. Sometimes the growth is slow ; sometimes, and more frequently, 
rapid. In all cases, bulk is temporarily increased by mental excite- 
ment, muscular exertion, and whatever suddenly and much excites 
the circulation. The tumour having become superficial by involve- 
ment of the skin, ulceration is likely to occur ; and hemorrhage 
follows, profuse, and not easily restrained ; demanding active interfer- 
ence, otherwise, by repetition or continuance, it may exhaust the 
patient. Or the ulceration may have a salutary result ; if surrounded 
and preceded by fibrinous exudation, the vascular structure may be 
consolidated, no bleeding taking place, even from an acute and 
wide ulcer ; and this consolidation advancing as the ulcer spreads, 
so as invariably to.precede and surround the breach, the adventitious 
structure may be altogether got rid of, partly by obliteration, partly 
by ulcerative loss of substance. Sometimes hemorrhage is vicarious 
in the female adult, taking the place of the menstrual discharge ; the 
tumour becomes tense and full at the return of each period ; a small 
fissure, or sore, forms in the skin, and from this the blood slowly 
distils ; such bleeding is seldom dangerous, or even excessive, and is 
not to be suddenly arrested, without means having been duly taken 
to secure return of the normal discharge." 



to the circumstances in which they are evolved. Tumours of erectile 
tissue do not, like varicose tumours, exhibit any dilated veins in their 
circumference. Vascular tumours, uneven on the surface, elastic, and 
of fungiform consistency, even at their base, are easily distinguished 
from abscesses of every description. It is, however, occasionally 
difficult to ascertain the extent of these tumours, for they frequently 
send prolongations deeply among the muscles, which are not indicated 
externally. Professor Boyer has related two remarkable instances ot 
this anatomical disposition. 

1152. Prognosis. — Vascular stains and excrescences are neveraffec- 
tions of much consequence in themselves. The case is very different 
in regard to congenital or accidental vascular tumours of the skin, 
especially to those consisting of erectile tissue. Left to themselves, 
they seldom continue stationary ; and when they have attained dimen- 
sions at all considerable, they can only be remedied by operations often 
of doubtful success, and sometimes extremely dangerous. 

1153. Treatment.— Compression, cold, and styptic applications, 
cauterization, artificial inflammation, the ligature used variously to the 
tumour itself or to the principal vessel that supplies it, and excision 
with the knife, have all been proposed for the cure of vascular tumours. 

After a careful review of almost all the cases of vascular or erectile 
tumours published up to the present time, and a comparison of the his- 
tories of these with the circumstances attending a great many others 
which he himself had seen both in England and in France, Mr. Tar- 
ral, in an excellent paper published in the Archives generates de Mede- 
cine, has given a summary of the different modes of treatment which 
have been proposed in these affections, the advantages or disadvan- 
tages of each, and the peculiar circumstances in which they are seve- 
rally applicable. 1 

Compression acts slowly, and cannot be had recourse to with advan- 
tage, or any likelihood of its proving successful save when the tumours 
lie over hard parts, which may be made to serve as points of support. 
Compression, to be decidedly useful, must also be applied with sufficient 
force to the whole extent and even to the parts beyond the circumfer- 
ence of the tumour. 2 The combined action of cold, compression, and 
styptic applications, as recommended by Mr. Abernethy, is not gene- 
rally deserving of much confidence. 3 

The ligature was employed with success by M. A. Petit 4 for 
pediculated vascular tumours. John Bell and White 5 have recom- 
mended a needle armed with a double thread of strong silk to be 
passed deeply under and across the whole mass of the tumour, and 
one half of it to be included within each of the threads. This plan 
of treatment is painful, and less certain in its effects than excision, 6 
which is the method usually adopted for the removal of vascular 
tumours of erectile tissue. It is also the kind of operation which, 
numerically considered, has been attended with the greatest amount 
of success, although, truth to say, it has occasionally been followed 
by alarming and even fatal hemorrhage. 

1154. Certain species of nsevi have been named as best attacked 
with the actual, or with the potential cautery. Quick lime has been 
recommended by one, 7 caustic potash by another (Graefe), and nitrate 
of silver by a third. Mr. Tarral has given a great number of cases 
which show incontestable, that simple cauterization of the more super- 
ficial parts of these tumours, may be had recourse to with frequent 
success; that by this means the smaller of them often disappear, 
apparently from the direct action of the escharotic thus applied, and 
that even the larger may by this means have their vessels obliterated 
and their vitality so much altered as to shrink and gradually to vanish. 
When the tumours are large, repeated cauterization is practised; the 
operation causes little pain. Wardrop, 8 who was the first to propose 

' Tarral (Claudius). Du traitement des tumeurs erectiles et particulierement du 
traitement par la caustique. (Archives generates de Medecine, Septembre et Octobre, 
1834.) 

2 Boyer quotes a remarkable case of the cure of a naevus of the upper lip and sep- 
tum of the nose obtained by pressure almost unremitting: kept up by the mother of 
the child (Traite des Mai. Chirurg., vol. ii. p. 269); M. Roux succeeded in. curing 
another similar case by the same means. 

a Abernethy's Surgical Works, vol. ii. p. 220. London, 1819. 

* Petit (M. A.) cited by Saviard. Obs. chir., p. 515, obs. 114. Paris, 1700. 

s White. Medic. Chir. Trans., vol. xiii. 1827. Arch. gen. de med., t. xvii. p. 445. 

s Petit (J. L.). CEtivres chir.,t. i.— Bell (J.). Surg. Works, vol. l. 4to. Edinb.,1801. 

i Callisen. Syst. chir. hodiern., vol. ii. p. 202. 

8 Wardrop. Lancet, London, 1827. 



3G0 



HYPERTROPHIC. 



and to practice this mode of using caustic in bloody nacvus, tells us, 
that he had never known the application followed by hemorrhage, and 
further, that its employment had been uniformly successful. 

With a view of exciting inllammation in these tumours, we have 
heen advised to inoculate vaccine matter upon their surfaces. 1 
Several eases are also quoted of cures performed by means of the 
ointment of tartrate of antimony, 2 rubbed into them ; and this plan 
has the advantage over the former of being applicable to those who 
have already had cow-pox and small-pox. 

Mr. Lawrence has proposed to pass a seton through large tumours 
of erectile tissue. 3 And Mr. Lloyd 4 has spoken of injecting them with 
a tluid containing from three to six drops of nitric acid to a drachm of 
water, care being taken to compress the circumference of the tumour, 
during the operation. Dr. Marshall Hall 5 has recommended a cata- 
ract needle with cutting edges to be plunged into these tumours, and 
their substance to be traversed in eight or ten different directions 
without withdrawing the instrument or perforating the skin anew. 

Of all these modes of treating vascular tumours, the plan of Mr. 
YYardrop appears to me the best. 

More than one excellent surgeon has further proposed and even 
practised the ligature of the principal arterial trunk whose branches 
are distributed to these tumours. 5 This operation has been imagined 
with especial reference to erectile tumours evolved in the orbit, and 
those situations in which they are inaccessible by any of the other 
means already enumerated, as well as to such as, from their immense 
extent, and the importance of the parts among which they penetrate, 
cannot properly be attacked with caustic, the ligature or the knife. 
It has also occasionally been performed as a preliminary to the remo- 
val of these tumours, and as a means of controlling hemorrhage, and 
sometimes only as a palliative, and to prolong for a time the life of 
the patient hourly threatened by the progress of the disease, (a) 

(a) Of the different modes of treating nsevi described in the text, 
that by ligature is preferable in most cases in which an operation is 
deemed necessary. I have, myself, repeatedly succeeded in removing 
these congenital tumours by applying tartar emetic plaster over them, 
and keeping it on sufficiently long to cause free pustulation and ulcera- 
tion. 

If the caustic, potassa fusa, for example, be used to produce ulcera- 
tion, it ought to be rubbed lightly, so as not to produce a large eschar, 
the separation of which would likely be followed by hemorrhage. 

The method by excision is spoken of in the text, in terms of more 
decided approbation than surgeons generally use when speaking of 
it. Mr. Miller will, we believe, be found to express the prevailing 
opinion on this point, when he says : " Excision, so applicable to 
tumours in general, is inexpedient ; the extent and activity of the 
component vascular tissue render that mode of removal in the highest 
degree perilous. To cut into the texture of such a tumour, when 
large and pulsating, w r ould be madness ; the gush of blood might 
prove almost instantly fatal. To cut even wide of the diseased 
texture, is not always a matter of safety ; unless the knife move 
cautiously, and the forceps and ligature follow nimbly after, the loss 
of blood will still be dangerous. The mode of removal by excision, 
therefore, must be limited to those tumours which are small — not 
larger than a prune — of no unusual activity, not fed by large and 
numerous arterial trunks, so situated as to admit of the incisions being 
made wide of the diseased structure, and also in a locality favourable 
for the use of the ordinary means of restraining hemorrhage. In all 
other cases, the ligature is preferable." 

The operation by ligature is thus briefly described by Mr. Miller. 
" A needle is passed beneath the mass, carrying a stout ligature ; the 
needle is withdrawn, and the ligature left ; its noose having been cut, 

' Hogdcon, of Birmingham, (Medico-Chirurgical Review, t. vii. p. 280, 1827.) 

1 Young, of Glasgow (Glasgow Medical Journal, t. i. p. 93, 1828). 

3 Lawrence. Lancet, 1831, p. 162.— Macil wain. On deep-seated nasvi, Med. 

Chir. Transact., vol. xviii. p. 1, p. 189, 1833.)— Gaz. med. de Paris, 25 Janvier, 1834, 

p. 54. 

* Lloyd. Cited by M. Tarral. (Mem. cite., p. 209.) 

* Marshall Hall, i-ond. Medic. Gaz., vol. vii. p. 557. 

« Travers. Medic. Chir. Transact., vol. ii. p. 1. London, 1809.— Dupuytren, cited 
hv M. Breschet. Traducitfji de Hogdson, sur les maladies des arieres et des veines, 
fvo. Paris, 18J9.. 



Historical Notices. 

1155. Vascular spots, and tumours of erectile tissue were observed 
at a very early period. But it is only since the writings of John Louis 
Petit threw light on their true nature, that really important researches 
have been instituted with regard to their structure and their treatment. 
For further information on this subject, I beg to refer to the works of 
the celebrated surgeons of our day, to those particularly quoted be!ow u 
and to the excellent paper of Mr. Tarral, already mentioned. 



CHELOID TUMOUR. 
Vocab. Art. Cancroid, and Keloid tumour. 

1 156. Under the name of Kelo'ide or Cancroide is described a species 
of oval or cylindrical-shaped tumour of a permanent character, reddish 
colour, sometimes with a smooth, but often presenting a wrinkled 
surface, of a hard and firm consistence, without pulsation or rushing 
in the interior, slightly prominent, spreading in flat patches, or send- 
ing off from the circumference cylindrical or ovoidal prolongations, 
which have been likened to the claws of a crab. 

1157. Symptoms. — The appearance of this description of tumour is 
not the same at its commencement as it is at a subsequent period of its 
growth. There arises at first on some point of the healthy skin, and still 
more frequently on the cicatrice of a phlyzacious pustule, of a wound, 
a burn, &c, a reddish point, of the form and dimensions of a grain of 
barley. This point is occasionally affected with pruritus of a pretty 
severe description. Several of these points have been seen arising 
simultaneously on different parts of the skin which had been irritated 
by the previous development of phlyzacious pustules. I have, for 
instance, seen them occurring on the face after confluent small-pox, 
and in the course of a few months acquiring all the characters proper 
to the cheloid tumour in its radiated or completely developed form. 

When the cheloid tumour is examined with care in the first stages 
of its growth, and when it does not yet exceed a small hazelnut or 

each portion is tied separately on either aspect, so as to include the 
whole of the morbid tissue ; pulling with as tight a strain as the liga- 
ture will bear, in order at once to kill the included part, and save 
both time and pain. If the swelling be circumscribed and prominent, 
this mode of deligation will be found very suitable ; if diffuse, a second 
needle and ligature may be passed at right angles to the first, and 
managed in a similar way; the tumour then being secured by four 
nooses instead of two. Or, if too flat and spread for even this, two 
hare-lip pins are passed beneath the base, at right angles to each 
other, and left permanently there, each extremity of each needle pro- 
truding somewhat beyond the integument ; then a stout ligature is 
thrown around the whole mass and drawn tightly, secured beneath 
the protruding ends of the needles ; in this way, the noose is made to 
embrace the wdiole of the diseased formation. In whichever way 
deligation is employed, it is often necessary, in the case of large 
tumours, to make a fresh application within a few days after the first, 
in order to expedite the sphacelation. Btit in all cases in which the 
integument is uninvolved, the use of knife and ligature may be 
happily combined ; the former being employed, in the first place, to 
reflect the integument in flaps, and thus to expose the diseased struc- 
ture naked and defenceless to the needle and ligature. In this way, 
strangulation is effected much more effectually ; the part is killed at 
once, and soon sloughs away. The flaps are then reponed ; and, in 
consequence, not only is the process of cure by granulation abbrevi- 
ated, but loss of substance saved, and consequently less cicatrix and 
deformity occasioned: — a point of some considerable importance, 
when it is remembered that the ordinary sites of the tumour are on 
the head, face, and neck. Sometimes the morbid structure is so 
diffuse, as to render inclusion of the whole, by one deligation, 
impracticable. In that case, it may be taken away in detachments ; 
the operation being repeated at different parts, successively." 

' Dupuytren. Clinique Chirurg. de l'Hotel-Dieu, t. iv. p. 1. Paris, 1834.— Dupuy- 
tren. Vide med. oper. de Sabatier, edit. Sanson, t. iii. p. 245. Paris, 1832.— Roux. 
Diet, de med. Art. Tumeur.— Tarral. Mem. cit.— Lawrence. Lecture (Lond. Med. 
Gaz., t. vi. p. 228). 



CHELOID TUMOUR. 



361 



(he barrel of a quill in size, according as its shape is ovoid or cylin- 
drical, its surface is found covered with numerous transverse wrinkles. 
Generally indolent, these formations are commonly unaffected with 
morbid heat, or pain, and it is very seldom, indeed, that they are the 
seat of any thing like painful shooting sensations. 

Several months, and sometimes many years after their first appear- 
ance, these tumours extend in length and acquire something of the form 
of a finger (Keloide cijlindracee, Alibert). The wrinkles of the surface 
become at the same time more conspicuous ; the tumour preserves its 
hardness unimpaired, and now looks like a kind of tuberosity, flattened 
at one of its extremities, whilst it appears withered and shrunk at the 
other. In this state the cheloid tumour is not affected with pulsation; 
neither does it communicate any thing like a jarring sensation to the 
hand applied to it, like vascular erectile formations ; yet its size is 
affected by various accidental circumstances ; it swells, for instance, 
under the stimulus of increased temperature, of violent exercise, of the 
approach of the menstrual period, &c. Cheloid tumours occasionally 
exhibit very small blood vessels on their surface, and almost always 
send off arms or radii from their circumference, which give them a very 
characteristic appearance. 

1158. Instead of extending in length only, the small reddish and 
resisting tumours in which cheloid formations commence, sometimes 
enlarge in all directions, and acquire a quadrilateral rounded or oval 
form {Keloide ovalaire, Alibert). The hard and prominent circumfer- 
ence rises unevenly, and the centre appears depressed. The bounda- 
ries of the tumour, now distinctly marked, are evident to the eye by 
the reddish colour of the new formation. This variety of cheloid 
tumour sends off prolongations from several points of its circumference 
in the form of cones, which are lost in the substance of the skin at the 
distance of several lines from the bounding line of the tumour. 

When the disease, thus far advanced, is left to itself, after an in- 
terval, generally of several months, its central part, or different points 
of its circumference, appear to become the seat of some new action 
which causes them to turn soft, to shrivel and wrinkle, and finally to 
assume the appearance of bands similar to those of the cicatrices that 
follow burns in the third degree of severity. The progress of the 
peculiar tumours under consideration is otherwise so slow, the incon- 
veniences they occasion are in general so trifling, that I have known 
patients refuse to submit to the curative means proposed for their 
relief. 

1159. Causes. — I am not aware that cheloid tumours have been 
observed among children previously to the period of the second 
dentition. The majority of the cases which have been published, 
and those I have myself seen, occurred among adults and the aged. 
Some slight circumscribed local inflammation, a scratch, the alteration 
of the skin consequent upon small-pox, a burn, &c, seem to prove the 
usual existing causes of these tumours. Their formation, however, 
appears to depend further on some peculiar state of the constitution. 
Although they have been met with in individuals of every variety of 
temperament, they nevertheless appear to be most frequent among 
persons of lymphatic constitution. 

This kind of formation is rare. I have not met with more than 
ftre cases of it in the course of my practice. In three of these the 
tumour arose over the sternum without assignable cause ; in another 
it occurred on the buttock of an adult upon the cicatrice of an exten- 
sive burn which he had received when but a few months old. In 
the last case I encountered, there were two tumours, one on either 
cheek; these supervened after small-pox. From the cases recorded 
by other observers, 1 women appear to be at least as liable to the dis- 
ease as men. Accident, however, has shown me four men, and only 
one woman affected with it. 

1160. Diagnosis. — There is no difficulty in recognizing the cheloid 
tumour when it has attained any considerable size, whether it appears 
under the form of a broad, reddish cylindrical crest or ridge, or 
that of a flattened tumour, sending off prolongations from its circum- 
ference, bearing some analogy to the claws of a crab. But the 
distinguishing features of the small reddish tumours by which these 

1 Alibert, in his Monographie des dermatoses, mentions eight cases of cheloid 
tumour, six of which occurred among women, two in men. One of these tumours 
was evolved on the face; a second on the neck; the rest occupied the sternal 
region. 

91 



varieties of the tumour begin in common with syphilitic, scrofulous 
and cancerous tubercles, and sanguineous na?vi, are not so decided 
as to be at all times readily at once appreciable. Still the cheloid 
formation, independently of any inference deducible from the most 
frequent seat of its development, the sternal region, presents charac- 
ters enough to distinguish it from any other form of cutaneous affec- 
tion. It is, for instance, harder than the scrofulous cutaneous tubercle 
even from its first appearance; its wrinkled surface is in obvious 
contrast with the smoothness and polish of the syphilitic tubercle : 
cancerous tubercles are usually affected with acute lancinating pains, 
which never occur in the early stages at least of the cheloid tumour : 
syphilitic, scrofulous and cancerous tubercles almost always end in 
ulceration, without, for a time at least, spreading superficially. The 
cheloid tumour extends, but does not ulcerate. Scrofulous tubercles 
are moreover peculiar to certain constitutions, and are very frequently 
accompained with ulcers, cicatrices and other alterations of a stru- 
mous nature. Syphilitic tubercles uppear under the form of an erup- 
tion ; the cheloid is very frequently solitary, and it is much more 
slowly evolved. Vascular nrevi and erectile tumours often present 
pulsations which are never observed in the cheloid tumour; these 
are besides soft, compressible, and disappear in a great measure 
under pressure, whereas the cheloid formation is hard and becomes 
pale, indeed, under the finger, but does not shrink or diminish sensibly 
in size. 

1161. Pror^nosis and treatment. — Cheloid formations do not seem 
to have any deleterious influence on the general health. The red- 
dish tubercles by which they begin have a constant disposition to 
extend ; but they only increase with extreme slowness and occasion- 
ally continue during life altogether stationary. They have even been 
seen, after attaining a certain size, to shrink and to disappear either 
in part or Avholly, becoming changed into a kind of cicatrice. 

I have made but a very few attempts to cure tumours of the 
description under review". When they are situated over parts such 
as the sternum, which afford bases for instituting pressure of sufficient 
amount and permanence, this means appears to me preferable to any 
other. In one case, in which I recently tried this plan of treatment, 
the tumour had already decreased considerably, when the patient, 
feeling little solicitude about the ulterior progress of the affection, 
demanded his discharge from the hospital. 

The excision and cauterization of cheloid tumours in the small 
number of instances in which one or other of these procedures has 
been instituted, have been followed by returns of the disease. They 
are therefore generally left to themselves : the symptoms that accom- 
pany them are nowise urgent, and the measures that have hitherto 
been tried for their cure have proved any thing but uniformly suc- 
cessful. 

Historical Notices and particular Cases. 

1162. The cheloid tumour was mentioned by Retz under the 
strange name of fatty tetter (dartre de graisse). 2 To Alibert we are 
beholden for the first accurate description of the disease. 3 

Case CLXXVI. — Cheloid tumour of the right buttock developed after 
a burn. Mousselet, forty-four years of age, presented himself among 
the out-patients at the Hopital de la Charite, on the 18th of May, 1834. 
This man has from his infancy had a tumour upon the right buttock, 
Avhich he attributes to the effects of a burn. The tumour is of the 
size of a child's hand, and is shaped very like a crab. In its centre 
it is formed of bands of a bluish-white colour, which terminate supe- 
riorly and inferiorly in prolongations of a very decided reddish cast ; 

2 This disease is very extraordinary: I have only met with three cases of it. The 
epidermis is not affected; it is only of a deep red colour, and is raised by a collection 
of solid matter, which here occurs in lumps of the size of an apricot, and there in 
rays the length of the finger, and as thick as macaroni ; or the substance appears 
under the form of flattened and extensive wens, much raised and as broad as one or 
both hands. These wen-like patches are singularly interlaced with bands of the same 
substance, of different thicknesses, resembling broad cicatrices, and form several 
folds and counterfolds as if there were sundry cicatrices placed one on the top or by 
the side of the other. Retz. Des mal. de la peau, et de celles de l'esprit, p. 55. Paris, 
1790. 

s Alibert. Precis theorique et pratique sur les maladies de la peau, 2 vols. gvo. 
Paris, 1810, Art. Cancroides, t. i. p. 417. Atlas, pi. 28-28 bis.— Alibert. Monographs 
des Dermatoses, t. i. Art. Keloide. Vallerand de Lafosse, Revue Med., Oct., 1829. 



362 



HYPERTROPHIC. 



prolongations are sent oil from its upper part in the form 

of a fork ; one of them ends in a small mass of a redder colour, 

harder consistence, ami greater prominence than the rest. The pro- 

ons were lust insensiblj in the substance of the skin. The 

most prominent of them was marked with very distinct transverse 

The father of this man is affected with a tumour over the sternum, 
and his brother has a number of congenital marks upon his breast. 
inplains of no pain in the tumour, but occasionally of a kind of 
smarting or pricking sensation. The tumour is evolved on the cica- 
trice of a burn which is still very apparent in one place. The object 
if this man's visit to the hospital was not on account of the tumour 
described, but of a fall which he had had some weeks before. He 
was bled. He is the father of four children, none of whom are affected 
with cheloid tumours. 

CLXXVII. — Cheloid tumour, depressed in its centre. A 
woman, aged sixty-five, presented herself among the out-patients at 
the Hopital de la Charite, in the course of the year 1831, having a 
cheloid tumour on the fore part of the chest. She says, that at the 
thirty-live years she received a puncture over the middle of the 
sternum with the point of a knife ; that a spot, the size of a pea and 
the seat of troublesome pruritus from time time, followed this wound. 
Ten years after the cessation of the menstrual discharge, this pruritus 
became still more urgent, and the spot began to enlarge. At the 
present time, twenty-eight years since the receipt of the puncture of 
the skin covering the sternum, upon the median line and about the 
level of the third rib, a transverse tumour is perceived, of a whitish 
colour in its centre, like the cicatrice of a burn, about a quarter of an 
inch in diameter perpendicularly, by about three inches in diameter 
transversely. From this central cylindrical production, three red rays 
or arms, rising about a line above the level of the surrounding integu- 
ments, and five lines in length, are sent off with remarkable symmetry, 
which bear no slight resemblance to the disposition and form of the 
claws of a river crab. 

According to the patient's account, the centre of this cheloid pro- 
duction, now white, and somewhat wrinkled like an old cicatrice, 
was formerly as red as the radii detached from the tumour. The red 
colour disappears on pressure. The tumour is painful and itchy. 



HYPERTROPHY OF THE CORION. 

1163. Hypertrophy of the corion or dermis sometimes shows itself 
externally in the shape of small lenticular tubercles, the colour and 
consistence of which are very nearly the same as those of the skin that 
surrounds them. These tubercles are scarcely ever seen among 
children, but they are not rare among adults and individuals of mature 
years. They occur most commonly on the upper lip, and on the alas 
nasi. They are occasionally congenital, and are then frequently sur- 
mounted by one or several strong and bristly hairs. They never ter- 
minate either in resolution or suppuration, and when they increase in 
size it is only in the slowest and most gradual manner. 

1164. It often happens as one of the consequences of obesity, that 
the skin in the vicinity of old ulcers, and as an effect of elephan- 
tiasis Jirabica, that the integuments covering the parts affected expe- 
rience a real hypertrophy, and acquire a mammillated or tuberculated 
appearance (vide Elephantiasis Arabum). 

1165. Hypertrophy of the corion and subcutaneous cellular sub- 
stance may be limited to a single region of the body. This species 
of structural change occurs more frequently in the nose than in any 
other part. 1 The affection takes place very slowly and gradually, 
and most commonly without any evident cause. It generally attacks 
individuals of mature years. Women appear to be its subjects very 
rarely. It occurs under three principal forms ; in one case the lobes 
of both ake nasi are affected with hypertrophy simultaneously, accom- 
panied with a notable development of the vascular rete of the skin, 




which assumes a vinous red colour ; in another instance one or more 
small tumours of the form and dimensions of the indurations of rosa- 
cea, appear upon the alae nasi; in a third instance these two forms of 
hypertrophy occur combined. 

Hypertrophy of the ake nasi extends by degrees towards the root 
of the organ. The small tumours or indurations that make their 
appearance on their surface may continue long stationary, and never 
exceed a small hazelnut in size, or they may attain dimensions much 
more considerable. Not only do they then deform the features, but 
they impede the free entrance of the air into the nostrils, and even of 
food into the mouth. The tumour has a knotty uneven surf; 
ternally, and is of a deep red or purple colour, traversed by an infinity 
of fine tortuous vessels. The various nodules composing the general 
hypertrophy are often separated from each other by deep fissures. 
When the affection is of very long standing, the integument of the 
cheeks sometimes acquires a colour and an appearance similar to that 
of the enlargement of the nose. The sebaceous follicles are very 
much developed, and the secretion from them sensibly increased. As 
the disease advances the enlargement extends in length, hanging 
down upon the upper lip and over the mouth in one or several lobu- 
lated masses. In the aged, the hypertrophied nose occasionally ulcer- 
ates superficially in one or several points of its surface. 

1166. The hypertrophy now described, although accompanied with 
a considerable morbid increase of the vascular rete of the skin and 
subcutaneous cellular membrane, differs in point of structure from the 
sanguineous erectile tumour. When wounded with a cutting instru- 
ment these enlargements bleed profusely, indeed, but their lamellar, 
hard and dense tissue, which is one of the principal elements in their 
composition, differs entirely from the open, spongy substance which 
constitutes the erectile tumour. Both in its external appearance and 
organization, this alteration of the skin of the nose has still less re- 
semblance to cancer. 

1167. Topical blood-letting is an efficient means of checking the 
progress of this affection. A woman of the name of Bertin, thirty- 
four years of age, became an out-patient at the Hopital de la Charite 
in the month of April, 1827. The point and left side of the nose were 
enlarged and of a vinous red colour. The redness and swelling 
disappeared on pressure, and were not accompanied with either heat 
or pain or itchiness. The affection had commenced with a slight 
pain in the alas nasi towards the middle of October last, having neither 
been preceded nor accompanied with any symptom of an inflamma- 
tory nature. The red tint of the part affected was most vivid in the 
morning, at the moment of waking; it declined slightly by and by. 
It had been temporarily increased by the application of a plaster which 
had been recommended to the patient, of the composition of which she 
knows nothing. Several applications of a number of leeches to the 
orifices of the nostrils subdued the swelling and the redness of the 
parts materially. 

1168. The local abstraction of blood is unavailing when the upper 
part of the nose has been swollen and injected for several years. 
Affections of this description, indeed, as they constitute simple deform- 
ities ratherj:han troublesome maladies, are not often made the sub- 
ject of any special treatment. A man, named Mocton, fifty-three 
years of age, of a sanguine temperament, is the subject of this kind of 
vascular and incurable hypertrophy of the root of the nose. It is 
now, April, 1827, nearly five and twenty years since the lobes of the 
nose began to swell and to present a ruddy violet colour. The size 
of the base is nearly the double of what it ought to be, and is of a 
violet hue, which becomes redder under the influence of increased 
temperature or after indulgence in strong liquors of any kind, a cir- 
cumstance, however, which does not prevent Mocton from yielding 
to temptation at very frequent intervals. Cold, on the contrary, ren- 
ders the tint deeper. The orifices of the cutaneous follicles are 
extremely open. The nose is unaffected with rosacea. 

1169. Patients often seek medical aid, the base of whose nose is 
surmounted with many cellular and vascular tumours. Civadier, 
Hey, Dalryrnple, and several other surgeons, have removed such 
tumours with success. Imbert Delonnes 2 removed a tumour of this 
description, which weighed two pounds, and hung down as low as 

2 Imbert Delonnes. Progrds de la chirurgie en France, 8vo. Paris, an. viii. 



OF THE SUBCUTANEOUS TISSUES. 



363 



the breast of the patient. When such tumours are only attached to 
the nose by a narrow pedicle, which, however, is not commonly the 
case, they may be removed with a ligature. 1 

1170. -Hypertrophy of the skin of the extremities is even more fre- 
quently met with than that of the nose. I once examined the arm of 
a woman, with M. Reynaud, who had had the right breast removed 
on account of a cancerous affection of the mammary gland. Subse- 
quently to the operation, the lymphatic glands of the axilla had en- 
larged, and become scirrhous; the right arm then became cedematous, 
and the skin of the forearm, hard, grayish, and tuberculated on the 
surface ; it bore a very considerable resemblance to the skin of the leg 
of the elephant. There was a large ulcer on the back of the hand, 
at the bottom of which the extensor tendons could be seen ; the dis- 
charge from this sore had been copious and fetid. Towards the upper 
and inner part of the arm there was a kind of excrescence which pro- 
jected nearly half an inch. The surface of this growth was smooth 
and reddish ; a part, into which an incision had been made, was of a 
dull white ; it was traversed by a number of small vessels; its general 
characters were in all respects those of encephaloid formations, espe- 
cially of that variety which is often found in the stomach. There 
were two other tumours of a similar kind, of smaller size, near this 
principal one. A careful dissection of the skin of the forearm ex- 
posed the following particulars : a great number of lobules or nipple- 
like eminences arose from its surface. The smallest might be regarded 
as simple papilla? very slightly developed, others were of the size of 
a large pea, or even of the extremity of the little finger. Those of 
considerable magnitude were uneven on the surface; secondary ma- 
millary eminences rose from, and gave them something of a mulberry 
appearance. In the spaces between them there existed a number of 
orifices, apparently belonging to the cutaneous follicles. An epider- 
mic formation, of a dirty gray colour, and of very considerable thick- 
ness, covered them ; the outer layers of this rather resembled a kind 
of scurf deposited irregularly than a proper membrane, and were 
rubbed off with the greatest ease. When thus removed, the adhering 
surface exhibited a multitude of elevations, which appeared to bury 
themselves by their bases, within the spaces between the mammillae and 
in the follicular orifices, and represented in exaggerated intaglio and 
relief the different particulars of the external surface of the skin. 

Under this layer there existed another of a dull white, covering the 
papillae and nipple-like eminences in a more uniform manner, and 
adhering to them more intimately ; after maceration for a few days, 
however, this inner layer could be detached with the same facility as 
the outer one, when it appeared under the guise of a second epider- 
mic lamina, its outer surface being of a dull white ; its inner aspect, 
on the contrary, appearing slightly sprinkled with black, apparently 
contained in a thin mucous-looking layer, entangling a little dark 
colouring matter. In some places this remained deposited on the 
papillae and nipple-like projections under the form of a layer which 
was readily removed by scraping. 

The numerous elevations which beset the surface of the skin imme- 
diately underneath it, now appeared so much the more conspicuous, as 
the thickened cuticular layers were removed, these having penetrated 
the spaces between them, and tended to conceal the extent of their 
relief. The papillae then appeared under a variety of aspects, accord- 
ing to their size; the smallest consisting of slight simple projections, 
somewhat flattened, and presenting a faint tinge of black upon their 
summit, similar to papillae generally, when slightly enlarged, but 
forming, especially when seen under water, a kind of nap or pile, 
extremely similar to that which is observed on the mucous membrane 
at the commencement of the small intestines, when it is examined 
under the same circumstances. There were others which did not 
differ from these, save in being a little less prominent; others again, 
of a larger size, radiated from a kind of central foot-stalk; to con- 
clude, there were nipple-like projections of small size, and patches 
of flattened laminae standing side by side, like the leaves of a book, 
and by their general reunion, composing mammillae of various magni- 
tudes. The epidermic lamina 1 , of which I have made mention first, 
did not penetrate between the layers of these composite mammillae ; 
they merely covered them generally. Divested of their common 

1 Ephem. Nat. Cur. dec. iii. ann. viii. et viii. Obs. clxxxiv. 



covering, and floating in water, as I said before, these elevations 
bore a strong, though, of course, an exaggerated, resemblance to the 
foliaceous and ramffied villi of the small intestines, when examined 
with a magnifier under water. 

The skin cut through perpendicularly, presented some differences 
of appearance before and after maceration. Before maceration, the 
corion, considerably increased in thickness, formed a deep layer, to 
specify the exact limits of which was easy. Its surface was plain in 
some places, as the direction of the line, which showed its termi- 
nation, indicated. In others it was sinuous, and the corion appeared 
to enter as a constituent part into the composition of the papillae and 
mammillary eminences. 

Under the corion there was a layer of considerable thickness which 
in some points was not very distinct, but which in others was easily 
distinguished by its slightly bluish cast of colour. This layer entered 
as an element into the organization of the elevations of the skin, and 
even formed its basis. It was infiltrated with a very considerable 
quantity of serum, and in the points corresponding to the elevations, 
and particularly to the larger of these, it was traversed perpendicularly 
by ramifications of arteries and veins, which expanded on the surface 
of the papillae and mammillary eminences. Some of these eminences 
were of a vivid red, not only on their surface but to a certain depth also. 
This appearance was destroyed by maceration. When the serous 
infiltration had flowed out, the corion was seen penetrating into the 
whole of the elevations. 

In this case of hypertrophy of the skin, as well as in many others 
which I have examined, the inner surface of the skin had nothing of 
the muscular appearance which Osiander 2 informs us he detected in 
the skin of the abdomen of several women who had died in child-bed. 
The corion, the papillary body, the albid and epidermic layers were 
truly hypertrophied, but the follicles of the skin did not appear to have 
participated in this anormal development. 



HYPERTROPHY OF THE SUBCUTANEOUS CELLULAR, AXD ADIPOSE 
TISSUES. 

1171. I have met oftener than once with individuals affected with 
accidental as well as congenital tumours, frequently pyriform and pedi- 
culated, varying in their dimensions from the size of an olive to that 
of a large pear, and consisting of cellular substance* which the skin, in 
a perfect state of health, or furnished with a larger number of blood- 
vessels than usual, covered externally. A man, fifty-one years of age, 
who died of dropsy in the Hopital St. Antoine, had a great number of 
congenital tumours of the above description on different parts of his 
body. Their size varied between that of a pea and that of a hen's 
egg. The smallest of these tumours were pediculated ; the largest 
were globular, soft and flaccid. There were several on the face, and 
some on the extremities ; but they were most numerous on the trunk. 
On incising the smallest of these tumours vertically, the ^cut was 
smooth, cellular, without any appearance of vessels ; but several were 
seen in the tumours of a somewhat larger size ; and they were so con- 
spicuous in the largest of all that the cut surface became covered 
with blood ; the tumours were also of a livid colour, and by com- 
pressing them, numbers of veins swelled up and became extremely 
conspicuous in their interior. These tumours contained no fat, and 
their white appearance or bluish cast in those places where they were 
traversed by veins, distinguished them sufficiently from fatty growths. 
Of a soft consistency, not creaking under the knife when cut, nor pre- 
senting those lines of a dull white, and those bluish veins so uniformly 
met with in scirrhous tissue, the tumours under consideration Avere 
evidently not of this nature. Over the surface of this man's body 
there were, further, a considerable number of congenital patches, 
some of a milk-coffee colour, others of the hue of wine lees. 

I have since seen a case exactly similar to the above among the 

2 Comment. Goetting., recent, vol. iv. 1820. 

3 The skin, says Beclard, is sometimes raised by quantities of tumours of differ- 
ent sizes formed of an accidental tissue of a white fibrous aspect, much more com- 
pact than the cellular, but softer than the ligamentous. This same formation is also 
frequently found in polypi, and especially in the submucous tumours of the vagina 
and vulva. Elem. d'Anat. gener., p. 294, Svo. Paris, 1823. 



3G4 



DEGENERATIONS. 



patients olleagtte, M. Rullier. Dagorn 1 lias given the details 

a vi iv remarkable instance of the occurrence of these tumours in a 
girl eighteen years and a half old, upon whose body there were eight 
of them, the largest weighing forty-six pounds. After the removal of 
this mass, it was found to consist of cellular substance, the cells being 
verj much cldated, and tilled with transparent serum intermingled 
with minute yellowish-coloured fatty llocculi. An artery and vein 
were observed to divide and subdivide in the interior of the tumour. 
The skin which covered it appeared thinner than natural. 

11 7:2. P. F. Walter 2 has figured and published a very extraordi~ 
nary o >us in the form of a tumour, which differs, among 

other particulars, from that detailed by Dagorn, in the skin which 
covered it haying been beset with hair, and in having contained a 
large quantity of adipose substance. 

1173. Hypertrophy of the subcutaneous adipose tissues gives rise 
occasionally to a single, soft, slightly mammillated tumour, generally 
of a llattened form, unaffected with pulsations and without change of 
colour of the skin (loupe graisseuse); tumours of this description, 
however, are not always single ; they occasionally occur in consider- 
able numbers under the skin of the upper parts of the extremities, 
which then appear covered with inequalities. I have met with 
several instances of tumours of this kind occurring without assignable 
cause in individuals who were by no means very stout. Tumours of 
this kind have been seen to form in the palm of the hand, 3 the skin 
of which then experienced a remarkable alteration, analogous to that 
of a variety of ichthyosis. Lorenz Ruff, fifty-three years of age, had 
been affected from his infancy with hard knubbly protuberances on 
his hands and feet which had become extremely troublesome from the 
time he began to labour with his hands. These tumours had increased 
imperceptibly, and, especially within the last three years, had acquired 
an enormous size. This man w^as in other respects strong and healthy, 
and had never been unwell, save with small-pox and dysentery. 
The hands and fingers, which were remarkable for their size, were 
covered on their palmar aspects with large excrescences. The nails 
looked like talons or spurs. Similar growths occurred on the inner 
side of the sole of the right foot, from the heel to the great toe; there 
were also several on the left foot. The tumours were of a grayish- 
white colour, of the consistence of soft horn, conveying to the "touch a 
sensation similar to that imparted by a mass of warts of different 
sizes. The larger were surmounted by smaller ones; here they 
formed isolated clusters ; there they were connected by parts project- 
ing in a less degree. Their surface, although dry, was sensible to the 
slightest touch, and bled with extreme facility; it remained acutely 
sensitive for several days, when a few of the'cuticular squamae with 
which it was covered, happened to be rubbed off. Pressure and a 
blow caused pain. Walking was painful, particularly upon a dry, 
and hard road ; and the patient could not continue it for more than 
an hour continuously, resting at frequent intervals, in which time he 
got no farther than another would have accomplished in a quarter of 
an hour. He required a long time to dress and undress, and the 
pain he then experienced was extreme. In rainy and windy weather 
he suffered from intolerable burning and prickling sensations in the 
diseased parts. The motions of the fingers were greatly impeded ; 
they could not be bent, but the motions in abduction and adduction 
remained. 

Several coloured engravings made from oil paintings add to the 
accuracy of these details. To the above case Behrends has assimi- 
lated that of a girl ten years and a half old, whose fingers were 
covered at their extremities with horny substances of a yellowish- 
brown colour, as thick as the finger, and from three-quarters of an 
inch to an inch and a half in length. The skin upon which they 
grew was red and painful. This case is related by Ab. Haskel. 4 

1 Dagorn. Observations Chirurgicales sur une jeune fille agee de dix-huit ans et 

ai portait sur le tronc huit loupes, etc, Svo. Paris, 1822. 

2 Vu! ler ^ h V Fr,) T Ueber die angebornea Fetthautgeschwiilste und andere Bild- 
ungsfehler, iol., fig. Landshut, 1814. 

j Behrends (J B.). Beschreibung und Abbildungknolliger AuswOchse der Hande 
nnd Fosse des Lorenz Ruff, in-fol. Frankfurt am Main, 1825. Traduit dans les 
Arch, gt-ner. de med., t. xui. p. 260. 

* New Engl. Journ. of Med. and Surg., vol. viii. No. 1. Boston, 1810. 



DEGENERATION*. 

1174. The degenerations of the skin include fibrous, cartilaginous, 
and osseous transformations, melanosis, tubercles and cancer ( 



FIBROUS DEGENERATIONS. 

1175. Under the name of special tumours of the skin, M. Vclpcau 
has published a very remarkable case which appears to belong to the 
class of fibrous degenerations of the skin and subcutaneous cellular 
membrane ; although indeed the spontaneous disappearance of several 
of these tumours by a process of internal suppuration is not altogether 
favourable to this opinion. 

Case CLXXYIII. — Indolent tumours formed at the expense of the 
skin upon different regions of the body. 5 On the 14th of July, a man, 
thirty-five years of age and well formed, presented himself for advice, 
on account of about a dozen tumours of a particular description 
formed at the expense of the dermis, and disseminated over different 
parts of the body — the face, neck, breast, crista ilii, the thigh, the 
flank, &c. It is now above thirty years since the first of these tumours 
made its appearance. Many others have been evolved at different 
times, and have been discussed by the use of various topical appli- 
cations. These tumours are slightly flattened and elongated ; they 
are generally about the size of the point of the thumb ; they appear 
to be covered by the cuticle ; their surface is rough and uneven ; their 
colour is very similar to that of the skin at large ; they may be 
squeezed pretty strongly without the patient complaining of pain ; in 
a word, all their external characters proclaim them to be of a fibrous 
nature. 

There is one, however, which differs from the rest in several par- 
ticulars. This is situated on the outer aspect of the right lumbar 
region. It is shaped like a mushroom or fungus, very much com- 
pressed, being one inch in thickness and above four inches in breadth. 
Its pedicle, which is extremely short, is three inches in circumfer- 
ence. The skin on the inner or under surface of the tumour is natural 
in colour, &c; that which covers its outer aspect is, on the contrary, 
of a redish gray tint, soft, fungous in appearance, and discharging a 
little watery fluid of a bitter-sweet and very disagreeable odour. 
During the last three months, and since it has been exuding this fluid, 
it has been readily made to bleed, and the pressure of the body when 
the patient lies down makes it painful; it is in fact on this account 
that the patient has been induced to seek for medical assistance. 

The tumour in question was removed in presence of M. Roux, by 
M. Berard, on the 11th of July. The operation was followed by no 
particular consequences, except that the whole of the other tumours 
which existed in different parts of the body softened and disappeared 
entirely, whilst the wound was cicatrizing. The whole became the 
seat of small abscesses before disappearing ; and the patient informed 
us that the same thing had happened with the same circumstances 
several times before. This fact appeared to us the more worthy of 
remark, from the tissue composing the one which had been removed 
not being of a nature that usually falls into suppuration. It evidently 
consists of a degeneration of the outer lamina? of the skin, which are 
nearly of the hardness of scirrhus, but differing from this in its want 
of homogeneousness, in the granular aspect of its cut surface, and in 
several other particulars. Words would convey but an imperfect idea 
of its structure, and we know of no object to which it can be com- 
pared. Let us only say that it could not be assimilated to the scirrhous, 
the fungous, nor to those degenerations that are simply fibrous ; neither 
did it resemble any species of cancerous degeneration ; nor, in fine, 
was it precisely similar to any of the kinds of morbid tissue described 
by pathologists. It appeared as if constituted by the dermis very much 
expanded (rarefie) in two thirds of its thickness, and intimately blended 
with an infinity of granules of a concrete cheesy matter. In our 
opinion, it forms a new, perfectly distinct, and yet undescribed variety 
of morbid production. 

With the above case I connect provisionally the following one, 

5 Velpeau. Arch. gen. de med., t. xii. p. 511. 



MELANOSIS. 



365 



which in the first edition of this work, I had associated with my ac- 
count of the molluscum of Bateman. 1 

Case CLXXIX. — Small, solid, flattened tumours of the face, trunk, 
and extremities. A locksmith, fifty years of age, of a sanguine tempe- 
rament, married, the father of a healthy family, and never having had 
syphilis, exhibited (in the year 1824) all the appearances of molluscum. 
The disease had begun on the forehead by a small tumour rather 
larger than a shilling, and gradually extended till its base was more 
than an inch in diameter, projecting so much as to annoy the patient 
when he put on his hat. He had had this tumour tied ; but whether 
the ligature had not acted to a sufficient depth, or had been inade- 
quately applied, the tumour reappeared, and several others of the same 
characters were evolved on different parts of the body. 

The skin, at the expense of which these tumours were formed, was 
soft and movable over the subjacent parts. The tumours were not 
painful when handled. They were hard, and generally red, but be- 
came paler and somewhat shriveled under the action of cold. The 
right cheek was beset by about a dozen of broad, flattened, whitish 
tumours, separated by narrow intervals, and projecting from the surface 
of the skin, in a manner similar to the wheals of urticaria. On the 
neck, several lenticular tumours were perceived. Several were also 
observed on the forepart of the chest and abdomen, particularly on the 
right side. The left side of the trunk, and the left arm, presented but 
a very small number of these tumours. The right upper extremity, 
on the contrary, was beset with a great number of them, of an oval 
or irregular shape, hard consistence, deep red colour, and very much 
raised above the level of the skin. The lower extremities, especially 
the legs, were covered with similar excrescences. Their bases here 
were broader, they were also more closely set, and appeared to form 
slightly mammillated bands. The principal functions of the body were 
perfectly regular. He was put upon a course of laxatives and baths 
for about two months, but without success. 



MELANOSIS. 



1176. Melanosis may appear deposited in grains within the sub- 
stance of the skin, or may form true tumours in its substance or upon 
its surface. Deposits of the same description almost always take 
place at the same time, in one or more of the internal organs. 

1177. The skin is occasionally beset with a considerable quantity 
of small spherical tumours, many of which are of the size, of the colour, 
and have even the lustre of black currants or juniper berries. They 
are black throughout, and, when cut through, present a great resem- 
blance to the parenchyma of the truffle. According to Breschet, these 
small tumours appear occasionally to spring from the tissue of Mal- 
pighi. When melanosis shows itself in this way on the skin, a matter, 
similar in all respects, is generally deposited in several other organs 
and tissues of the body. A. Gautier, cook, aged fifty-nine, of fair 
constitution, entered the Hopital St. Louis, Aug. 27th, 1816, on 
account of a disease which had appeared about two months previously, 
after violent grief. The complaint had begun with such feelings of 
general lassitude that the patient could not stand ; she felt at the same 
time benumbed over her whole body, and a few days afterwards, she 
was obliged to betake herself to her bed. She soon lost her appetite, 
got no sleep, and was then attacked with diarrhoea and vomiting. A 
number of small tumours now appeared in the substance of the skin 
on different parts of the body. On her entrance into the hospital, 
Gautier was in the following state : a great number of tumours, of the 
form, and particularly of the colour of black currants, were scattered 
over the anterior part of the thorax. The spaces between several of 
them in this situation were dotted with minute red points, very simi- 
lar to flea-bites. Over the breasts, the little black tumours were so 
much crowded that they formed a broad patch. Several of the same 
tumours of a larger size were also seen upon the abdomen ; some of 
them were here two inches in circumference. The arms and thighs 
were also the seat of several, especially on their inner aspects; the 
forearms and legs were unaffected. The patient was in an extreme 

1 Under the title of molluscum, Bateman describes globular sessile or pedunculated 
tubercles, containing atheromatous matter; this is an affection of which I shall speak 
when I come to discuss the diseases of the follicles. 

92 



state of debility ; her appetite was gone ; she vomited the small 
quantity of food she swallowed ; she got no sleep ; her bowels were 
relaxed; the breathing was laborious; she was tormented with fre- 
quent cough ; the pulse was extremely soft and very compressible. 
The symptoms went on increasing in severity for some days, and were 
speedily aggravated by the occurrence of general oedema, which, by 
giving a white look to the skin, caused the black colour of the tumours 
to appear even stronger than before. The patient died on the 25th 
of September. 

Sectio cadaveris. — The black tumours with which the skin was 
covered when cut into, presented a homogeneous substance of a 
black colour, of different degrees of intensity, and varying consistency, 
being in one of considerable hardness, in another almost pulpy. This 
substance, which was always enveloped in a cyst of cellular sub- 
stance, had all the characters of the production which has been 
described under the name of melanosis. Tumours of the same de- 
scription were found in the subcutaneous cellular tissue almost of 
every part examined ; they were not, however, nearly so numerous 
in the extremities as on the trunk, and especially within the abdomi- 
nal parietes ; they were also less regularly rounded and softer than in 
this situation. The cellular substance which surrounds the blood- 
vessels, nerves, and lymphatic glands, was literally loaded with 
them. They there formed by their agglomeration masses of the size 
of the fist. The nerves were still healthy, but the vessels were so 
intimately blended with the black depositions, that they could not be 
separated from them without being torn. In the substance of the 
thyroid gland melanotic tumours, perfectly distinct from the lobules of 
the gland, were detected. The lungs, the general colour of which 
was rosy, contained a few of these tumours of small size ; towards 
their base, and below the bronchial glands, many more were dis- 
covered, but of much larger size ; the bronchial . glands themselves 
were not black. In the mediastinum, and under the costal pleura, 
melanic tumours were also found, the size of which varied from that 
of a filbert to that of a walnut. These tumours were accumulated 
in great numbers in the epiploa and mesentery ; the duplicatures of 
these membranes were, so to speak, crammed with them. They 
were here smaller than common, the largest of them not exceeding a 
cherry-stone in size. Several were met with around the whole of 
the organs contained in the cavity of the abdomen, none of which 
appeared diseased, except the liver, which was greasy, and the gall- 
bladder, which contained five or six of the melanic tumours in its 
parietes. The heart and the brain were healthy ; the bones were not 
more brittle than usual. 2 

1178. Simple or compound melanic tumours constitute a third 
very remarkable kind of organic alteration. M. Ollivier d'Angers 
and I once dissected a melanic tumour which had been evolved on 
the sole of" the foot in an adult ; it was of a brownish colour, very 
similar to that of the truffle, nearly two inches in length, and rose 
about a line above the level of the skin that surrounded it. In dis- 
secting this tumour, we found that it was formed at the expense of 
the skin, which Avas altered, and impregnated with black matter. On 
the outer surface of this tumour several small white patches were dis- 
covered, three, four or five lines in diameter, which were nothing 
more than isolated pieces of epidermis. Viewed on its inner side, 
by which it was in relation with the subcutaneous cellular membrane, 
the skin presented a pretty uniform, bistry tint; the line of demarka- 
tion between the healthy and diseased skin is very distinct. The 
tumour was formed by the skin, become thicker and softer than 
natural, fungiform and black. No vessels, no scirrhous tissue, no 
cerebriform matter could be detected in this tissue, and the matter 
which coloured the altered skin adhered to it so intimately that it 
could not be squeezed out of it by pressure. The subcutaneous 
cellular tissue, the bones and the structures that covered them, were 
perfectly healthy; the skin alone was affected, and no other melanic 
alterations were discovered in the whole of the body. 

1179. Under the name of anthracine cancer, M. Jurine has described 
a kind of tumour of a more complicated structure, and composed of 
the accidental tissues proper to cancer and of melanosis united. 

Melanic tumours rarely inflame. Messrs. Breschet 3 and Ferrus 

2 Laennec. Auscult. Med., 2eme edit., t. ii. p. 38. 

» Breschet (G.). Considerations [sur une alteration organique appele degenere- 



366 



DEGENERATIONS. 



however, met with ulcerated melanosis, several inches in extent, 
■iiid situated in ihe right groin, in an old woman at the Salpetriere. 
a kind of blackish fluid which stained paper and 
linen in the same manner as bistre, rather than proper pus. 

1 180. It is always advisable to remove melanic tumours as speedily 

able, whether they be simple or compound, provided they be few 
in number and are developed upon a region of the body where they 
are exposed to be bruised or otherwise injured by pressure, &c, which 
always hastens their progress and causes them to increase in size. 
In any other cases the operation may be indefinitely deferred. When 
melanosis appears on the skin under the form of an eruption, it is 
always the evidence of a diathesis against which no effectual remedy 
has yet been discovered. 

Historical Notices and particular Cases. 

1181. M. Alibert has published a very remarkable case of cutaneous 
melanic tubercles with deposition of melanic matter in the epiploa, the 
mesentery, &C. 1 M. Breschet has seen a melanic ulcer of the skin. 
M. ( 'ni veil heir has published a remarkable instance of melanic tumour 
on the back and on the palm of the hand. Drs. Cullen and Cars- 
well- have reprinted this case, and have given several others of the 
disease. Mr. Fawdington 3 has detailed a case of melanic diathesis 
in which the skin itself was affected. Before any of these cases were 
made public, however, Dupuytren and Laennec had both directed 
attention to melanosis, and given a complete exposition of its charac- 
ters. It was next studied in a general manner by M. Breschet, who 
pointed out the particulars of its diagnosis from accidental formations; 
by Noack, 4 whose learned dissertation deserves to be particularly 
consulted ; by MM. Leblanc and Trousseau, 5 who have made many 
researches on the horse, and who consider melanosis as an accidental 
or new tissue ; by Albers, 6 who has published a curious case of 
abdominal tumour composed of fat, melanic matter, and blood. I 
have, in a preceding part of this work, (§756,) given several cases 
which show that certain melanic tumours bear a strong analogy to 
cancer in many particulars. 

Case CLXXX. — Melanic tumour of the forehead; melanic grains 
of the skin of the abdomen, fyc; death. M * * *, forty-nine years of 
age, tall, and of a spare habit, very excitable, possessing distinguished 
talents, passionately fond of music, and whose life had been very 
stormy, had not menstruated for a year, when Dr. Caballenas, her ordi- 
nary medical attendant, called me into consultation in the course of the 
month of August, 1834. Ten years ago a small blackish tumour had 
been removed from the right breast of this lady. The wound had 
been cauterized with arsenical paste, and a course of decoction of 
sarsaparilla administered. In 1832, a small blackish tumour, similar 
to the former one, and which appeared on the right side of the fore- 
head, was also removed with the knife; but shortly after the opera- 
tion, the cicatrice became possessed by a tumour of the same descrip- 
tion as that which had been taken away, surpassing it in size in the 
course of a few months. Several other blackish points at the same 
time made their appearance, scattered over the face and the rest of the 
body, and since this time additional crops have been evolved. The 
lady had for some time complained of pain about the region of the 
liver; oedema had once occurred in the lower extremities, and since 
the invasion of cholera, she had been affected with diarrhoea and con- 
stipation alternately. During the whole of the wdnter of 1833-1834, 
this lady gave herself up with the greatest ardour to study, sitting up 
late, living on stimulating diet, taking coffee largely, and even using 

scence noire, melanose, etc., 8vo. Paris, 1821. — Lecat also speaks vaguely of an 
ulcer which poured out a black matter. Traite de la couleur cle la peau humaine, 
870. (Amsterdam, 1767, p. 50.) Cruveilhier, Anat. Pathol., has figured an ulcerated 
melanic tumour. 

'Alibert. Nosolog. naturelle, 4to. Paris, 1817, p. 553, fig. 

= Cullen (William) and Carswell. On Melanosis (Transact, of the Medico-Chi- 
rurgical Society of Edinburgh, 1824, vol. i. p. 264). 

3 Fawdington (Th.). A case of melanosis with general observ. on the pathology 
of this interesting disease. With coloured plates. Manchester, 1826. 

* Noack (Car. Aug.). Comment, veterinaria-medica de melanosi cum tab. eeneis, 
4io. Pansns. 

5 Archives generates de med., t. xvii. p. 164. 

« Albers. Observ. suivie de reflexions sur "le fongus melanode. (Journ. complem. 
des sc. med., t. xxxix. p. 338.) r 



spirituous liquors all the while. This affected her general health, and 
in the spring of 1834, she was obliged to alter her whole plan of life ; 
she also took gelatinous and alkaline baths. The pain about the liver 
now returned; she became affected with cough, and for several days 
stria 1 of blood were observed in the expectoration. Some days after- 
wards she was attacked with haemoptysis, the quantity of blood lost 
being estimated at three ounces. She was bled to six ounces from 
the arm. The haemoptysis did not recur, but the cough, the oppres- 
sion of breathing, night sweats and diarrhoea, which had preceded it 
continued. In the middle of August, the oppression of the chest was 
excessive and constant ; a mucous rattle was heard especially in the 
posterior parts of the chest ; the pulse was hard and frequent. Six 
ounces of blood taken from a vein presented a buffy coat a line in 
thickness. The oppression went on increasing ; the pain in the liver 
gained in intensity, the patient became drowsy, and died on the 1st 
of September. 

The body was examined twenty-four hours after death. The ema- 
ciation was extreme. The melanic tumour of the forehead, divided 
lengthwise, presented the same colour as a truffle ; several small 
tubercles, situated within the substance of the skin, or in the subcu- 
taneous cellular substance of the trunk and extremities, were com- 
posed of pure matter of melanosis. 

In the substance of the vastus externus muscle of the thigh, there 
was a melanic tumour the size of a child's finger. The head was not 
opened. On the exterior surface of both lungs, especially of the right 
one, there were a considerable number of melanic tubercles. In the 
interior of both lungs a few small encephaloid masses were discovered 
as large as a hazelnut. In the right lung there was one tumour, the 
size of a chestnut, formed of encephaloid and melanic matter combined, 
several other smaller tumours in this and the opposite lung presented 
the same amalgamation. There was further a quantity of tubercular 
matter deposited in the summits of both lungs, and that of the right 
lung presented more than one small cavity. We also discovered 
several small deposits of pure or mingled cerebriform matter in the 
substance of the heart. Abdomen. — Similar alterations of structure 
were found in the liver, in the tissue of which there were numerous 
masses of pure encephalic matter, or of this mixed with melanosis ; 
the largest of these did not exceed an olive in dimensions. A consi- 
derable number of melanic granules were scattered among the epiploa, 
the ovaries, and the kidneys. The supra-renal capsules exhibited a 
small collection of pultaceous melanic matter. The spleen, stomach, 
uterus, and bladder were healthy. 



TUBERCULAR MATTER. 



1182. I have never observed a deposit of tubercular matter within 
the substance of the skin, but the following passage of Laennec de- 
serves to be quoted : 7 " It is nearly twenty years ago," says he, " that 
in examining several vertebrae, in which tubercular matter had been 
deposited, I grazed the forefinger of my left hand with the teeth of 
the saw. I paid no attention to the circumstance at the time. But 
next day the scratch was surrounded with an erythematous blush, and 
there was slowly formed a small rounded, compressed tumour, which, 
by the end of a week, had acquired the dimensions of a cherry stone, 
appearing to be situated within the substance of the skin. At this 
time the skin gave way in the point where it had been touched by 
the saw, and exposed a small firm yellowish body, precisely similar 
to a tubercle of an ochrey-yellow colour. I touched the part with de- 
liquescent hydrochlorate of antimony. This caused very little pain, 
and in a few minutes after the caustic had penetrated the whole of 
the tumour, I detached it with a slight degree of pressure. The action 
of the caustic had softened it to such a degree as to make it look exactly 
like a softened tubercle, of friable consistence. The place from which 
it had been turned out resembled a kind of cyst, the parietes of which 
were of a pearl-gray colour, translucent, and without redness. I ap- 
plied the caustic again. The wound soon cicatrized, and I never felt 
any ill effects from this accident." 

'With this case I shall connect an abstract of one related by Dr. 

' Laennec. Traite de l'auscultation mediate et des maladies des poumons et du 
coeur, 2d edit., t. 1, p. 649. 



DISEASES OF THE SEBACEOUS FOLLICLES. 



367 



Crampton ; : John Byrne, aged fifty-six, came into the hospital com- 
plaining of rheumatism. He was soon found to be phthisical. The 
skin of this man's body and limbs was covered with broad brown- 
ish or olive-coloured patches of different dimensions ; the skin in the 
spaces between these was pale and sallow. A number of tubercles 
of the same hue as the spots, were seen scattered among them. Seve- 
ral of these tubercles were about half an inch in breadth, and an inch 
in length, and soft to the touch ; others of the size of a split pea, 
resembled papula?, and others, of a pyramidal shape, were connected 
with the skin by slender but strong pedicles. These last felt as hard 
as cartilage. On the surface of the broad soft tubercles, small, hard, 
and prominent nuclei could be detected both with the eye and the 
finger. Byrne had enjoyed good health till the year before he came 
into the hospital. Yet it is five years past since the alteration of the 
skin described, first made its appearance ; to this, however, the pa- 
tient had paid little attention, as he suffered no inconvenience from 
it. He was filthy in his person, and given to drinking spirits. He 
entered the hospital in February, and died in August, of phthisis. 

On examining the body after death, the brown blotches had dis- 
appeared, or rather, they were lost in the general dark hue of the 
integuments. The tubercles of the skin had undergone no change. 
Those of a round or oval shape were composed of a caseous or gela- 
tinous-looking substance, penetrated the corion, and extended amidst 
the subjacent cellular substance. This stuff was dissolved by the 
water in which pieces of the skin were put to macerate. The pyra- 
midal tubercles again did not penetrate the corion ; they were com- 
posed of a white and very consistent fibro-cartilaginous looking sub- 
stance, without any appearance of blood-vessels. Some of these 
cartilaginous tubercles contained a glairy matter. The broader and 
softer tubercles bore a considerable resemblance to subcutaneous 
scrofulous tubercles ; but they had neither the redness, nor were they 
affected with the slight pain which so commonly accompanies deposits 
of the above description. The round and oval tubercles were of the 
consistence of cheese. 

The lungs contained tubercles in different states ; the upper lobes 
exhibited several cavities and softened tubercles. At the bottom of 
the lungs the tubercles were small and hard. The heart was very 
small. The liver small, hard, and of a deep colour, presented the 
tubercula diffusa of Dr. Farre. The spleen was also tubercular. 
The mucous membrane of the intestinal canal was red, and exhibited 
several slight ulcers, having the characters of those found in the 
bodies of individuals who die consumptive. 

This instance of complex degeneration of the skin, into which 
tubercular matter appears to have entered largely, is very remarkable. 



SPECIAL DISEASES OF THE SEBACEOUS FOLLICLES. 

1183. The sebaceous follicles of the skin are liable to a variety of 
affections. They sometimes appear under the form of small pearly 
elevations, in consequence of having undergone a truly fibrous or 
cellular transformation, occasioned by inflammation of the skin (after 
impetigo, the application of blisters, &c). Their secretion maybe 
increased in a very remarkable manner ; their secretion altered in a 
greater or less degree, may be pent up within their cavities, and give 
rise to grubs or worms in the skin, and to follicular swellings, or 
tumours; they have also been seen to become morbidly developed 
over tumours regarded as cancerous, 2 and under various other cir- 
cumstances. 



INCREASE OF THE SEBACEOUS SECRETION OF THE SKIN — [sTEARRIIOZa]. 

1184. The skin is known to pour out an oily or unctuous matter, 
which Mr. Cruikshank procured in the form of plates, by wearing a 

1 Crampton (J.). Case of tubercular affection of the skin. — Trans, of the Associa- 
tion of Fellows and Licentiates, etc., in Ireland, vol. v. 

2 Weber (L. H.). Obs. sur l'epiderme, les follicules cutanes, l'accroissement du 



woolen waistcoast night and day next his skin for a month, during 
the hottest season of the year. "This substance, rubbed upon paper, 
stained it like grease ; it burned with a white flame and left a resi- 
duum of charcoal. I designate the morbid increase of this secretion 
by the title of sebaceous flux. 

Symptoms. — Although this affection may occur in any part of the 
body, it is most frequently seen upon the nose, the eyebrows, and the 
hairy scalp, situations in which the natural secretion of the sebaceous 
follicles is always most abundant. It is generally confined to one of 
these regions, but in some rare cases it has been seen extending to 
almost the whole surface of the body. There are at all events two 
very different degrees of the affection. In the one, the finger passed 
over the surface of the affected skin, feels it unctuous and soft; and 
when the parts are covered with hair, the oleaginous matter, in con- 
creting, forms a kind of brownish incrustation, which I have fre- 
quently observed in the eyebrows, and at the roots of the hair of the 
head Even in those parts where the sebaceous matter is poured out 
in greatest profusion, the skin does not appear either red or sensibly 
altered; the orifices of the follicles are not even more apparent than 
usual. Patients, however, frequently complain of a kind of tin- 
gling, and sometimes of positive pain in the part affected; although I 
have also met with patients, especially young women, who assured 
me that they suffered no other inconvenience than the necessity of 
wiping their nose, forehead, or eyebrows very frequently when these 
were the parts affected, in order to prevent the accumulation of the 
unctuous matter, the appearance of which was extremely unpleasant. 
The loss of the hair of the parts affected is a very frequent accom- 
paniment of this first degree of the morbid increase of the sebaceous 
secretion. 

Another and rarer form of this affection [ichthyosis sebacea] appears 
with the following characters, most commonly on the face. The skin 
of the cheeks, nose, or eyebrows, appears covered with a kind of 
yellowish scurf, nearly of the colour and consistence of the cerumen 
of the ears. The skin looks thickened and unctuous around this 
deposit, which in some points is moist and oily, and in others of the 
consistence of yellow wax. The surface of the deposit is traversed 
in different directions by shallow lines which mark it out into a mul- 
titude of little compartments ; when several of these are detached 
accidentally, or are removed with the assistance of the douche of 
watery vapour, softening cataplasms, &c, the skin is exposed, usually 
of a brighter red than it is naturally, and almost always, as it were, 
riddled by a multitude of small holes, which are nothing else than the 
orifices of the follicles dilated, and many of them still filled with seba- 
ceous matter. Some hours afterwards, the skin thus cleansed, will 
be found to have become unctuous; and it is always, before long, 
covered with a fresh coating of scurf that acquires the same appear- 
ance as the first. 

Patients, under these circumstances, almost always experience pain- 
ful shootings in the parts of the skin affected, and these I have had 
described to me as so violent, that I should sometimes have been 
inclined to hold the statements as exaggerated, had I not had their 
accuracy confirmed by numerous observations of a similar kind, (a) 

(a) Respecting the anatomical lesions in this disease, Mr. E. Wilson 
says: — " In an instance of this affection which fell under my obser- 
vation about ten years since, I had the opportunity of examining the 
skin after the death of the patient from visceral disease. In this case, 
the scales were remarkable for their thickness; after being well 
washed, they were grayish in colour upon the surface, but white 
beneath, and evidently consisted of concreted sebaceous substance. 
On removing a portion of the epidermis by maceration, the ducts of 
the sebaceous glands and hair follicles were found distended with 
inspissated white secretion, and had a very beautiful and brilliant 
appearance, projecting like cones of pearl from the under surface of 
the membrane. The dermis presented a number of small deep pits, 
corresponding with these dilated ducts. The mouths of the distended 
excretory ducts opened upon the surface of the epidermis, some 
immediately beneath, and in the middle of the scales, and others by 
their borders. In the former situation, they could be seen as small 

volume de ces derniers organes dans les tumeurs cancereuses et les poils chez 
l'homme. (Journ. compl6m. des sc. med., t. xxix. p. 138.) 



368 



DISEASES OF THE SEBACEOUS FOLLICLES. 



Morbid increase of the sebaceous secretion very rarely ends spon- 
taneously; I have, however, met with instances of spontaneous cure 
anions young females in whom the affection had appeared with the 
mildest characters possible. In every case, even when treated with 
the greatest care and skill, this affection is very obstinate, and always 
lasts for a very long time, — many months, and sometimes even several 
vears. It is also very apt to recur upon parts which have already 
been its seat. 

118G. Causes. — I am not aware whether any proper flux of seba- 
ceous matter has ever been observed among infants. Adults, and 
individuals arrived at maturity of years, are the general subjects of the 
affection. Women are more frequently attacked with it than men. 
It is rather a rare disease. Several individuals who have laboured 
under it, have, as I know, suffered from rheumatism ; others expe- 
rience pains which appear to be of a rheumatic nature, in parts in the 
neighbourhood of the seat of the flux. I have never observed the 
affection occurring at the same time as rosacea, nor succeeding it. 
The affection is not contagious. 

1187. Diagnosis. — The morbid secretion of the sebaceous follicles 
that merely keeps the skin oily without drying or concreting on its 
surface, cannot be confounded with any other affection. But when 
the sebaceous exudation forms a yellowish checkered layer over the 
surface of the skin, the appearance of which is intermediate between 
that of squamae and of incrustations, it is very possible, without mi- 
nute attention, to mistake this affection of the sebaceous follicles for 
ichthyosis, 1 with eczema fallen into the squamous state, with pityriasis 
and chloasma. With regard to ichthyosis, it is enough to remember 
that it is almost always a congenital affection, generally extending in 
various degrees to almost the whole surface of the body, but always 
occurring in extremes lightness upon the face, without redness or pain 
of the skin, which is not unctuous to the touch, and in which the 
orifices of the sebaceous follicles are never conspicuous. Eczema, in 
the squamous state, (§ 348,) is always preceded by a serous exudation 

white points through the scale, and still more evidently when the 
epidermis was separated by maceration. 

" From the careful examination of this case, of which a preparation 
is now before me, and of other cases which I have subsequently 
observed, I have been led to the conclusion, that the scales, in this 
disorder, increase in thickness in two ways, first, by additions to 
the free surface, by means of the secretion poured out in the linear 
furrows of the skin, and, consequently, between the scales; and 
secondly, by additions successively made to the attached surface by 
the effusion of inspissated secretion beneath them. In the preparation 
before me, the growth of the scales by both of these processes is 
distinctly evident." 

' The two following cases related by Bateman and Thomson as examples of ich- 
thyosis of the face, appear to me to be instances of sebaceous concretion upon the 
surface of the skin. One of them is remarkable in a therapeutical point of view, and 
should encourage practitioners in similar cases to persevere with the decoct, of 
rumex acutus and the application of blisters over the parts affected. Bateman, after 
stating that the face is rarely the seat of ichthyosis, tells us that he nevertheless met 
with one young lady whose face was affected with this disease. A large patch 
covered both cheeks and met on the upper lip under the nose. A drawing is given 
of the appearance in pi. xviii. of Bateman's Atlas. Ur. Thomson met with a similar 
case which he showed to Bateman. The patient was about fifteen years of age when 
the affection made its appearance (1810). The first symptom was a scurfy appear- 
ance of the cheeks ; this was easily removed by the use of soap and water ; two years 
later (1812) this scurf increased in quantity and began to adhere more firmly. By 
and by it was so considerable that the patient consulted D. J. Gregory, of Edinburgh. 
By the use of stimulating applications the skin was cleansed in ten days; but the im- 
provement was merely transitory; the affection reappeared. Chalybeates, aloes, 
mercury to the extent of salivation, hot sea-water baths, the forcible removal of the 
incrustation by shaving or scraping, the action of an ointment composed of subcar- 
bonate of soda, spirit of turpentine, sugar and basilicon, a wash of corrosive subli- 
mate, and various other means were tried, but fruitlessly, to cleanse the skin during 
a succession of three or four years. It was at this time that the patient went to 
London for advice. The eruption now extended over both cheeks and met under the 
nose ; it was of a dirty olive-brown colour, and disfigured the face greatly, which was 
naturally handsome. The skin of the affected regions was as hard and rough as 
shagreen. Under Dr. Bateman's care the patient took pitch pills, external and inter- 
nal remedies, without any advantage, during six months. She then came under Dr. 
Thomson s care who, after trying a great number of remedies, was so happy as to see 
the disease yield to a decoction of the root of the rumex acu/us taken internally. The 
disease returned on leaving off this medicine several times, but always yielded to it. 
suspecting that the constant return of the disease was owing to a vicious action of 
the skin become habitual, Dr. Thomson applied a blister to the part, immediately 
after which the affection vanished to recur no more. (Bateman. A Pract. Synopsis 
&c, 7th edit. p. 80, 8vo. Lond., 1829.) ' r ' 



which has raised or impregnated the cuticle, whilst sebaceous deposits 
are spread over the outer surface of this membrane. The furfurae of 
pityriasis rubra cannot be confounded with the laminated incrustations 
of a sebaceous deposit. Chloasma, in point of colour, bears a stronger 
resemblance to the sebaceous deposit under review than any other 
form of cutaneous affection, especially when the sebaceous layer is 
extremely thin, dry and partially detached ; still they are distinguished 
by very numerous points of dissimilarity (§ 1070). 

1188. From this sebaceous concretion on the skin of adults it is 
necessary to distinguish the whitish unctuous and cheesy deposit occa- 
sionally observed on the bodies of new-born infants. This is known 
to be most abundant on the groins and axillae, behind the ears, on the 
scalp, wherever, in short, the sebaceous follicles are most numerous ; 
but the deposit in this case is natural and unaccompanied with pain. 
We have been recommended to leave this deposit of new-born infants 
undisturbed, and especially to respect the kind of cap which it forms 
by drying a few days after birth over the surface of the scalp. The 
propriety of such a caution appears to me so much the more question- 
able as all infants are not born with this kind of covering, and as I 
have never observed any ill effects follow its removal, when the in- 
fants were well protected against cold and damp. The scurf of the 
scalp left to itself increases in thickness, becomes matted with the 
hair as it grows, dries, splits, and is subsequently partially detached in 
scales or fragments. Whatever the thickness of the crust, it may 
always be got rid of by the use of tepid lotions, emollient poultices, 
and slight friction. The head of the child when cleansed ought to be 
covered for some days afterwards a little more carefully than before. 

1189. Prognosis and treatment. — I have seen sebaceous incrus- 
tation of the nose, cheeks, and hairy scalp, accompanied with, or 
followed by, the loss of a large quantity of the hair of the head and 
eyebrows, continue in spite of the use of the vapour douche and 
purgative medicines, for such a length of time, that it became at 
length impossible to assign any probable limits to the duration of the 
malady. Of all the means recommended for the cure of the com- 
plaint, the vapour douche is, notwithstanding, the most efficacious. 
I have also made use, at least with temporary advantage, of lotions 
of the sulphate of alumen. I have tried saturnine lotions, but with- 
out marked benefit, as well as decoctions of nut galls and bistort- 
root, infusions of the rosa gallica, &c. It is generally advisable to 
prescribe purgatives at the same time that the vapour bath is employed 
externally. 

Historical JYotices and particular Cases. 

1190. The morbid increase of the sebaceous secretion was described 
in the first edition of this work ; it has since been spoken of under 
the name of acne sebacea. I have already had occasion to say that 
Bateman and Dr. A. T. Thomson have given two cases of the affec- 
tion under the title of ichthyosis of the face. 

Case CLXXXI. — Morbid secretion of the sebaceous follicles of the 
nose; thick concretion. — A young woman, aged twenty-six, of weakly 
constitution, menstruating irregularly, perceived, about the beginning 
of the summer of 1825, that the alae of the nose, and neighbouring 
parts, discharged incessantly a yellowish oily fluid, which was depo- 
sited on the surface, under the form of little worms. It was easy to 
see that these worms were nothing else than the sebaceous matter of 
the follicles, which was renewed as fast as it was taken away. The 
matter secreted accumulated gradually, became hardened, and formed 
thick unctuous laminae, which could be removed without difficulty, 
and without causing any pain. Under them the orifices of the seba- 
ceous follicles were more conspicuous, and much larger, than they 
are naturally. The principal functions of the body were regular. 
The slight affection mentioned, required two months of treatment 
by the vapour bath. 

Case CLXXXIL— Morbid secretion of the sebaceous follicles, unc- 
tuous and ceruminous-looking deposit upon the skin of the face and 
scalp; partial baldness.— In the month of August, 1826, I saw a wo- 
man, of the name of Gouette, thirty-two years of age, labouring under 
a disease of the sebaceous follicles of the face. She had suffered from 
various illnesses in the earlier part of her life, and about eighteen 
months previously to the above date, had had first one, and at differ- 



MORBID SECRETIONS. 



369 



ent intervals subsequently, two other paralytic attacks of the left side 
of the face. She is now at times slightly deranged. 

The affection of the sebaceous follicles began in June, 1825, and 
had never been treated upon any particular plan. In August, 1826, 
the disease occupied the face and scalp exclusively. . These parts 
are covered with a brownish-yellow and unctuous incrustation, very 
similar to the cerumen of the ears, which extends over the middle of 
the forehead, and from the ridge of the nose over both cheeks, the 
left especially. It is lamellar, and composed of small compartments 
two or three lines in diameter, in contact by their corresponding edges, 
which are slightly raised and whitish. The integument underneath 
the incrustation is healthy in appearance, presenting no trace of in- 
flammation. On the left cheek the component laminae are thicker, 
more numerous, smaller, and separated by lines which traverse their 
whole thickness. Several parts of the skin, from which this incrus- 
tation has been detached, are covered with furfuraceous squamae. On 
the right cheek the incrustation is less continuous, the laminae com- 
posing it are thinner, and the skin over a space about an inch in 
breadth, presents a slight erythematous blush. The thickness of the 
laminae of the incrustation varies on all these different places, from 
a sixth or an eighth to a quarter or half a line. The compartments 
appear to adhere to the skin closely everywhere except on the fore- 
head, where they are loosened and somewhat raised at their edges. 
The pieces of incrustation are larger and thicker on the surface of 
the scalp generally than elsewhere ; on the upper and posterior parts 
of the head, however, they are small, dry, and furfuraceous in appear- 
ance. The left lateral part of the sinciput is bald over a space as 
large as the palm of the hand. On no part of the affected surface is 
any thing like a pustule, papula, or vesicle, to be discovered. The 
unctuous incrustation is plainly due to an increased secretion of the 
sebaceous follicles. The parts affected are the seat of an habitual 
smarting sensation. On the 7th of September, 1826, the patient ex- 
perienced, at five different times, the following sensations, which she 
designated by the title of attacks : in the left cheek and temple she 
first felt severe painful twinges ; some seconds afterwards, very violent 
contractions occurred in the cheek, which lasted five or six minutes, 
and were followed by quivering or trembling in the muscles of the 
face. The patient did not lose her consciousness, and the intervals 
between each attack were nearly of ten minutes' duration. I had 
made up my mind to combat the symptoms of the cutaneous affection 
by means of the vapour-bath, when I ceased to perform the medical 
duties of the hospital. 

Case CLXXXIII. — Morbid secretion of the follicles of the left eye- 
brow and forehead. — I had once a girl of eighteen, of sanguine tem- 
perament and enjoying habitual good health, under ray care, on 
account of a morbid affection of the sebaceous follicles of the left 
eyebrow and neighbouring part of the forehead. An unctuous, thin 
and uneven stratum of a yellowish-coloured substance, like the ceru- 
men of the ears, was spread over the affected parts, which were 
neither red nor tumefied. This incrustation, which had formed 
about two months before I first saw the patient, without known 
cause, was undoubtedly the effect of an exudation from the sebace- 
ous follicles of the skin. Fifteen vapour-baths caused this incrusta- 
tion to be detached, and it was not reproduced. 
I Case CLXXXIV. — Morbid secretion of the sebaceous follicles; 
ceruminous deposits on the forehead, scalp, abdomen and extremities. 
A woman, twenty-six years of age, the mother of several children, 
had suffered much from grief, and her catamenia had become irregu- 
lar. She felt a kind of numbness in her arms, and experienced 
some difficulty in performing certain motions. Soon after this she 
was attacked with a disease in the sebaceous follicles. When the 
alae nasi are compressed, the follicles of which are extremely appa- 
rent, numerous filiform and yellowish-coloured bodies are forced out, 
consisting of an unctuous matter, rather less consistent than the 
sebaceous fluid generally is. These bodies wiped away, the follicles 
were very speedily filled again. The forehead and scalp, the cheeks 
and abdomen, the breast and thighs, were entirely covered with this 
unctuous matter, which there formed a thick yellowish layer, of the 
consistence of the yellow wax or cerumen of the ears, and divided 
into an infinity of small triangular and quadrilateral compartments, 
which gave the deposit an appearance of being composed of squamae ; 
93 



but the epidermis had no share in the formation of the incrustation, 
which could be readily removed without pain to the patient, when 
the skin it concealed was found to be healthy, but shining and unc- 
tuous. The part thus denuded was speedily covered anew with unctu- 
ous matter, which smelt like rancid oil. The hands were also com- 
pletely concealed by this substance, which on them was harder, 
browner and less shining, by which it acquired a still greater resem- 
blance to squamae, although the epidermis situated under it was 
healthy. The vapour bath, used every other day for two months, 
effected the partial detachment of these ceruminous plates. But a 
yellowish oily fluid, abundantly secreted by the follicles affected, 
gave occasion to the speedy reproduction of the ceruminous-looking 
matter. The vapour bath was again tried during three months at 
different times. The hands and fingers, which could not previously 
be moved without great suffering, became freer. The incrustation 
of the face, in part detached, was no longer renewed, though the 
skin still continued shining and unctuous in appearance, — the seba- 
ceous matter was not now secreted in such quantity as to harden and 
form a stratum upon the surface. The abdomen, breast and thighs 
were almost entirely freed from the deposit; but it still continued to 
adhere to the hairy scalp. The hair was clipped short, and by and 
by the crust was lessened considerably in size. It was still more 
obstinate on the hands. Nevertheless the cure was nearly complete 
at the end of a year. 

Case CLXXXV. — Chronic rheumatism. Morbid secretion of the 
sebaceous follicles of the scalp, trunk and extremities. J. Thiolie, 
aged twenty-seven, became a patient in the Hopital de la Charit6 on 
the 21st of March, 1827. He had always enjoyed good health till 
1823, when he was attacked, whilst with his regiment in Corsica, 
with acute rheumatism, which continued for about eight months. In 
the month of August of the same year, he was attacked with a quo- 
tidian intermittent fever, which yielded to a fortnight's use of a cool- 
ing regimen. He has always felt more or less of the rheumatism 
since this time. His arms have lost flesh; they are stiff, and moved 
with difficulty, and almost useless to him. The motions of the legs 
are also slightly implicated, although they have not fallen away. 

The consequence of the patient's inability to use his arms has 
been great neglect of his person ; and a yellowish and unctuous 
scurf, from the drying of the matter secreted by the sebaceous folli- 
cles, has been formed over the skin of the parietes of the thorax and 
surface of the hairy scalp. On the chest, this deposit possesses the 
consistency, and all the other sensible properties of the ceruminous 
secretion of the ears ; it is uniformly spread, and forms a layer from 
an eighth to a quarter of a line in thickness. It is thickest under 
the clavicles and over the sternum, and ends three or four inches 
below the level of the mammae. A similar ceruminous-looking 
deposit occurs on the back, and forms a yellowish band, of the 
breadth of the palm, along the whole length of the vertebral column. 
The incrustation is divided, into an infinity of little irregular com- 
partments, from one to three lines in diameter, between which, parts 
of the skin are seen here and there uncovered. The matter, which 
is soft and unctuous to the touch, can be detached from the skin, 
which appears healthy, when it has not been irritated by rubbing. 
There is a deposit of the same kind above the clavicles, and on one 
or two points of the face. On the eyebrows it occurs in the shape 
of narrow and furfuraceous-looking lamellae. It is thicker over the 
rami of the lower jaw, and forms a thick layer w r ithin the meatus 
auditorius externus. It is less marked upon the external ears. The 
secretion of the meibomian glands does not seem to be augmented. 
The eyelids are never glued together when the patient wakes. The 
orifices of the sebaceous follicles of the nose are extremely apparent, 
and look like small black points. The skin of the whole face is 
habitually unctuous, as if it had been anointed with oil. The morbid 
secretion of the sebaceous follicles is more abundant on the hairy scalp 
than elsewhere, especially over the left temporal and parietal regions. 
The crust which it there forms is split into small compartments, most 
of which are loose and adherent to the hair, which is extremely unc- 
tuous to the touch. The scalp, freed from this deposit, appears per- 
fectly healthy; it is neither painful, nor affected with pruritus. Several 
locks of the hair are agglutinated, as it were, with this unctuous 
matter. Ceruminous-looking deposits of a similar kind exist on 






DISEASES OF THE SEBACEOUS FOLLICLES. 



various oilier pails of the body. The principal vital functions of this 
patient were healthy. Ho was immediately subjected to the action of 
■ pour bath, which appeared alike calculated lo prove beneficial 
to the affection of the skin, and to the rheumatic paralysis of the upper 
extremities. The ceruminous-looking incrustation was speedily de- 
tached and (he remedy was ordered to be continued. («) 

(a) Sebaceous Ichthyosis. — " A remarkable case of this disorder, 
disseminated in patches over the surface of the head, neck, and 
trunk, is recorded by Dr. Jacobovics, 1 under the erroneous appella- 
tion of tubercules bigarris,' a new variety of molluscum. Dr. Jaco- 
i' case difl'ers from ordinary instances of this disease, in the 
longer duration of the malady, its disseminated character, the exeoria- 
tions which resulted from its continuance, and the presence of inflamed 
tubercles intermingled with the patches. 

" The patient, M. N., was a tailor of bilio-sanguine temperament, 
fifty-six years of age, the nineteenth child of healthy parents. His 
mother had a slight cutaneous affection on the neck ; another had 
furfuraceous desquamations on the face ; two sisters had several small 
tubercles on the neck and bend of the elbow ; a sister's child had a 
similar growth. At the age of thirty, M. N. was attacked with 
severe pneumonia, which left him in unsound health for some years. 
On reaching his thirty-seventh year, the cutaneous disorder first'made 
its appearance ; it commenced on the neck in the form of small yel- 
lowish spots, beneath which one or more white points, the apertures 
of sebaceous ducts, loaded with secretion, were perceptible. These 
yellow spots gave rise to pruritus during the summer season, which 
subsided in the winter. Three years afterwards, on the occasion of 
a severe mental affliction, the disease showed a disposition to increase, 
and quickly spread over his neck, breast, and back. The disorder 
now assumed the appearance of little crusts, 2 having a roundish or 
irregular figure, and various colour ; for instance, some were yellow- 
ish-white, others fawn-coloured and brownish, others again blackish 
and livid, and covered with slight desquamation, but there was no 
constitutional disturbance, nothing to induce the patient to apply for 
medical assistance until the year 1833, when, annoyed by the violent 
pruritus and unsightly appearance of the disease, he presented him- 
self at Saint Louis. He was treated at this hospital for two months 
without benefit, and he returned to his business. Three months later 
his case was undertaken by Dr. Jacobovics, and presented the follow- 
ing characters: — 

" His hair was remarkable for its greasiness, as were several other 
parts of his body, particularly the skin of the front of the neck, which 
the author describes as feeling viscous and unusually soft. At the 
roots of the hair were numerous yellowish patches and scales of seba- 
ceous substance ; these greasy scales were also met with dispersed 
over many parts of the skin. On the forehead, the alas nasi, the 
cheeks, the back, and in several other situations, the apertures of the 
sebaceous ducts were very perceptible, and many of them were 
obstructed by inspissated secretion, which was dark-coloured in some, 
yellowish in others, and rose above the level of the surrounding skin 
in several. In other situations the sebaceous substance retained its 
softness and whiteness, and distending the excretory ducts, appeared 
like white points in the midst of the yellowish and discoloured 
lamina* 3 by which its escape was prevented. The crusts commence 

' "Du Molluscum, Recherches critiques, &c, suivies de la description detaillee 
d une nouvelle variete. Par M. M. Jacobovics. Paris, 1840." 

> » With no better reason, apparently, than that of adhering to the erroneous appel- 
lation which he had assigned to this disease, Dr. Jacobovics styles the crusts tuber- 
cles, or tumours, throughout his essay. They were unquestionably extravascut'ar for- 
mations, and mere depositions on the surface. In accordance with this view I have 
in every instance, altered the terms tubercle, or tumour, to crust. Besides, it does' 
not accord with my notions of pathology to admit the possibility of a tubercle or 
tumour, being converted by progressive development into a crust. But to agree with 
Ltr. Jacobov.es, such a doctrine must be embraced; for, after indicating a number of 
TestJbe'renl^hT 1 '-, 8 ' "^ ?°. m P le,ed ^ lhe crust > he remarks, in conclusion.- 
le..r uc den, son, iT T ^^ '? .««» noires et verda.res.et les .aches qui 
Senish c us s are ,ne jTf se f condair r es - Th »« » ^ say, that the black and 
wool" ncrn" e h 1 ™ '7 { ? rm t of ' les '^erculos brunatres.' Those who 

3? aSSASm^ ° f Df - Jacobo ™ s > * —» refer to his essay presented to 

,„;: ^ch^t^rt s i^1r;;: co £!jr l, T' ° r >- e »7i? h T hi,e co,our; 

white points as being beneath thepilerm'^F^^T' 5 ' and he describes lhe 
iii .li ,- , ^I'lueiinis. from the observation ofensps nf ihic 

kind, and particularly of the one above recorded ( § 504), I feel convinced [that the 



WORMS OR GRUBS OF TIIK SKIN. 

1191. Under the name of worms or grubs of the skin those small 
filiform bodies that can be squeezed out of the sebaceous follicles, arc 
familiarly known. These are soft, unctuous, easily crushed between 

by a whitish-yellow or brownish spot, of the diameter of a millet seed 
or lentil, but without prominence, and passed through a succession of 
stages which the reporter has accurately detailed. The yellow spot 
is attended with pruritus, and examined with a lens, a minute white 
point may be discerned in the centre of each. In a more advanced 
stage the yellow spot has increased in diameter, and is raised in the 
centre, when it presents three or four white points in place of one. 
By degrees the yellow spots become transformed into brownish crusts, 
having a maximum elevation from the surface of two lines (French), 
and a maximum diameter of six lines. These brownish crusts appear 
studded beneath the surface with white sebaceous points, which give 
the mottled (bizarre) character to the production, which awakened in 
the mind of Dr. Jacobovics the specific designation which he has 
assigned to the disease. The succeeding stages which the author 
has observed the sebaceous concretions to assume, are bluish crusts, 
punctated with white, and having a lobulated appearance, produced 
by the linear markings of the skin, and blackish crusts, punctated 
only around the edges, and intersected by deeper furrows, correspond- 
ing with the dermic lines. These latter were chiefly met with in the 
dorsal region ; after a time, the linear furrows increase in depth, even 
to the splitting of the crust into a number of small polygonal masses, 4 
which adhere firmly to the epidermis, and assume a deep blackcolour. 
The desiccated patches, rubbed by the dress, or scratched with the 
nails, are liable to excite suppuration of the dermis, and the pus, 
oozing from between the fractured masses, forms upon the surface a 
succession of irregular crusts, which resemble those of impetigo. 
Other crusts of a yellowish-green colour are also met with, resulting 
from the immediate desiccation of the brownish punctated patches, 
and these also become broken in the direction of the natural furrows 
of the dermis. 

" Besides the sebaceous crusts above described, there were inter- 
spersed on this man's skin a number of small tumours and tubercles. 
Some of these w T ere round or oval, prominent in the centre, of a bright 
red colour, smooth, and shining, covered by a thin and desquamating 
epidermis, and the seat of a troublesome pruritus. Others were of a 
bluish-gray colour, with raised and livid borders. These were the 
principal causes of a violent itching, and indulgence in scratching 
gave rise to excoriation and chapping of the edges, with a discharge 
of sero-purulent fluid. A third variety were vividly red, indolent, 
and of small size, varying from that of the head of a pin to that of a 
small lentil. But these tumours bore no proportion to the sebaceous 
crusts. They were, probably, the consequence of irritation caused 
by the sebaceous concretions, and can only be regarded as a compli- 
cation of the sebaceous disease. 

" As regards diagnosis, Dr. Jacobovics unfortunately allowed him- 
self to be dazzled by a word, and that word the most unmeaning in 
the entire vocabulary of cutaneous disease, I mean, molluscum. Thus, 
after recapitulating the physical characters of the preceding case — 
e. g., hereditary tubercles, varying in size from that of a lentil to 
that of a pigeon's egg (there were none so large in his case), round 
or irregular, usually sessile, brownish colour, consistent or softish, 
generally solid, no constitutional disturbance, &c. — he remarks, 
' Among the tuberculous diseases of the skin, none but the present 
genus is capable of assuming the whole of these characters, so I am 
bound to establish this in the genus molluscum.' An unfortunate 
preference, for molluscum is already synonymous with heterogeneum. 
In the treatment of this case the author employed purgatives and 
warm baths, but with only partial success." — E. Wilson, (op. cit.) 

yellow patch is a thin layer of inspissated sebaceous substance, adhering very closely 
to the epidermis; this I conceived to be gradually raised by the deposit of fresh seba- 
ceous matter beneath it, until the elevated crusts are formed, which are the distin- 
guishing feature of this case. The white points will consequently be seen beneath 
the sebaceous scale. I have already alluded to this appearance, and have before me 
a preparation in which it is well shown." 

4 "The masses are identical with the sebaceous ichthyosis described at the com- 
mencement of this section." 



FOLLICULAR ELEVATIONS— MOLLUSCUM. 



371 



the fingers, and vary both in length and thickness; they consist of 
concrete sebaceous matter pent up within the follicles; they are very 
commonly black or brown at the outer extremity; they commonly 
occur in greatest numbers upon the alai of the nose and the parts of 
the cheeks in immediate connection with these; they are .also fre- 
quently met with over the sternum, about the nipples," and in other 
situations where the follicles are known to be very abundant. These 
sebaceous concretions, moulded within the cavities of the follicles, 
may be forced out by pressing a fold of the skin, where they occur, 
between the points of the fore fingers; or they may often be seized 
with a pair of tweezers, or turned out with the point of a pin. They 
occasionally occur in such numbers as to constitute really a disagreea- 
ble and annoying disease of the skin. I was once consulted by a 
man, a tiler, who from his infancy had had the skin of his face, and 
of the inter-scapular and sternal regions, beset with grubs. The skin 
on these districts appeared to be studded with black points, and a 
multitude of filiform bodies, from one to two lines in length, could be 
extracted, when the orifices of the follicles became extremely appa- 
rent. The patient informed me that these concretions were more 
remarkable in winter than in summer. I merely recommended him 
to use the tepid bath frequently. 

These sebaceous concretions are sometimes few in number, when 
they generally occur of large size. A woman, forty years of age, had 
four on the right cheek, the tops of which were as large as the head 
of a pin ; and I have seen one under the right nipple in a young 
woman which was as large as a black- currant. 

These sebaceous concretions of the follicles of the nose are occa- 
sionally complicated with psydracious pustules, and the inflammation 
of a certain number of the sebaceous follicles themselves (acne punc- 
tata). In this case one of the best applications is an emulsion of 
bitter almonds used frequently. 



FOLLICULAR ELEVATIONS, (a) 

1192. Under this title I designate those whitish globular elevations, 
generally of the size of a pin's head, formed by the sebaceous follicles, 
full of an unctuous, whitish, solid matter. These follicular elevations 
are most commonly encountered on the eyelids and face generally. 
It is sometimes possible with the naked eye or a magnifier to distin- 
guish a minute dark point on the surface of these elevations ; this is 
the orifice of the follicle. If these small elevations be punctured 
with the point of a lancet, the sebaceous matter they contain may be 
squeezed out of them readily, and it is often very long before it accu- 
mulates again ; but this is more certainly prevented by destroying the 
follicle by means of caustic. Follicular elevations of the kind under 
review are often associated with the inflammation of the follicles 
which I have spoken of under the name of acne. They also occur, 
however, along with other lesions ; I, for instance, once attended a 
young woman affected with lupus of the nose, whose forehead was 
covered with these elevations. Among children of from seven to 
eight years old they are very frequently seen about the chin and over 
the cheeks. They occur but rarely among the aged. They occa- 
sionally disappear spontaneously. 

MOLLUSCUM. 

Under the name of molluscum contagiosum, Bateman has described 
a contagious disease, the seat of which appears to be the sebaceous 
follicles. 1 This affection I have not myself had an opportunity of 
observing. (b) 

(a) Under this may be mentioned the sebaceous horns, described 
in § 1117 and in note to § 1122. 

(b) Molluscum. — M. Gibert remarks that the genus molluscum 

1 A distinguished physician recommended to the care of Dr. Bateman a patient 
afflicted with molk-.scum which appeared to have been communicated by contact. 
The face and neck of the patient, a young female, were covered with rounded promi- 
nent tubercles, of different sizes, from that of a pin's head to that of a small bean. 
These tubercles were hard, slightly transparent, and nearly of the colour of the skin. 
They were sessile. A milky fluid could be squeezed out of the largest of them, 



Case CLXXXVL— Follicular elevations of the face. Q * *, aged 
twenty-five, had small-pox when seven years old, and had ever since 
continued subject to inflammation of the edges of the eyelids. 

comprehends several species, which have no characters in common 
with each other except these — cutaneous excrescences that are indo- 
lent, of a firm consistence, having nearly the same colour as that of 
the skin, and generally incurable. Most writers have described three 
species of it, viz.: 1. The endemic and contagious molluscum of 
amboyna ; 2. The sporadic and non-contagious M. ; and 3. The 
atheromatous M. described by Bateman. M. Gibert makes a fourth, 
which he calls stearin molluscum (Med. Chir. Rev., 1844). 

Molluscum co?itagiosum, says Dr. Paterson, writing in 1841 (Edinb. 
Med. §■ Surg. Journ.), is as yet to be regarded as entirely British — 
the latest authorities in France, Germany, and America, making no 
mention whatever of it in their respective countries. From Bate- 
man's description (Synopsis) we learn that molluscum is characterized 
by the appearance of numerous tubercles, of slow growth and little 
sensibility, and of various sizes, from that of a vetch to that of a 
pigeon's egg. These contain an atheromatous matter, and are of 
various forms, some being sessile, globular, or ilattish, and some 
attached by a neck and pendulous. The growth of the tubercles is 
apparently unconnected with any constitutional disorder; they show 
no tendency to, inflammation or ulceration ; but continue through life, 
having apparently no natural termination. 

A little farther on Bateman thus speaks of molluscum contagiosum. 
"The face and neck of this young woman were thickly studded with 
round prominent tubercles, of various sizes, from that of a large pin's 
head to that of a small bean, which were hard, smooth and shining 
on their surface, with a slight degree of transparency, and nearly of 
the colour of the skin. The tubercles were all sessile, upon a con- 
tracted base, without any peduncle. From the larger ones a small 
quantity of a milk-like fluid issued on pressure, from a minute aper- 
ture, such as might be made by a needle's point, and which only 
became visible on the exit of the fluid. The progress of their growth 
was very slow ; for the first tubercle had appeared on the chin a 
twelvemonth ago, and only a few of them had attained a large size. 
Some of the latter had recently become inflamed, and were proceeding 
to a slow and curdly suppuration ; and the cervical glands, lying 
under those on the neck, were also swollen, and discoloured as if 
proceeding to suppurate. The eruption was still increasing much, 
and not only disfigured her greatly, but had recently impaired her 
general health, and occasioned a considerable loss of flesh, by the 
irritation which it produced. 

" She ascribed the origin of this disease to contact with the face of 
a child, whom she nursed, on which a large tubercle of the same sot 
existed ; and on a subsequent visit, she informed me that two other 
children of the same family were disfigured by similar tubercles; and 
besides, that the parents believed that the first child had received the 
eruption from a servant, on whose face it was observed. Since my 
attention was drawn to this species of tubercle, I have seen it in 
another instance, in an infant brought to me with porrigo larvalis; 
and, on investigation, it was found that she had apparently received it 
from an older child, who was in the habit of nursing it. In this case 
the milky fluid issued from the tubercles, and may be presumed to 
be the medium of the contagion." 

In a " Notice of the Molluscum Contagiosum" by Dr. Henderson, 

through a very small orifice, similar to what might have been made with the point of 
a pin. These tubercles had grown very slowly; the first had appeared upon the chin, 
about a year ago, and only a small number had attained a large size. Several had 
suppurated and disappeared; the cervical glands had also enlarged, and seemed in- 
clined to suppurate. The eruption caused great irritation, and weakened the patient, 
who had lost flesh. This woman had nursed a child affected with a large tubercle 
of the same description, and she was of opinion that she had caught this disease her- 
self from the child. She informed me that two other children of the same family 
were similarly affected, and it was supposed that those who were first affected with 
the malady had received it from a nurse who had an eruption of the same description 
on her face. 

I have since seen another case of this affection in a child labouring under porrigo 
larva/is, which was communicated to the child by the woman who had charge of him. 
In this case, the milky fluid that exuded from the tubercles might be regarded as the 
means of the contagion. The liquor arsenicalis was prescribed to the young woman 
in small doses, and in a short time the number and size of the tubercles diminished, 
several also suppurated.— (Bateman. Pract. Synopsis, 7th ed., p. 382.) 






DISEASES OF THE SEBACEOUS FOLLICLES. 



His forehead, cheeks ami chin wore beset with follicular elevations, 

from half a line to a line in diameter, ami rising about half a line 

the general level of the integuments, a size they had attained 

[Edinb.Med. 8f Surg. Journ., 1841), he describes four cases of the dis- 
ease which he had an opportunity of seeing among children of poor 
parents residing in Edinburgh. 

" Three of these cases were children of the same family, and the 
fourth was a child of a neighbour in the habit of associating with the 
others. Though the circumstances are calculated to excite a suspicion 
that the disease was communicated from one to another of these by 
jion, I could not trace the transmission so conclusively as Bate- 
man and Thomson have done. One of the three children had 
exhibited the disorder six months previously, but from what source 
was unknown. A second became affected a month later; and the 
third only a fortnight before the date of my attendance. 

" The child first affected was eighteen months old when the mol- 
luscum appeared. The tubercles presented themselves first on the 
left upper eyelid, and successively affected the other eyelids and the 
face. When I saw the child, there were about a dozen tubercles on 
the face in various stages of development, and one only elsewhere, — 
on the right ankle. From the account I received from the mother 
of the progress and duration of the tubercles, it appeared that they 
differed much in these respects. Two had existed on the right upper 
eyelid for nearly six months; while several which had appeared on 
the hands had run their whole course in about a month. This diver- 
sity was doubtless dependent on the degree of exposure of the 
tubercles in the different situations to injury or irritation, for their 
disappearance, as stated originally by Bateman, is owing to inflam- 
mation, in consequence of which they suppurate slowly, presenting 
ultimately the characters of a prominent pustule. 

"It does not appear that the tubercles are necessarily numerous. 
A twin brother of the child to whom I have just referred, though 
affected with the disease five months before I saw him, never had 
more than two tubercles, one on the leg, and another on the shoulder. 
These had not then become inflamed. At the time when I saw the 
other two children, each had but one tubercle, but I did not learn the 
subsequent history of the disease in them. The twin children were 
very unhealthy. When committed to ray care, the child who was 
the most affected with the tubercles had a tumid belly, emaciated 
limbs, was subject to diarrhcea, and had a squalid appearance. The 
other was not in so bad a state at that time ; yet both continued 
sickly ; were in the following year affected with psoriasis gyrata ; and 
ultimately died within a few hours of each other, with the symptoms 
of acute hydrocephalus. I had not an opportunity of watching the 
course of the molluscum until its final disappearance in these children ; 
but I ascertained, nine months after they first came under my care, 
that the disease had disappeared, and that its duration had extended 
to twelve or thirteen months. The description and plate contained 
in Bateman's continuation of Willan's treatise on cutaneous diseases, 
correspond, in every essential particular, with what was presented in 
the cases to which I have been referring 

" Lately a fifth case of molluscum contagiosum has fallen under my 
notice, and has afforded mean opportunity of examining the structure 
of the tubercles, and the microscopic characters of the atheromatous 
matter which they contain. I am enabled by Dr. Paterson, of Leith, 
to mention the existence, at the moment of my writing this, of three 
other cases which have recently occurred in his practice, so that now 
twenty cases of this curious disorder are on record. 

" Of the following case I could obtain no history, either of the 
source of the disease or of its duration. The boy appears to have 
been an orphan, and was removed from the workhouse to the Royal 
Infirmary, where he fell under my care. 

^Philip Walker, aged eight, admitted April 17th, 1841. 

' This patient can give no exact account of the history of his case, 
but on admission he presents the following appearances. 

His head is covered in several places with large prominent 

scabs varying in size from that of a sixpence to that of a half-crown. 

On the lower part of the abdomen, the penis and scrotum, and 

about six inches in extent of the inner surface of both thighs, there 

are seen from three to four dozen tubercles, varying in size from a 



from having begun in the form of points that were nearly invisible. 
The greater number presented a small black point in their centre, 
similar to the puncta lachrymalia, from which I forced out a whitish 

millet seed to a pea. They are in general of a round form, but a few 
of them appear flattened, as if from pressure. In the majority the 
point of attachment to the skin is distinctly smaller than the remoter 
part ; still it cannot be called a peduncle. At the apex of each tuber- 
cle, a small dark-coloured point is seen, which marks the seat of an 
opening communicating with its interior, and exuding a milky-like 
fluid on pressure. On the left side posteriorly, about a finger's 
breadth from the spine, and at the lower part of the chest, there is a 
soft swelling an inch and a half in length from above downwards, 
and an inch and a quarter in breadth, of an elliptical form. In the 
centre of this swelling there is a smaller and gentler elevation, of 
a dull purplish colour, with vascular ramifactions, in the apex of 
which there is a small rounded aperture, from which a thickish matter, 
closely resembling finely ground rice boiled, can be squeezed. There 
is no pain in the swelling ; he says he has noticed it for many months, 
and that it was at one time much smaller. On the right arm, four 
tubercles, similar to those found on the pubis, exist, and ten are seen 
on the left arm. At the bend of the right knee, and upon the inner 
ankle of the left foot, a small superficial ulceration exists, which, in 
the latter situation, is partly covered with a dark-coloured scab. The 
feet are cedematous ; the skin over them is red, and they are tender 
on pressure. The abdomen is very tense, and yields a tympanitic 
sound on percussion. He has frequent and rather severe cough, 
especially at night. His tongue is foul, and pulse above 100. His 
bowels are somewhat loose, several thin yellow stools being passed 
daily. 

"The sound of percussion is impaired all over the right front, also 
from the axilla downwards laterally. Behind, percussion on the right 
side is less resonant than on the left, but not absolutely dull. The 
sound of respiration is somewhat harsh upon the right back, and upon 
the right front is dry and blowing, mingled with some sibilant rattles. 
The left side of the chest moves much more freely in inspiration than 
the right. The heart appears to beat in its natural situation ; its 
sounds are heard with remarkable distinctness over the left, as con- 
trasted with the right side. The left side of the chest, by measure- 
ment, is three quarters of an inch larger than the right. The skin is 
harsh and dry; pulse 108; bowels regular. 

"May 6th, noon. — At six, this morning, he became affected with 
sudden and severe pain in the hypogastric region, and now the pain 
and tenderness of the belly are general, with more timidity and ten- 
sion than formerly. Has had three stools since the pain came on ; 
is now breathing quickly, with some tracheal rattle and bronchitic 
thrills on the right front. There are several lymphatic glands con- 
siderably enlarged in both axillae and right side of the neck. Pulse 
126, scarcely perceptible at the wrist; extremities rather cold. He 
died eight hours and a half from the time when the pain occurred. 

" The body was examined on the 8th of May. It was much ema- 
ciated. A considerable quantity of turbid serum was found in the 
abdomen, with recent coagulable lymph in both iliac regions — in the 
basin of the pelvis, and on the upper surface of the liver. The sub- 
serous cellular membrane of the bowels, and of the parietes of the 
abdomen, was the seat of innumerable small whitish tubercles. The 
omentum was contracted on the colon, and filled with tubercular mat- 
ter. The mesenteric glands were large, and most of them filled with 
tubercular matter. The right lung was at its apex, and in several 
parts near its surface, the seat of tubercular masses; the whole lung, 
a good deal loaded with blood, and an ounce and a half heavier than 
the left, which was not affected with tubercle, and not particularly 
engorged. In a narrow, transverse, and old ulcer of the ileum, a per- 
foration was found. Several of the patches were dark, elevated, and 
firm." 

Dr. Paterson, in the paper already cited, gives a case that oc- 
curred in the practice of Professor John Thomson, of Edinburgh, 
which I introduce here : 

"March, 1821.— In a family, resident in the Canongate of Edin- 
burgh, there are three children, two boys and a girl, affected with 
molluscum contagiosum. About six months ago, small tubercles ap- 



MOLLUSCUM. 



substance, similar to curdled milk, but of rather greater consistence. 
The skin of the parts affected was not inflamed, or otherwise altered. 
The malady had appeared about four months ago. For the last five 

peared upon the face of the eldest boy, who, it is supposed, had caught 
the disease from some of his playfellows, although none of them at 
present are known to have had it, nor has it been known ever to have 
existed in the neighbourhood. From this boy the disease was com- 
municated to his sister, and to his little brother, a child of about nine 
months old, whom he occasionally carried about in his arms. The 
contagious nature of the disease is well evinced in the child. On the 
back of its hands a considerable number of tubercles are seen which 
have been produced by applying them to the face, and scratching 
those situated there during their inflammatory stage. Some of the 
tubercles are small, others large, some in a state of active inflamma- 
tion, others nearly of the same colour as the skin, and quite free from 
pain. A few of them are pedunculated, but the greater of these num- 
ber are attached by broad bases. They are seen on different parts of 
the face, on the forehead, eyelids, nose, lips, red of the lips, cheeks, 
and under the chin. Those under the chin have produced a consi- 
derable degree of inflammation of the skin, and tumefaction of the 
submaxillary glands. Two or three appear to be decaying, are shrunk 
and corrugated, and of a reddish-brown hue. It is three months since 
the first appearance of the disease. The mother, though in the con- 
stant habit of nursing the youngest child, has not been infected." 

Dr. Paterson continues: — "I am also enabled, through the kind- 
ness of Professor Thomson, to add another series of cases of this rare 
affection, which, some time after the last-mentioned ones, came, under 
his observation. 

" Professor Thomson was consulted regarding the child of a farmer, 
in the immediate vicinity of Edinburgh, who was affected with this 
disease in its characteristic form. It was traced to have been com- 
municated to this child of the farmer's by a child of one of the farm 
servants ; but this case could not be traced further. The farmer's 
child suffered severely from conjunctivitis, produced by the irritation 
of the tubercles on the edge of the eyelids. The disease was next 
communicated to the servant girl, who was in the habit of keeping 
the child during its illness, and appeared in its usual form on that side 
of the neck alone, against which the child was in the habit of laying 
its face when affected with the ophthalmia. The above cases appear 
to me extremely interesting in so far as they point out in the most 
unequivocal manner the contagious nature of the disease. 

" The first case of this disease, which I had an opportunity of 
witnessing, occurred at the village of Newhaven, in the month of 
December, 1840. The child, a girl about eighteen months old, ex- 
tremely robust and active, and belonging to one of the cleanliest and 
best class of fisher people, had been affected with the eruption for the 
last three months. It was first observed in the neighbourhood of the 
mouth and nose, and it now occupies the same localities, together 
with the lower eyelids, and a few thinly scattered over the cheeks and 
neek. The mother states that, when it was first seen, the tubercles 
had very much their present appearance. This child was nursed on 
one breast, and, although weaned, has the habit of still sucking it. 
The tubercles vary in size from that of a pin head to a horse-bean — 
the smaller ones having very much the white opaque appearance of 
pearly granulations, the larger ones being a little more coloured. 
The smaller ones are round, the larger ones oblong and irregular in 
shape, very much resembling that of a horse-bean. They are sessile, 
on a contracted base, not pediculated. The larger ones only emit a 
whitish fluid when pressed. They seem to be not the slightest source 
of uneasiness to the child, and do not even appear painful when pretty 
roughly handled. 

" This child communicated the disease to the breast of the mother, 
and it appeared entirely confined to the sebaceous glands around the 
nipple of that breast, which the child continued to suck. 

" The tumours on the breast are of various sizes, from that of a pea 
to a hazelnut, three of the larger ones being clustered together; all 
exude a thick whitish matter, when pressed between the fingers, and 
they seem to be equally insensible to the touch as those on the child. 
They first appeared on the breast about a month and a half after those 
on the face of the child. 
94 



years his hands had been covered with a great number of warts. He 
slept with his brother, who had no similar affection of the follicles of 
the skin. 



"The largest of these tumours latterly became inflamed and ex- 
tremely troublesome, from the irritation of the rubbing of the clothes 
against them. 

" Particular inquiry was made as to any other members of the family 
being affected with a similar eruption ; but no trace of it could be dis- 
covered, and an attempt to find out the source of contagion to the 
child proved equally unsuccessful ; indeed, from the inquiries made, 
had any similar case existed in the village, it must have been dis- 
covered. This series of cases was seen by my friends, Professor 
Simpson, Dr. W. Thomson, Dr. Mercer, and Dr. Lund, all of whom 
looked upon them as very characteristic of the disease in question. 

" Treatment. — Mrs. C, the mother, was anxious that something 
should be done for the tumours, as they afforded her considerable in- 
convenience from rubbing against her dress, and, at the suggestion of 
Professor Simpson, the tops of them were touched with caustic potass. 
The application afforded little uneasiness to the patient ; the escha- 
rotic destroyed a portion of the tumours, and the remainder soon 
sloughed off by their bases, leaving a healthy granulating surface, 
which healed kindly, and no return of them took place. 

"As the child's health was not in the slightest affected, no treat- 
ment whatever was had recourse to. The tumours as they enlarged 
generally suppurated, scabbed, and then fell off by their base, and as 
this happened to more of them than was generated, a decided dimi- 
nution soon took place, and at the present time there are only a very 
few remaining. 

" Case II presented itself at the Leith Dispensary for consultation 
on the 2d of April last. The child, Ann M'Queen, two years old, 
strong and healthy, has been affected with the disease for the last two 
months. The mother ascribes it to her having been carried about by 
a girl who had some c similar lumps ' upon her body, while they re- 
sided at Dundee, and immediately before they came to Leith. The 
eruption at present occupies the left side of the neck and shoulder, 
and a few are scattered here and there upon the same side of the face 
and trunk of the body. The disease resembles very much in appear- 
ance the case last described. The small tumours have the same pearly 
appearance, and the larger ones, being slightly redder than the skin, 
and exuding a milky fluid from the orifice at their apex. The tuber- 
cles at present appear in groups, and irregularly scattered over the 
surface of the skin ; their number may be from thirty to forty on the 
present patient. The mother states that the girl, who was primarily 
affected at Dundee, used to carry this child chiefly against that side 
of her neck. But neither the mother nor any other of the children 
in the family have any appearance whatever of the eruption. This, 
however, may be partly accounted for by the fact that the dress of this 
child being tied up round the neck, prevents, in a great measure, a', 
least, any immediate contact between the eruption and the skin of 
the other children. Several of the largest of these tumours were cut 
off with a pair of scissors, and the skin healed well afterwards ; others 
were destroyed with the caustic potass and nitrate of silver, but stil! 
the number of them on the body of the patient is not much dimi- 
nished. 

"The next case which presented itself was that of a young mar- 
ried man, whose wife I had attended in labour some weeks previous. 
It was observed during the progress of the labour, that numerous 
small tumours existed at the orifice of the vagina, and in the neigh- 
bourhood of the vulva, but, thinking that they might be condylomata, 
or warts, no further attention was paid to them. The husband, how- 
ever, shortly after, showed me a number of tumours on the penis, 
which bore the characteristic marks of molluscum contagiosum. Upon 
inquiry regarding similar tumours on his wife, he informed me that 
they were of the same kind as those on his penis. They occasioned 
him considerable annoyance, and he applied for the purpose of getting 
them removed. The larger ones were cut off with the scissors, and 
the smaller touched with nitrate of silver, and they have all entirely 
disappeared. 

"Since the above cases occurred, I have had an opportunity of 
witnessing a beautiful and well-marked case of this rare disease. 



374 



DISEASES OF THE SEBACEOUS FOLLICLES. 



JCXXVII.— Foliiculat > of the face. D * *, aged 

twenty-three, of a sanguine temperament, had observed for the last 

small, hard whitish lumps, two lines in diameter, and 

ing in a child, under Dr. Henderson's care, in the Royal In- 
firm a r\ . 

In the same volume of the Edinburgh Journal a case is reported 
by Dr. William Turnbull of Huddersfield. 

Prom Mr. £. Wilson we procure the following particulars of a cure 
of molluseum contagiosum, and description of the appearance of the 
tumours. Mr. Wilson does not believe the disease to be contagious: 

" An instance of this disease lately (March, 1842) presented 
itself to my notice, which was remarkable for the active development 
of the tumours. They were first perceived, about fifteen or twenty 
in number, dispersed upon the skin of the neck, face and shoulders 
of a little girl, four years of age. By the advice of the family medi- 
cal attendant she was sent into the country, and in the course of a 
few weeks became quite well, all the tumours having disappeared, 
ami no new ones being formed. Soon after her return to town, the 
mother brought her two other children — an infant and a girl six 
years old — to me. The mother and children were of blonde com- 
plexion ; they had light hair, and a thin delicate skin ; the mother was 
much alarmed at the development of these little tumours on her two 
other children as well as on herself, 'caught,' as she imagined, from 
the child first affected. I quieted her alarms relative to contagion, 
but was much struck by the fact of the almost simultaneous appear- 
ance of the disease upon four members of the same family. On the 
neck of the mother I found four or five of these little tumours closely 
resembling and of the size of currants, constricted at their base, and 
each presenting an umbilicated depression of impacted sebaceous 
substance, the aperture of the excretory follicle ; and she directed my 
attention to three ugly scars upon the face left by similar tumours 
recently healed. On the neck, face, and shoulders of the eldest 
child I found eight or ten little tumours, presenting all their stages 
of growth. One upon the shoulder was so completely pedunculated, 
that I was tempted to place a ligature around it, and in a few days 
it fell off'. On the infant they were less advanced, they were just 
rising from the integument, and each possessed in its centre the dark 
point of an excretory sebaceous follicle. The little tumours pre- 
sented no signs of inflammation ; they were of the natural hue, or 
somewhat lighter than the surrounding skin, from the whiteness of 
the secretion which they contained in their interior, and there was no 
areolar redness around their base. 

" Since the above account was written, I have again (August, 1842) 
been visited by this patient, on account of the development of a small 
angry tumour of a similar kind upon the margin of the upper eyelid 
other little girl, involving two or three of Meibomian glands. With 
Ibis exception the children have remained free from any return of 
the tumours. Upon inquiry as to the manner in which they disap- 
peared, the mother tells me, that they became black, and shortly 
after were rubbed off accidentally. One of large size, and situated 
behind the ear, in the child first affected, was snipped off by Mr. 
Tyrrell. The mother, who is out of health, has three still remaining, 
one of small size near to the angle of the right eye, and two upon 
the back of the hand. The former has supplied me with a fresh 
stock of matter for examination. 

"Upon examining these little tumours, I found them to present 
ill the characters of a small conglomerate gland, 1 consisting of seve- 
ral lobules held together by areolar tissue, and the lobules composed 
of ramified ducts and terminal sacculi. The ducts were remarkably 
dilated, particularly the central one, and were filled with inspissated 
secretion. The latter was identical in composition with the concreted 
sebaceous substance of the comedones (§ 511). The cells were of 
the same size, had the same appearance, and were intermingled in 
considerable number with epidermic scales. I differ in opinion with 
Dr. Paterson in not considering these cells as peculiar organisms, 
capable of nucleolar propagation when transferred to an appropriate 
nidus in another individual. I regard them as the normal sebaceous 
cell, which, as I have before remarked (§ 511), contains a granular 
substance, filling it more or less completely. In its early stage of 
' This observation confirms the description given by Dr. Henderson, § 531. 



a line and a half in height, and of an irregularly circular, conical or 
flattened shape. A small black point, similar to what might be pro- 
duced by the puncture of a needle dipped in ink, could be seen with 

formation, the cell, like all epithelial cells, is an adherent envelop of 
a nucleolated nucleus; subsequently the cell increases in bulk by 
endosraosis, and assumes the oval and more or less flattened form, in 
proportion to the larger or smaller quantity of fluid present in the 
ducts. The granular contents of the cells are due to the breaking 
up of the nucleus, and in proportion to the bulk of the cell and the 
quantity of its fluid; they either fill the cell completely, or leave an 
unoccupied interval around their circumference. In the myriads of 
cells of a small fragment of the concreted substance of one of these 
little tumours, I perceived cells of both the above kinds; but the 
number of the latter, few on the first examination, had very much 
increased on the following day, after I had left the tumour in weak 
spirit for twenty-four hours. 

" The difference in the appearance of the cells examined by Dr. 
Paterson, and by myself, appears to me to be immediately explained 
by reference to the physical difference in the contents of the tumours. 
In Dr. Paterson's case, the contents, as in Bateman's, were milky, 
and consequently, semi-fluid. Here, then, were the conditions favour- 
able to the production of cells, having a considerable interval filled 
with fluid between the granulous nucleolar substance and the mem- 
brane of the cell — a deposition which induced Dr. -Paterson to regard 
them as being composed of an external vesicle and an internal vesicle, 
the latter containing the granular substance. In my cases, on the 
other hand, the contained substance was concreted ; there was a 
deficiency of fluid, and the granulous substance filled the cell; and in 
exceptional cases only were any perceived in which a peripheral 
interval was observed. But on the second day, as I have before re- 
marked, when the mass had been steeped in weak spirit for a number 
of hours, the peripheral interval was evident in a considerable number. 

" On examining my new stock of sebaceous matter, (August 1842,) 
fresh from the patient, I found it to consist of cells heaped together 
like a pile of eggs, and intermingled with a large quantity of epider- 
mic scales in flakes. The mass consisted solely of these two sub- 
stances, without any granular matter or oil-globules. The cells were 
variable in their form, some being more or less cuboid, others irregu- 
lar from compression, some oblong, like the eggs of the ant, others, 
again, oval, but the most common form was ovoid, like that deline- 
ated in the figures of Dr. Henderson and Paterson. The cells pre- 
sented equal diversity in size, varying in their long diameter from 
(Hrs to r ^ T of an English inch, and in their short diameter from T j' 3 o 
to y-jLy : some of the cuboid cells measured T¥ Vo > the general size of 
the oval form was ^ long, and T oVo broad; there were several 
oblong cells, measuring T £ 5 by j^g ; and the common dimensions 
of the ovoid cell were ^^^ by T oVo- This size corresponds very 
closely with the cells of ordinary inspissated sebaceous substance, 
whether it be concreted or pulpy ; and also with the dimensions of 
the epidermic scales lying scattered among the cells. The contents 
of the cells were also various ; some were filled with granular sub- 
stance, in the midst of which, at some one point, the nucleus was per- 
ceptible ; others contained a homogeneous substance, separated into 
polygonal masses, mostly of a cuboid shape ; while others, again, were 
more or less filled with minute oil-globules. It is difficult to say which 
kind of cells were most numerous. I saw nothing like the double 
vesicle described by Dr. Paterson, and I think it possible that the 
appearance which he has delineated may have been produced either 
in the manner I have already suggested, or by the superposition of a 
single cell by several connected scales of epidermis ; or again, by the 
accidental position of the cell upon the epidermic scales in such a 
manner as to constitute a thin margin around it." 

Of treatment and the literature of the disease, M. Wilson thus dis- 
courses: — "In the case above detailed, I prescribed laxative medi- 
cine, and touched the tumours with nitrate of silver several times. 
By this treatment, I succeeded very speedily in removing them. I 
have mentioned that a ligature was placed around one ; a more expe- 
ditious mode of getting rid of them would be to snip them off with 
scissors. In adults, they may always be snipped off. On the mother 
of these children, I opened several with a lancet, and touched their 



FOLLICULAR TUMOURS. 



375 



the naked eye, towards the centre of each of these, from which, by 
compression between the thumb and forefinger, a globule of sebaceous 
matter could be forced. The parts affected were the seat neither of 
pain, heat nor itchiness. Several boils had recently appeared on the 
abdomen, and for the last three weeks the patient had complained of 
slight soreness of the throat. 



FOLLICULAR TUMOURS. 

1193. Besides the worms and elevations of follicular origin, now 
described, the retention and accumulation of the sebaceous matter 
within these organs, occasionally give rise to the formation of true 
follicular tumours J which have often been described under the names 
of wen, meliceris, atheroma, steatoma, &c, and have been confounded 
with proper encysted tumours. These follicular tumours may appear 
on almost any part of the body, but they have been principally observed 
on the scalp, on the face, and on the back. They are soft, indolent, 
and unattended with alteration of the skin around, or which covers 
them. The stuff' they contain very often resembles curdled milk. It 
acquires a very offensive odour when the parietes of the distended 
follicles are accidentally inflamed. A quantity of hair is not unfre- 
quently found mixed with the sebaceous matter. 2 When the tumours 

interior with nitrate of silver. Their return may be prevented by the 
plan of stimulation of the skin, recommended for the treatment of 
comedones. Dr. Thomson used sulphate of copper, and Dr. Paterson 
potassa fusa, in their treatment. 

" In the mode of cure of these tumours, I perceive another argu- 
ment against their contagious nature. They disappeared in the first 
child, on the recovery of her health, during a short visit to the 
country, without local treatment. In the case of the other two 
children, many of the little tumours fell off, and the disease got well 
under the use of the compound senna powder. The three at present 
upon the skin of the mother are attributable to a disordered state of 
health. Indeed, I have no hesitation in asserting that this family is 
the subject of a sebaceous constitution, and that any recurrence of dis- 
ordered health will bring with it a disposition to the formation of 
sebaceous tumours. 

" After having determined the nature of the small tumours above 
described, and having assigned to them the position which they ap- 
peared entitled to occupy in a natural system of classification of dis- 
eases of the skin, I read, for the first time, with attention, the cases 
narrated by Bateman, under the head of Molluscum, and was struck 
with the identity of Bateman's cases with those I had just witnessed. 
Pursuing my inquiry wdth a view to ascertain the true meaning of the 
term, and that which seemed to be intended in its original applica- 
tion, I came to the conclusion expressed by Dr. Jacobovics, 3 that 
Bateman must have borrowed the appellation from the essay of Dr. 
Ludwig, 4 the reporter of the celebrated case which occurred to Tile- 
sius. The author, in his preface, remarks — ' Reinhardi, visu feodum, 
corpus tectum est verrucis mollibus sivi molluscis.'' Alibert, Biett, 
Cazenave, and Schedel, on the contrary, attribute the origin of the 
term to some resemblance existing between the cutaneous tumours 
and the knots on the bark of the maple. 

" The earliest case on record of this affection, and the one in fact 
which, according to the above supposition, gave the designation to 
the disease, is that of Tilesius, recorded by Ludwig. I propose to 
make an analysis of this case, as well as of those which have been pub- 
lished on the same subject to the present time, in order to ascertain 
the opinions entertained by their respective authors of the cases which 
have appeared in their names. The result of this inquiry will, I 
trust, be a confirmation of my opinion respecting the pathology and 
true position of molluscum." 

' Bateman appears to have described follicular tumours under the name of Mol- 
luscum, vide his Pracl. Synopsis, 7th ed., p. 380, in which place he quotes a case from 
Ludwig, of a man whose whole body was covered with atheromatous tumours. Lud- 
wig. Historia Pathologica singularis cutis turpitudinis, fol. Lips., 1793. 

2 Cooper and Travers' Surgical Essays, vol. ii. 

3 " Du Molluscum recherches critiques, &c. Paris, 1840." 

4 " Historia Pathologica singularis cutis turpitudinis J. G. Reinhardi viri 50 anno- 
rum, &c. By Dr. C. F. Ludwig. Lipsia:, 1739." 



of the follicle often continues visible for a very long time ; but no traces 
of it are generally to be discovered when the tumours have attained 
a certain size. I have examined one of the tumours developed on 
the fronto-parietal region, and of the size of a partridge's egg. Towards 
its centre it rose about four lines above the level of the integuments. 
The portion of the scalp raised by the tumour had preserved its na- 
tural colour ; but it was, in a great measure, bald. The inner surface 
of the tumour was applied immediately to the bone of the cranium, 
being separated from it neither by piliferous bulbs, nor by adipose 
vesicles. On the outer surface the tumour adhered to the skin, from 
which it could not be removed in various places, where it was only 
separated by a small number of adipose vesicles and hair bulbs. This 
follicular tumour formed a perfect cyst without any opening. It con- 
tained a matter, the surface of which was white and of the consistence 
of wax, whilst that of the centre was soft and of a brownish-yellow, 
like a coffee-custard or cream. The portion of the cyst which adhered 
to the skin was cellular, red, and vascular; that of the opposite side 
was smooth and white, like a serous membrane. 

According to Meissner, 5 many of the tumours which have been 
described as polypi of the meatus auditorius externus, are owing to 
the excessive development or distension of a ceruminous follicle. 

In the body of an aged woman, who had died of pulmonary catarrh, 
six small follicular tumours, of the diameter of a silver threepenny 
piece, were found on the scalp, and ten others of various sizes, be- 
tween the shoulders and on the back. The majority of these were 
of a yellowish- white colour. I opened several of the smallest of 
them with the point of a lancet, and found that they contained athe- 
romatous matter. 

In examining the body of another old woman, aged eighty-seven, 
who had died in the HSpital St. Antoine, I found a follicular tumour 
on the right side of the pubes, in the direction of the inguinal canal, 
of the size of a hen's egg, on the centre of which there was a small 
black point like that of a grub of the face. I have seen a tumour of 
the same description, as large as a filbert, behind the right ear, upon 
which a similar black point was also remarked. In this case there 
was the rudiment of another follicular tumour behind the opposite ear, 
that is to say, a follicular worm of considerable magnitude. I have 
frequently seen tumours of the above description become the seat of 
chronic inflammation, and pus accumulate within the cavity of the 
follicle, the orifice of which then resembled a fistula. 

1194. Follicular tumours generally occur in numbers together. I 
have counted as many as fifteen on the scalp. They are always 
evolved with extreme slowness and successively ; they feel firm, and 
do not fluctuate under the finger; they are not so hard as encephaloid 
formations, the parietes of which are stronger and less yielding. 

It is not so common to find so large a number of follicular tumours 
evolved on the trunk and extremities. The eight wens (loupes) situ- 
ated on the body of the young woman whose case has been published 
by M. Dagorn, 6 differed in point of size and of structure from follicu- 
lar tumours. But it seems to me that we ought to refer to this class 
of accidental formations the cetheromatous tumours evolved on the face, 
trunk and extremities, of which mention is made by Ludwig, 7 and 
which Bateman quotes as a case of molluscum. According to some 
anatomists, these follicular tumours are evolved as a consequence of 
the obliteration of the orifice of the follicle. I have, however, seen 
many of large size in which the orifice continued very apparent. 

1195. The etiology of follicular tumours is very obscure; they 
occasionally appear due to an hereditary disposition ; to follow the 
application of repeated pressure, &c. They are more frequently 
observed among the aged than the youthful and full grown. 

1196. Treatment. — When the orifice of the distended follicle 
remains apparent, after having introduced a probe into the cavity, 
the sebaceous matter may generally be pressed out without much 
difficulty. This is but a temporary remedy, however, for the matter 
soon accumulates again ; to cure them permanently they must be laid 
are not of very large size, and are situated upon the trunk, the orifice 
open, and either cauterized or extirpated. Laid freely open follicu- 

s Diet, de Med., en 18 vol., Art. Polype. 

s Dagorn. Observ. Chirurg. sur une jeune fille agee de 18 ans, qui portait sur le 
tronc huit loupes, etc., 8vo. Paris, 1822. 
' Ludwig. Hist. Sing. Cutan. turpitudinis, fol. Lips., 1793. 






DISEASES OF THE PILIFEROUS FOLLICLES. 



!.u tumours are readily voided, and the inflammation that follows the 
operation is occasionally followed by their obliteration. They are 
also very readily dissected out, when they are not of very long stand- 
ing and large size. This operation performed on the scalp, is apt to 
be followed by erysipelatous intlammation, sometimes of considerable 
intensity ; so that many practitioners prefer to leave them alone there 
than to attack them with the knife, especially when they are nume- 
rous. These tumours are sometimes successfully treated by having 
inflammation excited in their interior, either by drawing a fine seton 
through them, or better by the injection of some stimulating Jluid, as 
of diluted alcohol, &c. 

Follicular tumours, especially those of the eyelids, may also be got 
rid of by being touched with the nitric acid, 1 or the butter of anti- 
mony, caustic potash, &c. The ligature is seldom applicable to this 
species of tumour. 

Follicular tumours of the scalp differ in their indolence, and in 
various other characters, from encephaloid tumours, which are occa- 
sionally developed upon this part. 



CALCULI OF THE FOLLICLES. 

1197. Instead of sebaceous matter, the follicles occasionally secrete 
a hard and stony substance ; Meckel found the whole of the sebaceous 
follicles of the haunch full of small calculi, in a boy; the piece of 
integument thus affected is preserved in his anatomical collection. In 
two other children, calculi of this description have been found in the 
>kin of the forehead and of the root of the nose. 2 



SPECIAL DISEASES OF THE PILIFEROUS FOLLICLES, 
AND ALTERATIONS OF THE HAIR. 

1 198. This group 3 includes congenital or accidental absence of the 
hair [alopecia) ; supernumerary hairs ; changes in the colour of the 
hair (canities, accidental staining of the hair); anomalous direction of 
the hair of particular parts, as of the eyelashes (trichiasis), the study 
of which falls within the domain of the surgeon ; defective confor- 
mation or structure of the hair-bulbs, the nature of which is still little 
known ; and the disease entitled plica, the characters of which I shall 
detail in the Appendix. 

119S. The greater number of the alterations which the hairs 
undergo result from an affection of their bulbs or secerning organs. 
The hair-bulbs are implicated in many diseases of the scalp, in favus, 
impetigo, &c. Plica itself, according to Schlegel, is nothing else than 
a particular inflammation of these organs. Inflammation of the bulbs 
generally occasions the loss of the hair; when the hair begins to grow 
again it is commonly finer and lighter in colour than that which was lost. 

The piliferous bulbs may be atrophied or destroyed by the com- 

1 Tenon. Application de l'acide nitrique au traitement de certaines tumeurs 
cnkystees (Memoires et observations sur l'anatomie, la pathologie, etc., 8vo. Paris 
:806. p. 220). 

* Voigtel. Handbuch der pathologischen Anatomie, 8vo. Halle, 1804, Erster 
Band, p. 85. — Horst. Manuductio ad Medic, p. i. cap. 2, sect. 2. 

3 Hippocrates speaks of the loss of the hair as an unfavourable symptom in 
phthisis; he also mentions baldness and whiteness of the hair. Celsus describes 
alopecia. Galen goes at great length into the varieties of colour of the hair. Aretauis 
inly notices the loss of the hair in elephantiasis. .<Etius and Paulus give a great 
number of recipes against grayness, baldness, &c. Avicenna begins his chapter: 
De decoloratione (jen. 7), with a lengthy account of the alterations of the hair, and the 
remedies they require. Mercuriali has entered still more fully upon this subject. 
The accounts of Lorry are even more complete and more accurate. But for the best 
details in regard to all the affections of the hair, the particular treatises published by 
the following auihors, ought especially to be consulted :— Plempius (De affectibus 
capillorum et unguium. Lovani, 1662), Sohvick (Diss, de morbis pilorum, Frib. 
1777), Meioomins (,De pilis eorumque morbis. Helmstaedt, 1740), J. P. Pfaff(De 
varietat.bus pilorum naturalibus et praeter-naturalibus. Hate, 1799), G. Wedemeyer 
(Hisiuna Pathologica P'lorum. Getting., 4to., 1813), Bueck (Diss, de pilis eorumque 
morbis. Halle, 1819), Villerrne (Art. poil. Diet, des Scienc. Medicales) ; and espe- 
cially the researches of Dr. B. Eble (Die Lehre von den Haaren, etc. 8vo. 2 vols. 
Wien.. 1931, tig.). 



pression of subcutaneous tumours; they sutler still more commonly 
from the progress and long continuance of favus, of syphilitic ulcers, &c. 

The growth of the hair has little influence on the other functions oi 
organs of the economy, yet observations are not wanting to show 
that cutting the hair may be prejudicial in some acute diseases.' 

Comparative pathology may, possibly, some day, throw new light 
on the subject of the alterations of the hair ; it has hitherto been but 
little cultivated under this particular point of view. M. Fred. Cuvier 
has observed the bulbs of the feathers in various birds very much 
injected and inflamed ; and after pulling out the feathers a very con- 
siderable development of the papilla; has been noticed. Is depilation 
followed by an analogous increase of the piliferous papilla"' ; and are 
they capable of inflaming in the same way as the bulbs of feathers? 

1199. Congenital deficiency of the hair is a malformation very rarely 
met with. It very seldom continues longer than the few first years of 
life, and ought rather to be regarded in the light of a late development 
of this appendage of the skin. 

1200. Supernumerary tufts of hair, i. e., patches of hair in situations 
where none is generally met with, 5 have been seen in different parts 
of the body : A young man had a congenital blackish patch on the 
upper and inner part of the thigh, which was not prominent, from two 
to three inches in diameter, and the edges of which were irregular and 
scolloped. This spot was covered with hair, and each particular hair 
presented a little enlargement at the place where it issued from the 
skin. I once saw a young man, sixteen years of age, who exhibited 
himself to the public under the name of a new species of savage or 
wild man whose breast and back were covered with light brown hair 
of considerable length, the surface upon which it grew being of a 
brownish hue, different from the colour of the surrounding integu- 
ment. Almost the whole of the right arm was covered in the same 
manner. On the lower extremities several small tufts of hair were 
observed, implanted upon brown spots from seven to eight lines in 
diameter, symmetrically disposed upon both legs. The hair was 
brown, of the same colour as that of the head. 

Ph. Fred. Von Walter 9 has published a very remarkable case of 
ncevus pilaris lipomatodes. 

Bichat informs us 7 that he saw at Paris, an unfortunate man, who, 
from the period of his bij^h, had had his face covered with hairs like 
those of a wild boar; and he adds, that the stories which are current 
among the vulgar, of individuals with a boar's head, with a wolf's 
head, &c, undoubtedly referred to cases in which the face was co- 
vered in a greater or less degree with hair. M. Vilerme saw a child 
of from six to eight years old, at Poictiers, in 1808, whose body, 
except the feet and hands, was covered with a great number of brown, 
prominent spots, of different dimensions, beset with hair, shorter and 
not so strong as that of the boar, but bearing a certain resemblance 
to the bristles of that animal. These spots occupied, perhaps, about 
a fifth of the surface of this child's skin. 

Grivet, aged twenty-six, became a patient in the hopital de la Pitie, 
Nov. 16th, 1826, on account of a bronchial affection. On both of 
this man's shoulders there was a quantity of black hair from six lines 
to an inch in length, fine and slightly frizzled, and different from the 
hair of other parts of the body, by appearing to be set within slight 
brown elevations of the skin which surrounded the root of each hair 
individually. I once met with a man of mature age, on the fore 
and outer part of whose thigh, over an extent of about six inches 
one way by about four the other, there was a thick crop of hair. The 
opposite thigh was but thinly beset in the same situation. This hair 
had appeared at the age of puberty, along with that which then began 
to sprout on other particular regions of the body. 

M. L. Dufour 8 has detailed the case of a young man, twenty years 
of age, whose sacral region was beset not with simple short hairs, 
but with a tuft as long, black, thick and pliant as that of the head. 

4 Lanoix. Observations sur le danger 'de couper les chevaux dans quelques 
maladies aigues (Memoires de la societe medicale d'emulation, 8vo. Paris, t.i. p. !)• 

5 Birgen (Carol Augustus). Diss, de pilorum praternaturalium generatione et 
pilosis tumoribus, 4to. Francofurti ad Viadrum, 1745.— Bose. Programma de pnz- 
ternaturali pilorum proventu, 4to. Lipsise, 1776. 

6 Walter (Ph. Fr. von). Ueber die angebornen Fetfhautgeschwulste, etc., fig. tol. 
Landshut. 

7 Bichat. Anat. generate, 8vo. Paris, 1812, t. iv. p. 827. 

8 Arch. gen. de med., t. xxvi. p. 274. Rev. Med., 2e serie, t. ii. p. 329. 



FELTING OF THE HAIR. 



377 



And what is particularly remarkable in this case is, that the skin from 
which it grew was as white and fine in its texture as the integument 
of the rest of the body. M. Campaignac showed me a similar case 
in which there was a large tuft of long black hair growing from the 
shoulder. 

1201. Certain pathological conditions may give rise to the acci- 
dental growth of hair. Boyer used to quote a case in his lectures of 
a man who, having had an inflamed tumour in the thigh, perceived 
this part become covered, in no long space of time, with numerous 
long hairs. I have seen a case of the same kind myself: A blister 
having been applied to a child two years old, was kept open for three 
months. Some time afterwards, the mother of the child called my 
attention to the circumstance that the whole of the part which had 
been raised by the blister was now covered with hair, which has 
remained ever since. 

A student of medicine lately showed me a number of hairy patches 
which he had on his skin, and gave me the following account of the 
circumstances under which they were developed : " During the sum- 
mer of 1829, I bathed frequently in the sea. I used to get out of 
the water, and dry myself in the hot sun of the South ; I then returned 
to the water. One day in particular, I continued in the sea longer 
than usual. Some days afterwards, changing my linen, I happened 
to look down upon my breast, and saw with amazement a broad sallow 
or coppery patch on the upper and outer part of the right side. 
Looking farther, I found another patch exactly like the first, over the 
iliac fossa of the same side. Both of these spots remain now exactly 
what they were in 1829 ; they have neither changed in colour nor 
extent." These patches are not uniform : they seem to consist of a 
great number of small patches, separated by intervals of different 
extent, where the skin has continued healthy. The colour of both 
patches forms a strong contrast to that of the rest of the skin, and 
may be compared to the tint of some white wood, which has been 
handled and soiled, rather than to that of copper. The colour is 
deepest in the centre of the patches. They are not affected with 
any kind of tingling or other unpleasant sensation. But they are the 
frequent seat of the pustules of acne. It is long since the hair that 
covers them made its appearance. Nothing had ever been tried to 
disperse these patches. They seemed owing to the prolonged action 
of the sun's rays. Were the whole of the small spots of which the 
broader patches are made up to be uniformly blended together, the 
tint of the surface would differ little from that which the forepart of 
the neck of labourers, who are constantly exposed to the heat of the 
sun, presents. 

The following case, which I have from M. Bricheteau, is a more 
remarkable instance still, of the occurrence of these accidental hairy 
spots. A young woman, nearly twenty-four years of age, having a 
white skin, and hair of a deep black, of weakly constitution, and 
reduced by a pregnancy during which she had suffered much, a miscar- 
riage and an extraordinary difficulty of swallowing, to the last stage 
of marasmus, began to recover in the summer of 1826, after six or 
seven weeks endurance of an illness which every one thought must 
inevitably carry her to the grave. Scarcely had she begun to take a 
little food, and to recover her strength, than the skin, which was 
dry, earthy, and, as it were, wrapped round the bones, became cov- 
ered, especially on the back, breast and abdomen, with a multitude 
of small elevations, analogous to those which appear under the 
influence of exposure to cold. These little risings became brownish 
at the end of a few days, and a hair was soon afterwards observed 
on the summit of each. This, at first, was very short, fair, and 
silky; but it grew rapidly, so that before the lapse of a month, almost 
the whole surface of the body, with the exception of the hands and 
face, became completely velvety. The hair thus evolved was after- 
wards thrown out spontaneously, and was not reproduced. 

1202. I have several times observed a well-marked, excessive 
development of the hair upon the chin and upper lip in young women 
whose menstrual functions were disordered. 1 Hippocrates speaks of 
the same thing: "In abderis, Phaetusa Phyteaa uxor, priore quidem 
tempore faecunda erat; cum autem maritus ipsius in exilium abiisset, 
menses multo tempore suppressi sunt ; postea rubores et dolores ad 

1 Burlin (Jac). De fseminis ex mensium sunnressione barbatis, 4to. Altdorf, 
16C4. 

95 



articulos oborti sunt. H<ec autem ubi contigissent et corpus virile 
factum est, et hirsute penitus evasit, et barbain produxit et vox, as- 
pera facta est: . . . idem hoc contigit etiam Nammysiae Gorippi uxori, 
in Thaso" (Epid. lib. vi. sect. vii). 

I may also remark that this growth of the beard is very common 
among females of a certain age, and that it is not unfrequent among 
those who are mothers of several children. 

In the beard and on the scalp, compound hairs, of a larger size than 
those around them are occasionally observed. 2 These compound 
hairs are often cleft at their free ends, and are sometimes formed of 
hairs of different colours, which separate when seized between the 
blades of the forceps, to be pulled out. They are produced by folli- 
cles set closely together, and communicating with the exterior by a 
single opening. 

1203. The hair on different parts of the body may accidentally 
grow to a considerable length. This unusual development of the hair 
is occasionally confined to a single region of the body. I once saw 
a Piedmontese, aged twenty-eight, strongly built, having the chest 
broad and large, and the muscles of an athlete, — the arm was above 
twenty-one inches, and the calf of the leg nearly two feet in circum- 
ference. This man had little beard, and the trunk was very scantily 
furnished with hair, but his scalp was covered with the most extra- 
ordinary crop : frizzled on purpose, it was above four feet ten inches 
in circumference. The hair was of a dark brown, approaching to 
black, extremely fine and silky. This phenomenon — excessive length- 
ening of the hair — has been particularly observed in plica. In 
phthisis the hair and eyelashes are often extremely long and very 
strong. 

1204. The growth or development of the hair may be accelerated 
by the state of the organs of generation. Moreau de la Sarthe showed 
a child to the Medical Faculty of Paris, in whom the precocious 
development of the testicles had influenced that of the hair to such 
a degree that at the age of six years the chest of this boy was as 
thickly beset with hair as it is usually in adults. It is well known, 
on the other hand, that eunuchs often lose the greater part of their 
beard. 

1205. The hair sometimes grows in a wrong direction, to remedy 
which, it is not always enough to pull them out ; it is often necessary 
farther to take away or destroy their generating bulbs. This is par- 
ticularly the case in Trichiasis, for which Vacca 3 has proposed a new 
and very advantageous mode of operating. 

Other instances of faulty direction of the hair are related by authors. 
Thus the hair has been seen growing in a direction the very reverse 
of that which it usually follows, sometimes towards the inner or 
adhering side of the skin. All these vicious directions of the hair 
are occasioned by deviations of the bulbs, or of the parts in which 
they are implanted. It is not uncommon, either, on the extremities to 
observe the hair rolled up spirally under the epidermis. The slight 
degree of irritation to which this gives rise, is followed by the forma- 
tion of a little elevation, from which a silky hair may be drawn out 
twisted round upon itself. 

1206. The hair presents several peculiarities in point of strength, 
dryness, moisture, &c. M. Alibert speaks of a woman whose hair 
was very crisp before marriage, but after pregnancy became so con- 
stantly moist, that it was quite impossible to make it curl. The hair 
of the axillse became unctuous in the same manner. 



FELTING OF THE HAIR. 
Vocab. False Plica. 

1207. Felting of the hair consists of an inextricable interlacing of 
this production. It is chiefly seen among individuals who, for many 
weeks or months, have paid no attention to their hair. It often occurs 
among females after long illnesses, &c. It is very common in Poland, 
where it has been observed by Messrs. Davidson, Kreuzer, Boyer, 
Rousille-Chamseru, Gasc, and others. Several writers have con- 
founded it with plica. 

2 Ollivier. Art. Poil (Dictionnaire de Miidecine, en 18 vol.). 

3 Arch. gen. de med., t. ix. 



378 



ALTERATIONS OF THE HAIR FOLLICLES. 



ling of the hair occurs independently of any alteration of 

be na i !. may take place among individuals 

labouring under chronic affections of the hairy scalp, especially when 

ir has been allowed to grow to a great length. The felted 

nay present very different appearances. The process is similar 

to what takes place in plica; but the circumstances under which it 

happens are different, and the simple phenomenon of felting of the 

mere appendage, must not be confounded with a serious affection of 

generating bulbs of the hair themselves. 

1209. When the felted mass of hair cannot be unraveled, it should 

be cut oil". 



CHANGES OF COLOUR OF THE HAIR. 

1210. The hair is liable to undergo certain changes of colour con- 
nected with some modification of that part of the bulb which secretes 
its colouring matter. M. Alibert gives us the case of a young lady 
who, after a severe fever which followed a very difficult labour, lost 
I fine head of hair, amidst a discharge of viscid fluid, which inun- 
Jated the head in every part. He tells us, further, that the hair grew 
again of a deep black colour, after the recovery of the patient. The 
same writer details the case of Jerome B * * *,born with brown hair, 
who, having lost it all in the course of an illness, had it replaced w 7 ith 
a crop of the brightest red. White and gray hair have also been 
known to be replaced, under particular circumstances, by hair of the 
colour which the individual had had in youth. We are even assured 
that the wmite hair of a woman, sixty years of age, changed to black 
a few days before her death. The bulbs in this case were found of 
great size, and appeared gorged with a substance from which the hair 
derived its colour. The white hairs that remained, on the contrary, 
grew from shriveled bulbs, much smaller than those that produced 
the black. This patient died of phthisis. 1 A very singular case has 
been published lately of a woman whose hair, naturally fair, assumed 
a tawny red colour, as often as she was affected with fever, and re- 
turned to its natural hue as soon as the febrile symptoms abated. 2 To 
conclude this subject, M. Villerme alludes to the case of a young lady, 
sixteen years of age, who had never suffered except from trifling head- 
aches, and who, in the winter of 1817-18, perceived that the hair 
began to fall off from several parts of her head, so that before six 
months were over, she became entirely bald. In the beginning of 
January 1819, her head became covered with a kind of black wool 
over those places that were first denuded, and light-brown hair began 
to spring from the rest of the scalp. Some of this fell out again when 
it had grown to the length of from three to four inches ; the rest 
changed colour at different distances from its ends, and grew of a 
chestnut colour from the roots. The hair, half white, half chestnut, 
had a very singular appearance. 3 The hair, as I have said, has occa- 
sionally been known to return in age to the colour it exhibited in 
youth.'' 

I shall only further add, with regard to the changes of colour un- 
dergone by the hair, that it may be dyed green, 5 blue, red, &c, by a 
variety of colouring matters with which it may be impregnated. The 
hair does not so long retain any accidental tint as the epidermis. 



CANITIES. [BLANCHING OF THE HAIR.] 

1211. Canities is the word used to signify the congenital and the 
senile or accidental loss of colour undergone by the hair. This 
blanching maybe general or partial. 

1212. The hair begins to be blanched at its free extremities; yet 
the hair is often seen white in that portion of its length which is 
nearest the skin, and black or brown in the rest of its extent. This 
disposition, the opposite of the former, is owing to the hair having 

Bruley. Sur un , changement subit de chevcux qui de blancs sont devenus noir. 
[Jonrn. gener. de med., t. iv. p. 290.) 
- Jonm. complem. des sc. medic, t. v. p. 59. 
3 Diction n. des sc medic, t. xliii. p. 302. 

* Diet de med., t. iv. p. 176. 

• Laugier. Cuivre retire des cheveux d'un ouvrier fondeur. Rev. med. t. x. 
p. 183. 



first been secreted black, and then, in consequence of some a!' 
of its bulbs, secreted white. 

1213. Among the aged, the hair of the head is that which first be- 
comes white. Men usually begin to get gray between the thirtieth 
and fortieth year of their age. The beard, the hair of the pubes, 
axillae, &c, generally become white later in life. The change 
almost always begins over the temporal regions. The white hairs 
are at first few in number, but they soon multiply, and end by spread- 
ing over the whole head. WTien these whitened hairs fall out, they 
are rarely followed by any reproduction from the bulb, so thatgrayness 
is often followed by baldness. Fair hair does not often become white, 
yet it frequently falls off at a very early age. 

1214. New-born infants 6 sometimes present tufts of hair upon their 
heads completely white. Schenckius speaks of a young man, whose 
beard grew white from its first appearance. Young men of from 
eighteen to twenty occasionally become gray. Paroxysms of rage, un- 
expected and unpleasant news, diseases of the scalp, such as favus, 
wounds of the head, habitual headache, over-indulgence of the sexual 
appetite, mercurial courses too frequently repeated, great anxiety, &c, 
have been known to blanch the hair prematurely. 

1215. Grayness is sometimes only partial. An adult, whose hair 
generally was brown, had a tuft of white hair over the right temple. 
Several other cases of the same kind have been recorded in periodical 
publications. Lorry tells us, that grayness of one side only is some- 
times occasioned by severe toothache. 7 Ludwig has known the eye- 
lashes become white after small-pox. 8 The beard has also been ob- 
served to be extremely white in one place and black in another ;° it 
has also been known to become white on one side of the face whilst 
it continued of its former colour on the other. 10 Cases of canities of 
the whole of one side of the body have also been detailed. (Diet, des 
Sciences Med., t. iv. p. 76.) 

1216. The blanching of the hair generally takes place slowly ; but 
there are very authentic instances on record of the occurrence of 
canities almost suddenly. 11 A person of my acquaintance, says Bichat, 
became almost entirely gray in consequence of some distressing news 
that reached him. 12 A similar case has lately been recorded by M. 
Cassan. 13 A woman of the name of Perat, summoned before the 
Chamber of Peers to give evidence in the trial of the assassin Louvel, 
was so much affected that her hair became completely white in a 
single night. In these instances certain changes depending on the 
state of the vital processes generally, must take place in the hair. 

When hair grows from cicatrices that are without pigment, it is 
generally colourless. The coincidence of the want of colour in the 
skin and in the hair, has been observed in the majority of instances 
of general or partial leucopathia. In senile canities the skin of the 
cranium does not participate in the absence of colour observed in 
the hair. 

1217. Gray hairs have been said to be without marrow or matter in 
the interior, in place of which there is an empty canal. Vithof assures 
us that the bulbs of those hairs which have become white, are of 
diminished size. 

1218. Treatment. — The blanching of the hair which accompanies 
general and congenital, partial and accidental leucopathia, and the 
canities which occurs with the progress of years, cannot be made the 
subject of any kind of remedial treatment. It were in vain to pull out 
the white hairs by their roots, or to bring about their fall by the use of 
depilatory powders and pomatums; the hairs that spring in their places 
would be no less white. Hair-dressers frequently make use of a solu- 
tion of the nitrate of silver to dye the hair when it has become while 
or gray ; it has the inconvenience of rendering the hair crisp and 
brittle, (a) 

(a) More illustrious examples might be cited in the cases of Sir 
Thomas More, Marie Antoinette, Queen of France, Mary, Queen of 

6 Schenck. Obs. Med. rar., lib. i. obs. 3. 

7 Lorry. Tract, de morbis cutaneis, p. 402. 

8 Ludwig. Prim. Lines Anatom. Palholog., p. 29. 

9 Hagedorn. Hist. Med. Physic,., cent. 3, hist. 55, p. 354. 

10 Brandis. Versuch uber Metaslasen, p. 172, note. 

11 Voigtel. Handbuch der Pathol. Anatomic Erster Band., p. 90. 

12 Bichat. Anat. gener., t. iv. p. 815. 

13 Archives gener. de medic. Janvier, 1827. 



ALOPECIA. 



379 



1219. When canities is partial, and consequent upon a chronic 
inflammation of the scalp which has extended to the piliferous hulbs, 
the hair, although thrown out, or eradicated, is often produced with 
its pristine form and colour. It sometimes happens that a hair is 
partially secreted white, and partially coloured. When eradicated, 
these hairs are followed by others that are generally entirely coloured. 
Veterinary surgeons have made similar observations upon animals. 
Horses exhibit white hairs upon the cicatrices of any wounds they 
may have chanced to receive ; these hairs are frequently replaced by 
ethers of the colour, or very nearly of the colour of the animal ; more 
frequently still, however, a second crop of white hair succeeds that 
which is lost ; and sometimes the parts once denuded are never covered 
again. It is almost superfluous to say that those parts whose bulbs 
have been destroyed by wounds, ulcers, &c, are never covered with 
hair at all. 



Historical Notices. 

1220. The ancients 1 ascribed natural canities (hoXiotyh and rtoju'ucrt? 
of the Greeks ; canities, canitia of the Latins), to a deficiency of sap 
in the hair, comparing it to the change which the leaves of trees 
undergo on the approach of winter. 

Celsus does not mention accidental canities. I have quoted several 
cases of premature blanching of the hair, in consequence of depressing 
moral emotions of different kinds, and have alluded to some extra- 
ordinary instances of sudden grayness occasioned by great mental 
anguish (§ 1216). Several other cases are mentioned by different 
authors. 2 



Vocab. Area, Cahities, Ophiasis, Porrigo decalvans. 

1221. Under this title are designated the senile, accidental or pre- 
mature, partial or total loss of the hair, and farther, the non-develop- 
ment of this appendage on those parts which are generally provided 
with it. These phenomena are, therefore, distinct from the loss of 
the silky and colourless down observed on the body of the foetus, 
which is detached as well previously to birth as after that event; it is 
also different from the moulting, or periodical fall of the hair and 
feathers among the lower animals. 

The scalp and chin, especially the former, are the usual seats of 
alopecia in man; the genital organs, axillae, eyebrows, and edges of 
the eyelids in both sexes, may be affected with general or partial bald- 
ness, (a) 

1222. Congenital absence 3 and ulterior defective development of the 
hair are phenomena of considerable rarity, which I have nevertheless 
had opportunities of observing. Such was the case of the man Beau- 
vais, who was a patient in the hopital de la Charite, in 1827. The 
skin of this man's cranium appeared completely naked ; although on 
examining it narrowly, it was found to be beset with a quantity of 
very fine white and silky hair, similar to the down that covers the 
scalp of infants; here and there upon the temples there were a few 
black specks occasioned by the stumps of several hairs which the 
patient had shaved off. The eyebrows were merely indicated by a 
few fine and very short hairs; the free edges of the eyelids Avere 
without cilia, but the bulb of each of these was indicated by a small 
whitish point. The beard was so thin and weak that Beauvais only 
clipped it off every three weeks. A few straggling hairs only were 
observed on the breast and pubic region, as in young people on the 



Scots, &c. I knew two individuals whose hair had become prema- 
turely white from strong mental emotion — fear and anxiety. 
(a) Men are much more frequently affected with alopecia than women. 

' Galenus. Comment, ap. Hippocratem. De Nat. Puer. xix. 4, et seq. — Cel, lib. v. 
sect. 28, etc. De Leuce. 

2 Alberti. Diss, de canitie prematura. Hal., 1729. 

3 Danz met with two Jews who had neither hair nor teeth. (Starks, Archiv. fuer 
die Geburtshiilfe, Bd. iv. p. 884.) 



approach of puberty. There was scarcely any under the axilla 1 . It 
was rather more abundant on the inner parts of the legs. The voice 
had the pitch and intonation of that of a full-grown and well-con- 
stituted man. Beauvais is also rather of an amorous disposition, — 
he has had syphilis twice. He tells us that his mother and both his 
sisters have fine heads of hair, whilst his father presented the same 
defect in the commodity of hair which he does himself. 

The loss of the hair in consequence of the advance of years (calvities), 
happens slowly and progressively, without appreciable alteration in the 
scalp. Among men who are bald, the hair of the whole upper and 
anterior part of the head is generally lost, so that nothing more 
remains than a semicircle of hair extending backwards from the one 
temporal region to the other. Among women the hair becomes 
white ; but bald women are much more rarely met with than bald 
men. Bichathas observed that before the hair drops out in the aged, 
the bulbs become gradually shallower, and that the slender canal 
which receives the roots, ends by disappearing. The follicles are 
also destroyed in certain partial baldnesses occasioned by the develop- 
ment of subcutaneous tumours. On the other hand, Bichat, in the 
body of a man almost completely bald, who had died of a fever 
which is designated as putrid, met with the slender conduits in their 
normal state, and even containing small sprouting hairs at their 
bottom. There is, therefore, a difference between the fall of the hair 
in the aged, and that which is occasioned by certain diseases. The 
whole secreting organ perishes in the first, the stem of the hair alone 
is detached in the second. 

1223. Partial alopecia? may be the consequences of various altera- 
tions of the secreting follicles of the hairs. 

1st. Some of these cases occur in convalescence from acute diseases, 
and appear to have been preceded by slight erythema, or pityriasis of 
the scalp. This loss of the hair is often accompanied with a pretty 
copious furfuraceous desquamation. The comb then detaches a large 
quantity of epidermic furfural, which are renewed with great prompt- 
itude ; the skin under them is generally found to be erythematous. In 
this variety of alopecia the hair falls off by degrees from the whole 
surface of the scalp. The hair looks thin, dry and brittle. 

2d. In other instances the hair falls off in consequence of various 
morbid affections of the skin, as of sycosis, impetigo, 4 favus, syphilitic 
eruptions, morbid secretions of the sebaceous follicles, &c. 

3dly. Alopecia is also occasionally the consequence of inflammation 
of the piliferous bulbs, induced by the previous occurrence of favus, 
impetigo, chronic eczema, &c. I once saw a young woman labouring 
under impetigo sparsa of the whole surface of her body, who lost her 
nails, her epidermis and her hair simultaneously, (a) 

(a) The remote causes of alopecia, acting by constitutional disturb- 
ances, or modification of nutrition, are well exhibited in the following 

4 Impetigo; loss of the eyelashes and hair of the head. P * *, twenty "years of age, 
entered La Charite, April 3d, 1827, labouring under impetigo of the upper lip and 
nose. For seven months he has had a constant discharge from the nose; during the 
last two, incrustations have been formed on the ala? nasi, septum and upper lip. These 
are now from two to three lines in thickness and almost obstruct all access to the 
nostrils. Several pustules evolved nearly an inch from the alse nasi, and on the sur- 
face of the chin, have all the characters of those of impetigo. The right eye is 
inflamed; the eyelids also inflamed have lost their cilia here and there. (V. S. ad 
§xii; veal broth with two drachms of sulph. sodas.) The incrustations were got rid 
of by means of emollient cataplasms, and the course which is proper in these cases 
was prescribed (vide Impetigo) with such success, that the patient left the hospital 
well on the last day of April. He had a relapse, however, and returned on the 16th 
of May, the disease having now attacked the scalp, and the hair of the districts impli- 
cated being much thinner than elsewhere. Sulphureous washes and baths, infusion 
of wild endive with a course of sulphate of soda, dissipated the disease a second time 
before the 1st of June, when a fresh crop of hair was beginning to appear on the 
regions that had been made bald. 

Impetigo of the left cheek; permanent alopecia; Siroux, a dyer, was attacked when 
two years old with impetigo of the left cheek, and since this time the same disease 
has recurred repeatedly. He had been twice a patient in the Hopital St. Louis, and 
I had myself had him as often under my care on account of it. The disease has 
constantly recurred upon the left cheek, between the temporal region and the chin, 
and between the ear and nose. In some of the previous attacks, the beard of this 
side of the face had fallen out, and in many places had never reappeared. There 
are now but a few straggling and colourless hairs, which may be pulled out with the 
greatest ease. On the right side the beard is rather strong. It is probable that the 
repeated attacks of inflammation of the left cheek, have ended by destroying or alter- 
ing very materially the piliferous bulbs of the part and rendered them incapable of 
performing their office. 



380 



ALTERATIONS OF THE HAIR FOLLICLES. 



4th!. remarkable varieties of alopecia, is that 

which Will. m has described under the name of porrigo decalvans. 1 
| ikin of the chin and checks of individuals affected 

from an article on the subject, by Dr. Todd, in the Cyclopedia 
p. 72-3): 
"Alopecia may be a sympathetic affection, not a symptom of a con- 
stitutional disease, but caused by a diseased or disordered state of 
some other organ or system of organs. The most common form of 
this description which has come under our observation, is that which 
proceeds from chronic inflammation of the mucous membrane of the 
stomach, giving rise to a particular form of dyspepsia, which has, for 
this reason, been called inflammatory. Of this nature, probably, was 
that mentioned by Galen (De Cur. Morb. Sec. Loc, lib. i. cap. 2,) 
arising from eating poisonous mushrooms; and that other noticed by 
Hippocrates (Ue Inlcrnis Affectibus, sect. 4.), in which the reader 
will readily recognize a well-marked case of the above-named form of 
dyspepsia (gastrite chronique) , and to which case there is, in an excel- 
lent record of modern medicine, (Journal des Progres, 1830, torn. ii. 
p. 43,) a parallel in form as well as in cause, and which, it is de- 
serving of attention, was afterwards succeeded by an attack of dia- 
betes raellitus. Of the same nature, also, was in all probability that 
species of alopecia termed by the Arabians (Avenzoar, Avicenna), 
bilious, in contradistinction to the other species which they called 
phlegmatic; which last, in all appearance, corresponded with that 
form described by Celsus as most difficult of cure, 'pejus est quod 
densam cutem et subpinguem ex toto glabrum facit,' coinciding with 
the observation of some modern writers, that if the skin is pale or 
insensible, and it is difficult, by friction, to produce redness, the case 
is irremediable. Of the same nature is the case given by Lemery, of 
a man, who, some months after excessive catharsis, lost successively 
all the hairs from his body; and also another strikingly singular case, 
which, both in its causes and its cure, justifies the opinion which we 
have ventured to give of the nature of this species of alopecia. It 
is so illustrative that no apology is required for relating it. " Lodo- 
vico Gnemmi, a Piedmontese, fifty-seven years of age, a person of 
great vivacity of temper, of a plethoric habit, but spare form of body, 
having the skin of a dull white colour, began, in the winter of 1825 
and 1826, to feel severe pains in the head, with a sensation of burn- 
ing heat over all the body, but most particularly in the skin; it was 
to such a degree, that, during the coldest night of winter, he was 
obliged to throw off his bedclothes. After having passed fifteen 
days in this painful state, he began, by degrees, to lose all the hairs 
of his head, then those of the beard, eyebrows, eyelashes; and in the 
course of a month, there was not to be found a hair upon the surface 
of his body, neither in the arm-pits, on the breast, on the genital 
organs, surrounding the anus, nor upon any of his extremities. All 
his skin was as smooth as polished marble, and the slightest trace of 
hairs could not be felt by the hand. He remained for two years in 
this state, so deformed by the loss of his hair that he hardly ventured 
to show himself in public, but always feeling on the surface of his 
body a sense of pungent acrid heat, more especially on the surface of 
the scalp, which was always morbidly sensible and painful to the 
touch. In the beginning of March, 1828, he was attacked with a 
severe peripneumony, which was treated and cured by the most active 
antiphlogistic remedies, viz. : low diet, general and local blood-let- 
ting, cupping, purgation, blisters, &c, and, strange to say, under the 
influence of this treatment, on the decline of so severe an inflamma- 
tory disease, and in a state of the greatest weakness of the circulation, 
the hairs which had disappeared for the space of two years, began 
again to shoot forth, and continued to do so during all his convale- 
scence. On their first appearance they resembled fine soft wool, almost 
colourless wool ; but they continued, every day, to approach nearer 
to their natural character, which they had fully recovered at the end 
of a month, when, owing to some imprudence in regimen, he was 
seized with an acute attack of gastro-enteritis, which carried him off." 
Journal des Progres, torn. xiv. p. 244.) 

OJ the same nature, also, are many cases of partial alopecia (por- 

- Dr. Elliotson met with a case of extensive porrigo decalvans in a child, who was 
21 he same '' rae •* c,ed . WI * s > mptoms of a disease in the hrain. Lond. Med. Gaz., 
vol. vn. p. 639. Ibid., vol. vni. p. 30. lb., vol. xi. p. 229. 



with this disease, presents one or more circular patches, entirely 
divested of hair, though surrounded with as thick a growth as is 
usually met with. The skin of these patches is smooth, without 
redness, and often even of remarkable whiteness. The areas of these 
patches extend gradually. When several exist near each other, the\ 
often end by uniting, 2 and if allowed to go on unchecked, a la 
portion of the scalp may be thus completely stripped of its covci i 
Neither vesicles nor pustules, nor any other form of eruption exists 
on the surface of these patches. Porrigo decalvans differs essentially 
in this particular from the partial baldnesses which are observed after 
favus, the annular syphilides, &c. 

The first hair reproduced on the surface of these bald patches, the 
skin of which, as has been said, very often appears somewhat blanched, 
is generally finer and of a lighter colour than the old hair in its vicinitj . 
I have observed this affection both among children and adults. I am 
not acquainted with the cause or causes which occasion it. 

1224. The Messrs. Mahon, under the title of teigne tondante, 3 have 
described a disease of the scalp, which both in its form and in many 
of its characters, resembles porrigo decalvans, but which differs from 
this affection in the appearance of the surface affected and the presence 
of several altered and brittle hairs. On one or more circular patches, 
the hair appears broken off to within a line or two of the skin. The 
surface of these patches is extremely dry, and presents asperities, 
cognizable by the eye, but especially by the touch, like the skin of a 
fowl. The part affected is slightly bluish, and by scratching, a fine 
and very white powder can be detached from its surface. The affec- 
tion begins in a point which spreads from its circumference ; a similar 
spot often forms in the neighbourhood of the one which appeared 
first, and the two may unite; the authors quoted have thus, in three 
or four instances, seen the head become entirely bald, and covered 
with asperities. They have observed the affection among several 
members of the same family. 

This variety is extremely rare ; I have only seen a single case of 
it in a child. 

1225. Alopecia is occasionally a symptom of constitutional syphilis. 
This effect of the venereal poison, which is mentioned by Rangonus, 
Fallopius, Massa, and Fracastorius, differs from the partial baldness 
occasioned by the development of syphilitic tubercles or ulcers, inas- 
much as the skin does not appear altered. Alopecia from this cause 
is extremely rare at the present day. 

1226. The existence of mercurial alopecia is extremely equivocal. 

rigo decalvans), which we have observed in adults as well as in chil- 
dren, and which we have had the satisfaction of remedying by treating 
the primary disease — chronic gastritis, or inflammatory dyspepsia. 

" This origin of alopecia also accounts for the connection which we 
have observed between it, lichen, urticaria, and pityriasis; sometimes 
coexisting ; sometimes succeeding each other ; all differently modified 
operations of the same cause. 

" To this description of alopecia ought probably to be also referred 
those which have been attributed to the use of certain kinds of food, 
and which have been said to prevail at particular places. Thus it is 
said not to be unfrequent in countries where the inhabitants live chiefly 
on fish ; as, for instance, formerly in the Shetland Islands, where bald- 
ness from this cause was so common, that it was a familiar saying that 
' there was not a hair between them and heaven.' (Sir R. Sibbald's 
Description of Shetland.) Thus Tournefort relates, that in the island 
of Mycone, one of the Cyclades, the children are either bald, or sel- 
dom arrive at the age of twenty without being so. And, though it is 
difficult to assign the cause, it must be acknowledged that alopecia 
(porrigo decalvans) has appeared to be more common at Brighton than 
in other places, and that all the cases the writer has observed in this 
place have afforded symptoms of chronic irritation of the mucous mem- 
brane of the stomach." 

The influence of constitutional causes, by enfeebled or perverted 
nutrition, is manifested in the falling off of the hair during phthisis; and 
after protracted fevers, and gout and rheumatism. Pregnancy is some- 
times an exciting cause. 

2 This is probably the state which the ancients described under the name of 
ophiasis. 

3 Mahon. Rech. Sur les Teignes, p. 133. 



ALOPECIA. 



381 



I have seen a great number of gilders, silverers of mirrors, &c, in the 
different hospitals of Paris, affected with tremblings and paralysis of 
the limbs, but in none of them did the mercury appear to have exerted 
any unusual influence on the hair, (a) Nevertheless in Forestus we 
read of the loss of the hair, accompanied with trembling of the 
extremities, and other accidents produced by mercury in a young 
gilder, eighteen years of age, (Forest, Opera, lib. viii. obs. 5). Arsenic 
would seem to have a more direct action upon the hair follicles of the 
skin ; it consequently enters into the composition of a number of 
depilatory preparations, (b) 

The beard may be affected with the whole of these varieties of alo- 
pecia, even with the affection denominated porrigo decalvans. It is 
more rarely that we observe the transient or permanent loss of the 
hair of the trunk and extremities. 

Alopecia has been seen evolved on one side only of the body. 
There is a case related by Ravaton, of a man, who, after a violent 
paroxysm (of rage), was attacked with amaurosis of the right eye, and 
with blanching and loss of the hair, eyebrows, and eyelashes of the 
same side. 

1227. Alopecia, to conclude, may be general. 1 The hair of the 
head, axilla?, pubes, &c, is then lost gradually and successively. 
Lemery tells us, that a man, after enduring hypocartharsis for several 
months, observed the hair gradually falling off all parts of his body. 
At the end of a year from this time his body was still naked ; the 
beard, which had formerly been strong, was now extremely thin ; 
the hair alone had come in as thick as ever, but much finer in its 
quality. 

We have just seen, says Peter Frank, a young man attacked with 
general alopecia. Except having had the venereal disease, from 
which he recovered, about thirteen years before, this patient has 
never been unwell ; his health, indeed, at this time appears to be per- 
fectly good. Nevertheless, about two months ago, he lost the whole 
of his beard, almost his entire head of hair, his eyelashes, and the hair 
of the pubes. The nails are, at the same time, lifeless, and con- 
sumed by a kind of dry sordes. The whole of this man's organic and 
animal functions appear to be in a state of perfect integrity ; the sexual 
appetite is not implicated, and his voice is unchanged. He only 
complains of a feeling of weakness during the last few days, (c) 

1228. Treatment. — The baldness of old age is incurable. Con- 
genital alopecia is generally the effect of a tardy development of the 
hair which does not appear till towards the end of the first or second 
year. In some very rare cases this baldness is permanent, in conse- 
quence of the follicles being wanting. 

The treatment of accidental alopecia is as various as that of the 
conditions which give rise to it. When it is occasioned by eczema, 
impetigo favus, &c, no other form of medication is required than 
such as is proper in these diseases. When these get well the hair 
sprouts naturally of itself, 2 unless the bulbs have been deeply altered, 
when no kind of trichogenous pomatum or oil avails to make it sprout 
again. When the skin is dry, tense, and furfuraceous, it is often well 
to shave the parts affected, and to anoint them with oil, or any other 
unctuous substance. 

In the affection called porrigo decalvans, and in all those cases of 
baldness that do not appear to be accompanied with inflammation of 
the skin, and consequent implication of the piliferous bulbs, we have 
been recommended to stimulate the parts affected with decoctions of 

(a) Mr. Lugneau (Diction, de Med.), participates in this opinion. 

(b) Late hours, and their frequent concomitants, intense thought, 
dissipation, also excessive venery, rank among the remote causes of 
alopecia. 

(c) Syphilitic alopecia has been already described (§ 925). 

1 Heister (Misc. Nat. Cur., dec. 1, ann. ii. obs. 103). P. Frank (Epitome de 
curandis horn, morbis, t. iv. p. 124), and Wells (Transact, of a Society for the im- 
provement of Medic, and Chirurg. knowledge, vol. ii. pp. 264-267), have related cases 
of general alopecia. There is one particularly detailed by Negronis, in the Journ. 
Gen. de Med., vol. v. — Diet, de sc. med. Art. Cas rares. General alopecia has been 
seen to follow intermittent fever. (Gaz. des Hopitaux, t. vii. p. 422. — Gaz. Med., 1834, 
p. 564.) 

2 When the hair is reproduced, after alopecia, it is not always restored of the same 
colour as that which was lost. (L. Lemery. Obs. d'un homme de 45 ans, robuste et 
fort velu, lequel perdit son poil, qui etait noir et qui revint blond. — Mem. Ac. sc. 
Paris, an. 1702, hist. p. 29.) 

96 



walnut-tree leaves, of the leaves of the solanum nigrum, of the cen- 
taurea minor, of mustard-seed, or with vinous or spirituous aromatic 
washes of various kinds, with unguents of cantharides, embrocations 
of the essential oils, as of the thyme, lavender, chamomile, &c, but 
I cannot take upon myself to say how far these applications are cal- 
culated to determine or to increase the secreting powers of the pili- 
ferous bulbs, having employed them all, without any very evident 
advantage, in different cases of the affection entitled porrigo decal- 
vans. [The translator has known the common mercurial ointment, 
used upon the patches, useful.] (d) 

The tinea tondons (Mahon) is also a very obstinate affection. 

Historical JVotices and particular Cases. 

1229. Baldness (the j*a5ap6oi$, fyaxaxpoais of the Greeks, the calvities 
of the Latins), was anciently distinguished from the morbid fall of the 
hair, entitled dx^Kixla. and &$iaots, the skin, in these affections, being 
blanched in the parts implicated. Both of these varieties have been 
included by Celsus, under the name of area ; ophiasis, in fact, does 
not differ from alopecia, save in its serpentine form. The fall of the 

(a) Dr. Todd (op. cit.) thus sums up the treatment of alopecia. — It 
would be difficult to say as much to the point, in the same compass. 

" From the distinctions of the different forms of alopecia which we 
have endeavoured to point out, may be easily understood how it may 
sometimes have been cured by phlebotomy ; by local depletion, as 
leeches, scarifications, and acupuncture ; by purgatives, low diet, and 
other antiphlogistic remedies ; how, at other times, simple local 
means may have succeeded better, as friction, no matter whether with 
the fat of the mole, the snake, the hedgehog, or the bear ; or with 
warm exciting substances, as camphor, turpentine, naphtha, lauda- 
num, resin ; with volatile oils, as those of laurel, rosemary, mace, or 
cinnamon, or with the distilled water of bees-wax ; with acrid sub- 
stances, as thapria, euphorbium, stavesacre, nasturtium, mustard- 
seed, garlic, onions, and tincture of tobacco ; with irritating applica- 
tions, as friction with fig-leaves, nettles, tincture of cantharides, and 
even the application of a blister ; how at other times advantage may 
have been derived from alkaline ingredients, which explains the use 
of the laxivia of wood-ashes, of burnt-cane, of the burnt hair of bears, 
and of applications containing the bile of different animals, and the 
ordure of birds, as the ancient remedy of stercus columbinus ; how at 
other times such astringent applications as alum, cimolian earth and 
wine, or green vitriol, the atramentum sutorium of Celsus, may have 
answered better ; and how, whatever be the form of the disease, or 
the nature of the treatment, the frequent shaving of the diseased parts, 
which has been recommended by all writers, is a remedy always 
applicable. 

" When there exist signs of an inflammatory state of the pilous fol- 
licles, or erythema of the surrounding skin, leeches may be applied 
with benefit, and a course of purgative remedies is of great service. 
But when the disease of the follicles appears to arise from an inflam- 
matory slate of the mucous membrane of the stomach, leeches must be 
applied to the scrobiculis cordis, and a regimen of mild bland diet 
must be insisted upon. In the first case the best local application is 
any mild demulcent liquid, as decoction of bran, or mallows. But 
when the skin, from which the hairs fall, indicates a deficient degree 
of vitality, the parts may be excited by local stimulants. (R. olei 
macis 3ii ; alcohol giv. M.) Penciling the surface with a solution 
of nitrate of silver, or rubbing it with a liniment of olive-oil, and as 
much nitric acid as makes it pungent, but not acrid, has been found 
to answer the same purpose. Of the use of the celebrated oil of 
Macassar in such cases we have no experience, but the solution of 
sulphate of copper in alcohol, lately very much recommended by a 
German physician, has failed in our hands. When the skin is fur- 
furaceous, or the cuticle hard, shining, and impermeable, like parch- 
ment, it is of great use to wash it frequently with some alkaline or 
sulphurous solution (R. Liq. ammonia acetatis f.gii ; ammonia carbo- 
natis Sii ; alcohol f.gss ; aq. fontan. f.^iv. Fiat lotio). But when 
either of the foregoing states of the skin is connected with a deranged 
state of the general health, it is unnecessary to say that this demands 
the chief attention." 



382 



DISEASES OF THE UNGUEAL MATRICES. 



eyelasl ed Ihe name ofptilosis, from the Greeks, and (his title 

ii I,,,- retained. Mercuriali treats of these affections at length; but 

ghl to have distinguished them from the fall of the hair — the 

apillorum, which occurs as a consequence of many acute 

IS< 9. 

The loss of the hair, as a disease, or a symptom of disease, has not 
been viewed as possessing so much importance in modern times, 
except during the prevalence of Greek elephantiasis and syphilis, in 
the middle ages, when it constituted one of the striking features in 
these diseases. 

Willan, as the name implies, chose to class circumscribed alopecia 
among the porrigos, with the epithet decalvans. 

Cam CXC. — Alopecia of the scalp, under the form of circular 
patches. . llopecia circumscripta (Porrigo decalvans, Willan). A. T. 
Doucet, eight years and a half old, was presented among the out- 
patients at the Hopital de la Charite, June 16th, 1827. This child is 
well grown for his years. He has laboured for several months under 
partial alopecia of the scalp, in the form of circular irregularly cir- 
cumscribed patches. The oldest of them appeared about seven 
back, on the upper and posterior part of the head, and has extended 
gradually, till it is now an inch and a half in diameter. Examined 
narrowly, its surface is found to be covered with a considerable 
quantity of line downy colourless hair. Other three patches were 
formed from three to four months ago ; the largest of these is an inch 
in diameter. The skin is free from all traces of inflammation ; neither 
is there any desquamation from the parts affected. The patches are 
smooth, and look paler than the rest of the scalp ; the hair is as thick 
immediately around them as it is elsewhere. The fall of the hair 
goes on circularly and without changing colour previously; the fall 
is certainly owing to an affection of the secreting bulb, the precise 
nature of which it is impossible to specify. There are a good many 
pediculi on the surface of the scalp, which is quite free from vesicles, 
pustules, scabs, &c. The affection seems to implicate the piliferous 
bulbs alone. The father of this child informed us that he had never 
had any thing the matter with his head beyond what we saw. The 
glands of the neck were neither painful nor enlarged ; the principal 
functions were regular. The father, having informed us that the down 
upon the largest patch had appeared since he had rubbed the part 
with butter, I recommended him to continue the same application. 

Case CXCI. — Partial alopecia of the scalp and beard, preceded by 
blanching of the hair over the affected patches. 0. Duvau, twenty-five 
years of age, of a sanguine temperament, having chestnut hair and a 
brown beard, presented himself among the out-patients at the hopital 
de la Charite, April 4th, 1827. On the left side of the chin there 
was a whitish circular patch, twenty lines in diameter, devoid of 
beard on a cursory view, although, when examined more narrowly, it 
was found to be beset with a fine, soft, and colourless down. The spot 
was the more remarkable from being bounded by the brown stubble 
of the beard. The hair began to be detached from it from eight to 
ten months ago ; and it enlarged circularly, from the centre towards 
the circumference. Another small spot, about half an inch in diame- 
ter, occurs towards the middle of the lower margin of the jaw, and 
on the opposite side of the face there is a third spot, nearly of the 
same dimensions, which dates about four months back, and has long 
continued stationary. On the right parietal region there is a tuft of 
light hair, covering a surface of about an inch in diameter, which 
succeeded a corresponding tuft of the chestnut hair that suddenly 
became white, and fell off without any appreciable cause. Several 
of the individual hairs of the whiskers have turned in the same man- 
ner. Although the skin of the naked patches presents no signs of 
inflammation, the patient assures us that he feels a kind of numbness 
in the parts, and that their circumference, especially on changes of 
weather, is tender to the touch. The hair upon the axillae and genital 
organs presents nothing unusual. 

This patient had a gonorrhoea about eighteen months ago, that is 
to say, previously to the affection of the hair bulbs. He caught a 
second about six months since ; in both instances he was treated by 
means of diluents, and the disease lasted several months; the naked 
patches showing no disposition to extend, and new hair even beo-in- 
n.ng to appear on their surface, I did not recommend any of the topical 
applications usually prescribed in these cases. I had but recently 



gone the round of them without manifest advantage, in the case of a 
young man, affected exactly in a similar manner, for whom M. Bour- 
dois de Lamotte was also consulted. 



SPECIAL DISEASES OF THE UNGUEAL MATRICES AND 
OF THE NAILS. 

1230. The greater number of the alterations which the nails un- 
dergo depend on an affection of the portion of skin which secretes 
them. Still, they may be modified in their conformation and texture 
without the skin which produces them appearing to have suffered 
any appreciable lesion. Of this kind especially are the changes 
produced by the habitual contact of the alkalies, acids, neutral salts, 
various colouring matters, &c.' 

1231. The portions of skin which secrete the nails, and which are 
in relation with them, are subject to inflammation of different kinds 
{onychia). They are also liable to a variety of other diseases, which 
are common to them and the other regions of the body, such as ecchy- 
mosis, eczema, psoriasis, lepra, &c. 



1232. The matrices of the nails are liable to become inflamed during 
the course or as a consequence of different cutaneous phlegmasia?. 
These pulpy and vascular tissues, however, do not present such a 
variety of forms of inflammation as the skin at large. I designate 
under the general title of onychia, the whole of the inflammatory 
affections of that portion of the corion which is in relation with the 
nails. 

1233. Onychia may be partial, or general. It may occur on the 
edges or towards the root of the nail. It also presents specific charac- 
ters according to the cause which has produced it, and as the disease 
assumes an acute or chronic type. The following varieties of the 
affection have been distinguished. 1st. Onychia from outward vio- 
lence. 2d. Lateral onychia, — the nail growing into tlie s/cin. 3d. 
Onychia from an internal cause (onychia eczematosa, scrofulosa, syphi- 
litica, &c). 

1234. Onychia yVom an outward cause. 

1235. 1st. One of the most common varieties of onychia is that 
which is occasioned by contusions of the ends of the fingers, and by 
punctures under the nail. Punctures of this kind, though trifling in 
appearance, are often followed by acute inflammation of the matrix of 
the nail, characterized by heat, acute pain, and, by and by, the forma- 
tion of a layer of pus between the skin and the nail. A quantity of 
purulent serum is now secreted around the nail, between it and the 
epidermis, which is detached after having been raised by pus effused 
beneath it. At length the nail drops off, after a lapse of time of vari- 
ous extent, the shorter commonly as the inflammation has been more 
acute ; the dermis is then exposed, and a new nail is not in general 
long in being reproduced. 

This inflammation, which has been classed by several pathologists 
along with panaris (whitlow), or phlegmon of the points of the fingers, 

' Hippocrates studied the nails with reference to diagnosis and prognosis. De 
intern, affectionibus, sect. v. p. 549, ed. Foes. — Ibid. Praenotionum liber, p. 39.— De 
morbis : xal 01 ov U ^ EC txumcn, ungues adunei. Celsus was the first who described ony- 
chia. Avicenna (Libri in re medicu omnes, Venet., 1564, lib. iv.), speaks of the 
different alterations the nails undergo, of their inflammation, their fissures, their 
deformities, their becomingwhite, of sub-ungueal ecchymosis, &c. Senncrtus (Opera, 
t. iii. De Unguium vitiis, p. 858), mentions the greater number of the affections to 
which the nails are subject: "Ungues crassi, inaequales, rugosi ; unguium labnties; 
unguium color mutatus; curvatura unguium; fissura unguium; unguium casus; 
redu viae ; paronychia." The diseases of ihe nails have in fine been especially studied 
by Franc, de Franckenau (Geo. Fred.) (Onychologia curiosa, sive de unguibus 
tractatio physico-medica, non lantum eorum physiologiam ac therapeiam tradens, 
etc., 4to. Jenae, 1641), Werner (Diss, de unguibus humanis varioque modoquo pos- 
sunt corrumpi, 4to. Leipsick, 1773), Bleck (Philipp. Ed.) (De Mutationibns un- 
guium morbosis, cum tabula aenea, etc., 4to. Berolini, 1816,) and Patissier (Art. 
Ongles, Diet, des Scienc. Med.). 



ONYCHIA. 



383 



is, however, a very different affection. It commonly resists emollient 
applications, fomentations, the local abstraction of blood, &c. When 
it is caused and kept up by a foreign body under the nail, this part 
must be cut and scraped down, until nothing more remains than a thin, 
soft and unresisting lamina, and this being divided, the pus which 
has been secreted is allowed to escape, and the foreign body is easily 
extracted. This plan of proceeding is much better than to divide 
the nail forcibly and at a single stroke either of the knife or scissors. 

1236. When this kind of onychia is caused by a bruise, the nail 
may be split ; the matrix then becomes deeply altered, secretes, for a 
great length of time, a sanguinolent and very fetid matter, and the 
skin and subjacent cellular membrane often become the seat of most 
painful inflammation, which must be treated by absolute rest of the 
part, general blood-letting, the local application of leec/ies, emollient 
cataplasms, and fomentations, &c. Among the aged, and in scrofu- 
lous subjects, a wash of a solution of chloride of lime is successfully 
used to destroy the fetid odour of the discharge. 

1237. 2d. A second and not less remarkable variety of onychia is 
that which is commonly spoken of, as the nail growing into the flesh. 1 
This affection is often the result of the mechanical irritation acci- 
dentally caused by the nail in consequence of a faulty configuration, 
irregular growth, a great convexity, &c, of the part. It is also induced, 
perhaps more frequently than by any other cause, by the pressure of 
tight shoes. 

1238. The great toe, and especially its outer edge, is almost always 
the seat of this kind of onychia ; it is at all events extremely rare in 
the other toes, and never occurs in the fingers. In the beginning of 
the affection the patient experiences a certain degree of difficulty in 
walking, to which he very commonly pays little or no attention ; the 
pain, however, increases, and the skin where pressed upon by the edge 
of the nail gives way; walking now becomes almost impossible ; an 
ulcer is formed covered with sprouting fungi, so acutely painful as to 
prevent the patient from putting his foot to the ground. At a still 
later stage, the inflammation extends to the root of the nail, which 
then becomes partially loosened. The patient, if he attempts to walk 
at all, can now only do so by resting his heel on the ground. The 
suppuration is often profuse, being poured out from the surface of a 
soft and spungy fungous mass, and is rendered more offensive by 
being mixed with that of the perspiration of the feet. When left to 
itself, the fungous growths become larger and larger, and the inflam- 
mation sometimes extends to the periosteum and bone. 

1239. This variety of onychia is said to have been mistaken for 
gout in a particular case. Such a mistake could only have arisen 
from a very superficial examination of the parts affected. It is more 
difficult to distinguish the accidental form of the disease now described 
from certain other varieties. Still, as Dupuytren has judiciously ob- 
served, the fungous excrescences to which partial lateral onychia, 
caused by the mechanical irritation of the nail, gives rise, occur in 
front of and on the side of the nail, whilst in the onychia that is inde- 
pendent of this cause, the fungous excrescences commonly sprout from 
the root of the nail. 

1240. W r hen lateral accidental onychia has only existed for a few 
weeks, and the affection has evidently arisen from the pressure of the 
soft parts against the edges of a hard and crooked nail, this may be 
cut away or reduced in its thickness, whilst the pressure of the neigh- 
bouring toes is prevented by a pad of cotton or wool put between 
these and the suffering member; and this, with rest for a time, the 
use of emollient cataplasms and fomentations, and a shoe sufficiently 
easy afterwards, will often prevent the disease from going further, 
and even effect its cure. But when one of the edges of the ungueal 
matrix is deeply cleft, ulcerated, and covered with fungous excre- 
scences, other steps are required to remedy the evil. Albucasis and 
Paul, of jEgina, recommended us to detach the nail from the neigh- 
bouring parts, with a probe, and after having raised it, to remove the 
fungous excrescences surrounding it with a knife, and afterwards to 

1 Royer-Gollard (Hyppol.). De quelques alterations des ongles et de la peau qui 
les environne (Repertoire general d'Anatom. et de Physiolog. Patholog., etc., 4to. t. ii. 
182G). — Robbe (L. C). Que ['affection designee sous le nom d'ongle rentre dans 
les chairs se compose de deux affections entierement differentes par leurs causes, 
leur nature et leur traitement, 4to., 182fi. — Michaelis. Considerat. sur l'ongle rentre 
dans les chairs. (Journ. complem. des sc. medic, t. x.xxviii. p. 373.) — Lawrence. 
Lectures on onychia and paronychia. (Lond. Med. Gaz., vol. vi. p. 226.) 



touch the surface with some form of liquid caustic. The actual 
cautery was also once in vogue for this disease, and has been used 
lately by Mr. Wardrop. Ambrose Pare directs us to push a straight 
edged bistoury through the base of the soft parts covering the nail, to 
remove these, and then to cauterize with the red hot iron. This pro- 
cedure of the old surgeon has been recently employed by Messrs. 
Lisfranc and Brachet, with success. Fabricius ab Aquapendente 
recommended little pads of lint to be insinuated under the edge of 
the nail raised and gently loosened from the parts below it, and the 
fungous excrescences to be flattened by direct compression. Desault 
modified this procedure, and placed a piece of tinned iron of proper 
breadth and bent into a gutter, between the edge of the nail, and the 
soft parts around it, at the same time that he used compression to 
reduce fungous flesh. Richerand proposed to replace the tinned 
iron plate towards the end of the cure by a piece of sheet lead. This 
mode of treatment*, which is both painftd and of difficult execution, is 
frequently followed by relapses. M. Guibourt advises the half of the 
nail on the healthy side to be cut away by thin lamellae. The nail 
being then no longer compressed on this side, grows towards it, and 
escapes from the tender and irritated structures of the diseased side, 
so that at length the cure is accomplished. Faye would have us to 
reduce the thickness of the middle of the nail in the direction of its 
length by scraping, then to make an incision in the form of the 
letter V, the base towards the free end of the nail, removing the parts 
included between the legs of the letter, and lastly, by means of a 
fine metallic wire, passed through holes drilled in the free extremity 
of the nail, to approximate the edges of the wound. The portion of 
the nail that presses in upon the quick is thus elongated from the 
tender parts, and the cure is effected. Dupuytren employs the fol- 
lowing plan. The patient is seated on a chair before the surgeon, 
who passes one blade of a pair of straight, strong and sharp scissors 
rapidly under the middle of the nail nearly to its base, and divides 
it at a single stroke. He then, with a pair of pliers, seizes that half of 
the nail which keeps up the disease, by its anterior part, or both halves 
in succession, according to circumstances, and by turning each back 
upon itself, detaches it from its connections with the matrix. He 
next applies the actual cautery to the fungous growths, if they chance 
to be very considerable. This procedure is extremely painful ; but it 
frequently leads to a speedy and permanent cure. 

1241. OnychiayVom an internal cause.-^-Five principal varieties of 
this affection are reckoned: 1st. Onychia eczematosa; 2d. Onychia 
squamosa; 3d. Onychia scrqfulosa; 4th. Onychia syphilitica ; and 5th. 
Onychia maligna. 

1242. 1st. Eczematous onychia generally attacks the matrices of 
several fingers or toes, at the same time that eczema appears on some 
region or other of the body. I once saw an old man above eighty 
years of age, who, at the age of twenty-one, had had an attack of 
gout for the first time, and had every year, for nine successive years, 
had a severe return of this complaint. A milk diet continued unde- 
viatingly for three years, interrupted these renewals of the gout, 
which was thirteen years in showing itself again. Since then it has 
recurred at various intervals, five or six years generally elapsing 
between each new attack. This old man remembers to have had a 
tettery affection of the axillae when he was about eighteen years of 
age, which was attended with considerable discharge. For the last 
twelve years he has been subject to eczema, at one time in the squa- 
mous, at another in the humid state, between the buttocks and about 
the margin of the anus. Two years ago an affection of the same 
kind made its appearance about the nails of the toes, and subse- 
quently about those of the fingers. The nails of the toes are particu- 
larly remarkable for their deformity ; they are of a greenish-yellow 
colour, and are detached from their matrices, being raised upon a 
mass of solid matter of the same colour, and of a faint and sickly 
smell, three or four lines in thickness, which even extends beyond 
their ends and edges. The nails are painful when cut, the action of 
the knife or scissors jarring the roots. A yellowish liquid matter 
occasionally exudes from under the lateral parts of the nail, which 
are then more than usually painful. I did not recommend any active 
form of treatment in this case to the eczema of the breech and nails. 
The patient was merely advised to keep the parts clean, and small 
doses of sulphur were prescribed internally. It is now three years 






DISEASES OF THE UNGUEAL MATRICES. 



be consulted mc, and, notwithstanding his great age, his general 
h has improved. 
I once gave mj advice to a woman who was affected with a run- 

i, entirely routined to the last phalanges of the fingers, 
and even to the parts over the roots of the nails, without implication 
of their mati 

12 18. I have already given the characters of squamous onychia 

of scrofulous onychia (739), and of the onychia that is a con- 

sequence of the venereal disease, (926). To complete the history 

of this form of the affection I subjoin the two following cases from 

M. Lelut's paper. 

CXCII. — Venereal infection. Onychia. J. L., a widow wo- 
man, aged thirty-seven, underwent a mercurial course for the first 
time at the hopital des Yeneriens, on accountjDf an eruption of pustules 
upon the skin, and a discharge from the vagina. "When the patient 
left the hospital the eruption had disappeared, but the discharge con- 
tinued, and there was a slight sore at the left corner of the mouth. 
A week afterwards, this sore spread, aphthae appeared in the mouth, 
and the eruption of the skin recurred. The patient was put anew 
upon a course of sudorifics, and of corrosive sublimate, and all symp- 
toms of disease disappeared, except the leucorrhoea. In the month 
of September, the patient, to relieve a violent headache, put her feet 
into hot water with a quantity of fiour of mustard in it. Almost 
immediately afterwards the toes of the right foot became chapped ; 
the parts around the nail of the left forefinger next inflamed and sup- 
purated, and the left thumb, the right forefinger and thumb, and all 
the toes of the right foot became affected successively in the same 
manner. The patient returned for the third time to the hospital on 
the 10th of October, labouring under the infirmity described, inca- 
pable of walking or of using her hands. {Emollients ; leeches to the 
hack of the right foot ; veal broth.) 13th. The nail of the left finger 
was taken away. 20th. The extremity of this finger has the form of 
a spatula ; red vascular lines appear on the back of the left hand 
(leeches). The last days of October, tumefaction of the lymphatic 
glands of the inner aspect of the left arm (the sore of the great toe 
only dressed with calomel ointment). The nails of the thumbs are 
forced forwards without being completely loosened from their matrices. 
The horny laminae of the nail appear on the matrix of the left fore- 
finger ; the sore of the great toe, behind the root of the nail, bleeds: 
the nail of the right forefinger is taken away ; new horny lamellae 
show themselves on the back part of the sore of the left forefinger, 
and by and by on that of the right. Nov. 5th. The nail of the great 
toe removed. The whole of the sores are dressed with a weak solu- 
tion of chloride of soda in water. No mercurial medicine is pre- 
scribed ; the sores are all cicatrizing. The thumb nails are growing 
with all their normal characters. Nov. 21st. A piece of the nail of 
the great toe that had been left is taken away, and the sore soon 
cicatrizes, but no new nail is reproduced. The sores of both fore- 
fingers are also healing around the horny plates of the matrix. Dec. 
2d. The nail of the left great toe is detached spontaneously without 
pain. 5th. Th'e patient left the hospital with the whole of the ulcers 
cicatrized. 

Case CXCIII. — Venereal infection; onychia. A. M * * *, aged 
twenty-two, a prostitute, was discharged from the Hopital des Vene- 
riens, in the month of August, 1826, after having gone through a 
mercurial course for an eruption of flat tubercles about the vulva, and 
a discharge from the vagina. On quitting the hospital, there were 
symptoms of incipient inflammation of the soft parts covering the 
ungueal matrix of the left forefinger. The right forefinger and great 
toe soon afterwards became affected in a similar manner. The patient 
returned to the hospital on the 21st of September. The nails of the 
fingers mentioned are partially detached ; the suppuration from under 
them is profuse and very fetid. The patient is put anew upon a 
course of the solution of corrosive sublimate, and afterwards of sudo- 
rifics. The sores are dressed with emollients and anodynes alter- 
nately, and the nails are extracted. The suppurating surfaces then 
look red and uneven ; they are extremely tender, and surrounded 
with a prominent rim; the pain is very severe ; the patient is incapa- 
ble of walking; she sleeps badly, although she has a pill every nio-ht 
containing a grain of the extract of opium. The sores bleed when 
exposed to the air; they are dressed with solution of chloride of 



soda, and two grains of opium are prescribed instead of one. Leeches 
were subsequently applied to the left finger. The sores continue 
nearly stationary. In the beginning of November, anomalous horny 
plates begin to appear upon the matrices of the right forefinger and 
great toe; but the sores in general do not appear to have improved. 
Nov. 14. The nail of the forefinger is taken away. The anomalous 
horny plates increase in extent. The sublimate is continued. In 
the beginning of November, these horny productions arc taken away, 
and the diseased ungueal matrices are touched with the actual cau- 
tery. After the detachment of the eschars, fresh anomalous horny 
plates are secreted by the matrices. The suppuration is still fetid, 
and the patient walks with great difficulty. 

1249. Under the name of onychia maligna, Mr. Wardrop 1 describes 
an inflammatory affection, characterized in its earliest stages by a 
slight degree of swelling and a red circle surrounding the root of the 
affected nail. The thumb and great toe are much more frequently 
the seat of this affection than any of the other toes or fingers. The 
kind of crescent formed by the skin over the root of the nail by and 
by changes into a roll of a purple red colour, more elevated and more 
acutely sensible at the point where the nail appears to adhere most 
intimately ; this is before long occupied by bleeding and fungous sores. 
Purulent matter, of a brownish, grayish, or greenish-yellow colour, 
generally very copious in quantity, extremely offensive in its odour, 
and often mixed with blood when the affected parts have been exposed 
to the air, exudes between the root of the nail and the skin. The 
nail thickens, loses its colour, becomes of an earthy yellow or blackish- 
green hue, and is detached at its root, when it deviates from the side 
which happens to adhere most intimately, and soon leaves the greater 
portion of the matrix from which the root has receded exposed. At 
length it falls spontaneously, or is easily taken away, when small 
portions of its substance are frequently left on the anterior and pos- 
terior part of its matrix. Thus divested of its natural covering, this 
secreting organ looks red, uneven on the surface, inflamed, overspread 
with yellowish or grayish fetid pus, surrounded with an inflammatory 
roll, which bleeds when brought into contact with the air, or when 
the diseased fingers are moved. It generally happens that pretty 
broad horny productions are now eliminated from the surface of the 
diseased matrices. These are soft at first, and for some time seem to 
blend and be confounded with the concrete pus that adheres to them ; 
they are of a brownish, often of a greenish-yellow colour, and shoot 
in general obliquely, sometimes perpendicularly, from the middle or 
edges of the matrices. Two or three of these of smaller size are often 
seen uniting into one more or less irregular in its shape. These 
abortive ungueal productions often appear to keep up irritation, and 
the finger then acquires the form of a spatula. The inflamed skin 
which surrounds the horny productions bleeds when exposed to the 
air, and is the seat of pain of the most intolerable kind. Red lines on 
the affected parts announce the extension of the inflammation to the 
lymphatic vessels, or to the neighbouring veins. If the toes be the 
seat of the affection, walking is impossible. A febrile state fre- 
quently accompanies the disease when arrived at this severe stage ; 
and sleep, entirely broken, cannot always be procured by the exhibi- 
tion of opiates. 

This variety of oynchia, 2 the cause and nature of which are but 
little known, is not to be confounded with the two preceding varie- 
ties. And yet the nail in the flesh, when it has been long neglected, 
or aggravated by irritating topical applications, fatigue, &c, does 
occasionally assume very many of its characters. 

Onychia maligna is always a troublesome, protracted, and painful 
disease. 3 Cases have been seen in which six months of sedulous 

1 Wardrop. On diseases of the toes and fingers, in Med. Chirurg. Trans., vol. v. 
p. 129, 1814. 

2 A young man, eighteen years of age, who had never had venereal disease, after 
a severe attack of dothinenteritis, had onychia in both of the great toes, which got 
well under the use of the sulphureous bath. 

3 A man, twenty-six years of age, had suffered from suppuration around the outer 
edge, first of his right great toe nail for two years, and next of the same part of the 
left foot, which he ascribed to the pressure of too tight boots. The parts on the 
anterior lateral aspect of the right toe were removed, and the wound touched wilh the 
nitrate of silver. Four days after this, fungous excrescences aroseon the inner edge 
of this toe-nail, for which nothing was done. June 6th. 1834. The nail of the right 
great toe appears of a pale rose colour; its conformation and thickness are natural. 
The edges of the ungueal matrix are red, painful, and in a state of suppuration. The 



SUBUNGUEAL ECCHYMOSES— FAULTY CONFORMATION OF THE NAILS. 



385 



treatment have scarcely produced any apparent amendment. It rarely 
gets well under the antiphlogistic plan. Mr. Wardrop found mercu- 
rials of more avail. Frequently the only recourse that is left us, is to 
destroy or to remove the ungueal matrix entirely. In performing this 
operation, M. Dupuytren was in the habit of seizing the affected ringer 
or toe between the thumb and forefinger of his left hand ; with a 
convex-edged scalpel in the right, he then made a semi-lunar incision, 
the concavity pointing forwards, upon the dorsal aspect of the digit, 
at the distance generally of about four lines behind the roll of integu- 
ment overlapping the root of the matrix ; the flap was then seized 
with a pair of forceps and dissected off. The wound that results from 
this operation generally cicatrizes in from a fortnight to three weeks. 

The following case appears to me deserving of being assimilated 
to onychia maligna : 

Case CXCIV. — Chilblain, and contusion of the left great toe; ony- 
chia. Sophia Brachet, twelve years and a half old, was admitted 
into the Hopital des Enfans Maladies on the 25th of April, 1827. Of 
sanguine temperament, and well grown for her age, she has never 
been affected with chronic inflammation of the skin or swelling of 
the lymphatic glands. Last winter the great toe of the left foot was 
affected with chilblain, which had got nearly well, when the toe was 
violently bruised, by some one treading on the child's foot. The 
ungueal matrix inflamed after this accident, became very painful, and 
poured out a profusion of foetid discharge. The child had 'to keep 
her bed for some time. During the first month of her stay in the 
hospital, local and general sulphureous water-baths were employed 
alternately without success. About the end of May the whole point 
of the toe was swollen and livid. The skin at the root of the nail 
formed a semi-lunar roll, nearly a line in thickness in its middle, w T hich 
was ulcerated, fungous, blackish, or of a vivid red, according to the 
quantity of blood which had exuded from it. Two-thirds of the an- 
terior surface of the ungueal matrix were in a state of suppuration ; 
it looked like an elliptical hollow space, surrounded by a circular roll 
of tumefied and tender integument. The nail was perceived at the 
bottom of the hollow, its two anterior thirds detached from the matrix, 
raised, and turned back upon the dorsal aspect of the remaining 
adhering third. The nail was of a brownish hue, and traversed by 
transverse striae. On the 30th of May the nail was seized with a pair 
of dissecting forceps, and removed. It presented something of the 
appearance of a miniature saddle. Its anterior part was rough and 
corroded; its posterior portion, which adhered intimately to the skin, 
was smooth and natural. (Simple dressings.) On the third day, the 
wound looked sanious ; the suppuration was scanty. By and by the 
surface affected looked red, and secreted healthy pus ; the violet hue 
and swelling of the skin, which had existed before the operation, had 
disappeared, and the w r ound began to cicatrize. June 8th. The sore 
somewhat sanious; and a new nail began to be seen at its upper part 
(compresses wateredwith solution of chloride of lime) . The wound looked 
better; cicatrization advancing. 11th and 12th. The wound again 
became sanious; the cicatrice appeared to give way. The new nail 
advances apace ; the swelling and violet colour of the toe recur. 13th. 
The sore is cauterized with the acid nitrate of mercury. 18th. The 
eschar produced is detached. 19th. The swelling and violet tint 
have almost disappeared. The sore is bright, and secretes laudable 
pus. If the disease recurs, the matrix of the nail will be excised. 

Historical J\otices. 

1250. Celsus, 1 under the name of nttpvyiov, appears to indicate the 
fungous excrescences that sprout from the inflamed matrices of the nails. 
He recommends these growths to be treated with catheretics, and, if 
the disease returns, to excise or to cauterize the matrix : " Si malum 
non vincitur, purgandus scalpello, tenuibusque ferramentis aduren- 

surrounding skin, especially that which covers the root of the nail, is red but not 
broken. The great toe of the other foot is in the same state, but rather less inflamed. 
Eighteen months ago, the outer half of the nail was eradicated, and the surface cau- 
terized. A new nail was produced, which causes the patient as much pain in walk- 
ing as the old one. All the other nails are healthy. The patient has never been 
affected with syphilis. 
1 Celsus. De re medica, lib. v. sect. xix. 
97 



dum." Galen 2 specifies certain remedies against paronychion ; /Etuis 1 
is more diffuse in his therapeutical principles. The description of the 
inflammation of the nails, which Paulus 4 gives very fully, bears con- 
siderable resemblance to the description of onychia maligna with 
which Wardrop has presented us. Pare was acquainted with the 
advantage of removing the soft parts implicated in lateral accidental 
onychia/ a procedure lately recalled to notice by M. Amussat. Stiil 
more recently, onychia has been made the subject of especial study 
by Dupuytren and his pupils. 6 I have already signalized the princi- 
pal observations that have been made on scrofulous (729) and on 
syphilitic (926) onychia. 



SUB-UNGUEAL ECCHYMOSES. 

1251. Bruises of the dorsal aspect of the points of the toes and 
fingers are transmitted through the thickness of the nails to the pulpy 
substance upon which these organs are implanted, and frequently 
there occasion ecchymoses, and extravasations of blood often of con- 
siderable extent. When the nail is injured to its root, it is soon 
loosened and detached, after which it is replaced by a new one. 

When any of the nails have been bruised, it is well to plunge the 
hand into cold water, and if pain and swelling afterwards come on, 
recourse should be had to emollient cataplasms ; the processes by 
which the old nail is detached, and the new one formed, may then 
generally be left safely to nature. 

When the fingers are crushed and wounded, and the nails broken 
and torn, those portions of these last that are half detached, should be 
cut away with flat scissors ; those that adhere, though ever so slightly, 
should be left. To take them away at once would only cause a great 
increase of pain, and of the inflammation that must necessarily follow 
from the reparation of the injury that has been done. 

When the nails are removed by a surgical operation, the matrices 
occasionally bleed rather profusely. This hemorrhage is readily com- 
manded by compression and the use of some form of cautery. 



FAULTY CONFORMATION OF THE NAILS. 

1252. The nails may be entirely wanting, or be only imperfectly 
evolved. This deficiency, which occasionally appears to be heredi- 
tary, is extremely rare. Bleck informs us that there is a foetus in the 
anatomical museum at Berlin, which presents this anomalous con- 
formation of the fingers. 

1253. The nails are occasionally lost accidentally, in consequence 
of injury, onychia and ablation. If their matrices have been super- 
ficially inflamed, they are reproduced, but not always with perfect 
regularity of shape. 

1254. The detachment of the nail is a frequent consequence of 
acute or chronic inflammation of their matrices following a bruise, a 
burn, frost bite, venereal infection, and sometimes happening from no 
evident cause. But the nails are also occasionally lost, like the hair, 
in certain cases of alopecia, without their matrices appearing to be 
affected with inflammation at all (alopecia unguealis). 

1255. The nails may he faultily developed in various degrees. In 
some individuals labouring under paralysis, the secretion of the nails 
appears retarded. When their matrices have been partially destroyed 
by ulceration, or removed, they are secreted ever afterwards uneven 
and imperfect. 

1256. Supernumerary nails are also observed on the hands of indi- 
viduals with six fingers. A man of the name of M * * * had a super- 
numerary finger attached to each of the thumbs ; one of these consisted 
of one phalange only ; the other of two ; both were furnished with nails, 
like the other fingers. 

2 Galeni. Opera omnia : De medicam., lib. iii. 89 ; CI. vii. p. 339. 

a ^Etius. Tetrabiblos: ad paronychios, id est unguium abscessus, p. 796, fol. 
Basileae, 1549. 

* Paulus iEgineta. De re medica, lib. vi. cap. 85. De unguium ptervgiis. Parisiis, 
1532. 

s Pare (Ambr.). (Euyres completes, lib. xviii. ch. 32, fol. Paris, 1561. 

s Lelut. Etudes sur l'onglade. 



3S6 



ALTERATIONS OF THE NAILS. 



ict/t of the nails' constitutes a kind of de- 
, the origin of which is not always the same. 1st. The nails 
U'l't long to themselves, among the aged, 3 often acquire a considerable 
I had an old man under my charge lately, who had suffered 
with prurigo and lichen, and who had allowed his 
nails to grow to the length of talons, in order to have a good imple- 
ment always In him with which to allay the intolerable pruritus he 
endured. Rouhout, in 1719, sent a description and drawing of some 
ous nails, to the Academy of Sciences of Paris. The largest of 
ili. se was the hit great toe nail, which, from its root to its extremity, 
red four inches and three quarters ; the laminae of which it con- 
were placed one over the other like the tiles upon a roof reversed. 
This nail and several of the others were of unequal thickness, and were 
curved variously, probably in consequence of the pressure of the shoe, 
or of the neighbouring digits. My friend, M. Bricheteau, physician of 
the HSpital Necker, lately sent me two monstrous nails from the great 
toes of an old woman who had lived in the Salpetriere. They are very 
thick, about three inches in length, and spirally twisted, like the horns 
of a ram. Saviard informs us, that, in 1817, he saw a patient in the 
1 lotel Dieu, who had a horn, like that of a ram, instead of a nail, upon 
each great toe, the extremities of which were turned to the metatarsus, 
and overlapped the whole of the other toes of each foot.s 

1 258. Excessive growth of the nails has occasionally been observed 
in individuals labouring under Arabian elephantiasis, 4 chronic rheu- 
matism, and anchylosis of the joints; the skeleton of Simorre, pre- 
served in the Museum of the School of Medicine of Paris, is remarkable 
for the anchylosis of all the articulations, and the considerable size of 
the nails. The fingers and toes, spread out and anchylosed, are ter- 
minated by nails of great length, and nearly of equal thickness. A 
woman of the name of Melin, surnamed the woman with the nails, 5 
presented another and not less curious instance of the same thing. 

Malformed nails of large size have also been seen among children 
and adults, who, at the same time, presented horny productions upon 
the skin. Ash has published the case of a girl, twelve years old, in 
the Philosophical Transactions, 6 upon almost every one of whose 
articulations there were horny growths tuberculated at their base, and 
hard at their summit. The fingers and toes, the knees and elbows, 
were beset with these productions, some of which were four inches 
in length. They fell off occasionally, and were replaced by others 
of the same description. Musams 7 has given an account of a similar 
case : the nails of a girl, aged twenty, grew to such a size that some 
of those of the fingers were five inches in length. They were com- 
posed of several layers, whitish in the interior, of a reddish-gray on 
the exterior, full of black points. These nails fell off at the end of 
four months, and were succeeded by others. There were, besides, 
horny laminae on the elbows, knees and shoulders, which bore a per- 
fect resemblance to nails, altered in their structure. These horny 
productions looked like talons ; they were only sensible at their point 
of insertion into the skin. Various other parts of the body, particu- 
larly the backs of the hands, presented these horny productions; one 
of them was four inches in length. This horny growth appeared after 
small-pox. 

1259. To whatever the anomalous growth of the nails be owing, it 
is well to remove those portions which project beyond the extremity 
of the finger or toe, to prevent them from interfering with the motions 
of the hands and feet. If not excessively thick, they may be cut off 
with a pair of scissors, after having been softened by soaking in warm 
water. Cutting pliers, or a fine saw, will always enable the operator 
to take them away without pain to the patient, when they are exceed- 
ingly strong and hard. 

1260. The nails are sometimes misplaced. Th. Bartholinus tells us 

1 Several writers have given representations of these mal-formed and monstrous 
nails— vide commercium litterarium Norimb., 1734, p. 173.— Eph. Nat. Cur., dec. 
2, aim. 1, p. 385, fig.— Bartholin. Acta Hafn., i. obs. 16, epist. 2, pp. 732-727.— Mal- 
pighi.^ Op. Posth., p. 138, tab. 19, fig. 3, 6 



pi. De sedibus et causis morborum. Epist. 68, art 

, „ M, Aouveau recueil d'observations Chirurgicales, 8< 
127. p. b ' 



1776 



vo. Paris, 1702, obs. 

•. Histor. brachii pratomidi. Haller. Disput. Chirurg, t. v. p. 460, fig. 
rfemo.re sur la maladie de la femme dite aux ongles. Paris, 8vo. 



* Ephem. Nat. Cur., dec. 2, ann. i. p. 385. 

> Mushjos. Diss, de unguibus monstrosis. Hafniee, 1716. 



of a young woman, the nail of whose forefinger was situated on the 
side, not the back of the extremity of the digit. In another case, in 
which the lingers were wanting, the same anatomist found the nails 
implanted on the stump of the hand. 8 

1261. The nails are occasionally observed to become exposed to- 
wards their roots, as if the skin, which covers these parts, had shrunk 
upwards (ficus unguium). I have remarked this peculiarity among 
curriers. At other times, on the contrary, the cutis and cuticle extend 
a considerable way down upon the back of the nail, where they form 
a kind of tunic, which has been entitled pterygium unguis. 

1262. The nails occasionally present certain peculiarities of shape: 
they are sometimes exceedingly arched or hooked (ungues adunci, 
Hippocrates), among the consumptive who have become very much 
emaciated. This remark has been reproduced by Duretus in his com- 
mentary upon Hippocrates ("Phthisicis ungues sunt more cujusdam 
seme uncinati)." 

1263. When the matrices of the nails have been once diseased, 
their products occasionally present one or more longitudinal ridges, 
or grow in the shape of irregular cones. Those nails that have been 
divided and torn out after the mode of Dupuytren, occasionally con- 
tinue long to overlap in the line of the division. 

1264. Loder informs us that he has seen the nails become of a 
chalky whiteness in a person labouring under paralysis. All have ob- 
served the small white specks that often appear in the nails, which 
the ancients denominated fiores unguium, to which Fallopius tells us 
the vulgar of his time gave the title of lies (Mendacia), as they do in 
France at the present day. 

1265. Among convalescents from malignant fevers, ReiP has seve- 
ral times seen the nails become white. In icterus they occasionally 
become yellow ; in subungueal ecchymoses they look black; in inter- 
mittent fever, in cyanosis, and under exposure to cold, they appear 
livid ; in anasarca 10 they are of a pale white, &c; but all these various 
tints are merely reflected through the nail, according to the varying 
colour of the matrix. 

1266. To conclude this part of the subject, the nails are often 
observed stained of different colours by a variety of inorganic sub- 
stances; they become brown when rubbed with nitrate of silver, black 
when impregnated with sulphuret of lead, sulphuret of mercury, &c. 

1267. Tumours of various descriptions are occasionally developed 
in the structures that lie under the nails. Royer Collard speaks of a 
case in which the nail of the great toe was raised by a bony tumour, 
which had existed for several months, and grew from the last pha- 
lange of the digit. I have met with the nails deformed and forced 
back from their bases towards their roots by warts evolved under part 
of the matrix near their free extremities: L. Lion, aged twenty, had 
a very voluminous wart on the extremity of the left forefinger ; it 
consisted, in fact, of several confluent warts evolved under the 
extreme end of the nail, which was raised almost vertically. The 
wart was uneven, very hard and almost horny in its structure, of a 
grayish colour, and extended across almost the whole of the point of 
the finger, along the outer edge of the nail beyond its root. This 
compound wart was destroyed by the application of nitric acid. 
Melanic tumours (§ 756) and vascular tumours, have also been seen 
evolved beneath the nails. 

1268. Besides these various malformations, original or accidental, 
of the nails, their substance may be altered, — thickened, softened, 
hardened and eroded (defcedatio, degeneratio, scabrities unguium). 
These alterations, which are almost always the effect of chronic onychia, 
have also been observed among individuals affected with plica; some 
of them, appearing under these circumstances, have been figured by 
De Lafontaine. 

The horny substance of the nails has been seen to undergo extensive 
changes, without the agency of outward and appreciable causes, as 
well as without any evident affection of their matrices. Black relates 
a case of this kind which is the more remarkable from the affection 
appearing to have been hereditary: " Est rnihi amicus carissimus cui 
quum nonum cetatis annum ageret, in digito annulari manus dextrae 

8 Hist. Anat. cent., ii. lib. 44, t. p. 240. 

9 Reil. Memorabil. Clinic. Fascic, iii. p. 206. 

10 Double. Signes semeiotiques fournis par les ongles. Journ. gener. de Medec, 
t. i. 33, p. 397. 



GANGRENE OF THE SKIN. 



387 



unguis monstrosus, carvatus, rugosus, et asper excrevit, in quo usque 
ad hoctempusnilmorbosianimadverterat; quam forraam monstrosam 
unguem subiissc ille narrat sine causa interna seu externa morbosa vel 
mechanic^. Adfuit autem haec deformitas jam in raatre, et eodem 
temad tetatis eademque lege, quam antea diximus, nempe ut simulac 
nonum ad eetatis annum proventi essent, in sororibus et fratribus 
appareret." {Op. cit., p. 9.) 

1269. I have already said that a part at least of varying extent, of 
the nail, that is reproduced after an attack of chronic onychia, pre- 
sented neither the semi-transparency nor the smooth and polished sur- 
face of the original nail. Under the agency of a very different cause, 
the action, namely, of dilute acids on the nails, they occasionally 
present a multitude of parallel lines on their surface, and are occa- 
sionally even resolved into a kind of brush. 

1270. Several anatomists have been of opinion that the nails were 
formed by the superposition of a series of horny laminae. I have 
observed this structure of the nails in a man of the name of Meyer, 
seventy years of age, who came into the Hopital de la Pitie, labour- 
ing under chronic inflammation of the bladder. The nails of this 
patient's fingers were thickened and composed of numerous super- 
posed and softened horny lamina?. The ends of the nails were worn 
away obliquely, or beveled off', so as distinctly to exhibit the different 
layers of which they consisted, and which were by so much the more 
extensive, as they lay more superficially. The surface of the nail 
of the left ring finger was uneven, that of the right corresponding 
digit was traversed longitudinally by an angular ridge. 

1271. Reproduction and accidental production of the nails. When 
a nail is torn away by violence, or detached by the progress of diseased 
action in the subjacent integuments, it is slowly reproduced, and at 
length restored with more or less of the character of the original nail ; 
but it is very seldom, indeed, that nails are observed to be developed 
upon those phalanges of the fingers or toes which are not usually or 
naturally provided with the peculiar vascular tissue that constitutes 
the ungueal matrices. Tulpius appears to have met with this patho- 
logical condition: "Ungues, in digitorum apicibus semel deperditos, ite- 
rum renasci novum non est ; sed rare- id conspicitur fieri in secundo aut 
tertio articulo, prioribus amputatis, in quibus tamen non semel eosdem 
vidimus non seeds progerminare debitamque acquiere formam ac si in 
digitorum consisterent apicibus, deponente nunquam sollicitudinem 
suam officios natura." 1 M. Marechal de Rougeres, 2 VoigteP and 
Ormancey 4 have since related instances of similar productions deve- 
loped on the second phalange of a finger after the loss of the first : A 
woman had for several months laboured under an ulcer of the point 
of the middle finger of the right hand, in consequence of a whitlow 
which had occasioned the loss of the third phalange, and the whole 
of the digtal articular surface and part of the compact bony structure 
of the second. On examining the sore, M. Ormancey saw a bony 
sequestrum which appeared to keep it open. This he extracted, and 
dressed the stump with saturnine cerate, until cicatrization was com- 
plete. Some months afterwards the patient returned to call on M. 
Ormancey, who now saw, not without astonishment, that the nail had 
been reproduced; instead of following the ordinary direction, how- 
ever, it lay directly over the face of the stump, growing from the 
back towards the palmar aspect of the digit, as if to cover and pro- 
tect the stump. M. Blandin 5 has met with a case of the same descrip- 
tion ; and a third occurred very recently at the Hopital de la Charite, 
in the person of a woman who had lost the whole of the third pha- 
lange of one of the fore-fingers in consequence of whitlow. The 
soft and fleshy cushion which here covered the second phalange was 
terminated by a small, blackish nail, like a grain of spur rye. It is 
probable that the soft parts of the third phalange, and the ungueal 
matrix especially, had not been wholly destroyed in these cases. Mr. 
Chevalier speaks of analogous cases in his Lectures. 6 

1 Tulpius. Obs. med., lib. iv. obs. 55. Amstelodami, 1641, 12mo. 

2 Journ. de Med., t. xxvii. p. 177. 

3 Voigtel. Handbuch der Pathologischen Anatomie, 8vo. Halle, 1805. 

4 Journ. de Mldecine, de Chirurgie, de Pharmacie, etc., p. 218, 8i r o. Paris, Mars, 
1809. 

5 Blandin. Anatomie Topographique, p. 558, 8vo. Paris. 

6 Chevalier (Th.). Lectures on the general structure ot the human body, &c , 
8vo. Lond., 1833, p. i. etc. 



GANGRENE OF THE SKIN. 

1272. Gangrene of the skin may result from pustula maligna, from 
erysipelas of a severe kind, from frost bite, deep burns, the action of 
concentrated and strong alkaline solutions, compression, the ligature 
of the principal artery of an extremity, &c. It may also follow other 
gangrenous affections in different parts, as is occasionally seen in the 
gangrenous mouth of young children, and of the external parts of 
generation in little girls. It is likewise met with in the gangrene of 
the aged, and in cases of spontaneous gangrene with the formation 
of clots in the principal arterial trunks of the limb affected ; lastly, 
external gangrene has been known to prevail epidemically. 

Gangrene of the skin may, further, occur in the course of serious 
diseases of another nature. There was an old woman who died in 
the H.ipital de la Charite from the effects of a simultaneous affection 
of the lungs and intestines, added to erysipelas of the face and scalp, 
who, during the course of her illness, had an oblong gangrenous 
tumour developed on the sacral region, accompanied with vivid red- 
ness of the skin. Near this tumour a considerable number of very 
superficial eschars were seen, which looked at first sight like the 
crusts of a pustular eruption, but differed evidently from these in the 
smooth appearance of their surface, their dryness, their uniformity, 
and especially in the mode in which they were set or framed within 
the substance of the skin. Some of them were surrounded by a deep 
red blush, similar to that which bounds parts when stricken with 
gangrene ; others began to be separated from the living tissues by a 
ring of suppuration. In endeavouring to detach them, their intimate 
connection with the tissues beneath was conspicuous. In other places 
the eschars were destroyed in their circumference, and were only 
visible in the form of a patch in the centre of a superficial ulcer. 
Lastly, in a great number of points, slight superficial excoriations 
were observed, without puffing of their edges, of a circular or some- 
what indefinite shape, different in their appearance from ordinary 
ulcers, and in all respects similar to those which have already been 
indicated as consequences of the detachment of gangrenous eschars 
formed by the most superficial laminae of the skin. 

Very shortly before this patient died, the whole of the eschars were 
separated ; the edges of an incision which had been made through the 
principal gangrenous swelling over the sacrum, were loosened, very 
much swollen, red and painful. Shreds of grayish and mortified cellu- 
lar tissue were seen at the bottom and around the edges of the wound, 
to which they adhered but slightly. On opening the body after death, 
the extent of the loosening around the edges of the great wound, was 
ascertained to amount to several inches. The sacrum was not de- 
nuded. The edges of the sore were flaccid and without redness. The 
cuticle had disappeared from its circumference, as if the skin had been 
long in maceration ; and even where it still appeared, it could be de- 
tached to a considerable extent with great ease. A piece of the skin 
affected presented the following alterations: 1st, its surface was de- 
nuded of epidermis ; 2d, two or three round bluish ecchymosed spots, 
the effect of leech bites, were perceived ; 3d, the whole of this surface 
was pierced with very small holes. The regular arrangement of these 
holes, their slightly elliptical form, the possibility of penetrating into 
their interior with a pin, which entered a small oblique, and very 
superficial cavity, showed that they were formed by the orifices of the 
cutaneous follicles. 4th. The most superficial stratum of the skin was 
destroyed in a great many places, whence resulted excoriations of 
variable extent and depth. The smallest of these could only be dis- 
tinguished with minute examination, or the aid of a magnifying glass, 
and might readily have been mistaken for the orifices of follicles, such 
as those I have mentioned ; but they differed from these in resisting 
the entrance of the point of a pin into any cavity. They were very 
superficial ; their bottom was almost on a level with their edge ; in 
fact, they were only distinguished by their somewhat paler colour from 
the rest of the integuments. The excoriations, of middling size, were 
still less distinguishable. The appearance they presented might have 
been very accurately produced by shaving off* the most superficial 
strata of the integument with a sharp instrument. Their edges were 
without tumefaction, or redness; their bottoms smooth ; their colour 
very nearly that of the surrounding skin. A number of minute open- 



3S8 



CICATRICES OF THE SKIN. 



inga were visible on all, into which the point of a pin penetrated 
obliquely and gained the sebaceous follicles, whose orifices had been 
The holes in these parts were consequently of larger size 
than the orifices mentioned a little ago, and instead of leading to the 
shut sacs of the follicles merely, permitted the pin to penetrate as far 
as the subcutaneous adipose tissue through the areola? of the corion. 
The alteration resembling, as has been said, the surface which is pro- 
duced by shaving away the corion horizontally, the areolae w T ere 
observed to increase in size, in proportion as the excoriation extended 
more deeply. Where this was the case not only did the openings on 
the surface lead directly down to the subjacent adipose tissue, but 
the head of a pin could even be passed through one of them. The 
subcutaneous cellular tissue in this point was inflamed, and the corion 
detached by the effusion of a little pus beneath it, which by pressure 
could be forced through many of the little openings that have been 
described. 



CICATRICES OF THE SKIN. 

1273. Cicatrices of the skin are distinguished : 1st, into those which 
result from a particular modification undergone by the skin after cer- 
tain inflammatory affections ; 2d, into those which consist of a tissue of 
new or recent formation, bearing a closer or more remote resemblance 
to the portion of the skin which it replaces. 

1274. Among the first order of cicatrices there are some, a know- 
ledge of which is important, inasmuch as they are characteristic of 
the affection which has produced them, such as those of vaccinia, of 
lupus non exedens, those also that are occasioned by the action of tar- 
trate of antimony, the bites of leeches, ulcerated blisters, superficial 
burns, &c. The whole of these cicatrices have many features in 
common ; their colour is in general of a duller white than that of the 
healthy skin which surrounds them, and their surface appears to be 
beset with a great number of minute depressions, which in many cases 
exhibit pretty closely the areolar structure of the corion. These cica- 
trices occasionally present particular appearances : the cicatrices of 
blisters and of variola, for instance, are often seen covered with ex- 
crescences ; when they occur on parts that are covered with hair, this 
appendage is generally white or colourless. I have seen a large cica- 
trice covered with small reddish tumours similar to the cheloid forma- 
tion in its earliest stages. Some of these cicatrices do not rise above 
the level of the skin ; they are even in many cases rather below it (the 
cicatrices of cow-pox), in others they are elevated (leech bites, the 
cicatrices of acne, &c). I have observed the cicatrices that follow 
the action of the tartar emetic ointment on the skin, presenting this 
prominence in a very remarkable manner : there was a man under my 
charge in the Hopital de la Charite almost the whole of the skin of 
whose abdomen was covered with prominences of a dull white colour, 
slightly wrinkled and nearly of the size of sixpences, which at first 
sight bore no inconsiderable resemblance to some peculiar species of 
tubercular eruption. 

1275. When a portion of the integuments and even of the subjacent 
parts has been destroyed by a wound, by sloughing or ulceration, a 
new integument is often produced which resembles, or at least is 
analogous to that which has been destroyed, and is always the same 
in its whole extent, whatever the diversity of parts that are to be 
covered {second species of cicatrice). After the primary symptoms, 
which vary with the nature of the cause giving rise to them, have 
subsided, a series of secondary phenomena commence, the nature and 
succession of which are constantly the same. These are, 1st, the pro- 
duction of a layer of coagulable lymph, similar to that by which simple 
solutions of continuity are repaired; 2d, the formation of granulations 
and the secretion of pus ; and 3d, the cessation of this purulent secre- 
tion and the formation of a cicatrice. The layer of coagulable lymph, 
similar to that which constitutes false membranes, inorganic, at first, 
but soon organized, becomes covered with small conical, red, fleshy 
elevations, and then constitutes the granulating membrane. This 
membrane is cellular, vascular, very contractile, and extremely apt to 



disappear and to be reproduced ; by and by it is covered with a dis- 
tinct cuticle, and acquires the appearance of the skin. 

The corion of cicatrices, extremely thin and flimsy at first, more 
vascular and consequently redder than the normal membrane, becomes 
by slow degrees whiter, denser, and harder than this last. It also 
assumes a smooth and shining appearance, very probably depending 
on the absence of papillae and of piliferous bulbs, as well as from its 
tension and intimate adherence to the subcutaneous cellular tissue. 
The epidermis and rete-mucosum are reproduced gradually : the layers- 
first formed are readily detached from the surface of the dermis ; if 
the pigmentary matter is deposited at all, it is always at a later period. 
Bichat, indeed, maintained that this structure was never reproduced, 
and that cicatrices were alike colourless among all the races of man- 
kind ; but this position is untenable, and the cicatrices that follow 
solutions of continuity in the negro are often as black as the rest of 
the skin. 1 

1276. The corion of completely formed cicatrices is less elastic, 
and adheres more intimately to the subjacent cellular tissue than the 
tissue it replaces ; in fact it is continuous or forms one with the cel- 
lular tissue from which no art can separate it. It is not so tough as 
the natural corion ; even old cicatrices of the lower extremities are 
readily and frequently torn. 

There are some cicatrices which, in point of conformation and struc- 
ture, partake of the nature of those both of the first and second species; 
such are those that result from confluent variola in some cases, from 
simple rupia, from certain syphilitic eruptions, and frequently from 
burns. 

1277. The situation, extent, form and depth of cicatrices often in- 
dicate in some sort the nature of the affections that have preceded and 
occasioned them : such are the cicatrices of variola, vaccinia, zona, 
the serpiginous syphilide, lupus, &c. 

1278. When a cicatrice is very irregular, when it interferes with 
the motions of the muscles or articulations over which it lies, we 
have scarcely any efficient remedy for the evils it induces, but a sur- 
gical operation, analogous to that which Celsus 2 recommends and 
describes in a remarkable passage, and which Fabricius Hildanus, 3 
Dutcrtre, 4 H. Earle/ and Dupuytren have all performed with suc- 
cess. 

The effects of great distension of the skin ought to be distinguished 
from cicatrices. When, for instance, the mamma? have been excess- 
ively distended during the period of nursing, and after women have 
suckled several children, the skin covering them is intersected with 
irregular lines, and wrinkled angular spaces of a brighter white than 
the rest of the integuments. These, as I have satisfied myself by dis- 
section, are owing to a separation and deformity of the tissue of the 
corion, become thinner and less transparent. Individuals who are 
extremely corpulent, who are, or have been affected with ascites, and 
women who have had families, have the skin of the abdomen seamed 
with these white lines, which run in all directions, but especially 
transversely ; these constitute, the Vitiligo obesorum, the Vit. hydro- 
picorum, and the Vit. gravidarum, of Frank. 

1279. To bring this portion of my subject to an end, I shall only 
farther speak of certain anomalies in the structure of the corion, which 
are observed very rarely. 

In the interior of the body, cutaneous productions 5 are sometimes, 
through with extreme rarity, encountered. These adventitious tissues, 
which are generally met with in the ovaries, have been ascribed to 
fcetal abortions. 

Congenital deficiency of the skin to a greater or less extent over 

1 Marx. Sur le pigmentum de la peau des negres. (Bull, des sc. med. de Ferus- 
sac, t. xvii. p. 328.) 

2 At si digiti vel in utero protinus, vel propter communem exulceralionem postea 
cohasserunt, scalpello diducuntur dein separatim uterqne non pingui emplastro cir- 
cumdatur; atque ita per se uterque sanescit. Si vero fuit ulcus in digito, etc. (Cel- 
sus. De re medica, lib. vii. sect. 22.) 

3 Fabric. Hild. (Gui.). Cent. i. obs. 83. 

4 Dutertre (P.). Reflexions et observations sur les plaies en general, 4lo. Paris, 
1805. 

5 Earle. On contractions after burns or extensive ulcerations. (Med. Chir. 
Transact., torn. v. p. 96.) 

' Bricheteau. Observ. de kystes dermoides et pileux, suivies de quelques remar- 
ques sur les productions organiques (Journ. complem. des Scienc. Medic, t. xv. 
p. 298.) 



DISEASES OF THE SKIN AND MUCOUS MEMBRANES. 






various regions only occurs in those cases in which the splanchnic 
cavities are not completely closed. The epidermis has been found 
primarily defective among new-born infants. 

The skin has occasionally been known to undergo a remarkable 
extension in adults and the aged : Mr. Chevalier 1 mentions a case in 
which the skin of the breast and left side of the trunk generally was 
so loose that it could be folded or wrapped round a considerable 
portion of the body. Under the name of Dermatylosic, M. Alibert 
relates a considerable number of cases of this elongation of the skin 
of the face, eyebrows, neck and abdomen. The most interesting is 
that of a peasant of Gisors, whose head was of extraordinary magni- 
tude, owing to the large folds of integument with which it was enve- 
loped. The skin of the left eyelid was two inches in length, and fell 
down over the cheek. The edge of the upper eyelid projected like 
the mouth of a carp; the ear was dragged downwards; the parts 
covered with hair were beset with a stronger growth than usual. The 
united weight of these folds of the skin formed an uneven mass 
which dragged down the integuments covering the upper part and 
sides of the head. 

The same author details another case in which the upper eyelids 
were the parts especially affected. They were so much elongated 
that they fell down over the eyes and the whole of the cheeks. An- 
other case was that of a man, sixty-two years of age, the skin of 
whose neck, singularly lax and furrowed, formed a kind of triangle 
which fell over the front of the chest, and bore a very strong resem- 
blance to the dew-lap of the ox, or the loose folds of skin that depend 
from the throat of some large species of mastiff. The face of this 
man was ploughed with longitudinal furrows which united together 
in the chin. 



PARALLEL BETWEEN THE DISEASES OF THE SKIN AND 
THOSE OF THE MUCOUS MEMBRANES. 

1280. Studied under the twofold point of view of conformation 
and structure, the tegumentary membranes of the outer surface, and 
of the inner passages of the body, have characters which are common 
almost in their whole extent. In both particulars, however, they present 
modifications that are sufficiently striking, according to the regions 
or variety of parts they cover. These features of resemblance, and 
these differences, explain the fact of the skin and mucous membranes 
presenting a great number of analogous and common alterations, and 
a certain number of others which are peculiar to each. The import- 
ance of the comparative study of these affections has been felt; but 
few physicians and pathological anatomists have hitherto given their 
minds to inquiries of this description. 

The observations of Hebreard 2 have shown that the skin may 
become changed into a mucous membrane, and this, in its turn, into 
external integument, under certain circumstances. In fact, when any 
portion of the outer surface of the body is for a long time subtracted 
from the influence of the atmosphere, as during the treatment of cer- 
tain fractures, when the leg is kept for many weeks bent upon the 
thigh, and the integuments of the femoral and crural portions of the 
popliteal region are maintained in contact, and in the folds of the skin 
of very lusty infants, we see that the cuticle softens and disappears, 
and that the surface of the cutis ends by secreting mucus exactly 
like a mucous membrane. On the other hand, we know that in old 
cases of prolapsus of the uterus, and of the anus, the mucous mem- 
branes of the vagina and intestines become thickened and dry, and 
by degrees acquire every appearance of the skin. 

To the first sketch of Hebreard quoted, succeeded the more exten- 
sive work of J. B. Wilbrand, 3 who, after a careful study of the tegu- 

1 Chevalier. Lectures on the general structure of the human body, etc., 8vo. 
London, 1823. 

2 Hdbreard. Memoire sur l'Analogie qui existe entres les systdmes muqueux et 
dermoide (Memoires de la Societe Medicale d'emulation, t. viii. p. 153). 

3 Wilbrand (M. J. B.) (Das Hautsystem in alien seinen Verzwelgungen, Anato- 
misch. Physiol, und Patholog. dargestellt. Giessen, 1813), J. F. Meckel (Manuel 

98 



mentary system of every region, proceeds to show that a certain 
number of alterations and affections are common to the two grand 
divisions of the general involucrum of the body, (a) 

1281. The study of inflammation and of its products or effects, 
embraces so many the more objects, as the elementary tissues of tin 
organ which is affected are more numerous and varied. It is there- 
rore easy to perceive beforehand that the affections of the externa! 
integument or skin, the organization of which is so much more com- 
plex than that of the mucous membranes, will exhibit a greater num- 
ber of morbid modifications than these latter structures ; that among 
the mucous membranes, those of the mouth, pharynx and oesophagus 
provided as they are with an epithelium, or cuticle, will present 
lesions more varied in their appearances than those of the stomach 
and intestines, which themselves may be expected to offer a greater 
number than the serous membranes, the organization of which is still 
more simple. (6) 

1282. The greater number of the exanthematous inflammations 
measles, scarlatina, urticaria, &c, attack both divisions of the tegu- 
mentary membranes simultaneously. The running of the eyes, the 
nasal, laryngeal and tracheal catarrhal affection of measles corre- 
spond to the exanthema of the skin, which characterizes the diseast 
on the general surface, and the matter secreted by the bronchi pre- 
sents a peculiar character in relation with the species of inflammatioi. 
which is going on. In scarlatina the mucous membrane of the mouth 
and pharynx almost always, and that of the stomach and intestines 
occasionally, presents a dotted redness altogether analogous to tha'. 
which is observed upon the surface of the skin. The eruption in this 
disease is followed by desquamation of the cuticle, and the mucous 
membranes furnished with an epithelium, cast this pellicle off in a 
precisely similar manner. 

On the surface of the mucous membranes we also observe red 
patches, or efflorescences, which must be held as of the same natun 
with erythema, and probably, also, roseola of the skin. I have re- 
peatedly seen red patches upon the lips and conjunctivas, in cases of 
erythema mar ginitum ; and I have known this affection complicated 
with pulmonary catarrh. The mucous membrane of the intestinal 
canal occasionally, also, presents circumscribed red patches, distinct 
from clusters of inflamed mucous crypts, and formed by the mem- 
brane itself, injected and thickened, and generally covered with a 
ropy red viscid mucus. On this membrane, too, we frequently en- 
counter bands, and diffuse red suffusions, analogous to certain varieties 
of erythema occurring in the skin. 

The submucous cellular tissue of the intestinal canal differs so 
essentially from the subcutaneous cellular membrane, that it is nor 
difficult to assign a reason for our never meeting with inflammatio: 
in this situation, which we can approximate rigorously to erysipelas. 

The skin, in a state of inflammation, never presents the vascular 
ramifications we observe on the surface of the mucous membranes in 
this condition. 1 This is owing to a remarkable difference in the moth 
of distribution of the submucous and subcutaneous vessels, and to the 

(a) See ante, pp. 46-7, some observations on this point by Un- 
American editor. 

(b) It is now asserted that all the mucous surfaces are lined will 
epithelium, either of a cylindrical or tesselated arrangement, and tha: 
it is formed, developed and detached in the same manner as the 
epidermis. See Mandl, Manuel aVAnatomie Generate, p. 543. As the 
epidermis is renewed some days after birth, and from time to time 
afterwards, so, likewise, is the intestinal epithelium often detached in 
long hollow or tubular pieces, like the fingers of a glove, and at all 
times it is freely given off and carried downwards by aliments and 
secreted fluids. 

d'Anatomie generale, descriptive et Pathologique, trad, de l'allemand, avec des note?, 
par Jourdan et Breschet. Paris, 1825, 3 vol. 8vo.), have laid the foundation for 
this comparative study. Messrs. Roche and Sansen havealso presented general con- 
siderations of great interest on the Pathological Anatomy and Physiology of th< 
mucous and cutaneous systems in their Nouv. Elemens de Pathologie Medico-Chir- 
urgical, 4 vols., 8vo. Paris, 1827. 

* Billard has made a particular study of the alterations of the mucous membram 
of the intestinal canal. His observations have served me as points of comparison in 
contrasting the various diseases of this tissue with the affections of the skin, — vide 
Billard (C). De la membrane muqueuse gastro-intestinale dans l'etait sain et dan- 
l'etat inflammatoire, etc., 8vo. Paris, 1S26. 



390 



PARALLEL BETWEEN 



lilar thickness of the skin and of the mucous membranes. The 

r injections observed on the nose and cheeks, are 
• be regarded as an anomalous, non-inflammatory develop- 
of these parts. The capillary injection of the 
ke that of the mucous membranes, is, in one instance, the con- 
sequence of inflammation, and, at another, of mere passive conges- 
er death; these two species of redness of skin 
nguished, like those of the mucous membranes, by the 
els in their vicinity. 
In line, if we except the white wheals of urticaria, and the patches 
ola, we find in the mucous membranes almost the whole of the 
varieties, in form and appearance, presented by the exanthematous 
inflammations of the skin. The internal exanthemata, however, are 
icompanied with any desquamation corresponding to that which 
irved on the exterior of the body, except in those regions — the 
mouth, pharynx, ami oesophagus, in which the mucous membranes 
are furnished with an epithelium. In the stomach, intestines, trachea, 
be loss of the epidermis is represented by a modification in the 
.ion of the mucus which covers their surface. 
As to the brown, gray, or slate-like discolorations presented by the 
mucous membranes, in consequence of their inflammation, we ob- 
serve very similar tints following chronic inflammatory affections of 
lie skin. 

i. Affections analogous to the bulbous inflammations of the 
skin, are observed in those mucous membranes that are provided 
with an epithelium. Large, prominent bulkc, indeed, are never ob- 
ierved on these parts; in the mouth they are always flattened. The 
serum, as it is formed, seems to permeate the epithelium, which be- 
comes of a dull white colour. No bullae are ever discovered in the 
stomach and intestines of those who have died whilst labouring under 
pemphigus. They cannot even be excited there by artificial means: 
Bichat applied a piece of blistering plaster to the mucous membrane 
of the intestine in a living dog; the effect of this was to produce a 
circular patch of inflammation, but no blister. It would be absurd 
to denominate as bullae those collections of pus or serum occasion- 
ally met with in the submucous tissues, which ought to be assimilated 
-cutaneous abscesses or infiltrations. 
:. 1 1 is familiarly known that on opening a blister produced 
by the action of epispastics upon the skin, a membraniform con- 
cretion is frequently observed. This, like the pseudo-membranous 
formations of the serous tissues is principally composed of fibrin. 
Blistered surfaces, too, occasionally become covered with a true 
membraniform pellicle. If this be removed the papillary surface 
096 extremely red, and the network of vessels, loaded with 
blood, which traverse it in all directions, are observed to pour out 
a fluid which adheres to the inflamed surface and gradually concretes 
into a new pellicle, thin and transparent at first, but which soon 
acquires greater thickness and opacity. Oil impregnated with the 
active principle of cantharides, applied to the tongue and lips, pro- 
duces an effect very similar to what it does when rubbed on the 
-kin ; yet the alteration bears greater outward resemblance to an 
inflammation with pseudo-membranous deposit, than to bullous in- 
flammation. And there is, in fact, a pseudo-membranous pellicle 
leposited under the raised epithelium, 1 which, thin and semi-trans- 
parent at first, becomes, before long, thicker and more opaque, being 
in all respects very similar to the ordinary false membranes of blistered 
surfaces. It appears, therefore, that the stimulus which, applied to 
the skin, produces a bulla, with or without a sub-epidermic false 
membrane, when applied to the mucous membrane of the mouth, 
ions a fibrous concretion under the epithelium, and when ap- 
plied to the intestine, is followed by simple redness and inflamma- 
tion. This diversity of effect, according to the part interested, is 
also observed among new-born infants affected with thrush, in whom 
'-membranous deposits, sometimes apparent on the hands, 
aely distinct in the mouth, pharynx, and oesophagus, but 
have never been observed in the stomach and bowels. 

'J he pseudo-membranous concretions produced upon the mucous 

s by the action of cantharides, although presenting the 

anatomical characters of those of diphtheritis, differ from these in one 

uL Bret 2^ eaU ' DeS inllamrn;i - du tissu muqueux, etc., Svo. Paris, 



essential feature peculiar to this disease, namely, in not being conta- 
gious, as diphtheritis unquestionably is. It would appear, also, from 
what Messrs. Brelonneau, S. Bard, and Trousseau say, that besides 
the false membranes of various forms and dimensions which arc 
observed in the course of many bullous, vascular, and pustular in- 
flammations, the skin may be primarily affected in some rare cases 
with inflammation, accompanied with the elimination of false mem- 
branes of the same nature as those of diphtheritis. 2 

In the course of the year 1814, I observed the blisters of a great 
number of patients in the Hotel Dieu, become covered with a thin 
membraniform fibrinous deposit, adherent to the papillae, and pre- 
cisely similar to that which I perceived at the same period upon the 
wounds and ulcers attacked with hospital gangrene. There seems 
to be some analogy between angina with formation of false mem- 
branes, and hospital gangrene occurring in inflamed skin : besides 
the similarity of their anatomical characters, both of these forms of 
inflammation are contagious. 

1285. True vesicles are never seen, save on the mucous mem- 
branes that are covered with epithelium. 3 The lips are often attacked 
with herpes, and zona may extend to the inside of the mouth. The 
aphthae that occur in the cavity of the mouth and on the surface of 
the pharynx, appear to be analogous to one or other of the varieties 
of herpes. I have met with eczema confined to the mucous mem- 
brane of the lips and extending into the inside of the mouth. It also 
occasionally appears confined to the mucous surfaces of the nipple, of 
the penis vulva, and verge of the anus. I have observed chronic 
and very rebellious coryzae accompanied with discharge from the 
nostrils, and very considerable pruritus of the nasal fossae, which 
were preceded by eczematous affections. 

Mercurial stomatitis and angina are analogous to the affection of 
the skin which is described under the name of hydrargyria ; the 
whitish patches of the mouth and pharynx that then occur, and that 
are often regarded as fibrous and pseudo-membranous, are principally 
formed by the epithelium, thickened and detached from the mem- 
brane beneath it. We never observe any affection of the mucous 
membranes that can be compared to scabies. 

12S6. Pustular inflammations have never been observed on the 
mucous membranes with the form and characters which they present 
on the skin, except on those that are furnished with an epithelium. 
When the cause producing the pustules has extended its influence to 
those parts of the mucous membranes that have no epithelium, the 
form of the inflammation is necessarily modified. Variola, for in- 
stance, which appears with the characters of a truly pustular eruption 
on the mucous membrane of the lip, inside of the mouth and pharynx, 
as well as on the skin, gradually loses its strong features as it appears 
on parts more remote from the surface of the body. In the trachea 
the pustules are replaced by small while circular patches of the 
dimensions of variolous pustules, but formed by a simple deposit of 
pseudo-membranous matter. In the stomach, and along the course 
of the bowels, nothing more is apparent, even at the height of the 
disease, than red, circular spots, which seen alone, would hardly 
recall variolous pustules to the mind. 

Impetigo occasionally attacks the mucous membrane of the angles 
and of the interior of the mouth, as well as of that which lines the 
nasal fossae. In the chronic coryzae which often accompany impetigo 
of the ake nasi, the nasal fossae pour out a thick matter which con- 
cretes in the shape of crusts. When impetigo extends into the 
mouth, white and pustular-looking points are perceived in its interior. 
The inflammation of the follicles of the edges of the eyelids or of the 
hairy scalp, which frequently coincides with, or follows attacks of 
impetigo, is a disease analogous in its nature to this last affection. 

The typhoid follicular eruptions (taches typhoides lenticulaires) and 
gangrenes of the skin occasionally observed, must be assimilated to 
the follicular eruptions and gangrenous patches that occur in the course 
of the intestinal canal in dothinenteritis. 

The corion or dermis of the mucous membrane does not present, 

2 Lelut, eludes anatomiques sur lepithelium 4to. Paris, 1827. 

5 When ulcers appear behind the ears, says S. Bard, or on different other parts of 

they require peculiar treatment. The discharge ought to be encouraged 

by the frequent use of tepid milk and water fomentations ; unctuous applications of 

all kinds are prejudicial, for they tend to suppress the secretion (Dretonneau, op. cit., 

p. 483). 



DISEASES OF THE SKIN AND MUCOUS MEMBRANES. 



391 



like that of the outer integument, a regular areolar or cellular tissue ; 
it is rather spongy and fungous, and does not consequently present 
any alteration analogous to the fwnmcular affections of the skin. 
Neither has it been known to suppurate after the manner of the skin 
in the following case : I had directed the application of a large mus- 
tard poultice to the side of a young man, labouring under pleurisy, 
and who died from effusion into the cavity of the chest. Next day, 
and the day after that, the skin presented a red colour, similar to 
what it has in scarlatina ; but on the third day, the irritated skin was 
perceived to have assumed a dull white or milky hue. The epider- 
mis could be raised and detached with a pin, and the sensibility of 
the outer layer of the corion appeared to be blunted. The patient 
having died, the milky- white colour of the integument was ascertained 
to be occasioned by an infiltration of pus, with which the corion 
seemed to be impregnated. By squeezing the skin between the 
fingers, the pus could be forced by an infinity of small orifices from 
its surface, and flowed in a continuous current when one or two inci- 
sions were made into its substance. 

1287. In prurigo pudendi, and prurigo prteputii, it very rarely hap- 
pens that true papula: can be detected on the mucous membranes of 
the vagina and prepuce ; they are almost always to be detected in the 
neighbourhood, on the pubes, scrotum, labia majora, &c. 

1288. Tubercular inflammations have, on the contrary, been seen 
pretty frequently attacking the mucous membranes. Primary cancer 
of the velum palati, for instance, begins in the development of tuber- 
cles analogous to those observed on the skin. Cancerous tubercles 
of the cheek are occasionally observed at the same time that tubercles 
of the same nature exist on the velum palati and palatine arch ; cir- 
cular hypertrophied patches, and cancerous tubercles of the skin are 
also met with in those individuals who are affected with scirrhus of 
the mucous membrane of the stomach. The tubercles of Greek ele- 
phantiasis are evolved, not only on the exterior of the body, but very 
commonly also on the palatine arch and the nasal fossa?. Lupus is 
well known occasionally to commence in the interior of the nose. 

1289. Lepra and psoriasis perhaps never implicate the mucous 
membranes; but pityriasis sometimes shows itself upon the lips. 
Were affections of the nature of any of these developed on the mu- 
cous membranes unprovided with epithelium, their appearance would 
necessarily be entirely changed. 

1290. Several forms of gangrenous inflammation observed on the 
skin, may also appear on the mucous membranes ; malignant pustule 
has, for example, been seen on the tongue ;' and whilst it is evolved 
externally, the stomach and different other internal viscera may be 
simultaneously attacked (Case XCVI). Gangrene is occasionally, 
though rarely, observed attacking the ileum and coecum as well as 
the skin, in typhus fever. 

1291. The multiform inflammations are simplified in their forms 
when they occur on the mucous membranes. Still burns appear with 
the erythematous, bullous and gangrenous characters in the mouth 
and oesophagus. 

It is certain that almost all the forms under which syphilis appears 
upon the skin, occur on the mucous membranes provided with an epi- 
thelium. Syphilitic exanthemata, pustules, tubercles, ulceis and ex- 
crescences have all been seen on the mucous membrane of the mouth, 
of the nipple, labia majora, glans penis, &c. Several forms of vene- 
real inflammation have also been observed on the conjunctiva, in the 
interior of the nasal fossa?, of the mouth, pharynx, larynx, rectum, &c. ; 
it is a very general opinion, however, that the oesophagus, stomach, 
intestinal canal and bladder are never the seat of syphilitic affections. 
Some have even gone further, and have said that since the irregular 
grayish ulcers, with peculiar characters, encountered in the intestinal 
canal, which they have even eroded in different directions, are notto 
be considered as syphilitic in their nature, neilherare the ulcers of the 
skin which present corresponding characters, to be regarded as truly- 
syphilitic. For my own part, I hold the characters of all the different 
forms of syphilitic eruption to be so definite and decided, that I am of 
opinion those ulcers of the intestines, which, in their external charac- 
ters, approximate those of the skin, require to be examined with 
greater care and attention than have yet been bestowed upon them 
before any conclusion of the kind above indicated, can be come to. 
1 Loud. Med. Gaz., June, 1834. 



1292. Ulcers and perforations of the mucous membranes, especially 
of the intestines, like those of the skin, follow inflammations of vari- 
ous kinds, abscesses of the subjacent cellular tissue and gangrene. 
Softening (ramollissement), rather rare in the skin, the corion of which 
is substantial and tough, is much more common in the mucous mem- 
branes. 

1293. From this hasty sketch of the diseases of the internal and 
external integument of the body, it is easy to perceive that they 
bear a great analogy to one another. The epithelium, like the epider- 
mis, is altered under the influence of inflammation, and the mucus 
which they both pour out under peculiar circumstances, is modified 
like these, in the points where it is secreted in their stead ; the vas- 
cular rete of both becomes injected, and the corion thickened; the 
villi of the mucous membranes increase, and the papilla? of the skin 
are extended: the follicles of both integuments often enlarge, and 
accidental morbid secretions take place from the one as from the 
other. In a word, if the whole of the forms of phlegmasia? observed 
in the skin, are not encountered in the mucous membranes, and seve- 
ral of them are modified in their outward appearance, it is entirely 
owing to the differences of structure presented by these two tissues, 
which are amply sufficient to account- for every discrepancy observed 
in their morbid phenomena. 

1294. Congestion and hemorrhage frequently take place into and 
from the external and internal integument simultaneously. In certain 
kinds of death, from apoplexy, strangulation, &c, the skin and mu- 
cous membranes alike present livid blotches on their surface, and 
occasionally spots of ecchymosis. The blue colour of cyanosis 
appears on the skin and mucous membrane of the lips, mouth, and 
stomach at the same time. Purpura?, ecchymoses and petechia? occur 
on the interior as well as the exterior covering. As to the material 
differences observed between the hemorrhages that take place from 
the mucous membranes and the skin, these are due, in very great 
part at least, to difference of structure. The vascular rete of the 
surface of the cutis vera or corion, is less developed than that of the 
mucous membranes; these, when covered with epithelium, have this 
membrane much thinner than the cuticle, and in many places are 
entirely without any tissue of the kind, circumstances which we may 
presume favourable to the flow of blood from their surface ; whilst 
opposite conditions rather determine the deposit of this fluid under 
the form of petechia? and ecchymoses, in the substance of the skin. 
The absence of epithelium on the membrane lining the nasal fos 
explains the greater frequency of epistaxis than of bleeding from the 
mouth. 

1295. The neuroses of the skin, like those of the mucous mem- 
branes, ought to be made the subject of new inquiries; the effects of 
injury to, or alteration of, the subcutaneous nerves, are much better 
known than those of lesion of the submucous nerves. 

1296. The absence of pigment in the mucous membranes of the 
human body explains why we do not find in these membranes any 
alteration which can be assimilated to leucopathia of the skin ; for 
the morbid paleness of the mucous membrane of the intestines, al- 
most always connected with a diminution of its thickness, is of a 
totally different nature, and appears to be generally consequent on 
inflammation. 

Individuals affected with general nigrities do not generally present 
any corresponding alteration in the mucous membranes, although I 
have seen it extend in the form of brownish spots to the surface of 
the tongue. 

The mucous membrane of the intestines has been several times 
observed discoloured black, particularly by Morgagni. Andral 2 lias 
also seen the surface of the large intestines of a deep black colour, 
inhering in the mucous membrane, which had in other respects pre- 
served its usual thickness, the mucous crypts only being particularly 
enlarged. The colouring matter came off and blackened a piece of 
linen with which the surface of the membrane was wiped ; the colour 
was, in the judgment of M. Andral, perfectly distinct from the brown 
hue presented by the same surfaces when affected with chronic phleg- 
masia?; he regarded it as the effect of an accidental secretion and 
deposition of colouring matter, similar to that which takes place 
naturally in the tunica choroidea of the eye. I have several times 
2 Revue mtdicale francaise et etrangere, t. ii. p. 148. 



392 



DISEASES OF THE SKIN AND MUCOUS MEMBRANES. 



face of the tongue dotted with a bluish black. Ephi- 
lis, lentigo and chloasma have no counterparts on the internal mu- 
cous in . although these last, and especially those of the glans 
and vulva, occasionally exhibit accidental discolorations. They are 
tinted yellow, but in a less degree than the skin in icterus, and like this, 
In v acquire a leaden or slate colour under the long-continued internal 
the nitrate of silver. I have, further, observed vascular naevi 
penetrating into the interior of the mouth. 

1297. 1 nder the title of hypertrophy from an inflammatory cause, 
indurated thickenings of the mucous membranes coincident with other 
inflammatory lesions, have been designated. With these we must 
assimilate those thickenings and indurations of the skin, which are 
observed along with psoriasis and lichen of long standing, with tuber- 
cular inflammations, &c. The title of hypertrophy, however, ought 
to be reserved for the indication of cases of simple exaggeration of 
the normal tissues of the skin. Such, with reference to the mucous 
membranes, are certain anomalous developments of their tissues gene- 
rally, and of their villi and follicles particularly, which are sometimes 
encountered, — alterations, the counterparts of which are observed in 
the skin in cases of ichthyosis and elephantiasis arabica. Billard 
quotes several cases to show that the mucous glands of the intestines 
may acquire an anomalous magnitude independently of inflammation. 
The skin is also occasionally observed to be covered with a greater 
number of follicles than it exhibits in the usual state. I have seen 
this excessive development of the follicles, especially among indi- 
viduals of mature years, and the aged, in the skin of the neck, on 
the sternal, on the scapular regions, and sometimes even over the 
whole surface of the body. 

1298. The submucous, like the subcutaneous cellular membrane, 
may be the seat of cedema, ecchymosis, and abscess; but the deve- 
lopment of tubercular matter, which takes place rather commonly in 
the submucous, occurs very seldom in the subcutaneous cellular 
tissue. The case is otherwise with regard to scirrhus, cancer, and 
melanosis, which occur with no less frequency in and under the skin 
than in and below the mucous membranes. A multitude of other 
alterations are common to the two integuments. Excrescences of the 
glans penis and female vulva correspond to warts developed on other 
parts. The diverticula of the intestinal canal even bear some analogy 
to the digitiform appendages of the skin; the mucous membranes are 
occasionally beset with accidental hairs like the skin ; in the subcu- 
taneous cellular tissue cysts are somtimes observed analogous to those 
occasionally discovered in the submucous cellular membrane ; the 
peculiar tumours described by Dagorn and Tilesius, covered with the 
skin, may be regarded, in point of conformation at least, as analogous 
to certain polypi evolved below the mucous membrane, &c. The 
rudiments, of various rare affections of the corion and cuticle, are 
even to be traced in the mucous membranes. I have dissected the 
tongue in several cases, in which the papillary system, very highly 
developed, was covered with an epithelium whose thickness, the 
double or triple of what it is generally, brought' forcibly to mind the 
appearance of the epidermis in certain cases of elephantiasis arabica, 
and of local ichthyosis. I once saw a child, eight years of age, the 
skin of whose axilla?, bends of the arms, popliteal regions, and ante- 
rior part of the neck, presented so considerable a development of the 
papilla? that the whole of these parts appeared to be covered with a 



continuous crop of warts, almost as moist on their surface as the 
mucous membranes themselves. The skin of the abdomen was brown 
and rugous, as it is in certain cases of ichthyosis. Circumscribed 
hardnesses and horny appendages, similar to those pretty frequently met 
with on the skin, have also been seen developed on the mucous mem- 
branes. 

With regard to the accidental ossifications of the integuments, it 
does not seem to me that any conclusion can be drawn from the im- 
perfect case recorded by Gillaiseau (Bullet, de la Facultede Med. de 
Paris, t. i. p. 224), and several others still less decisive. 

1299. The study of the cicatrices of the external integument is 
fraught with a greater degree of interest than that of the cicatrices of 
the mucous membranes. Cicatrices of these latter tissues acquire 
more speedily the appearance of the membranes themselves, and on 
that account, remain for a shorter while visible than those of the skin. 
They are also, like the primary tissue they represent, less complex 
than those of the external integument. In the skin, the epidermis 
and dermis are, of all the elements, those which are most speedily 
reproduced. The pigment is never deposited till a much later period, 
and the sebaceous follicles and piliferous bulbs are scarcely ever re- 
produced at all. 

Several cicatrices of the skin, such as those of burns, of serpigi- 
nous syphilis, lupus, acne, and leech bites, present peculiar charac- 
ters, familiarity with which completes the knowledge of the causes 
that produce them. 

Various animals are occasionally developed on the surface of the 
skin of man, and on that of the internal integument also. The dif- 
ference of the places they frequent is in accordance with the no less 
remarkable differences they exhibit in their organization. 

1300. The teeth are the only dependences of the mucous mem- 
branes which it is possible to assimilate to the hairy appendages of 
the skin. Like the hair, the teeth, as it is well known, may be 
faultily formed in a greater or less degree, and run in a variety of 
directions other than those they follow in the normal state. The 
alteration of the dental pulp seems to correspond to that of the pili- 
ferous papilla, and the fall of the teeth in the aged is a phenomenon 
of the same description as senile alopecia. 

1301. To conclude this subject : when the body begins to putrefy, 
the external and internal integuments present livid marks, which 
correspond to the larger veins of the subcutaneous and submucous 
tissues. It is often of importance not to confound this appearance 
with that occasioned by congestion or inflammation. The subcuta- 
neous cellular tissue more frequently becomes emphysematous in the 
earlier stages of putrefaction, than that which is distributed under the 
mucous membranes; and there is one alteration exhibited by the skin, 
as the body is hastening to decay, nothing analogous to which is seen 
on the mucous membranes ; this is a kind of blebs or blisters of dif- 
ferent sizes, which are formed by a quantity of sanguinolent serum, 
frequently mixed with a few bubbles of air, effused under the epider- 
mis. In the point upon which these phlyctena? are formed, the corion 
has sometimes a greenish look; the epidermis is always readily 
detached from the part near these phlyctenaa ; these two circumstances 
will always suffice to distinguish the alteration in question from the 
blisters occasioned by burns, frost bite, pemphigus, cedema, and the 
action of cantharides. 



APPENDIX. 



1302. In this appendix I shall describe, first, the organized living 
creatures which are observed on the surface of the skin, in its sub- 
stance, or in the subcutaneous cellular tissue ; secondly, Arabian 
elephantiasis, a disease in which the skin is not at first implicated, 
which ends in causing the hypertrophy of its different component 
layers ; thirdly, diseases peculiar to certain countries, or to certain 
epochs, several of which have been very imperfectly described ; 
fourthly and lastly, certain diseases of animals which are capable of 
being transmitted to man. 



ORGANIZED LIVING CREATURES INHABITING THE BODY 

OF MAN. (a) 

1303. Many animals may be developed, or may exist accidentally 
on the skin of the human subject. Some grow, live, and generate 

(a) Notice has been taken already (in note at pp. 196-7) of vegeta- 
ble organized matter, growing on the human skin in certain diseases, 
and more especially in favus. As the subject is a novel one, it 
may not be deemed amiss to introduce here the substance of Dr. 
John Hughes Bennett's observations, confirmatory of those of Mr. 
Gruby. — " On the Parasitic Vegetable Structures found growing in 
living animals. In Transactions of the Royal Society of Edin- 
burgh." 

" In the Comptes Rendus des Seances de V Academic des Sciences, for 
July and August, 1841, M. Gruby has inserted some observations 
regarding the crusts of tinea favosa, or porrigo lupinosa according to 
Bateman, for the purpose of establishing a more complete diagnosis 
of this disease than had previously existed. For this purpose, he 
had recourse to the microscope. By means of this instrument he 
ascertained — 1st, that tinea consists in the aggregation of millions of 
mycodermatous plants. These are formed of articulated filaments of 
a diameter from toVo" to 2so of a millimetre ; they spring from an 
amorphous mass of which the periphery of each capsule of tinea is 
composed, and give off towards its centre oblong or round homoge- 
neous corpuscles, which are the reproductive spores. The longitu- 
dinal diameter of these corpuscles is from ¥ ^ to y^o" °f a millimetre, 
and the transverse is from 3^ to y-J-o- The cells of the tubes some- 
times contain small round transparent molecules, of a diameter 
varying from ,075-0 to T sW °f a millimetre. The seat of these vege- 
tations he ascertained to be in the cells of the epidermis. The true 
skin is compressed, not destroyed ; and the bulbs and roots of the 
hairs are only secondarily affected. The disc of the capsule, which 
is not at the commencement perforated, opens by a small hole in the 
centre. This enlarges, and the plants push through it, so that, at a 
more advanced period, instead of there being a central depression in 
the capsule, there is a convexity, and its edges disappear. M. Gruby 
inoculated 30 phanerogamous plants, 24 silkworms, 6 reptiles, 4 
birds, and 8 mammifera, but only induced the disease once, and then 
in a plant. The human arm was inoculated five times, but, inde- 
99 



on the surface of the integuments, such as the pediculus humani cor- 
poris, the pediculus capitis, the pediculus pubis, and the pulex irritans ; 
others penetrate the epidermis, such as the acarus scabiei and the 
pulex penetrans. Other insects deposited within the substance of the 

pendent of a slight inflammation and suppuration, no effect was 
produced. Dr. Bennet some time after examined the crusts on the 
head of a boy who laboured under the disease, and immediately 
detected the cylindrical and ramified appearances described by M. 
Gruby. Dr. Bennett, on continuing his observations still further, 
satisfied himself that pustules are not essential to the disease, though 
frequently present. Hence, will appear the error of classifying the 
porrigo lupinosa among the pustuke. According to Dr. Bennett, 
desquamation of the cuticle always precedes the development of the 
disease. Dr. Bennett made several observations in order to ascertain 
the correctness of M. Gruby's statement, viz., that the plants grow in 
the substance of the epidermis. He found that the entire inferior 
surface of the capsule is formed of epidermic scales, thickly matted 
together. These are lined by an amorphous, finely-granulated matter, 
from which the plants appear to spring. Superiorly, however, the 
epidermic scales are not so dense. These observations indicate the 
probable mode in which these plants are deposited on the scalp. We 
have seen that the appearance of the peculiar porrigo capsule was 
preceded by a desquamation of the cuticle. Hence, it is more proba- 
ble that the matters, from which the vegetations are developed, 
insinuate themselves between the crevices, and under the portion of 
epidermis thus partially separated, than that they spring up originally 
below, or in the substance of the cuticle. Dr. Bennett failed, as did 
also M. Gruby, in communicating the disease to other individuals, or 
from one part of the same individual to another, although it is gene- 
rally conceived to be of a highly contagious nature. 

" Dr. Bennett mentions that he has observed crusts upon the face 
of a living common house mouse, similar in every respect to those 
which constitute the porrigo favosa in man. The crusts were of a 
more irregular form, prominent in the centre, not forming distinct 
capsules or perforated by a hair. When examined microscopically, 
they presented the cylindrical tubes and sporules en masse, in every 
respect identical to those which grow on the scalp of man. It has 
been observed that the odour of the crusts of porrigo favosa is similar 
to that of mice, which makes it not a little singular, that the myco- 
dermatous plant, constituting this disease, should be found growing 
on these animals. Whether the disease be peculiar to man and the 
rodentia, is a question yet to be answered."— Med.' CHr. Rev., 1841. 

The conclusions deduced from these fairly by Dr. Bennett are, 1st. 
" That these vegetations always arise in living animals previously 
diseased ; 2d. That their presence indicates great depression of the 
vital powers and impairment of the nutritive functions ; 3d. That the 
peculiar constitution favourable to their growth is the tubercular or 
scrofulous in the mammalia, birds, or fishes, and most probably in 
reptiles and insects ; and 4th. That the therapeutic indications are — 
1. To invigorate the system, and 2. To apply locally such applica- 
tions as tend to destroy vegetable life. Dr. Bennett has found more 
than once a vegetable structure in the black deposit, which collects 
on the teeth and gums of individuals in the last stage of typhus." 






PARASITIC ANIMALS. 



h nun skin, in the state of eggs, are there hatched, live in the form 
of l.u vip, ami emerge at length in the shape of winged insects, as the 
cutrus, so common in sheep, oxen, and horses; finally, one species 
of the onto/. >a, the filiaria medinensis is occasionally met with deve- 
loped beneath the skin. 1 



PEDICULI. 

1304. The existence and development of a very great number of 
pediculi or lice, in a particular region, or over the whole surface of 
the human body, is designated under the name of phthiriasis (<j>0«pi'a<»$ 
from <j>9tip pediculis). 

Pediculi are apterus parasitic insects, the flattened bodies of which 
are covered with a skin which is hard at the edges and transparent 
in the centre; they have a small distinct oval or triangular shaped 
head, supplied in the forepart with a fleshy excrescence, enclosing a 
small sucker, which appears to be simple; they have two short filiform 
antenna?, with five joints, and two small round eyes. The corslet, 
almost square, is rather narrow in front. They have six short thick 
feet, all of equal length, each consisting of a haunch of two pieces, of 
a thigh, a cylindrical leg, and a strong scaly, conical, arched hook at 
the extremity. The abdomen is round, oval, or oblong, lobulated or 
incised, and showing eight rings on the sides. It is provided with 
sixteen sensible stygmata, and with a scaly point at the posterior 
extremity in the male. 

Swammerdam not having been able to discover male organs in any 
of the pediculi he dissected, and having as constantly met with an 
ovary, concluded that these insects were hermaphrodites. Leuwen- 
hoeck afterwards succeeded in distinguishing the male from the 
female, and gave an exact representation of the organs which charac- 
terize the male. According to him, the males have a bent stilette 
which they carry in the abdomen, and with which they can pierce 
the skin ; he even conceives that the great itchiness which these 
creatures occasion proceeds from the prick of this sting, the introduc- 
tion of the sucker into the skin, according to him, scarcely producing 
any sensation. De Geer mentions his having observed a similar sting 
at the extremity of the abdomen in several pediculi. According to 
De Geer, the end of the abdomen is rounded off in the males, whilst 
in the females, which have no sting or piercer, it is notched. 

Pediculi are oviparous, and the females, after the intercourse which 
fecundates them, deposit their eggs, known by the name of nits, upon 
the hair and clothes. The young are not long in emerging from the 
eggs ; they change their skin several times, and after these changes 
are in a state to generate. To ascertain the periods of propagation, 
and the length of time required for the growth of these insects, Leu- 
wenhoeck took two females, and placed them in a black silk stocking 
which he wore night and day. At the end of six days, each of them, 
without decreasing in size, had deposited fifty eggs ; at the end of 

' It has been supposed possible for other animals to exist in the human skin, and 
Etmuller has been quoted as the authority for this assertion ; he informs us, in fact, 
that he has seen a peculiar disease in new-born children, produced by small worms 
lodged underneath the skin, which occasioned violent itching and irritation only to 
be subdued by the expulsion of these animals. According to his account, these pre- 
tended worms, which medical men have named cirones, or comedones, are of a coal- 
black colour; they have two antenna?, and a tail terminating in a tuft of hair. But 
in the present day, the observations of Etmuller, and those which have been more 
recently published upon the same subject, by M. Bassignot (Histoire de la maladie 
connue sous le nom de crinons qui attaque les nouveau-nes a Seyne, en Provence; 
Memoires de la Societe Royale de Medecine, 1776) are generally allowed to be inac- 
curate. Sebaceous deposits within the follicles of the skin have been mistaken for 
worms. The furia infernalis of Linnaeus seems also to be an imaginary worm. The 
characters which have been assigned to it by this celebrated naturalist, are, in great 
part, applicable to the gordius and filiaria. 

The larvae of the genus musca, and of several other genera, may be accidentally 
developed in the meatus auditorius of children who are neglected, on the surface of 
ulcers, &c. Other insects sometimes inflame the skin by their stings. The bug 
(cimex lectularias), by means of its trunk, sucks out the blood and throws an acrid 
fiuid of a peculiar nature into the wound. The bite of this insect is followed by the 
development of a papular or tubercular elevation of a yellowish-red colour. The 
gnat (culex pepiens) produces still more painful stings, followed by small hard 
nimouis also of a yellowish-red, accompanied with heat and violent itchiness The 
rmget, or mowers mile (acarus autumnalis, Linn.), fastens itself to the skin, and pro- 
duces the most insupportable itching, which is soon followed by small yellowish 
inflamed tubercles. These insects are destroyed by bathing the skin with pure alco- 
hol or strong vinegar. Finally, other insects, bees, wasps, hornets, spiders ant<= &c 
by puncturing the skin, occasion a greater or less degree of pain and irritation ' "' 



four and twenty days the young ones had produced others in such 
numbers, that in the course of two months these two females might 
have seen eighteen thousand of their descendants ! 

The three species of pediculi observed on the human body are 
known by the name of pediculus humani capitis (Ue Geer), pediculus 
humani corporis (De Geer), pediculus pubis (Linnaeus). They all live 
upon blood, sucked through their trunk, which is not seen unless 
when in action. 

1305. Pediculus capitis. — The body is of a grayish-brown, the 
lobes of the abdomen are rounded. Linnaeus considers the pediculus 
capitis as a variety of the pediculus corporis, from which it differs in 
the skin being harder and darker, and the corslet and abdomen being 
edged on each side by a blackish-brown streak. M. Latreille also 
thinks that they may be considered as a single species. The pedi- 
culus capitis lives on the head, and, according to Willan, does not 
quit the hairy scalp spontaneously. 

Pediculi capitis are transmitted from one individual to another. 
Want of cleanliness and diseases of the hairy scalp do not produce 
them. If they are often observed among the children of the poor, 
whose heads are not kept clean, and in those who have long fair 
hair ; if persons who are negligent in removing the scurf which is 
formed by perspiration and the use of powder, or who are affected 
with chronic inflammation of the hairy scalp, favus, &c, are often 
troubled with these insects, and if they are frequently observed among 
convalescents from a variety of diseases, it is merely because the 
want of cleanliness insures their propagation, and renders their de- 
struction more difficult, and because certain conditions are more 
favourable to their existence and increase than others. Some false 
notions, current among the lower classes, are very favourable to the 
production of pediculi: they imagine that persons affected with these 
insects are generally otherwise healthy, that they suck away the bad 
blood; and, finally, that the existence of a certain number of pediculi 
on the hairy scalp proves a kind of drain which must not be sup- 
pressed without the greatest care, (a) 

The existence of pediculi capitis is announced by a greater or 
smaller amount of itchiness. When these insects are numerous, 
persons affected with them are constantly scratching the head ; in 
children, the pruritus which follows the first itchiness is sometimes 
accompanied by loss of sleep, and great nervous irritability. Pedi- 
culi multiply to a disgusting degree under the scabs of favus, and in 
the neighbourhood of the ichorous exudation of eczema of the hairy 
scalp. But although very numerous, they never cause marasmus, and 
still less death. The instances of the deaths occasioned by lice, detailed 
or mentioned in the dissertations of George Franck, of Franckenau, 
and republished, without critical remarks, in the Dictionnaire des Sci- 
ences Medicales, and in the abridgment of the same, are, at the best, 
tales to frighten children, who are negligent of their hair. 

Pediculi capitis may always be destroyed by combing the hair fre- 
quently, or by shaving the head, when the hair is covered with nits. 
The same end is also as fully accomplished by washing the head with 
an alkaline solution, in which some of the seeds of staphysagria are 
infused. Oil of lavender, or a decoction of the smaller centauria, 
has been likewise recommended as an application to the hairy scalp 
infected with pediculi, or powdered parsley seeds may be sprinkled 
among the hair, with the effect of destroying them; finally, the head 
may be lightly rubbed with a small quantity of weakened mercurial 
ointment. This last means has been said to have produced very serious 
effects in several children, such as coma, a state of great debility fol- 
lowed by convulsions, &c. I have used it repeatedly, always with 
success, and never with any ill consequences. 

1306. Pediculus corporis. — The body white, broad, and flat, with- 
out spots, and the eyes black; the notches or lobes of the abdomen 
shorter and less distinct than in the pediculus capitis. This species 

(a) Some individuals are more disposed than others to be infested 
with pediculi. Parent-Duchatelet informs us, in his elaborate work 
on Prostitution in Paris, that the heads of very few of the unfortunate 
women of the town, even of the better class, are free from pediculi. 
It is stated that the members of one of the first aristocratic houses in 
England have some difficulty in keeping themselves free from pediculi 
corporis. Curling's Lectures on the Entozoa.— (Med. Gaz., 1837-8.) 



PEDICULI. 



395 



exists on those parts of the body which are habitually covered, on the 
trunk and extremities, rarely on the head. Its nits are agglomerated, 
and generally deposited in the folds of the linen, and other parts of 
the clothes; of those who live amidst filth, particularly of such as wear 
flannel, and to whom a change of linen is a rarity. These insects 
often multiply in a disgusting manner among prisoners, galley-slaves, 
sailors, and the aged who live in poverty and wretchedness. 

The name of phthiriasis or morbus pedicularis, has been applied 
to the development of this species in great numbers. The morbus 
pedicularis is always the consequence of the successive and multi- 
plied reproduction of one or more of these insects, accidentally con- 
tracted. 

This insect is found on the surface of the skin of the extremities, 
and particularly of the chest and axillae, in the body linen, and on 
the clothes generally; the skin is not altered unless the pediculi are 
extremely numerous, and the individuals have been long affected with 
them. In this case, small papular, conical, and reddish elevations, 
and still more frequently, tubercular spots, and accidental pustules, 
are frequently seen on the surface. Scratches and excoriations are 
also frequently observed. But various other concomitant lesions may 
exist accidentally at the same time, such as prurigo, ecchymoses, &c. 
Such is the morbus pedicularis divested of the hypothetical and un- 
founded details with which its history is mixed up. As to the spon- 
taneous generation of these insects, Aristotle, Theophrastus, and 
Avicenna have all admitted it; attributing the occurrence to a bad 
state of the body, to heat and putrefaction of the blood, &c; but this 
was at a period when the prodigious fecundity of these animals was 
not known. Some modern writers have, nevertheless, adopted this 
old opinion, and have quoted the following cases in support of it: 
1st. An innumerable quantity of pediculi are sometimes observed to 
be developed on the head of a young infant, without any appearance 
of eggs on the hairy scalp, and without either the mother or nurse 
being affected with pediculi. 2d. M. Mouronval assures us that 
several patients, affected with prurigo pedicularis, have come repeat- 
edly to the Hopital St. Louis to beg for advice and relief; simple 
baths were first administered to cleanse the skin, after which the pa- 
tients were clothed in fresh linen, and put into a perfectly clean bed ; 
but notwithstanding this, the shirts of these individuals were found 
covered, a few moments after, with small pediculi, which could only 
have proceeded from the skin. 3d. In this strange disease (phthi- 
riase), says Lieutaud, lice appear not only in prodigious quantities on 
the outside, but they also generate under the integuments, and even 
under the pericranium ; and what is still more surprising, is that some 
have even been found on opening dead bodies, which, after having 
perforated the cranium and the two envelops of the brain, were 
actually lodged in the substance of this organ itself. In opposition 
to these various assertions, it may be alleged that Lieutaud's cases 
never occurred; that the fact quoted by M. Mouronval will only be 
conclusive after we are assured that there existed neither pediculi 
upon the body, nor nits upon the hairs, when the persons left the 
bath, which was not ascertained ; and, finally, that M. Bremser's re- 
mark cannot be considered as decisive, unless it be proved that the 
infant had not contracted nits or pediculi in its contact with other 
persons, and that its clothes had not accidentally become infested, 
circumstances which would require such minute examination, as it 
would be exceedingly difficult to carry into execution. Nevertheless, 
I must confess, that at the end of any serious illness in children, I 
have often seen the head become covered, almost suddenly, with a 
great quantity of pediculi, and when those about them were not in 
any way affected in the same manner. 

1 307. Some writers assure us, that they have seen small tumours or 
little elevations on the skin, full of these animals. Foreest, or Fores- 
tus, says that his father had seen a case of this kind, and he himself 
mentions two others. Rust states, that he was once called to a con- 
sultation, in behalf of a male child, thirteen years of age, labouring 
under a large tumour on the head, which had resisted every variety of 
remedy tried for its dispersion. This tumour was very much elevated 
above the surface, flabby, without any fluctuation, and presented no 
trace either of present or former inflammation, or lesion of the integu- 
ments of the cranium. The patient, who seemed cachectic, only com- 
plained of an insupportable itchiness in the inside of the tumour. This 



tumour had appeared after the termination of a nervous fever, and in 
the space of eight months had increased considerably. An incision 
was now made into it, when it was found to contain an immense 
quantity of small white pediculi. It contained nothing else, and the 
patient soon got well. In these later times, Dr. Heberden has quoted 
a similar fact from Edward Wilmot. Bernard Valentine gives an ac- 
count of a man, forty years of age, who experienced the most insup- 
portable itchiness over the whole body, the skin of which was full of 
small tubercles. Some of these small tumours were opened, and found 
to contain neither blood, serum nor pus, but such an immense quantity 
of pediculi of different sizes, that the patient was nearly dying of fright. 
Can we reasonably suppose that had these tumours been carefully 
examined, they would have been found to consist of dilated cutaneous 
follicles, into which pediculi had penetrated? 

The development of pediculi corporis has been spoken of as a very 
serious disease. Some modern writers have related, after the ancient 
traditions, that Herod, Sylla, Ennius, Philip II, of Spain, &c, died of 
the morbus pedicularis. An examination of the viscera of these illus- 
trious men would probably have led to a very dilferent conclusion. 
Still it is possible, that a great number of these insects infesting infants 
or aged persons already labouring under some other disease, might 
occasion such insupportable itchiness and loss of sleep, as would ma- 
terially aggravate the evils under which they suffered. Others have 
thought that the spontaneous development of pediculi might sometimes 
be salutary. M. Fournier, in the Dictionnaire des Sciences MC'dicales, 
quotes the case of an old man affected with rheumatic gout of the 
right side, in whom a great number of pediculi corporis were deve- 
loped, although there had been no neglect of cleanliness chargeable 
on the patient ; the pains ceased on this occurrence, and returned after 
the disappearance of the pediculi. 

1308. Pediculi corporis are easily destroyed by sulphureous water 
baths, sulphureo-alkaline frictions, sulphureous fumigations, or baths 
of the bichloride of mercury. An unguent composed of three parts 
of sulphuret of mercury, one part of hydrochlorate of ammonia and 
thirty-two of hog's lard, is also successfully used for this purpose. 
The clothes should be fumigated with the vapours of sulphur or of 
mercury. 

A variety of other compounds have been recommended, into which 
the seeds of the staphysagria, Cocculus Indicus, tobacco, various salts 
and mercurial oxides enter as constituents. The effects of some of 
these medicaments should be carefully watched. Frictions with 
tobacco ointment, or an ointment containing the active principle of 
tobacco, have sometimes occasioned convulsions and vomitings, and 
mercurial inunction may produce salivation, disorder of the bowels, 
and other symptoms more or less serious. 

Writers who have believed in the spontaneous generation of pediculi 
with a view to destroy the unknown cause which gives rise to the deve- 
lopment of these insects, have recommended bleeding, bitters, purga- 
tives, anti-scorbutics, pills of the protochloride of mercury, and a 
variety of other remedies, which may be injurious or useful, according 
to the nature of the disease with which the individuals are affected 
upon whom these pediculi corporis appear. 

1309. Pediculus pubis, Linnaeus, Fabricius, Geoffroy. — This species 
is rather smaller than the preceding ones, its body is rounder, flatter 
and more compressed; its corslet is very short, and almost blends with 
the abdomen, which presents posteriorly two projections in the shape 
of horns ; the feet are curved underneath. These insects remain fixed 
in the same situation and attach themselves very firmly to the skin, 
above the level of which they scarcely rise. They are found at the 
roots of the hairs of the genital organs, of the beard, the eyebrows, 
the eyelids, and the axillae ; they also occasionally propagate on the 
trunk and extremities, when these are pretty thickly covered with hair, 
but it is very remarkable that they never fix themselves on the hairy 
scalp. The sting of this species, which is very sharp, has led some 
naturalists to denominate it pediculus ferox. It is known in France 
under the name of morpion, and in England under the title of crab^ 
louse. Pediculi pubis occasion an insupportable itchiness. When 
they are numerous, the skin appears sprinkled over with small red 
spots, resembling drops of blood, which are said to be produced by 
the excrement of these insects. Persons affected with them often 
detach them from the skin with their nails, and papular elevations 



396 



PARASITIC ANIMALS. 



ntly appear on the points which they occupied. This species 
propagates like the preceding ones, and increases with great rapidity. 
frictions with mercurial ointment over the parts where the p 

pubis appear, generally succeed in destroying them, without there 
being anv occasion to shave off the hair to which the nits of these 
attached. 
Powdering the parts infested with calomel, also destroys them. 
Badis of the bichloride of mercury, sulphureous water-baths and sul- 
phureous fumigations are more expensive and less efficacious means 
of getting rid of these insects. 

1310. Before concluding this article, I think it necessary to observe 
that symptoms similar to those produced by pediculi may be occasioned 
by acarides, an insect very closely allied to the Ixodes, but capable, 
according to M. Bory Saint Vincent of forming a new class, charac- 
terized by a small sucker, accompanied with two feelers consisting of 
four joints. M. Bory Saint Vincent has observed these insects upon 
a woman of about forty years of age, who, after having experienced 
violent itchiness over the whole body, was very much astonished to 
see thousands of acarides on all the parts which she had scratched. 
(Jourrn. des compl. Sciences Medicates, torn. xix. p. 182.) In a case 
of prurigo senilis, Willan also observed an insect, which he says could 
not be classed either with the genus pediculus or pulex. 

Historical JYotices. 

1311. The first accounts of ^fltipiWi?, or morbis pedicularis, are to be 
found in Aristotle, ( Opera, cap. xxxi. lib. v.,) a disease under which, if 
Pliny is to be credited, Sylla, the dictator, sunk(Plinii secundi JV'a/'wr. 
Hist., fol. Lugduni, 1587, p. 273). Galen {Definit. Med. Gaz., p. 96, 
introd. Isag. 116), Celsus {Be Medic, lib. vi. sect. vi. p. 15), and 
Paul of /Egina( Opera, lib. iii.page 34), speak of phthiriasis of the eye- 
lashes, and all recommend the use of staphysagria. Galen also men- 
tions the morbus pedicularis. Galeni ( Opera: de theriacd, ad Pisonem, 
cap. 18). Schenck (Obsei'v. Medicinal, in fol. lib. v. De phthiriasi), 
and Forestus {Opera Omnia, fol. De phthiriasi), have more recently 
attracted attention to the morbus pedicularis. 

In these later times, Heberden {Commentarii de morborum Historia 
et GuraUone, p. 278, 8vo. Londini, 1802), has quoted a case in which 
a number of tumours full of pediculi were observed. Fournier {Art. 
Cas. Rares in Diet. des. Se. Med., t. iv. p. 252), gives several cases 
of the same kind ; and Marchelli {Memorie della Soc. Medic, di Genova), 
has spoken of a woman upon whom six or seven hundred pediculi 
were destroyed daily ! (a) 



PULICES. FLEAS. 1 

1312. Fleas are apterous insects, the head and corslet of which are 
distinct, the mouth consisting of a beak or sucker. Two species 
have been observed on the human body : Pulex irritans, pulex pene- 
trans. 

1313. Pulex irritans, the common flea, according to Linnaeus, is an 
apterous insect, distinguished by its oval compressed body, covered 
with a pretty strong skin, and divided into twelve segments, by a small 
head, very much compressed, rounded superiorly, truncated, and 
ciliated anteriorly, and by two small eyes situated one on either side. 
Near the origin of the beak, yve find a pair of pincers inserted, which 
are presumed to be antennae ; they are composed of four nearly cylin- 
drical joints ; the abdomen is very large ; the extremities are strong, 
particularly the hind ones, calculated for leaping, and have large legs, 
and thighs, and tarsi consisting of five joints, the last of which termi- 

(a) Full accounts of pediculi humani, under the subdivisions of P 
humanus vel capitis, P. jmbis and P. subcutaneus vel corporis, are 
given by M. Raspail {Histoire Katurelle de la Sante et de la Maladie, 
844, t. 2e, pp. 93-104). This writer intimates that many diseases, 
and some of internal organs may be produced by pediculi. He 
believes that plica has this orio-in. 

PW^AAST' ^™™ *• Sciences Nature.les, 8vo., t. xliv. 



nates in two elongated hooks. The two fore legs are inserted almost 
immediately under the head. 

1314. The bite of a flea occasions as insupportable a sensation as 
that of a bug. The small ecchymoses which the bites give rise to, 
differ from petechia) in presenting a central point, the colour of which 
is deeper and does not disappear under pressure, like the rosy a; 
which surrounds it. These insects seem to show a particular pre- 
ference to some persons, and the irritation caused by their bites may 
occasion serious nervous symptoms in children. 

1315. Pulex penetrans, of Linnaeus 2 (the penetrating flea, chiko or 
jigger). The beak of this species is a third longer than its anterior 
haunches, which distinguishes it from the preceding one. The chiko 
is a real scourge to the inhabitants of the West India Islands, and 
South America. This insect has been described by Sloane 3 as occur- 
ring in Jamaica, by Marggraf, in Brasil, and by Catesby, in Carolina. 
The female makes its way under the skin of the inhabitants of these 
countries, more particularly under the nails of the toes, and towards 
the heel ; and there establishes itself. The itching it occasions is 
slight at first, and in the commencement nothing is perceptible but a 
small blackish spot ; by degrees, a little tumour of the size of a pea 
appears on the punctured part ; it is reddish if the insect be super- 
ficially situated, but no change takes place in the colour of the skin if 
it have penetrated deeply ; this small tumour is formed by a kind of 
bag containing a sanious pus and a great number of small, white, oval, 
oblong globules, which are the eggs of the insect. Left to itself the 
tumour bursts spontaneously, and gives rise to an ulcer over the sur- 
face of which the eggs spread and are hatched. These insects are 
not long in appearing in the surrounding parts, and create in then- 
turn other ulcers, the cure of which is very difficult and sometimes 
impossible. In some rare cases in which the insects insinuate them- 
selves into the skin of the back of the foot, the ulcers which are the 
consequence end in caries of the bones and the loss of the toes. 
Gangrene has even been known to take place from this cause, and 
we are further assured that death may be the result of a long con- 
tinuance and extensive diffusion of this animal under the skin, ne- 
groes being often seen to perish in the colonies from this cause alone. 
For the rest, those only who are negligent of personal cleanliness are 
attacked by this insect, which seems to delight in hot, filthy, and ill- 
ventilated places. 

1316. The treatment consists in dislodging the insect; a pin is the 
implement usually employed to raise the skin and lay bare the bag, 
which must be carefully detached without being burst ; the only 
means of destroying the chiko being to get away the bag entire. The 
membrane only of the bag left behind is sufficient to produce erythe- 
matous inflammation and ulcers of a very bad description. The 
negroes are very expert in the operation of extracting these nests of 
the chiko; so much so that the surgeons of the country are never 
called upon to practice it. After the extraction, the little wound is 
dressed with tobacco, either in powder or decoction, or with a decoc- 
tion of certain acrid plants of the country, with mercurial ointment, 
calomel, a solution of the nitrate of mercury, &c. 

The treatment of the ulcers occasioned by this insect, if they are 
neglected, becomes exceedingly troublesome, and it is only after 
repeated incisions that patients can be freed from the mischiefs attend- 
ing the continuous presence of these creatures under the skin, (a) 

(a) The justice of the title of pulex to this insect, and of regarding 
it as akin to the common flea or pulex irritans, is denied by M. Ras- 
pail {op. cit.), who expends a good deal of erudite criticism on the 
subject. He arrives at the conclusion that the so called pulex pene- 
trans, jigger or chiko, is really the acarus Americanus vel JEgyplicus, 
and the same with the European acarus reduvius or tique, that infests 
dogs. 

M. Raspail, after describing the effects of the irritation of this insect 
on the skin of the human subject, enlarges the picture so as to make 
the subsequent and prolonged afflux and hypertrophy of tissue, to 

2 Dictionnaire des Sciences Naturelles, pi. 54, fig-. 4, 5, a, a, b. 

8 Sloane. A voyage to the Islands of Madeira, Barbadoes,&c. London, 1707, vol. 
ii. fol. fig. — Marggraf (G.). Historia; rerum naturalium Brasilia;, libri octo. Amster- 
dam, 1648, fol.— Catesby (Marc). The natural history of Carolina, &c. London, 
1771, fol. — Audouin. Dictionnaire classique d'histoire naturelle, art. Chique. 



ACARUS SCABIEL 



397 



ACARUS SCABIEI. 

1317. M. Raspail, so distinguished for his admirable microscopic 
researches, has given so complete and faithful an account of this 
insect that I cannot do better than copy it here. "This insect, on a 
cursory view, appears white ; with good eyes, a number of reddish- 
brown spots may be perceived covering a part of its body. There 
is no occasion for a magnifying glass to see it plainly running on a 
coloured surface. It is about half a millimetre in diameter. A sim- 
ple lens suffices to enable us to count the feet, distinguish the mouth, 
and recognize the various details which De Geer has indicated. 
When the insect crawls, and it is seen through a microscope, it 
appears flattened, and in the transparent parts it presents curved and 
parallel streaks which give it the appearance of the scale of a fish. 
Examined with a glass of the same power, the forefeet and the head 
are seen to be susceptible of being concealed under the body, by 
being curled underneath it, in the same manner as the forelegs and 
head of a turtle are drawn under its shell. The conformation of the 
dorsal surface of this insect is favourable to this action, as it over- 
hangs the whole of the body, and advances like a shield or roof over 
the forefeet and head. The posterior portion of the body of this 
animal, examined particularly, presents eight hairs of unequal lengths, 
the shortest being situated towards the anus. Four of these hairs 
belong to the four posterior feet, and the four others are inserted two 
on each side of the anus-, on as many small tubercles which are not 
distinguishable unless forced out by pressure with the point of a needle. 
On the disc of this dorsal surface a series or system of shining points 
is perceived. On looking at the animal in profile, the large white 
spot of the centre is found to consist of a protuberance considerably 
elevated ; the anterior and the posterior surface are alike raised, and 
each of the small curves of the back is surmounted by a stiff trans- 
parent hair. The four rows of points which descend towards the 
anus, and towards the head, present the longest hairs. The contour 
of the body presents lobes of different forms according to the motions 
of the animal and the positions which it takes. As for the streaks 
which we have already mentioned, they cover the whole surface of 
the body. It was an error to imagine that they were only simple 
folds of the skin ; they form a great cellular network, the cells of 
which are linear and hollow, and the interstices, which I entitle vas- 
ular, are in relief. This network resists sharp instruments power- 
fully ; so powerfully, indeed, that it would be difficult for the observer, 
with the best inclination in the world, to transfix the insect with the 
point of a needle, when he was extracting it; and it is even very 
difficult, with the assistance of the lens and appropriate dissecting 
instruments, to seize and crush or divide it ; it slides and bounds 
under the instrument, and the stiff hairs which cover its back do not 
a little serve to increase the difficulty of anatomizing it. Not only 
is the body then found to possess considerable toughness, but the feet 
and oval appendage, which, being rendered diaphanous by the refrac- 
tion of the light, appeared to be of an extremely delicate texture, are 
discovered to be scaly and horny, and do not yield under the instru- 
ment. 

Such are the general and particular aspects of this insect when it 
crawls and presents its back to the eye of the observer. But when 
it is turned over, and the lower surface of its body is examined, its 
organization is found so much more complicated as to require a more 
particular study. The two pairs of forelegs and the head are then 
clearly seen to be implanted in so many sheaths into which, however, 
it is impossible for them to recede. These sheaths form a sort of 
plastrum of a singular appearance. 

The head is inserted within a notch or angle, the summit of which 
is prolonged upon the thorax in a line of a golden red. The head is 
extremely simple in its form, of a purplish colour, and curving down- 
wards to where it ends in a sucker, which does not appear to me to 
be formed of any apparent system of mandibular forceps. Examined 
in acetic acid, two transparent vesicles appear on each side of the 
head, which may be naturally presumed to be the two eyes; on the 

which it gives rise, a modification of disease analogous to, if not 
identical with, elephantiasis, or Barbadoes leg, Pian, and Mai Rouge. 
100 



nucha two pairs of points are seen, each surmounted with a hair. 
These hairs, when they pass the curved head, appear to be of unequal 
length, because two are inserted on the posterior pair, and two on the 
anterior pair of points. 

The edges of the sheath of the two feet nearest the head extend in 
two reddish lines, and approach each other at the level of the line 
which comes from the tail of the creature. The edges of the sheaths 
of the other two legs unite in the form of red lines at the convexity 
of those lines of which we have spoken, a distribution resembling in 
some sort a fan. The legs are composed of four joints and an 
oblique basilar piece which appears like a triangle, with its hypo- 
thenuse turned towards the posterior part of the body. Each of 
these articulations is covered with hairs, of which only those on the 
sides are visible. The last joint is covered with very short prickles, 
and armed beneath with a stiff hair, which is terminated by a flexible 
cavity, capable of producing a vacuum, like the soft glutinous pads 
of certain animals much higher in the scale, such as the tree frog ; 
these pads enable the insect to fix itself in any position. The joints 
are not very distinct, and can only be counted after long examina- 
tion. These five anterior members are half covered, as I said before, 
by the projection of the dorsal surface of the body. 

On the belly two pairs of other organs are seen, which De Geer 
considered as four hairs enlarged at their bases and attached to the 
belly. These four supposed hairs are the four hind legs, which 
although shorter than the forelegs, possess the same essential organi- 
zation, only they are without the apparatus, or accompaniment adapted 
for progression, which I shall designate under the name of ambula- 
crum. Except this trifling circumstance all that is observed in the 
fore feet is found in them. 1st. The reddish line which borders the 
sheath, the opening of the sheath, the hypothenuse, and the four 
articulations. Here the ambulacra are replaced by very long hairs. 
Upon the whole, the hairs of the hind feet which are nearest the 
head, are more developed than those of the two most remote. When 
seen with the lens, this arrangement of the feet looks very like De 
Geer's figure, and the red line bordering the sheath appears to be a 
hair which swells into a red vesicle in the region of the foot, and is 
produced in the form of a white hair at the top of the vesicle. 

The anus sometimes appears projecting and sometimes hidden, but 
to see it very plainly it is only necessary to let the insect dry, when 
the dermis, on account of its hardness, retains its shape, the abdomen 
shrinks, and the direction of the anus is plainly seen through the 
transparent dermis. This animal externally is as white as snow, ex- 
cept the feet and the sucker ; but if seen by refracted light it appears 
yellow, like all the white tissues of animals. This happens from the 
decomposition of the rays of light which pass through the organic 
substance, a decomposition in virtue of which the least refrangible 
rays, such as the yellow, alone reach the eye. 

Although the hairs of the forelegs and head of this insect are 
directed forwards, it is easy to see that having the power of bending 
its feet and sucker underneath, these hairs can prove- no obstacle to 
its progress through the skin. But the structure which facilitates 
this operation, is the presence of the hard papillae of the back, which 
being directed backwards, offers such resistance in that direction, as 
prevents the creature from receding; above all it is assisted by the 
hard scaly case of the trunk which forms a covering like the shell of 
the tortoise. I think I have already remarked that the ventral is 
streaked in the same manner as the dorsal surface. 

1318. M. Gras has described with much care the furrows or covered 
ways (cuniculi) already indicated byBonomo, Casal,and Adams, and 
at the extremity of which the acarus scabiei is generally found. In 
fact, if the vesicles of scabies in the hands, and in some cases in the 
feet, are examined with care, it will be seen that several of them pre- 
sent on their summits or on some part of their surface a small blackish 
spot; this sometimes extends in the form of a semicircle, and is 
found to be situated on a small whitish point. On other vesicles a 
blackish or whitish and sometimes a sinuous punctuated line is seen 
departing from this point, and traversing almost the whole surface os 
the vesicle ; in this case, when the epidermis which is raised by the 
serum is removed, and examined with a lens, the punctuated line is 
found to be formed in its substance ; with the assistance of the light 
of the sun, a small brownish point will be seen at the extremity of the 



V e 



PARASITIC ANIMALS. 



■ uniculiis which is farthest removed irom the vesicle, and on raising 

idermis io this place, the acarus can bo extracted. It is worthy 

if remark that there isno communication between this cuniculus, and 

the caviiv of the vesicle, and that it is always easy to remove the 

•earns without causing any discharge of serum. 

M. G saw two aniiculi begin in the same vesicle, although 

d ways frequently intersect each other. Sometimes the 
cuniculi are not seen near all the vesicles; in many individuals 
affected with scabies they are not even to be met with readily except 
on the hands; the burrows generally extend from two to four lines 
from the resides. M. Gras having placed an acarus on one of his 
. the insect took twenty days to trace a burrow of two lines in 
length; another insect was only three days in making a cuniculus of 
die same extent. 

There is no relation between the number of vesicles and burrows. 
In some persons affected with scabies, burrows are seen without vesi- 
cles in their neighbourhood; but at one end of these burrows, a small 
point of skin, which has lost its epidermis, and appears surrounded by 
a minute edging of this substance detached, is frequently observed; 
in other places, even such a trace of a vesicle does not exist, as oc- 
curred to M. Gras, who, having placed acari on different places in the 
skin, first observed cuniculi formed by the insects, and vesicles only 
some time afterwards and at a certain distance from them. 

The insect may be extracted by means of a pin, by introducing the 
point obliquely into the epidermis, and turning it back; the acarus is 
often thus discovered at once, which, so long as it is not wetted w T ith 
the serum of the vesicle, seems to attach itself with great ease to the 
point of the pin. This insect is at first motionless, and it is not until 
after three or four minutes that it is seen to move its legs and begin 
to walk with rapidity. In a temperature of from fifteen to eighteen 
degrees, these insects may be kept alive three or four days after their 
extraction. 

Acari are very seldom found alive in persons affected with scabies 
after they have been for two or three days under treatment ; and yet 
this disease is seldom cured before the tenth and sometimes even the 
fifteenth day. The acarus has been sought for in vain in individuals 
affected with other diseases of the skin, — prurigo, eczema, lichen, &c. 

1319. In the article on scabies, I have mentioned the principal 
works relative to the history and particular study of this insect (§ 371), 
but I think it proper again to quote the work of M. Raspail and that 
of M. Gras, whose observations I have here copied. Raspail. Mt>m. 
Compared if mr Pllistoire Naturelle de VInsecte de la Gale, fig. 8vo. 
Paris, 1834. — Gras. Recherches sur VJlcarus ou Scarcopte de la Gale 
de r/tomme, 8vo. Paris, 1834. (a) 



FIL1ARIA MEDINENS1S. GUINEA WORM, &C. 

1320. Under the name of filiaria, a genus of the entozoa is indicated, 
the principal characters of which I shall here particularize : a cylin- 
drical filiform and very long body, decreasing in a very slight degree 
only towards the extremities, which are blunt ; a very small articular 
mouth, terminal as is the anus also, in all probability; the male organ 
short, somewhat rounded, and situated before the point of the tail ; 
the intestinal canal very distinct, and extending the whole length of 
the body. The filiaria inhabits the cellular tissue of animals of all 
classes. 

1321. The most celebrated of all the species of the filiaria has 
been observed in the human subject. It is known to naturalists by 
the name of filiaria medinensis, (b) dracunculus or Guinea worm. 
The body of this species of filiaria is of a dirty white, which becomes 
yellow in alcohol ; its size, nearly equal in its whole extent, varies 
from that of a thick fiddle-string to that of a straw. The length of 
the fihana medinensis varies between nine and forty-two inches 

(a) M. Raspail, in the work already quoted, (in note to § 1311,) 
tome Ire, pp. 441-475, gives a detailed and an amusing history of 
(he progress ot observation and opinion, respecting the acarus scabiei, 
together with engravings of the imaginary and the real insect. 

(b) A name given to this worm by Avicenna, after the city of 
Medina, in the environs of which he had most frequently seen it. 



(Heath), a foot, a cubit, and more (Kaempfer), three feet and a half, 
Rhenish measure (Grundler), more than two ells (Kunsenmuller), 
eight to ten feet (Gallandat), and even eight ells (Fermin). The head 
is furnished with a kind of sucker, formed by the enlargement of the 
lip surrounding the mouth, the orifice of which is very small. The 
tail is terminated by an inflected hook. The filiaria medinensis bears 
the greatest resemblance to the filiaria of the monkey. 

According to the recent researches of Jacobson, certain filiaria at 
least are composed, not of one single individual, but of an assemblage 
of individuals, living under or within the same skin. M. Jacobson 
received an Arab into his hospital, who had a tumour near the outer 
ankle, which was discovered to be occasioned by a dracunculus ; this, 
after several fruitless attempts, was extracted by the ordinary process. 
A second tumour having appeared on the other ankle, it was laid open, 
and the knife having divided a portion of the worm longitudinally | 
a purulent-looking matter issued from the opening, which, on being 
examined with a microscope, presented a crowd of small elongated 
filiform worms, with the head somewhat enlarged, and a short tail, 
much thinner than the body. Upon extracting the whole of this dra- 
cunculus, all its parts were found to present the same appearance. 
That which had been extracted from the first tumours was ascertained, 
on examination, to exhibit precisely the same structure. 

M. de Blainville presented a portion of the internal substance of 
this worm, collected by M. Jacobson, to the Academy of Sciences. 
Seen through a microscope, it was almost entirely formed of small 
animals, in perfect accordance with the description given by that 
talented anatomist. M. de Blainville thinks that it would be interest- 
ing to ascertain whether all dracunculi presented the same peculiar 
organization [Gazette Med., 1834, p. 216). (a) 

1322. The history of this entozoon presents a very remarkable 
peculiarity, for which it is impossible to account satisfactorily at the 
present day. The inhabitants of the torrid zone alone are almost 
ever affected with it. The principal observations which have been 
made on this animal, have been collected in Arabia-Petrea, on the 
banks of the Persian Gulf, of the Caspian Sea, and of the Ganges, in 
Upper Egypt, in Abyssinia, in Guinea, &c. I do not believe that it 
has been developed in the human subject in Europe. (6) 

(a) M. Raspail [op. cit.), denies the accuracy of this statement of 
Mr. Jacobson. The filiaria consists, the former tells us, almost entirely of 
a very long ovary ; the head and thoracic region seeming to be one of 
its extremities. The intestinal canal, which traverses the whole body 
from end to end, being very minute and easily broken, we can under- 
stand how Jacobson should have believed that this long body was 
only a sac filled with vermiculi; for, as the filiaria is both viviparous 
and oviparous, it is easy to see, at a certain period, the small worm 
through the transparent envelopes of the ovum or egg. And again, 
very seldom does it happen that the filiaria can be extracted from 
the body in which it is imbedded, without its head and tail being 
torn off under the effort of traction ; and then the ovary is left, 
seeming to the eye of the examiner to be a tube filled with eggs. 

(b) The following succinct summary of the localities and subjects 
of filiaria medinensis, and the symptoms and mode of treatment when 
it is imbedded beneath the skin, is derived from Mr. Curling's Lec- 
tures on the Entozoa, already referred to. 

Locality and Subjects of Filiaria. — " It occurs at all ages and in 
both sexes, and appears to be endemic in the tropical regions of Asia 
and Africa, where it appears generally in the hottest seasons. It is 
by no means confined to the natives ; many facts tend to show that it 
may be communicated from one individual to another; and Lind and 
other writers are of opinion that Europeans, on visiting the countries 
where it exists, become affected with it by contact with the negroes. 
In America it is said to make its appearance almost exclusively 
amongst the negroes, and chiefly in those who are newly arrived from 
Africa. We occasionally meet with it in this country, in individuals 
who have recently returned from the tropics. There is a specimen 
in the Museum of the College of Surgeons, twenty-two inches in 
length, which was extracted from the leg of a boy who was a patient 
of the late Sir W. Blizard, at this hospital. We have also a worm 
in the museum, removed by Mr. Headington, who was formerly 
surgeon of this hospital, from the leg of a sailor, where it had been 



FILIARIA. 



399 



The filiaria raedinensis has been most generally observed in the 
subcutaneous cellular tissue of the human body, particularly of the 
lower limbs. Of one hundred and eighty-one cases collected by Sir 

imbedded for two years ; and there was another patient in the hospital 
at the same time, likewise affected in this way. From some obser- 
vations by Sir James Macgrigor, it would appear that the disorder 
originating in these worms prevails at times in an epidemic form. 
Thus he mentions that some troops having embarked, after a residence 
of two months at Bombay, were attacked whilst at sea so generally, 
that out of three hundred and sixty, as many as one hundred and 
sixty-one became affected with it. Clot Bey, a French surgeon, in 
the service of the Pacha of Egypt, mentions that he has seen as many 
as a hundred patients, labouring under Guinea worm, in hospital at 
one time. Little seems to be known which can account for the 
development of this parasite, though authors have speculated abun- 
dantly on the subject. It has been noticed, however, that it occurs 
much less frequently amongst the officers than the common soldiers, 
and those who occasionally lie on the ground, or go about with their 
feet and arms naked." 

Symptoms. — " The Guinea worm may remain imbedded beneath the 
skin for many months, without occasioning any inconvenience, but 
sooner or later it excites irritation and inflammation in the structures 
around, which vary in severity according to the constitution of the 
individual, and the situation and size of the worm. The symptoms 
commence in a formicating sensation or uneasiness under the skin, 
accompanied with a superficial cord-like elevation on the surface. A 
phlyzaceous vesicle or pustule forms, which bursting, gives exit at a 
circular aperture, either immediately or after suppurating for a day or 
two, to the head of the worm. These local symptoms are preceded 
usually by slight derangement of the system generally. When situated 
about the fingers or toes, the worm is often productive of much suf- 
fering, and is with difficulty got rid of. When deeply seated it some- 
times causes considerable fever, great swelling, and tedious abscesses 
and sinuses, giving out a serous ill-conditioned discharge for many 
months without the worm making its appearance. 

" The treatment consists in the cautious and gradual extraction of 
the worm, special care being taken to avoid breaking it across, as 
this accident is liable to be followed by an aggravation of the inflam- 
mation, and the formation of sinuses in its course, together with great 
constitutional disturbance. These unfavourable effects are attributed, 
by Hunter, to the contact of dead animal matter, with a large extent 
of living surface, to which it now bears the relation of a foreign body ; 
such violent symptoms being rarely seen so long as the dracunculus 
is alive and uninjured. When the worm protrudes, it should be laid 
hold of and gently drawn out from its resting-place as far as possible. 
The part removed should then be secured at the aperture with a strip 
of plaster, or tied to a piece of stick, and the traction may be repeated 
once or twice in twenty-four hours until the entire worm is brought 
away — a process often requiring many days, or even a month, for its 
completion. Some surgeons recommend cutting down upon the 
middle of the animals, and by pulling simultaneously at both ends, 
shortening the period requisite for the removal of the dracunculus — a 
plan which is practised by the native Indians. When the worm is 
got rid of, the sinus usually closes readily. The use of internal 
remedies and external applications do not appear to be of any essen- 
tial service. Sir James Macgrigor found that the extension of this 
affection amongst the troops was checked by requiring great attention 
in regard to cleanliness, and separating the soldiers troubled with 
these worms from those that were free from them." 

M. Sigaud (op. cit., pp. 133-35), represents the filiaria medinensis 
to be common among the negroes of Brazil. He mentions cases in 
which the worm was extracted of the length of seven feet ; and also 
a case in which violent inflammation had seized on the whole of the 
right leg, and gangrene, even, appeared in spots. Free incisions were 
practised and cataplasms of camphor and flour of manioc were applied 
to the parts, while tonics were administered internally. The cause 
of all these formidable lesions was then found to be a filiaria, which, 
with some difficulty, was in part extracted. Cicatrization, aided by 
various dressings, the chief of which was the root of the milhomens, 
began about the twenty-seventh day. But, ere long the negro cora- 



J. Macgrigor, it is calculated that in one hundred and twenty-four of 
them, this worm was situated in the feet, in thirty-three in the legs, 
in eleven in the thighs, in two in the scrotum, and in two in the hands. 
Ksempfer found it in the hollow of the ham and in the scrotum ; Pere 
has seen it in the head, the neck and the trunk; Bajon assures us that 
he has twice seen it under the mucous membrane of the ball of the 
eye, &c; Chardin pretends that the filiaria medinensis almost always 
occurs singly, while Bajon and Bosmann assure us that it is not un- 
common to meet with several of them in one patient at the same time. 

It seems to be an established fact, that this animal is never deve- 
loped except on the human body. Lcefler, who lived many years in 
those parts of Africa where the inhabitants are troubled with it, never 
heard that it had, on any occasion, been observed in water ; and 
Hind, who has also carefully examined the water of these countries, 
never detected either these worms or their eggs in it. The contrary 
opinion has arisen from this species of filiaria, having been taken for 
a true gordius, which is supposed to possess the power of making its 
way, and living underneath the skin. 

The great size which the filiariae, extracted from the human body, 
sometimes acquire, would lead one to imagine that these animals do 
not occasion the phlegmon which proclaims their existence, until some 
weeks, or even months, after their formation. This inflammation of 
the cellular tissue soon ends in suppuration ; and upon the spontaneous 
or artificial opening of the abscess, one or more inches of the filiaria 
generally protrude. 

This animal is extracted by being repeatedly and very gently drawn 
out. The imperfect extraction of the filiaria is said to be followed by 
very serious symptoms. 

1323. There is much difficulty in France in procuring the filiaria 
medinensis to examine its organization. I have seen one very well 
preserved in the collection of the Jardin du Roi. It is about three 
and twenty inches long, from the head to the tail, and one line in 
diameter throughout. It is generally flattened, and the two terminal 
openings are very distinct. M. Henri Petroz, chief apothecary to 
the Hopital de la Charite, possesses another of these animals, which 
was extracted from the foot of a negro of Guinea. This worm is 
about twenty-five inches long; it is yellowish, like cat-gut, which 
probably arises from its having been so long preserved, dried, and 
rolled on a small piece of wood. One of the extremities, the tail, is 
hooked, and near it, under the microscope, a small tubercle is seen, 
in the centre of which is an opening. The other extremity, examined 
by a microscope, magnifying twenty-five times, appeared unequal, 
irregular, and jagged. The head had probably been broken or crushed. 
Finally, M. de Blanville says (Grundler. Traduction Francaise de 
Vouvrage de Bremser sur les vers intestinaux) , that he possesses a 
filiaria medinensis, which was sent to him by M. Delorme, the author 
of some very interesting observations on this entozoon (Journal de 
Physique, Chimie, &c, August, 1818). (a) 

plained of fresh pains, as intense as those under which he had formerly 
suffered and in the same spot. On careful examination, a new 
inflammation was found, the centre of which was in the form of a 
flattened tubercle of a pale colour. This was opened, and the re- 
mainder of the worm was seen and gradually withdrawn; after which 
the inflammation soon subsided, and the leg was perfectly healed. 

(a) The opportunity denied to M. Rayer has been afforded to M. 
Maisonneuve, of Paris, who has published his observations in the 
Archiv. Gen. de Med., of which we give a summary as follows. 

"In October, 1843, he received into his wards, at the Hospital of 
St. Antoinc, a man named Ede, aged twenty-eight, who had, five 
months previously, returned from Senegal, where he had served as a 
soldier two years and a half. About a month before he entered the 
hospital, he perceived on his left foot, for the first time, a small 
tumour, which gave rise to a dull pain in the vicinity of the articula- 
tion, and was accompanied by considerable itching, for which he in 
vain tried poultices, rest, and various other plans of treatment. M. 
Maisonneuve was surprised to see a vigorous man enter an hospital 
for what appeared nothing more than a very small phlegmonous 
tumour on the level of the posterior extremity of the fourth metatarsal 
bone, and merely made a small incision, afterwards ordering a poul- 
tice. On examining the wound the following day, he observed a 



400 



PARASITIC ANIMALS. 



13 2 1. Several writers have confounded ihejiliarla medinensis with 
. aquatleus. This mistake was the more likely to occur 
from die circumstance of the body of the Gordius being in the form of 
a thread, as well as that of the jMaria, but the former differs from 
the latter, in its body presenting the transverse folds of the annehda, 
to which natural order it belongs, inhabiting like them soft waters, 
slimy places, subject to inundations, fee, whilst the filiaria are true 
entozoa. In addition to this, all the gordii examined by M. de Blan- 
ville, presented the anterior extremity of the body, divided in the form 
of pincers, which is not the case in the filiaria. Besides, in combating 
the opinion of Joerdens, who thought that the Gordius aquaticus 
might make its way under the skin of the human body, M. Bosc has 
verv judiciously remarked, that the organization of this species of Gor- 
dius renders it incapable of piercing the integuments, and that it has 
never been seen in the subcutaneous cellular tissue of the human sub- 
ject. After having examined some specimens, belonging to this species 
of Gordius, which my friend Doctor Asselin and I had collected in the 
ditches of the forest of Meudon, we became satisfied of the accuracy of 
the observations of M. Bosc. Finally, it is known that Pallas no where 

kind of white filament, which he seized with his fingers; it gave way, 
but broke when he had drawn out about six inches. On ascertaining 
from the patient that he had lately inhabited Senegal, it occurred to 
M. Maisonneuve that it might be a guinea-worm, and he then exa- 
mined the man more attentively. In the vicinity of the furunculous 
tumour there was a slight degree of oedema, which extended to the 
malleoli ; pressure over this region was painful. At the superior and 
external part of the same leg, just below the head of the fibula, there 
was another small tumour, very similar to the first. It was indolent, 
merely gave rise to slight itching, and had only been perceived by 
the patient about fifteen days previously. From this tumour there 
passed a kind of flexuous, irregular cord, which he at first thought 
was a varicose vein; after turning round the anterior part of the leg, 
it lost itself in the calf; its consistence was hard, like that of whip- 
cord. It was evidently a second worm. The man was muscular, 
and in the full vigour of youth. He had never suffered any thing of 
the kind whilst in Senegal, nor had his white companions, although it 
was common among the negroes. In the course of the fortnight which 
followed the man's admission, several phlegmonous tumours formed 
round the external and internal malleolus, and on being incised, 
exposed different portions of the filiaria. It was entirely extracted, 
but not without some trouble, as it broke repeatedly. One day, on 
pressing the superior furuncular tumour, a few drops of a white fluid, 
like whey, escaped. This fluid was examined with the microscope, 
and found to contain myriads of small cylindrical worms, with thin, 
pointed tails. They w 7 ere amazingly active in their motions, and on 
being examined in water, were not found to present any tentacula or 
appendages of any description. Some of them remained alive seve- 
ral days. The head of the filiaria showing itself at the tumour, M. 
Maisonneuve seized it with his fingers, but it broke. He then took 
up a fold of the skin over its course, and by a transverse incision, 
exposed several circumvolutions of the worm. It was situated in 
the lamellar subcutaneous cellular tissue ; he dissected it out with 
care, passing a sound underneath, and was thus able to extract all 
the superior portions. It was about as thick as a crowquill, and very 
like the vas deferens near the epididymis. On exercising traction by 
the part exposed, it broke, and a second incision and dissection were 
resorted to. The remainder of the worm was found curled up on 
itself in the cellular tissue, like the superior part, and was obtained 
in the same way; a small piece of the caudal extremity was left, but 
extracted the following day by the patient himself. 

u -M. Maisonneuve remarks that this case is very interesting, as it 
establishes a point in natural history which has been much debated — 
viz., the existence of the filiaria as a distinct species of animal, capa- 
ble of propagating itself whilst in the human economy. As long, in 
all probability, as the dracunculus merely increases in size, its pre- 
sence, says M. Maisonneuve, gives rise to scarcely any local disturb- 
ance, but when the period of reproducing arrives, it makes an effort 
to perforate the skin, and thus occasions a furuncular tumour. It 
is singular that these parasitical animals should thus discharge their 
young externally." — Lancet, Feb. Stk, 1842. 



met with so great a number of Gordii aquatici as in the lake of 
Waldei ; but he could not learn that this worm had ever been known 
to make its way under the skin of any of the persons who had bathed 
in this lake. 

Historical Notices. 

1325. The dracunculus was known to the ancients: " quemadmo- 
dum, in quodam Arabiae loco (ut aient) in tibiis hominum dracunculi 
vocati nascuntur, nervosa natura, colore crassitudienque lumbricis 
similes" (Galeni Opera, fob, class. 4, de locis affectis., lib. G). Aetius 
has given a very good description of it, and an account of its treatment 
after Leonides ( Tetrabl. iv. sermo xi. in fol. 1549, p. 800). Avi- 
cenna (liber quartus ; de venh medeni), speaks also of having seen it. 
Schenck ( Obs. Medic, lib. v. de dracunculisJElhiopiceet Indies, propriis) , 
has collected a number of facts relative to the history of the filaria. In 
these later times, new, Gonneau ou Veine de Medine et sur Vusage 
du sublime corrosif dans cette maladie (Journ. de Med., Janvier, 1760;; 
Macgrigor, (Sir James,) medical sketches of the expedition to Egypt 
from India, 8vo. London, 1804 ; Paton, cases of Guinea worm, with 
observations, (Edinb. Med. and Surg. Journ., t. xi.); Scott (Will.), 
and Kennedy (Alexander), Remarks on the Dracunculus (Edinb. Med. 
and Surg. Journ., t. xvii. p. 96) ; Grant (Robert), extracts from a cor- 
respondence on the filiaria medinensis (Edinb. Med. and Surg. Journ., 
t. xxxv. p. 122). Two cases of the extraction of several dracunculi 
performed in France, have been related by M. Brulatour (Journ. de 
chimie medicale, t. vi. p. 624). Grundler, in his treatise, de vend medi- 
nensi, has given an original representation of the filiaria medinensis, 
wdiich has been republished in several works, and in particular in the 
Encyclopedic MHhodique, t. xxxix. fig. 3. 



1326. OZstri are dipterous insects characterized by the almost com- 
plete absence of a mouth, which has caused them to be designated by 
M. Dumeril astomata. Their larvae deposited under the skin of the 
human body, and more frequently under that of the ox, occasion small 
circumscribed and painful inflammations. 

1327. The species of cestri which live under the skin of animals 
have been described with much accuracy by Mr. Clark ( Trans, of 
the Linncean Society of London) . Mr. Say (Journal of the Jlcademy of 
Natural Sciences of Philadelphia, vol. ii. pp. 353-60), thinks, with 
Linnaeus, that there really exists a species of oestrus, the larvae of 
which inhabit the human body ; an opinion which is discountenanced 
by Fabricius, and other modern entomologists, but which Mr. Say 
founds on the following observations, contained in a letter to Dr. Har- 
lan from Dr. Brick, who had extracted the larva, afterwards submitted 
by Mr. Say, and described by him in the Journal of the Academy. 
Dr. Brick writes: — " After a very sultry day's march, and being very- 
much fatigued, I went to bathe in the Chama, a small stream empty- 
ing in the lagoon of Maracaibo. Not long after coming out of the 
water, I received a sting from some insect, in the left leg, over the 
upper and fore part of the tibia ; it was several days attended with a 
considerable degree of itching, but without any pain, and I continued 
on my journey some few days longer without experiencing much 
inconvenience, except during several periods of perhaps two or three 
minutes continuance, when an acute pain came on suddenly, and was 
severe whilst it continued, and then as suddenly subsided. On my 
arrival and during my continuance at II Rosario de Cucuta, I walked 
with difficulty ; there was a considerable tumefaction over the tibia, 
which had the appearance of an ordinary bile (phlegmon) ; in the 
centre there w T as a small black speck ; the usual applications were 
used without any success, and the tumour became more irritated and 
inflamed, and thus it remained for some days, attended at times with 
a most acute pain, which for a few minutes was almost intolerable. 

" In returning to Maracaibo, I had to descend the Cottatumba in 
an open boat, without any shelter, and being wet to the skin by the 
cold rains which fell every night, I suffered much, and was almost 
constantly tormented by the tumour, which became more painful at 
those particular periods than usual ; during this passage, which lasted 



ARABIAN ELEPHANTIASIS. 



401 



for twelve days, I was induced to scarify it, and had recourse to the 
usual topical applications, but without success. At times I imagined 
that I felt something moving, and suspected that there was something 
alive beneath the skin. 

" After my return to Maracaibo I became scarcely able to walk, 
and was in a manner confined to my quarters. In this situation I con- 
tinued two weeks longer, the tumour having begun to discharge, and 
without any diminution of the painful periods. 

" Being now nearly worried out, it occurred to me to try a poultice 
of tobacco, which was used for several nights, having previously 
scarified the tumour ; during the day, I frequently dusted it with ashes 
of segars : as an ingredient I used rum instead of water in making the 
poultice. On the fourth morning after this remedy, I felt considerable 
relief, and on the fifth, with a forceps, I drew out the worm which 
you have now in your possession, and which was then dead. 

" In a few days the sore assumed a healthy look, and in ten days 
was perfectly healed up — although, at times, I yet experience a heavy 
pain in the part from whence the worm has been taken. It had tra- 
veled on the periosteum along the tibia for at least two inches. The 
severe pain which I experienced for those periods, I attribute to the 
irritation of some of the branches of the nerves distributed to the parts 
by the worm in its progress. Respecting this worm there are different 
opinions among the Spaniards and Creoles. Ouche is the name it is 
called by some, who say it is produced by a worm which crawls on 
the body from the ground, and penetrating the skin, increases in size. 
Others maintain that they are produced from the sting of a winged 
insect which they call Zancudo; 1 others again call the insect Husano ; 
for my part I am rather inclined to think that they are produced from 
the sting of a winged insect which deposits its egg. 

" N. B. Should it even be proved that the form of the anterior part 
of this larva is owing to the violence used in extracting it, of which 
there is no appearance, still it will stand as distinct from other known 
species." 

1328. Mr. Say thinks that this larva, which was sent to Dr. Harlan 
by Dr. Brick, belonged to the oestrus genus. He describes as follows: 
— " The form of this larva is clavate, the posterior moiety of the 
whole length being dilated and somewhat depressed ; the segments of 
this portion are armed with transverse series of small, black, horny 
tubercles, dilated at their bases, near their tips rather suddenly 
diminishing to a filiform curved hook, pointing forwards and with an 
acute termination ; these series are six in number on the back and 
sides, placed in pairs, and three in number on the abdomen ; near the 
posterior termination of the body are numerous minute tubercles of 
the same character with the others, excepting that they conform to no 
regular series; the anterior moiety of the body is entirely glabrous, 
cylindrical, or rather elongate conic, of a much smaller diameter than 
the posterior portion, and truncate at the tip ; the lips at the posterior 
termination of the body are short, and the intervening fissure of but 
little width. 

"Total length eleven-twentieths; greatest width more than three- 
twentieths of an inch." 

1329. Mr. Say compares this larva to that of the oestrus in oxen, 
horses, sheep, and to that of the hemorrhoidal oestrus, several of the 
characters of which it presents, but still it exhibits distinctive ones 
of its own. (a) 

M. de Humboldt has seen in South America, Indians whose abdo- 
mens were covered with small tumours produced, as he presumedly 
the larvae of the oestrus. Finally, M. Howship read a paper to the 
Medical and Chirurgical Society of London, on the 26th Nov., 1832, 
on the cestrus of the human body in which is contained an account of two 
new cases, one of an cestrus found in the cellular tissue of the shoulder 
of a soldier at Surinam ; the other of an cestrus in the cellular tissue of 
the scrotum of a young man of Santa Anna, in Columbia. — (Gaz. 
M6d. de Paris, 1834, p. 71.) (b) 



(a) I have replaced the imperfect and in some respects erroneous 
extract from Mr. Say's paper, in the text, by the introduction of the 
main parts of it from the Journal of the Academy of Natural Sciences. 

(b) M. Raspail, who is disposed to attribute so many diseases to 

1 "The word Zancudo is used by the Soiuh American Spaniards to denote several 
species of culex."— S. 
101 



FIRST GROUP. 
INTUMESCENTI^. 

1330. This group comprises several diseases with which the skin 
is not primarily affected, but which occasion hypertrophy of its differ- 
ent layers. These diseases, sometimes preceded or accompanied by 
fever at the commencement, are almost always followed by permanent 
intumescence or enlargement of the parts affected. 

ELEPHANTIASIS ARABICA. 

1331. Certain enlargements of the limbs, scrotum, labia majora, 
face, &c, usually accompanied by hypertrophy of the skin, distinct 
from phlegmon, from oedema and from bloody tumours, have long 
been and are still described or designated under the name of elephan- 
tiasis arabica, or Arabian elephantiasis. 

1332. Symptoms. — Elephantiasis Arabica generally attacks the 
lower limbs; one limb only is most frequently affected, but both may 
be implicated either at the same time or successively (Alard., obs. 1. 
3). Hendy has described a variety of this disease under the name 
of Barbadoes leg: M. Alibert designates it by that of Vtpre Elephantine 
tuberculeuse. 

In a great number of cases this enlargement of the lower extremi- 
ties is announced in an acute manner by a more or less severe pain 
in the groin and ham, following the course of the vena saphena, and 
principal trunks of the lymphatic vessels, and next by the appearance 
of a red line, or hard, knotty, tense cord, resembling a chain of small 
subcutaneous tumours, extending from the bend of the groin to the 
knee or ankle, (Hendy, cases 2. 4. 9,) or from the ankle to the groin 
(case 8) ; or still otherwise, by an attack of erysipelas. In almost all 
cases, the skin assumes an. erythematous hue, and the subcutaneous 
cellular tissue becomes the seat of considerable tumefaction. The 
neighbouring joints are stiff" and contracted ; frequently from the 
commencement, there are long-continued shivering fits, great thirst, 
uneasiness, restlessness, violent retching, vomiting, occasionally deli- 
rium, then intense heat, accompanied with palpitation of the heart, 
followed by general or partial sweating, and the cessation of the 
febrile symptoms. In the course of one or more months these phe- 
nomena return in the shape of paroxysms at shorter or longer inter- 
vals, which may vary in number from three (Hendy, case 17), to 
fourteen in the course of a year (Hendy, case 16), or may only recur 
at the end of seven years (Hendy, case 19). These fits, the number 
and duration of which can neither be foreseen nor calculated, are 
followed by a progressive increase in the size of the limb, which 
would appear at first to be owing, in a great measure, to the depo- 
sition of a certain quantity of serum or coagulable lymph within 
the cellular tissue. The limb afterwards becomes hard and no 
longer retains the impression of the finger. The lymphatic gan- 
glions of the groin and ham, often very much increased in size, are 
sometimes otherwise apparently healthy and indolent. In this second 
stage of the disease, it exists without any further inconvenience than 
that which the deformed state of the limb necessarily occasions. It 
sometimes assumes such extraordinary shapes, and becomes so entirely 
out of proportion to the other parts, that it is impossible to form an 
idea of the extent of alteration undergone without having seen some 
cases, or the drawings of the disease which have been published. 
In one case the tumour is full and uniform like a well-filled bag or 
bladder; in another, it is in divisions as if each successive fit had 
formed and left its own particular swelling. 

After the first attacks, the skin is usually pliant, and does not ex- 
hibit any change of colour; vessels sometimes appear creeping beneath 
it, and give it a brownish hue ; by degrees, however, it becomes hard, 
particularly in the neighbourhood of the ankle joint, and is covered 
with elevations and small veins; the epidermis then often becomes 

insect and entozoic origin, asserts his belief that the cure of cancerous 
fungus of the uterus, in which extirpation was performed byRecamier 
and Marjolin in 1825, was caused by larva? of the oestrus. 






INTUMESCENCES. 



Finally, chaps and fissures arc sometimes 

be limb, which now I iccessively deformed. The 

sionally becomes the seat of very obstinate chronic 

s. Such anomalous developments are not 

always preceded by the symptoms of acute inflammation of the vessels 

and lymphatic glands, or of the veins of the inner part of the lower 

ioned in almost all the recent cases of the glandular dis- 

; Barbadoes related by Hendy, and in many others, in which it 
had been of long standing (cases 1 1, 16. 17, 18. 21). In fact, these 
enlargements son cur after ulcers of the legs (Andral), re- 

acks of erysipelas, of lichen agrius, or eczema rubrwm. 
The knotty, hard and tense cord is not then seen, as in the woman 
Berton (Alard, obs. 1). This system was not perceived by M. Bouil- 
laud [Archives generates de medecine, t. vi. p. 56), in a woman 
lower extremities, enormously enlarged and as hard as a stone, 
had become like those of an elephant. The intumescence in this 

in fact, followed the obliteration of the crural veins and the 
vena cava. I have given the history of a patient in the first edition 
of this work, in whom the anomalous development of one of the lower 
extremities coincided with a varicose state of the veins of the thigh. 
t. . Anatomical researches. — Despite these enlargements of the 
lower extremities, the distended skin may retain its natural thickness, 
and almost its natural colour; but hypertrophy more frequently takes 
place, at least in some parts, and there it bears a close resemblance 
to a fibrinous deposit, or the buffy coat of the blood ; the epidermis 
covering it is also generally very much thickened. Mr. Chevalier 
(Med. and Chirurg. Transactions, vol. ix. p. 63), found the papilla? 
of the skin exceedingly enlarged, lengthened, and projecting from the 
surface of the dermis; on the points where these papilla? were less 
developed, the epidermis was thinner; the corion was so much hyper- 
trophied, that in some places it was half an inch thick, and presented 
the granular appearance which is observed in large quadrupeds. On 
its inner surface it adhered to the indurated cellular tissue with which 
it was evidently blended. In other respects it was neither injected 
nor altered in its colour. 

In the body of a woman who, fifteen years previously, had suffered 
from an ulcer in the right leg, which had increased to an enormous 
size, and the skin of which was very hard, rough, and of a dark 
brown colour, and in some places absolutely black, like that of the 
hand of a negro, M. Andral found the subcutaneous and intermuscular 
cellular tissue sensibly hypertrophied and hardened, more and more 
so as it lay nearer the dermis; this had also increased considerably 
in thickness, and in several places could not be separated from the 
indurated cellular tissue, each seeming to be but different degrees of 
the same organization. The papillary body laying over the corion 
was greatly developed, evidently distinct from the dermis, and appear- 
ing to stand in the same relation to it as the villi do to the intestinal 
mucous membrane. Situated over the papillary body, again, and 
between it and the epidermis, there were three very distinct layers; 
the innermost of the three penetrating between the eminences of the 
papillary body, receiving no vessels, and consisting of a fibro-cellular 
tissue [couche albide profonde of Gaulthier, couche^pidcrmique of Du- 
trochet) ; the second, situated more externally, composed of extremely 
delicate blackish filaments, interwoven in the true sense of the word, 
forming a network which was exactly similar to the coloured rete of 
the negro; finally, a third, quite close to the epidermis, and, in par- 
ticular places, forming only a white line similar to the epidermic layer 
of the papilla? ; but thicker in others, and hardened as though formed 
by a series of superposed scales; this was certainly the couche albide 
i/uperficielk of Gaulthier, the couche cornce of Dutrochet (Archives 

les de medecine, March, 1823). 
I have made similar observations on the structure of hypertrophied 
skin in the first edition of this work (vol. ii. p. 560). M. Gaide and 
I have since repeated these anatomical researches, and he has pub- 

■ the results ( Cases of the individuals named Mlard and Four- 

After having incised the skin in the direction of its thickness, 

the following layers were discovered, reckoning them from the more 

internal to the more superficial strata. 1st. Small lobules of adipose 

. connected togther by a healthy laminated tissue, forming a 
subcutaneous layer. 2d. Above this was placed the corion, repre- 

. by a transverse band of a pale yellow colour, evidently hyper- 



trophied, th> of which were less distinct than in the natural 

state; it was, besides, loaded with a great quantity of serum, which 
was easily made to ilow out by compressing it between the fi 
From its inner surface it sent oil' whitish fibrous prolongations, which 
penetrated .some depth into the subcutaneous cellular tissue. 3d. 
Above the corion a second layer was seen, composed of parallel 
fibres, running from the outer surface of the corion towards the 
epidermis. This second layer, evidently formed by the papillae elon- 
gated, and of a ruddy violet colour, was of unequal thickness in 
several parts, and varied from two to three lines and a half in length. 
These two first layers of the skin were rendered distinct one from 
the other, both by the opposite directions taken by their fibres, and 
by a transverse line which resulted from their difference in colour. 
Between the parallel fibres of the papillary layer small vessels might 
be distinguished by the naked eye ; these were, of course, more dis- 
tinctly perceived when examined under the magnifying glass. The 
superficial surface of this second layer presented small eminences, 
mostly lenticular, separated from one another by deep furrows, evi- 
dently formed by the most elongated papilla?, whilst the smaller ones, 
united in the same line, gave rise to the formation of the wrinkles 
of which I have spoken. By maceration, the papilla? which formed 
these elevations became free, and appeared, when examined under 
water, like the pile of velvet or plush. Above the papilke a third 
layer exists, distinct from the epidermis which covers it; it is that 
which has been designated under the name of the lamina albida seu 
cornea. In detaching this third layer, very delicate filaments are seen 
tending towards little whitish bodies, situated, and, as it were, attached 
to the inner surface of the lamina albida (follicles) : these small bodies, 
variously disposed, either singly and scattered, united in parallel series, 
or agglomerated in the form of larger or smaller patches, all or almost 
all came away with the lamina albida to which they adhered. Some 
of these follicles are perfectly round ; others are longer, and terminate 
in a point at one of their extremities in the form of tears ; others, again, 
still longer, appear cylindrical; some present, in their centre, or on 
their outer aspects, a blackish point, which would seem to be their 
orifice. The epidermic layer, disposed like the preceding, in the 
form of a membrane, and, like it, transparent, where it is not formed 
of accumulated squama?, is also in contact, on its inner surface, with 
small follicles similar to the preceding ones. United in general in 
the form of patches, these were more particularly apparent on the 
parts which correspond to the squama?. This disposition of the layers 
is always seen. From the inner surface of the epidermis small pro- 
longations are sent off, which surround the hairs to their bulbous 
extremities, and are very distinct from the follicles. 

1334. In elephantiasis Arabica, the subcutaneous cellular tissue has 
been found harder in proportion as it was nearer to the dermis. The 
adipose tissue has been known to become enlarged in a very extraor- 
dinary manner. I have also found the cellular tissue infiltrated as it 
is in dropsies of long standing. M. Fabre has seen the subcutaneous 
cellular tissue converted into a thick, hard, almost fibro-cartilaginous 
layer, presenting, in several places, small ossified plates, adhering so 
closely to the aponeurosis of the leg, and to the nerves and vessels 
which traverse it, that it was impossible to separate them. The sub- 
aponeurotic and intermuscular cellular tissue participated in the same 
alterations, but in a less degree. In a woman, who died in the H6- 
pital de la Charite in 1820, whose lower limbs were affected with 
elephantiasis, M. Andral found under the skin, and in the place of 
the muscles of this limb, which were reduced to some thin discoloured 
shreds, an enormous mass of hard, condensed cellular tissue, with 
cavities here and there filled with serum, and partaking, in more than 
one place, of all the qualities of cartilage. (Precis d?analomie patho- 
logique, t. i. p. 277.) 

1335. Hendy has found the lymphatic glands hardened, or in a 
state of suppuration, and much larger than they are in their natural 
state. The absorbing vessels were dilated, and their coats so much 
weakened as to be incapable of standing injection. I never observed 
these large absorbing vessels in any of the cases of elephantiasis 
Arabica which I have dissected. M. Fabre says that he found it 
quite impossible to discover these vessels in the midst of degenerated 
subcutaneous cellular tissue. I have frequently found inguinal glands 
of much larger size than they are in a healthy state ; but in scrofulous 



ARABIAN ELEPHANTIASIS. 



403 



subjects, (he same morbid development is observed, without dropsy 
or any morbid increase in the limb having taken place. In the body 
of Allard, whose case M. Gaide has published, the lymphatic glands 
were not found to be larger than those of several other bodies which 
we examined for the sake of comparison on the same day ; the glands 
of the left groin only were of a deep red, whilst those of the right 
side were of a milky whiteness. The vessels which were distributed 
to these glands were not larger than they are in the healthy state. 
In another patient who died of elephantiasis of both of the lower 
extremities (case of Fournier), the lymphatic vessels situated on the 
back of the left foot, and inner edge of the great toe, were as small 
and delicate as in the healthy state. The glands of the popliteal 
region had undergone no alteration ; but from the left groin to the 
point w r here the aorta sends off the renal artery, a string of lymphatic 
glands existed, each of which was almost of the size of an almond ; 
some of the glands of the groin were red, or reddish, others were 
white, and easily crushed between the fingers ; those lying over the 
femoral artery, all those which extended from thence along the outer 
side of the iliac vein, and in the front of the psoas muscle, were 
white, crushing easily between the fingers, and discharging a whitish 
fluid like pus, or softened cerebriform matter. Besides this string of 
altered glands, we discovered others in the cavity of the lesser pelvis 
beneath the common iliac vein, forming, by their union, a sort of 
glandular subperitoneal layer, which extended over the internal sur- 
face of the ischium. The lymphatic vessels which were distributed 
to the glands of the groin were not larger than in the healthy state ; 
and although the chain of glands of which I have spoken adhered to 
the iliac vein, this vessel did not appear to be evidently compressed 
by it. M. Bourgeoise ascertained that the lymphatic glands of the 
right leg were not larger than in the healthy state ; the lymphatic 
glands of the ham presented no alteration; the inguinal and pelvic 
glands, not nearly so large or so numerous as those of the opposite 
side, disposed in a band round the iliac vessels, penetrated the 
smaller pelvis ; in other respects they presented the same anatomical 
characters as those of the left side. 

1336. In the compte rendu of M. Allard's work, and in a case since 
published (Archives Generates de Medecine, v. ii. p. 215 and 372), M. 
Bouillaud called the attention of the profession to the obliteration or 
obstruction of veins, as an occurrence, the influence of which he had 
already pointed out in causing the development of local dropsical 
affections. Since the publication of these researches I have had an 
opportunity of observing the contraction of one of the venae saphena?, 
and the obliteration of the other, in a case of elephantiasis of both 
legs. (Mtmoirede M. Gaide ; obs. d : 'Allard.) In the left leg the vena 
saphena, laid bare along its whole extent, appeared in the form of a 
cylindrical cord of a yellowish-white colour, and not transparent, 
about a third less in size than the same vein in its natural state ; the 
cavity of this vein was found almost obliterated at the point of junc- 
tion between its middle and lower third ; the vessel having been cut 
across in this place, a central point was distinguished upon each of 
the cut extremities into which a fine wire of the diameter of that 
which is usually inserted into silver catheters could be introduced, 
though not without difficulty ; the calibre of this vessel had become, 
in some sort, capillary, through an extent of about two inches ; its 
sides being double their usual thickness; the vein cut across trans- 
versely in any point where it was contracted, continued gaping in the 
same manner as an artery. The femoral vein towards its junction 
with the vena saphena, contained clots of recent formation ; most of 
the other veins of this extremity presented no alteration. The vena 
saphena of the left leg contained fibrinous clots of old formation, and 
adhering by their surface to the internal membrane of the vessel; the 
calibre of this vessel was not contracted, but its sides, like that of the 
right vena saphena, were thickened, and resembled those of an artery. 
I ought to add, that in estimating the thickness of the walls of these 
vessels, the difference which naturally exists between those of the 
lower extremities and those of the upper was taken into account, and 
that to prevent all mistake I took an opportunity of comparing the 
thickness of the particular veins examined in several subjects. 

In the case of elephantiasis of the leg, published by M. Fabre, the 
vena saphena laid bare from one end to the other, could not be traced 
in the middle part of the leg; it was only found at the distance of 



about four finger-breadths below this point ; a very fine probe intro- 
duced in*to the upper and lower part of the vein led to two shut sacs. 
This vein in the remainder of its course was so much contracted, as 
only to allow the passage of a small silver stilette with great difficulty 
along it. Its sides were hypertrophied, and like those of an artery- 
The external saphena, except that it was nowhere obliterated, pre- 
sented the same appearances ; the anterior tibial and fibular veins con- 
tained blood. The posterior tibial vein was obliterated in a part of 
its course. No obstacle to the course of the blood existed in the 
popliteal, femoral, or external iliac veins, &c. 

1337. Henly found the small arteries of parts affected with elephan- 
tiasis larger than they are in a healthy state. In two cases seen by 
M. Gaide, at the Hopital St. Antoine, the arteries of the extremities 
presented no alteration. In a case, the particulars of which are re- 
lated by M. Fabre, the anterior tibial and fibular arteries were ossified ; 
they contained a little blood ; the posterior tibial vein was converted 
into a cylindrical bony stem into which the blood no longer penetrated ; 
the femoral and popliteal arteries were also equally ossified ; similar 
ossifications were found in the arteries of the other extremity. 

1338. In a particular case which Naegle examined, he found the 
tibial nerve increased in size, presenting on its surface and in its in- 
terior round and oval-shaped nodosities, forming so many small cysts 
which contained a clear fluid, limpid in some places, and turbid in 
others. In three cases of elephantiasis Arabica which I have dissected 
with great care, the nerves presented no alteration. In M. Fabre's 
case the great sciatic nerve, after having preserved its natural size to 
the middle of the thigh, afterwards increased continually in its dimen- 
sions till it reached the ham, where it was of such magnitude that its 
several branches were each much larger than the trunk which sent 
them off. In the thickness of the external popliteal nerve a gelatinous 
hydatiform mass was found, of a pale red colour and the size of a 
small almond, pretty firm in its consistence, and having the medullary 
fibrils of the nerve parted and applied around it. The branches of 
the external and internal popliteal nerves were themselves so much 
increased in bulk that the tibial nerve, the cutaneous muscular branch 
and the anterior tibial were each four times their natural size, and 
presented several enlargements. These nerves, although very hard, 
still preserved pretty evident traces of their peculiar organization. 
M. Ferrus met with a similar disposition of the nerves in the leg of 
an old woman affected with elephantiasis. 

1339. Hendy commonly found the muscles softened and blanched. 
I have also seen them less deeply coloured than in the healthy state ; 
in a patient of M. Fabre's, several of the muscles were increased, 
others decreased in size ; each of them was converted into a fatty 
substance. They were very hard, and creaked under the scalpel ; 
the sokeus muscle presented this degeneration in a greater degree than 
any of the rest ; here and there a kind of streak of bony matter ap- 
peared, which seemed to occupy the spaces between the muscles, and 
some of which were connected with certain bony excrescences that 
rose from the surface of the periosteum of the tibia. 

1340. In the cases of elephantiasis of the lower limbs, which I have 
had the opportunity of examining anatomically, the bones had under- 
gone no change. But in several patients, and among others, in a 
woman whom I attended in the Hopital St. Antoine, the tibia of the 
diseased leg was three times the size of that of the opposite side ; in 
M. Fabre's patient, too, the inter-osseous ligament of the leg only 
existed for the space of about an inch in the situation where the ante- 
rior tibial vessels pass through it ; no further vestiges of it were seen ; 
it was replaced by an osseous uneven lamina covered with asperities, 
and a line in thickness in some places. This bony lamina adhered so 
intimately to the tibia and fibula, that these two bones, thus soldered 
together in their whole extent, really formed no more than one. The 
surfaces of the lower peroneo-tibial articulation were so completely 
united that no trace of division between them could be discovered, 
even after more than three months of maceration. The circumference 
of the tibia was almost the double of that which it is in its natural 
state ; that of the fibula in the middle was fully more than triple. 
These bones, thus closely united, were covered with a prodigious 
number of shorter or longer asperities, bedded in the soft parts, their 
edges being prolonged in the form of prominent ridges, twisted in 
various ways, so as to represent in some sort a series of canals crossed 



404 



INTUMESCENCES. 



bi \ essels and nerves, which ramified upon their surface. The upper 

nea of the fool presented similar ridges to those on 

la and fibula. The density of the tissue of the tibia was such 

! only be sawed across with very great difficulty ; in colour 

.mil compactness of texture it resembled ivory. The bony surfaces of 

m-tarsal articulation were healthy; none of the hard or soft 

of the plantar aspect of the foot participated in these alterations. 

i. Funis and Cruveilhier have observed similar morbid appear- 

. and M. Larrey, in his description of elephantiasis, speaks of 

violent pains felt along the course of the bones. 

1 '! 1 1 . With respect to lesions of the viscera accompanying or coin- 
ciding with elephantiasis .Irabica in the lower extremities, the follow- 
ing is what I observed in the body of the man Founder: the larynx, 
uhea and bronchi, were natural; each of the pleurae contained 
from eight to ten ounces of serum. The left lung was crepitating 
and loaded with serum which flowed out when pressed between the 
lingers ; there was no trace of sanguineous engorgement in this lung, 
but on the posterior part of the lung of the right side there was, and 
the whole mass of this organ felt firmer and resisted pressure more 
powerfully than that of the left side. 

The pericardium was in a healthy state ; the heart, of the natural 
size, contained some fibrinous clots in the right cavities ; the thoracic 
aorta was healthy; the cavity of the abdomen contained a small 
quantity of transparent serum. The internal surface of the stomach 
was divided into two portions by a deep line of demarkation, which 
separated the anterior exactly from the posterior part; in the former, 
the mucous membrane was healthy ; the latter was, on the contrary, 
almost without any trace of mucous membrane, and of a dead white; 
its surface was covered with bluish vessels which projected from it, 
and contained a larger or smaller quantity of blood, so as to give this 
region a blue and red marbled appearance. The mucous membrane 
terminated abruptly in a sharply cut edge in the pyloric region, whilst 
towards the cardia it was continuous with the mucous membrane in a 
state of health ; in some parts of this region the softened mucous 
membrane had a grayish aspect, which contrasted on the one side 
with the alteration which I have met, just described, and on the other 
with the healthy portion of the organ. The small and large intes- 
tines presented numerous vascular ramifications, separated from each 
other by parts in wduch the softened mucous membrane appeared to 
have lost some portion of its substance. The mesenteric glands pre- 
sented no particular appearance, the liver was enlarged, and its yellow 
substance pretty abundant; the finger could with difficulty be pushed 
into its substance. 

The kidneys, larger than in the healthy state, presented a more 
decided alteration on the left than on the right side ; their whole 
substance, but particularly the cortical part, was of a morbid yellow- 
ish-white, very different from the usual colour of these organs. The 
brain and its membranes had undergone no alteration. 

In another case, of a woman named Mary Allard, the peritoneum 
was covered with numerous granulations over almost its whole extent, 
particularly where it formed the epiploon; the portion of this mem- 
brane covering the intestinal canal was very much injected. The 
cavity of the lower pelvis was partly filled with a sero-purulent effu- 
sion; some whitish lines appeared on the stomach, over which the 
raucous membrane was softened, and very sensibly diminished in 
thickness. A similar alteration had taken place in several parts of 
the small intestine. In the large intestines, and particularly in the 
descending colon, small, round ulcers were met with, surrounded by 
the mucous membrane, blanched and of a dead white. In the situa- 
tion of the sigmoid flexure of the colon, the subperitoneal cellular 
tissue was loaded with a profusion of purulent matter ; large sinuses 
existed here, but without communicating with the intestine ; this 
alteration extended a considerable way into the cellular tissue of the 
lower pelvis ; the other viscera of the abdomen appeared to be in a 
healthy state, (a) 



(a) Dr. Musgrave {Edinb. Med. and Surg. Joum., No. 902), terms 
the disease ?nigratory inflammation of the lymphatic system. He tells 
us: " Whatever may be its original seat, the patient is never secure, 
whde the constitutional disturbance subsists, from a sudden retroces- 
sion to some vital organ. I have seen it in the same case translated 



13 12. Elephantiasis Arabica seldom attacks the superior extremities. 
M. Allard, however, quotes four cases of the disease occurring in the 
anus. In one (case 7) the hard and permanent swelling of the left 
arm occurred after the application of a blister. In another (op. fit., 
p. 190), the right arm increased to such a size that it weighed two 
hundred Genoese pounds, forty of which consisted of serum ; the 
swellings of the arm and forearm resembled a distended bladder or 
skin ; the arteries, the veins and the nerves had undergone no altera- 
tion; but the lymphatic vessels were very much dilated and loaded 
with lymph. The third is a case of Fabricius Hildanus. The fourth 
is extracted from Hendy, who relates several others of the same 
description, in which the disease appeared in a very acute form, by a 
sort of numbness in the shoulder and arm, the enlargement of a gland 
in the axilla (case 13) or elbow (case 5) and a red line running over 
the inner part of the arm and forearm, (b) 

I have myself observed three cases of elephantiasis of the upper 
extremity, but the progress of the disease in all was chronic. One 
occurred in a woman who had had the right breast taken ofF for a 
cancerous affection of the mammary gland, and in whom the lymphatic 
glands, become scirrhous, compressed the axillary vein (first edition, 
viii. p. 630) ; the second case I met with has been published by M. 

from the scrotum to the head, from thence, after some hours, descend 
with the rapidity of lightning to the abdomen ; again migrate to the 
chest, to return, perhaps, to the encephalon and prove fatal there; or, 
under more favourable circumstances, resume its comparatively harm- 
less situation, and run its subsequent course, as if nothing untoward 
had occurred ; and, while occupying the different cavities, giving rise 
to the ordinary symptoms of acute inflammation of that particular 
viscus which it had selected for its temporary abode." 

(b) A parallel case is related by Dr. Sanderson, of Oxfordshire 
(Lancet, 1838-9). The narrative is interesting, and runs as follows : 

"Mrs. H., aged 49, of spare habit, lymphatic temperament, and 
healthy constitution. Ten years ago, perceived a small tumour in 
the right mamma, the size of a broad bean, movable, unattended 
with pain or discoloration of the part. No constitutional disturbance ; 
gradually increased to the size of a walnut, still unaccompanied by 
pain, but occasionally felt in the breast a slight tingling sensation. 
Plasters and steaming appear to have been the only remedies used by 
her former medical attendant, after which the surface of the breast 
became red, and eventually the skin gave way. No matter eva- 
cuated, but an irritable sore produced ; the diseased portion, the size 
of a large cork, (said to have been carcinomatous, but doubtful as to 
its real character,) was removed by an operation five years ago. The 
wound has never entirely healed, but continues to this time, exhibiting 
an ill-conditioned appearance, and discharging a thin sanious matter. 
Six months after the operation, three or four glands in the axilla be- 
came enlarged and painful, and some time afterwards experienced a 
general sense of numbness to pass down the arm until it reached the 
hand, when the use of the limb appeared at once to be lost. The 
arm next began to swell, and a dragging, twisting pain to be felt along 
it ; the integuments on the back part of the hand especially began to 
expand, and gradually to develop the extraordinary circumscribed 
mass of disease it at present exhibits, overhanging and projecting, as 
it does, several inches beyond the fingers, which seem, as it were, im- 
bedded in it. 

" The head obliged to be supported in the direction of the affected 
side, from the contraction of the muscles, and the natural inclination 
of the body to bend towards the diseased limb. 

" The arm is completely covered with a thick brownish incrusta- 
tion, or a sort of scaly efflorescence ; and springing up in different parts 
of this crust, are five or six tubercles of a dusky-red colour, slightly 
sensible to the touch, varying in size from a pea to that of a cherry. 

" There is a large massy tumour extending upwards from the dor- 
sum of the hand, in figure and size much resembling a round quartern 
loaf, or what is generally called an oven or batch-cake ; the surface, 
smooth, red, and shining, sensible to the touch, hard and firm, from 
time to time exhibiting a slight disposition to form alike efflorescence 
to that on the arm, but only in limited points, where there have first 
been small ulcerations and a discharge of serosity. 

" The fingers are much expanded, flattened, and nearly lost in the 



ARABIAN ELEPHANTIASIS. 



405 



Gaide ; the subclavian, axillary and brachial veins were here filled 
with a fibrinous clot of long standing, adhering to the inner mem- 
brane of these vessels, and of a yellowish-gray in the centre. In 
the third, which was detailed by M. Bonnet, of Poictiers, and in which 
the left forearm was the part affected, we found the basilic vein hard, 
and filled with a coagulum which adhered closely to its inner mem- 
brane ; this hard and solid clot was blanched or of a grayish colour, 
intermixed with red stria?. 

1343. The history of elephantiasis occurring in other regions of the 
body, is less complete ; elephantiasis of the scrotum is almost the only 
case which has been made the subject of correct anatomical research. 
Elephantiasis of the hairy scalp is very rare. M. Ricord has given 
two cases of it in the Revue Medicale, vol. ix. p. 13. 

1344. Elephantiasis of the face sometimes only attacks it on one 
side; such was the case with the patient whose history forms the 
subject of M. Alard's ninth case, and in whom the elephantiasis 
would seem to have been complicated with eczema of the ear. "Wil- 
lier's (Alard, case 2) is a remarkable case of elephantiasis of the 
face: after committing a debauch at table, this patient experienced 
a violent pain in the left cheek and below the zygomatic arch : this 
pain soon extended under the chin; the submaxillary glands en- 
larged and felt painful; the face swelled and became erythematous; 
and he experienced nausea and slight shivering fits. At the end of 

tumefaction, with the exception of the little finger, which is nearly 
absorbed, being reduced to a mere skin. These parts (the fingers), 
have a moistened or sodden appearance, from a constant oozing of a 
serous fluid, proceeding from the under surface of the tumour. 

" The circumference of this enormous enlargement is, at the base, 
29 inches, that of the upper arm 19 inches, and that of the lower arm 
15 inches. 

" The most remarkable fact connected with this interesting case is, 
that, during all this morbid action, carried on for a period often years 
in the breast, and in these parts, the general health has been uniformly 
good up to the present time ; appetite excellent ; digestion perfect ; 
tongue clean ; bowels regular ; pulse 75 ; no fever, nor any other 
constitutional disorder. 

" It seems difficult to account for this extraordinary morbid form- 
ation, unless we suppose that the irritation excited in the breast, in 
the first instance, produced a diseased action in the lymphatic vessels 
and glands, from the axilla downwards, which, by repeated effusions 
of serous or gelatinous matter poured into the cellular membrane under 
the thickened skin, and upon the cuticular surface, have produced the 
present tumid and scaly condition of the limb. My friend, Mr. Rye, 
who is attending the case with me, and who intends taking a drawing 
of the limb, in its present state, agrees with me in thinking the disease, 
in character and appearance, more like that which, at the present day, 
is termed elephantiasis (the elephantiasis of this country), than any 
other with which we are acquainted. The case has been regarded by 
us as one of considerable interest, inasmuch as we are not aware of 
there being another exactly similar placed on record. 

" The uniformly good health enjoyed by the patient, the curious 
alteration of the whole cuticular surface, and the extraordinary magni- 
tude and aspect of the limb in general, and the hand, in particular, 
invest the history of the case under consideration with a high degree 
of interest and importance. Our present narrative, however, must be 
incomplete until an opportunity is afforded of following the disease to 
its termination, and of examining the pathological character of the 
parts involved in this peculiar morbid action. For this reason we 
refrain, at present, from encroaching further on your columns until the 
above deficiency can be supplied. 

" I may just add that I have been informed by the practitioner who 
saw the disease in its early stages, that it then assumed very much 
the character of erysipelas, especially on that part of the skin covering 
the back of the hand ; in some points appearing red and vesicating, 
in others pouring upon the surface a serous fluid ; and, again, in others 
forming a slight incrustation, which afterwards desquamated ; and 
that a constant repetition and succession of these processes were 
carried on, during which time the whole limb was rapidly acquiring 
an increased magnitude." 

102 



six months, another attack, after which the patient perceived that the 
face continued puffed; this attack was followed by several others, 
and the face became larger and larger. In similar cases tumefaction 
may arrive at such a height that Schenck speaks of a man whose 
head exceeded that of an ox in size ; the lower part of the face was 
entirely covered by the nose, which had to be raised to enable this 
unhappy being to breathe (Obs. Med. Rar. Nov., &c, lib. i. p. 12). 
I have seen one case only of elephantiasis of the face which super- 
vened after repeated attacks of erysipelas. 

1345. This disease causes the breasts to increase to such a size, 
that they are obliged to be supported by bandages passed around the 
neck. Salmutius (Cent. 2 obs. 89), speaks of a woman whose breasts 
increased to such a size that they hung down to her knees. She 
had, at the same time, glandular tumours as large as the head of a 
foetus, under the axilla?. M. Borel, physician in Castres, also quotes 
the case of a woman whose breasts became so large that they were 
obliged to be supported by straps which passed over the shoulders 
and neck. 

1346. M. Alard relates as a case of elephantiasis, that of a lady 
of Berlin {Ephem. Mat. Cur., 3 anno. 2, p. 71, 1694), who had an 
abdominal tumour, the lower part of which reached to the knees. 
This tumour, situated under the skin, outside of the cavity of the 
peritoneum, was formed of a congeries of small pouches, agglome- 
rated, and adhering to one another, like the swimming bladders of 
some large fish. Seven of these cells, adhering very closely together, 
formed the circumference of this tumour, and an eighth occupied the 
centre. Each of these cells was itself divided into several small 
compartments, which enclosed a clear and limpid fluid, like the 
white of egg, but of greater consistence in some, and in several similar 
to the boiled white of an egg. The contents of others again, were 
yellowish, greenish, or reddish. On the peritoneum being opened, no 
vestige of disease was found in the abdominal cavity. No sensible 
alteration had taken place in the veins, which were only found to be 
a little out of place. 

M. Delpech also quotes a case of elephantiasis of the walls of the 
abdomen, observed in a young woman, four-and-twenty years of age, 
born at Toulouse, who had three conical tumours on the abdomen, 
adhering to the sides of this cavity, near the hypogastrium and um- 
bilicus, two on the right side, and the third on the left. These 
tumours were of the structure of those enlargements which constitute 
andrum ; that is to say, a cellular tissue, the cells or areola? of which are 
of great magnitude, separated from one another by very extensive 
and semi-opaque laminae, covered with very much dilated lymphatic 
vessels, and some few sanguineous vessels, of extreme tenuity, and 
but little ramified ; the intestines were filled with a serum, half liquid, 
half solid, and rendered almost opaque by a considerable portion of 
albumen. 

1347. Next to the lower limbs, the scrotum is the part of the body 
which is most frequently attacked with elephantiasis Arabica; this 
part and the penis often acquire an enormous size when affected with 
the disease. This alteration has been improperly designated by 
Larrey under the name of sarcocele d?Egyple; by Prosper Alpinus 
under that of hernia carnosa ; and by Kaempfer, under that of endemic 
hydrocele of Malabar. M. Alard relates three cases of the disease 
from Hendy (obs. 16), from Gilbert (obs. 5), and from the Epheme- 
rides Curiosorum Naturae (obs. 108, p. 212). M. Dumeril has seen 
a remarkable case of the affection in a man upon whom all the 
resources which art possessed had been lavished in vain. M. Delpech 
relates two cases of it, one of which afforded him the opportunity of 
performing an extraordinary operation. This last patient, who was 
thirty-five years of age, had been afflicted with his infirmity for ten 
years. The skin of the scrotum had become excessively hard, 
thickened, tuberculated, and intersected with deep wrinkles; the 
enlargement, pasty at first, had afterwards acquired a greater consist- 
ence, and became hard and very heavy. The tumour formed by the 
scrotum weighed, when it had attained its maximum size, about sixty 
pounds ; under or within this shapeless mass, the penis and the testi- 
cles were buried ; it seemed to be divided into three unequal masses, 
two lateral and one anterior, where a sort of umbilicus was seen, 
through which the urine passed. This patient did not experience 
the erysipelatous affections, accompanied with fever, shiverings, 






INTUMESCENt i.-. 



observed bj Kaempfer [Amcenit. Exotic, fasc. 3, obs. 
. Hendy, and Gilbert, in similar rases. 

other inquirers have ascertained that the disease is not 

always accompanied by these phenomena; and in the patient ope- 

upon by M. Delpech, the same alterations of the skin and cel- 

wbich are observed in elephantiasis of the limbs, were 

found; the organs of generation were healthy. 

In another individual, who was operated upon by M. Larrey, one 
of the testicles was found to be healthy, the other smaller than in its 
natural state ( Campagnes, t. ii. obs. 1, p. 122). In a third case, which 
en republished by M. Alard, independently of the alteration in 
Ihe skin and cellular tissue of the scrotum, it was discovered, after 
death, that the testicles were inflamed like the rest of the parts. The 
ri^ht testicle, after having been stripped of the tunica vaginalis, was 
-s than a goose's egg in size. It was divided into three com- 
partments: a gelatinous and thick matter infiltrated the upper and 
lower parts, and the middle was occupied by a substance nearly the 
si/e of a walnut, into which the vasa efferentia emptied themselves, 
without appearing to have undergone much alteration. The tunica 
albuginea was much thicker than in the healthy state, and contained 
a pale fluid, lodged in small divisions like those of a lemon. On 
opening the tunica vaginalis of the left side, two quarts of serous and 
almost colourless fluid were discharged ; the same state of things was 
found on the opposite side. Upon removing the integuments cover- 
ing the penis, which were three fingers thick, this organ was found 
to be of its natural size, or even smaller than it should have been; 
the corpora cavernosa could not be inflated as they usually may. All 
the rest of the body was healthy, except the right kidney, the ulcera- 
tion of which had no doubt caused the patient's death. Finally, 
according to Hendy, the disease peculiar to Barbadoes may attack 
the testicles and the inguinal glands at the same time (case 10). 

Elephantiasis Arabica may also be complicated with scrotal hernia, 
of greater or less magnitude, as it was in the case of a man, named 
Lajoux, of Toulouse, the details of which the Societe de Medecine 
of that city has published in its transactions. The following case, 
detailed by M. Fabre, is another instance of the same kind, occurring 
in an old man seventy-three years of age, who was affected with ele- 
phantiasis of the scrotum, and with double inguinal hernia. When 
this patient was fasting, the upper part of the tumour gave a clear 
sound on being struck, whilst in the lower part the sound was dull; 
after eating, however, the dullness extended along the whole of the 
right side of the tumour, and the sound remained clear in the upper 
part of the left side. It was enough for the patient, whilst fasting, 
to drink a certain quantity of liquid, to cause the sound immediately 
to become dull on the right side. M. Fabre concluded, and with 
reason, that the stomach was displaced in this case, and formed a 
hernia on the right side. 

1348; I saw, some years ago, under the care of M. Dupuytren, in 
the Hotel Dieu, a woman of the town, in whom elephantiasis Arabica 
was developed in the labia majora, which were of an enormous size. 
Similar cases have been collected by Gilbert (Alard, case 2), Larrey 
( Campagnes d' Egypt, t. ii. p. 127), and by Talrich (Delpech, mem. cit.). 

Elephantiasis Arabica may also be developed on the verge of the 
anus, a case which Bavle was the first to observe. 

1349. Upon dissection, this enlargement of the cellular tissue does 
not present any appearance similar to scirrhus in whatever part it is 
incised. No scirrhous induration or cerebriform matter is discovered, 
but merely a kind of very hard oedema, a cellular tissue, full of a colour- 
less fluid, which can be at all events partially squeezed out by strong 
pressure. The enlargement is hardly ever confined to the verge of 
the anus ; it generally extends to a greater or less distance into the 
cellular tissue of the buttocks, where it terminates gradually {Did. 

Sciences Medic., t. iii. p. 609). 

1350. M. Alard gives a curious case as one of elephantiasis of 
ide of the body, but it is deficient in essential details, (on. cit., 

p. -219). 

Finally, certain anomalous enlargements of the tongue, of the uvula, 
of the submucous cellular tissue of the intestines, and of the subserous 
cellular tissue of the epiploons, have been assimilated by some writers 



to Arabian elephantiasis, and will be described hereafter (see Glos- 
socele). (a) 

(a) The following description of Brazilian elephantiasis, with its 
frequent complications, is derived from an instructive volume (.Me- 
dical Topography of Brazil and Uruguay, with Incidental Remarks, 
Philadelphia, 1845), by Dr. G. R. B. Horner, of the United States 
Navy : 

''Elephantiasis exists in every form and degree: spares no sex, 
age, nor condition ; pays no respect to natives or foreigners ; affects 
the poor and rich : harasses servant and master ; affects the plebeian 
and patrician. The poor and labouring classes, however, are most 
annoyed by this disease; and the negro population, both the slaves 
and free portion, have a full share. The persons most affected with 
elephantiasis, strictly speaking, and according to the derivation of the 
name, are those who live miserably, or are obliged to make much use 
of their feet, and have them frequently, and for a long time, exposed 
to the sun without shoes or any thing else to protect them. One of 
the best evidences of this fact was, that I knew a sailor to bring on 
a violent inflammation and swelling of his feet, similar to elephantiasis, 
from such exposure. Had the irritation been kept up, I have little 
doubt a chronic affection would have been induced, and a permanent 
enlargement taken place. I have observed, also, that the labouring 
class of people, particularly men who stand or walk much, and wo- 
men who are in the habit of washing clothes and immersing their 
hands in hot water or other warm fluids, have them or their forearms 
affected. 

" Of the pathology of elephantiasis, it may be well for me to make 
a few remarks, and first of its causes. The chief remote ones at Rio 
are, without doubt, the heat and moisture of the climate, rendered 
more injurious by the miasmata and impurities without and within 
the crowded city, situated chiefly in valleys overhung by high moun- 
tains, and divided by hills. That these are the most efficient causes 
is proved by the acknowledged fact, that since John VI came from 
Portugal, lived at Rio, and drained, cleaned, and otherwise freed the 
city of noxious substances, the disease has declined considerably. 
The luxury and indolence of the people, and the general relaxation 
of their systems, from climate and other debilitating agents, may like- 
wise be mentioned as remote causes. The exciting are, heat directly 
applied to the parts, and different irritating things put upon or lodged 
in them. Of the latter, chigues may be called the most common and 
efficient among the slaves and other people who are in the habit of 
leaving their feet uncovered. Erysipelas is one of the exciting causes, 
according to one of the most respectable native physicians; and when 
this attacks the scrotum, it becomes enlarged very rapidly: but this 
erysipelas is probably brought about by the same causes, primary and 
secondary ; and as it affects the same tissues — the tegumentary and 
cellular — it may be looked upon as a mere premonitory symptom of 
ordinary elephantiasis, or that attended with increase of substance in 
the parts diseased. That attended with a decrease of it is called 
Greek elephantiasis or leprosy — as said when I spoke of my visit to 
the hospital appropriated to it, and is of a less acute kind — is slower 
in its progress — and though the parts are seldom much enlarged, with- 
out doubt is owing to the same causes in most instances. The chief 
difference in the two forms of the disorder consists in the action of 
the absorbents and capillaries. These, in common elephantiasis, 
excrete and add to the parts ; but in the leprous kind, the former 
take up and carry off, first the cellular, serous, fibrous, and other soft 
tissues, and then the osseous. That this is the true difference, is satis- 
factorily proved by what is to be seen in the patients affected in the 
hospital; where the same person, nay, the same part of the body, is 
affected with both kinds of the disease. For instance, the legs may 
be seen enlarged — the lips most unnaturally increased, while the toes 
and nose are wasting away, if not already totally absorbed. That 
this phenomenon should occur, is not more unaccountable than the 
formation of a fibrous, cancerous, or other tumour, while in the same 
person an ulcer should be devouring the soft tissues, or a caries be 
destroying the hardest bones. 

" Of the two forms of elephantiasis, it is not easy to say which 



ARABIAN ELEPHANTIASIS. 



407 



1351. Causes. — Individuals affected with Arabian elephantiasis 
may suffer from a variety of acute and chronic diseases, either before 
or after the occurrence of the intumescence, which sometimes appears 
after repeated attacks of eczema. Mentzell and Bayle have seen gout 
coincide with Arabian elephantiasis; patients affected with elephan- 
tiasis Grceca (see elephantiasis Grceca), have sometimes presented, 
not only oedema of the lower limbs, which is common, but the true, 
hard, and bulky enlargement of Arabian elephantiasis also. Upon 
the whole, then, several alterations of the veins (varices, phlebitis, 
contraction, obliteration, &c, &c), and various forms of inflamma- 
tion of the skin (erysipelas, eczema, lichen, ulcers), are the diseases 
which are the most frequently observed before the development of 
Arabian elephantiasis, or during its course. 

Elephantiasis Arabica shows itself above all in those parts of the 
body in which the veinous circulation is slower than usual ; — in the 
lower extremities, and in the scrotum in men. This disease is neither 
contagious nor hereditary. It is seen in persons of all ages, most 
frequently in adults, more rarely in the aged, and in children. Chaus- 
sier presented to the society of the Faculty of Medicine of Paris, on 
the 1st of March, 1810, the leg of a still-born infant, on which two 
deep constrictions, and a considerable tumefaction of the back of the 
foot, very similar to elephantiasis, were seen. Out of thirty cases of 
this disease which I have met with in Paris, more than half had 
occurred without any appreciable external cause. There is not, per- 
haps, a department in France in which this singular affection has not 
been observed. Delpech assures us that he has seen numerous cases 
in Roussillon, particularly in the neighbourhood of Elne. According 
to Casal, it is very common in the Asturias. (Hist. Aatur. y medic, 
de el Principado de Astur., pp. 321, 323.) I am not aware that any 
other observations have been made either in England or on the Con- 
tinent, with the view of ascertaining whether particular topographical 

occasions the most inconvenience to the sufferers : for one lops off his 
members, the other enlarges them to an enormous extent — and both 
deprive of the means of obtaining a livelihood ; one by a deficiency, 
the other by an excess. A seamstress and shoemaker lose their fingers 
by one form of the disorder ; a footman and porter have their legs and 
scrotum so much increased by the other, that the former can only stand, 
and the latter has as much as he can carry about his own person. A 
belle, ambitious of having the smallest of feet — the most delicate of 
ankles — has them converted into stumps, or such heavy clubs, that 
all elasticity of gait is destroyed ; and so far from dancing well, can- 
not walk with common grace. A beau, desirous of displaying his 
finely-formed features, and causing every belle to look with admira- 
tion at his noble Roman nose — his expressively dark eyes — has the 
former converted into a genuine pug, or insignificant Grecian ; and 
only one of the latter is left to view the ruins of the once sublime 
bridge, and the extinction of its fiery fellow orbit. 

" Cases of scrotal elephantiasis are nearly as numerous, if not quite 
as much so, as those of the feet; and the first attain the greatest mag- 
nitude of any other form. One or more instances have occurred 
where it was so large that a wheelbarrow was requisite to carry it; 
and two cases I saw of it were about four feet in circumference. One 
of them was that of a negro in the Miseracordia ; another, that of a 
late officer of customs, who resides in the Rua dos Bazotes, or Bus- 
son's street, which takes its name from the number of such persons 

residing on it. Dom Francisco H. C had been afflicted with the 

complaint only three years, and he, nevertheless, had the scrotum 
formed into a vast tumour of nearly the natural shape of the part. 
The skin was quite firm, smooth, of a reddish-white colour, and felt 
soft, but was firm and elastic ; the prepuce spread out six or eight 
inches around, and divided into irregular lobes, semitransparent, fun- 
gous, and entirely concealing the glans. This was embedded in the 
mass. His feet and legs, just above the ankles, were correspondingly 
enlarged. The first were too big for shoes, and protected by mocca- 
sins; the second were bottle-shaped, and a linen sac, supported by 
straps, held the unwieldy scrotum. Dom Francisco is no longer able 
to obtain a livelihood by labour, and receives alms privately. His 
age is fifty-six years; and as his chin and face are becoming affected 
more and more, he must expect to spend the rest of his life in misery 
beneath the weight of his irremediable disease." — pp. 106-8. 



conditions or other circumstances have really a marked influence on 
the development of this disease. In the island of Barbadoes its fre- 
quency is attributed to the sudden impression of cold, to the extreme 
coolness of the nights, and to the currents of air which blow through 
all the houses. We are assured that this disease is endemical in some 
regions of the torrid zone, and it is principally seen on the left bank 
of the Ganges, in Egypt, Nubia, &c, countries which are continually 
under influences nearly of the same kind, (a) 

1352. Diagnosis. — When Arabian elephantiasis is announced by 
febrile symptoms, accompanied with pains along the course of the 
veins, vessels and lymphatic glands of a limb, it presents almost the 
same characters as certain cedemas observed in puerperal women, in 
whom the principal veins of the extremities have been found ob- 
structed by fibrinous clots. (Rayer; article OSdema. Diction, de 
Medecine in 21 volumes.) When the skin has become uneven or 
tubercular in Arabian elephantiasis, the alteration which takes place is 
somewhat similar to that which is seen in elephantiasis Grseca, but in 
the latter the inequalities or tubercles follow spots of a tawny colour, 
and do not constitute its principal outward character; whilst in Arabian 
elephantiasis the lesser swellings and tuberculations are accidental, only 
appear during the last stages of this disease, and are always accom- 
panied by other lesions of the parts under the skin. The point in 
brief which it is of the greatest consequence to ascertain in cases of 
elephantiasis Arabica, is whether the tumefaction of the parts affected, 
be produced by indurated cellular tissue, impregnated with serum 
and hypertrophied, by adipose tissue, or by an anomalous develop- 
ment of the skin, muscles, and other tissues which enter as com- 
ponent parts into the organization of the limbs or parts affected, 
whether the vessels and lymphatic glands be inflamed or not, and 
whether the enlargement be the result or not of some obstruction to 
the course of the blood occasioned by compression, dilation, contrac- 
tion or obliteration of one or several of the veins. 

1353. Prognosis. — According to Dr. Hendy, in some rare cases, 
elephantiasis Arabica has been known to get well spontaneously. A 
man affected with elephantiasis of the scrotum, after having had 
several attacks, was awakened one morning by an uncomfortable 
dampness round the thighs ; this proved to be water which had been 
effused through a crack in the diseased skin. About six ounces of 
the fluid were collected in a basin. A few months after this the patient 
had another recurrence of a similar evacuation from the scrotum, 

(a) The following succinct account of the geographical distribution 
of elephantiasis Arabica, is given by Dr. Scott, in the Cyclopcedia 
of Practical Medicine. — " This disease is in a remarkable degree 
endemic in the island of Barbadoes, on the southwest coast of 
Ceylon, in the neighbourhood of Cochin, on the Malabar coast, 
in some parts of Japan, in Egypt, and in Abyssinia. It occurs 
not unfrequently in almost all of the West India islands and British 
settlements of South America ; in the Polynesian Isles ; and in the 
provinces of Castile and the Asturias in Spain. Sporadic cases occur 
over Europe generally, and perhaps in all parts of the world. 

" Persons liable to this disease. — In Barbadoes elephant leg was, 
until about the year 1704, confined to the black population. A white 
inhabitant was attacked in that year; and before the year 1760, when 
he died, the disease was common among the white population. In 
general, it would appear that imported Europeans are not liable to 
the disease unless they reside for a considerable time in the island. 
It is perhaps owing to this circumstance that soldiers are very rarely 
affected with it. 1 

" In Ceylon the disease is confined to the indigenous inhabitants, 
including the half-caste and Creoles. Imported inhabitants, compre- 
hending Europeans, Africans, Malays, or natives of the peninsula of 
India, may be said to be exempted from its influence. There is only 
one instance known of a native of Europe having become affected ; 
and in his case the disease did not appear before he had been a resi- 
dent at Point de Galle between thirty and forty years. 

" Soldiers and other imported Europeans are not liable to it at 
Cochin." 

1 Dr. Hendy slates that horses are liable to the disease in Barbadoes, and that it 
had been reported to him that dogs, horned cattle, and poultry, were sometimes af- 
fected with it. 



408 



INTUMESCENCES. 



after which this part was reduced almost to its natural size. (Hendy, 

1364. Treatment. — The inflammatory symptoms observed in the 
first stage of elephantiasis Arabics, should be treated by emollient 
applications, tepid baths and bleeding; the fears which have been 
entertained against bleeding are unfounded. I have employed it with 
success in the paroxysms, the length and intensity of which it certainly 
moderates. In the chronic stages of the disease, bleeding has been 
followed by momentary relief at least, when the patient has com- 
plained of a feeling of painful distension of the parts affected. I 
have also seen very happy effects produced by local bleedings, from 
the groin, the hollow of the ham, the axilla:, &c. The part affected, 
placed as constantly as possible in a position that facilitates the return 
of the blood towards the heart, should be covered with emollient 
cataplasms, or wrapped in tlannels steeped in soothing and narcotic 
decoctions. If the enlargement is developed on one of the lower 
extremities, the patient should keep his bed for several weeks, (a) 

Emetics and purgatives have been administered at this period with 
various success; I rarely make use of them myself. The antispas- 
modic effects of the sublimed oxide of zinc in doses of eight grains 
a day, have been much spoken of. Hendy assures us that this remedy 
allays the sickness and uneasiness which patients experience in the 
periodical exacerbations of elephantiasis. Several physicians of the 
island of Barbadoes, struck with the frequency of the vomitings 
during the paroxysm, have thought it necessary to encourage the 
sickness, and even to provoke vomiting by the exhibition of emetics. 
Dr. Hendy objects to this practice. 

In women, pregnancy is a very unfavourable circumstance. A 
young woman, of Havre, having married against my advice, became 
pregnant three times; after each pregnancy the right leg, which was 
affected with elephantiasis, became more and more enlarged. 

A great number of patients have been cured by compression, either 
alone or combined with other means. This method was completely 
successful in the hands of Bayle and M. Alard, in one of their patients 
who had been affected with elephantiasis for twelve years. A strong 
man w y as employed to press the leg of the patient every morning in 
all directions, during three quarters of an hour or an hour, after which 
a roller was firmly applied from the toes to the knee. M. Lisfranc 
has also been very successful in these cases by the judicious combi- 
nation of scarifications, compression and local bleedings. I have 
myself obtained unhoped-for cures by this method. It is more espe- 
cially applicable in cases of elephantiasis of the limbs, consisting of 
simple hypertrophy of the cellular tissue without infiltration of serum. 
If it does not succeed completely when the tumefaction is partly 
owing to anomalous development of the muscles and bony tissue, it 
determines at all events the absorption of a certain quantity of fat and 
serum, and this is a result which we are always happy to obtain. 
Compression alone is found to suffice in a majority of cases ; scarifi- 
cations seem now to be rarely used ; when it is thought necessary to 
have recourse to them, they should be made at such a distance from 
each other as shall prevent the inflamed circles, which are or may be 
formed around them, from meeting. The inflammation produced in 
an extremity by twenty or thirty scarifications of from half an inch to 
an inch in length, is not in general considerable; if it should increase 
to any degree of intensity, local and general bleedings must be had 
recourse to in combination with emollient and cold narcotic applica- 
tions. It will be necessary to wait until the first scarifications are 
healed before others are made ; several practitioners have recom- 
mended blisters and issues to the parts affected with elephantiasis. 
I have tried the effect of flying blisters. The trials which have been 
made with arsenical preparations upon patients labouring under 
elephantiasis, but without any evident advantage, should not be 
repeated. (b) 



(a) We must regard Arabian elephantiasis as a constitutional dis- 
ease with febrile action and phlogosis, which, if not checked, ends in 
a deposit in some organ or limb. The treatment recommended by 
Rhazes, of general blood-letting with emetics, laxatives, diet and 
rest, is the best. It is that adopted by M. Rayer and also by Dr. 
Musgrave, who also used to apply leeches and fomentations to the 
limb, and administered calomel until the mouth was affected. 

(b) Instances have been quite recently related {Brit. $ For. Med. 



Patients who have been affected with elephantiasis should continue 
to wear a laced stocking, or a tight bandage after recovery, particu- 
larly when several of the veins of the extremity are in a varicose 
state, (a) 

1355. Harassed and worn out by the enormous weight of the parts 
affected, many patients have insisted upon amputation as a last re- 
source for an incurable disease. M. Alard assures us that those who 
have survived such an operation have become affected with elephan- 
tiasis in other parts of the body, or that they seldom failed to sink after 
one or more attacks of an inflammatory affection of the viscera, to 
which they seemed to become liable. A woman who, from the age 
of fifteen years, had suffered frequent attacks of the Barbadoes ma- 
lady, was so much incommoded by the size of the affected limb that 
she begged it might be amputated. This was done; but a short time 
afterwards she had so violent an attack of the disease on the other 
leg that she sunk under it (Hendy, case 24). A woman, named 
Mary Pecout, whose case I have related in the first edition of this 
work, underwent amputation of the right thigh, in the month of 
March, 1823, after having been affected with Arabian elephantiasis 
from the age of seven years. In January, 1825, the disease attacked 
the right arm, and was treated successfully by M. Lisfranc by local 
bleedings, scarifications, and blisters. To these unsuccessful cases 
of amputation, Delpech opposes that in which M. Delmas, chief 
prosector of the faculty of Montpellier, amputated the arm under 
circumstances exactly similar, and without its being followed by any 
relapse. A patient operated upon by M. Larrey for elephantiasis of 
the scrotum, was in a fair way of recovery when this celebrated sur- 
geon left him to proceed to Alexandria. Authier, operated upon by 
Delpech, on the 11th of September, 1820, left the hospital of Mont- 
pellier in the early part of February, 1821, apparently in good health, 
but with a slight cough. On his arrival at Perpignan he was pale 
and completely blanched in appearance ; his pulse was extremely 
small. He died on the 23d of the same month of inflammation of 
the liver, of the peritoneum, of the right hypochondrium, and of the 
pleura of the same side. M. Talrich operated with success, in 1811, 
on a young woman affected with elephantiasis of the sexual organs. 
Na?gele has been equally successful in the amputation of a leg in a 
case of elephantiasis. The question, therefore, as to the propriety 
or impropriety of amputation is not entirely settled, (b) 

Historical Notices. 

1356. The first pretty accurate ideas in regard to this disease are 
to be found in Rhazes (cum Serapio, Averrhoe, edit. G. Franks), 
1533, in Haly-Abas, and in Avicenna (Libri de re medicd omnes, in 
fol., Venetiis, 1564, vol. i. p. 952, elephantia), and it is on this account 
that the disease we are discussing received the name of elephantiasis 
Arabica or Arabian elephantiasis. The disease has been since noticed 
by Forestus (Opera, lib. xxiv. p. 453), by Mercuriali (Demorbis cuta- 
Jiesis, lib. ii. cap. v.), and by Kfempfer (Amcenit. Exot. fasc. 3, p. 58). 

Rev., April 1845), of cures of elephantiasis by the use of the Carlsbad 
waters. Iodine, in solution, with salines, merits a full trial in conjunc- 
tion with its external use in the form of ointment of iodide of potas- 
sium, or of liniment holding this salt in solution. The vapour bath 
is also a useful adjunct. 

(a) Change of climate, or at least of locality, should be recom- 
mended. 

(b) A case of elephantiasis of the scrotum occurring in a negro 
boy, nineteen years of age, on the island of St. Croix, is related by 
Dr. W. H. Ruan (Amer. Journ. Med. Sciences, vol. vi.), in which he 
amputated the diseased part. The operation was performed on the 
8th of November 1828, and on the 26th of January following, the 
youth returned to his work on the plantation. The communication 
was made by Dr. Ruan, in February 1830, leaving the inference that 
to that date all had gone well in this case. The disease had begun 
in early boyhood with erysipelatous inflammation of the scrotum, penis, 
and surrounding skin and cellular substance. 

Doctor G. R. B. Horner (op. cit.), says that this operation has been 
repeatedly performed at Rio de Janeiro, ''and it is said with success 
in some cases." 



ARABIAN ELEPHANTIASIS. 



409 



Elephantiasis Arabica has been observed in Egypt, by Prosper Alpinus 
{Medicina Methodica, Lugd. Batav., 1719), and by the medical officers 
of the French army that invaded Egypt (Larrey, Relation hist, et chir. 
de PExpedit. d' Egypt, in 8vo. Paris, 1812, 1817). J. Hendy (On the 
glandular disease of Barbadoes, translated into French by'Alard, in 
Mini, de la Society Medicate d'cmul., t. iv. p. 44), studied it among the 
natives of Barbadoes. M. Alard, who has published a learned essay 
on this disease (De V inflammation des Vaisseaux absorbans, lympha- 
tiques dermoides et sous cutanea, (Elephantiasis des Arabes,) new edition, 
in 8vo. fig. Paris, 1824), thought that the anomalous developments 
which characterize it were constantly preceded by inflammation of the 
lymphatic vessels and glands, (a) The cases of M. Bouillaud (Ob- 
servations d' elephantiasis des Arabes, Archives Generales de MEdecine, 
t. vi. p. 567), and some others published subsequently in the first 
edition of this work, and detailed under my own eye, by M. Gaide 
( Observations sur V elephantiasis des Arabes, inserted in the Archives 
Generales de Medecine, t. vii. p. 553), would lead us to imagine that 
varicose states, and contractions, and obliterations of the veins, as also 
eczematous and erysipelatous inflammations, were in many cases not 
less efficient causes of these intumescences. The researches of M. 
Fabre may be consulted with advantage (Observations de V Elephanti- 
asis des Arabes. Revue Medic, Oct., 1830), and a case of Arabian 
elephantiasis, by Martini and Horack, published under the title of 
Obs. rarioris degenerationis cutis in cruribus elephantiasis simulantis, 
Lipsiae, in 4to., 1828, as also the various cases which have been pub- 
lished on elephantiasis of the hairy scalp (Ricord, Revue Med., t. 
ix. p. 13), of the arm (Hensler, Histor. brachii pccrlumidi, in Haller, 
Disputat. Chirurg., vol. v.; Ludoff, Casus elephantiasis inbrachio ob- 
servatce, in 4to., Erford, 1703, in 4to.), of the scrotum and penis (Tal- 
rich, Revue Med., t. i. p. 180; Wadd, cases of diseased prepuce, 4to., 
London), on the pathological anatomy of the skin in elephantiasis, 
by M. Andral (Revue MEd., t. xiii. p. 224), and on the treatment of 
this disease, by Lemasson (Influence salutaire d'un erysipUe sur une 
elephantiasis des Arabes. Journ. hebd. 2de serie, t. iv. p. 408), on 
elephantiasis cured by antiphlogistics (Revue MEd., 2de serie, t. iv. p. 
489), and some cases of amputation published by Naegele (Archives 
Gen. denied., t. xiii. p. 126), and by Clot (Gazette des hopitaux, 1833, 
p. 388), are all interesting, and all deserve to be consulted, (b) 

(a) The monograph of M. Alard is both learned and comprehen- 
sive. After giving the anatomy, physiology and pathology of the 
absorbents, the author examines the state of the knowledge of ele- 
phantiasis among the ancients and the Arabians. He next indicates 
the regions in which it is met with, and analyzes the description of it 
by different writers. Then follow cases occurring in Europe, the 
precise seat of the disease, the textural and organic changes to which 
it gives rise, its symptoms, causes and treatment. Several good en- 
gravings are attached to the work. 

(b) M. Sigaud (op. cit., 1844), tells us that this disease is endemic in 
parts of Brazil, where it is called the erysipelas of Rio de Janeiro. It 
is also called elephantiasic leprosy, and Foot of St. Thomas. 

Doctor Pennock, on " Observations on Elephantiasis" (Amer. 
Journ. Med. Sciences, vol. xiv.), details a case of elephantiasis of the 
Arabs complicated with frambcesia, which terminated fatally, and of 
which the post-mortem appearances are described. It will interest, 
we are sure, the reader, and hence is transcribed for his benefit. 

" Barbier, aged twenty, by profession a joiner, entered the Hopital 
St. Louis, service of M. Biett, in the autumn of 1833. In the month 
of December, I collected the following facts respecting his case. 

" He was born in the Department of Haute-Saone ; has never been 
in tropical climates, but has always lived in France, and his parents 
were free of all cutaneous disease. His nourishment has always been 
good. During the first years of childhood until he was nine years of 
age, he enjoyed good health ; from that period until the age of seven- 
teen he was affected with a succession of abscesses in the groins, on 
the neck, arms, and at the external extremity of the left clavicle. 
From the appearances of the cicatrices, there is no doubt but that 
these abscesses were scrofulous. They are of a brown colour, almost 
livid, intermixed with white, of an irregular form, and an uneven 
surface. 

" The present affection commenced two years ago, immediately 



above the great toe of the right foot, by a slight elevation and dis- 
coloration of the skin, attended with local pain and some fever; these 
symptoms were followed by a small, soft, projecting tumour of a red 
colour which bled upon the slightest touch. 

" Six months afterwards the patient contracted a Menorrhagia, 
which ceased in a month under the treatment of injections of infusion 
of marsh-mallow, drinking the decoction of sarsaparilla and the liquor 
of Van Swieten. No secondary symptoms followed, but the cutaneous 
affection was subsequently augmented ; since that time he has not had 
any venereal symptoms. The disease extended itself by the succes- 
sive formation of the spongy tissue from the toes to the superior part 
of the thigh. It presents, according to its degree, four principal forms. 

" First. Asmall, indolent, subcutaneous tubercleof the sizeofapea, 
causing a slight elevation of the skin. This is the commencement. 

" Second. Convex elevations exactly circular rising from one to four 
lines above the skin, surrounded by a brown circle varying in diameter 
from a quarter of an inch to one and a half inches, of a red colour, soft, 
spongy, analogous to the fungus of wounds, and bearing some resem- 
blance to raspberries lying side by side, and exuding a red serosity. 

" Third. Masses formed by the union of the above, but of irregular 
forms of variable size, covering the leg and the inferior part of the 
thigh. The greater part of these tubercles have the same appearance 
as those which are isolated. Where the healing process has com- 
menced, the surface is drier, less elevated, and not so irregular. At 
the superior and inferior part of the leg the vegetations have the forms 
of small fleshy tongues, imbricated, resembling the crest of the cock. 

" Fourth. Cicatrices, which are sometimes large, smooth, of a 
white colour, slightly elevated above the healthy skin ; sometimes the 
fungosities seem to have dried up without changing form, and have 
assumed a brown, livid appearance. 

" The union of all these alterations has changed the form of the 
limb, and gives it the appearance of the elephantiasis of the Arabs. 
The circumference of the superior two-thirds of the diseased leg is 
one inch more than that of the corresponding part of the other : the 
inferior third is one inch and three-quarters more than the left. The 
limb is the seat of excessive itching, and when cauterization is at- 
tempted by the per-nitrate of mercury, the patient suffers excruciating 
pain. With the exception of the cutaneous affection, his general 
health appeared good during the winter of 1833-4. Treatment — 
Infusion of hops for habitual drink, with 3ij sub-carb. soda, per oj.; 
alkaline baths daily, and cauterization with per-nitrate of mercury 
(nitrique acide de mercure). 

" April and May. — After the first of April, excessive diarrhoea 
commenced, attended with extreme prostration of strength ; the tongue 
was red, dry; thirst extreme ; abdomen slightly painful upon pressure; 
the pulse frequent (88), and feeble; his usual cheerfulness forsook 
him, his mind became depressed, and he complained bitterly of his 
situation. The diarrhoea was arrested at intervals by regulating his 
diet, and by opiates and astringents, but was renewed by the impru- 
dent excess of the patient. During this time the vegetations, (fun- 
gosities,) and the tissue of the cicatrices ulcerated, and the diseased 
limb was covered with extremely painful ulcers, very irregular in their 
forms, their edges perpendicular, and internally of a grayish colour. 
The slightest pressure upon them produced an exudation of very foetid 
pus. With these symptoms the patient died on the second of June. 

" Autopsy thirty' hours after death. — The skin on every part of the 
diseased limb was thickened, and with the cellular tissue beneath 
was from one-fourth of an inch to an inch and a half thick. On the 
cicatrized points the epidermis was smooth, and beneath this the 
entire thickness of the cellular and adipose substance, with the excep- 
tion of a few isolated masses of adeps, was replaced by a white, 
fibrous, aponeurotic tissue, which was firmly attached to and blended 
with the dermis. In the points in which cicatrization had not com- 
menced, the epidermis appeared detached from the dermoid mucous 
tissue, which was red, thickened, slightly uneven, (marnelonne ,) 
bearing some resemblance to the intestinal mucous membrane, and 
could be raised without dissection from the subjacent adipose layer. 
In the middle of the thigh between the sartorius and rectus femoris 
muscles, was an abscess of the size of a goose-egg, containing a white 
tenacious pus; and on a level with the internal malleolus, all the 
cellular tissue, for the space of two inches, was changed into a sanious 






INTUMESCENCES. 



BARBADOES LEG. 

". In the month of February, 1755, a lover prevailed in the 
i characterized by a cold stage of four or five hours 

11, a hot fit, &c., headache, and frequently severe pains in the 
er was sometimes ephemeral, and occasionally lasted 

e than tour or live days; ii, however, much more generally 
continued longer, and then there supervened inflammation of the leg 
similar to that which accompanies the fever of elephantiasis, but 
without swelling of the lymphatic glands, and without any hard cord 
in the limb. The inflamed part was of a vivid red ; small phlyctenaj 
and there over its surface, as in erysipelas, and desquama- 
tion took place after the cessation of the inflammatory symptoms. 

An epidemic of the same description recurred during the month of 
February, 1757, but marked by several important varieties, which 
were probably ascribable to the excessive heat of the weather upon 
this occasion. The fever was now accompanied with pain in the 
stomach, nausea, cough, and sometimes with delirium and coma. The 
local affection was exhibited in the feet, legs or arras of either side, but 
never of both sides at once, and was distinguished by the same redness 
and swelling as in elephantiasis ; the swelling, moreover, increased 
after the fever had ceased. During the next month many persons 
were no otherwise affected than with a troublesome cough, which 
ceased as soon as the tumour appeared on the arm or hand. The dis- 
ease continued with this phasis till the month of June, when it assumed 
new features: the heat became more considerable, the thirst greater, 
the pains in the back and limbs much greater than at first, and the 
tumours or swellings were apt to fall into suppuration, instead of being 
resolved, as they were through the preceding stages of the disease. 
(Hendy, James. A treatise on the glandular disease of Barbadoes, 8vo. 
London, 1784.) Hillary, W. (06s. on the air and the concomitant 
m. diseases in the Island of Barbadoes, 8vo. London, 1759.) (a) 



ANDROI AND PERICAL. PEDARTIIORACE AND ENDEMIC HYDROCELE. 

135S. These are two affections analogous in their nature to Arabian 
elephantiasis, which prevail endemically on the coast of Malabar, in 

mass of a slate-gray colour, and of a fcetid odour. At the external 
healthy parts of the leg, the adipose substance was two lines in thick- 
ness, soft, and of a clear light-yellow colour; in the diseased parts, on 
the contrary, it was an inch thick, and separated into masses by a 
white tissue. This tissue was firm, resistant, and was penetrated 
with difficulty by the scalpel; the cells formed by the interlacing of 
its fibres contained, beside the adeps, a great quantity of serous and 
gelatinous fluid. In the parts which were highly diseased, the skin 
was entirely destroyed, and the ulceration extended to the adipose 
layer ; on the internal and superior part of the leg, and beneath the 
aponeurotic fascia, was an abscess of the size of a hen's egg, contain- 
ing greenish pus, and partly lined with a false membrane. The 
tunics of the internal saphena vein were thickened, and when cut 
across, the cut extremity remained open like an artery. The tendons, 
bones and periosteum were healthy. 

" Thorax. — A small group of tubercles were found at the summit 
of the right lung. Near these was a cavity traversed by fibrous bands, 
and was evidently a cicatrized tuberculous cavern. The rest of the 
lungs crepitant, and floated when thrown on water. 

" Heart. — The heart was soft, and the parietes of the ventricles thin. 

" . Ibdometii — The liver was much enlarged ; it not only occupied 
gastric region, but extended into the left hypochondriac ; the 
volume of the left lobe was almost equal to that of the right, its entire 
weight eight pounds. Externally and internally it was yellower than 
usual. The gall-bladder contained a greenish bile; its ducts were 
unobstructed. The mucous membrane of the stomach, and the intes- 
ui their entire extent, had its normal colour and consistence. 
There was neither redness nor softening, nor induration of this tissue." 

(a) There was no call for separating Barbadoes leg from elephan- 
in the preceding section, since the former is merely the latter 
disease endemic in Barbadoes,— as it is in so many other places. See 
note ante to § 1351. 



the island of Ceylon and Japan. The one attacks the foot (perical), 
the other the scrotum (andrum). 

1359. Perical, or febrile foot, is very common among the natives of 
Cochin. Young persons are attacked more frequently than adults, 
and these oftener than the aged. A very general opinion is, that the 
Christians, among whom the disease is very common, bring it from 
the Coromandel coast. The disease attacks one or other of the lower 
extremities ; very rarely both at once, and always occurs on the lowest 
part. 

Those affected with it have an attack of phlegmonous inflammation 
every month, which vanishes after a few days, but leaves a swelling 
which degenerates so that the extremity becomes triple, quadruple 
and more, its former size. It is uneven, cedematous, hard, of a 
scirrhous appearance, and often the seat of ulcers which discharge a 
serous-looking fluid. The swelling generally extends to the toes, 
rarely ascends above the calf of the leg, and never affects the knee. 
It is occasionally also observed in the thigh, which, however, may be 
simply infiltrated from the scrotum when this is the part affected, as 
it is in the endemic hydrocele. Although the tumefied part be hard, 
and have a brownish and deformed appearance, it never becomes 
gangrenous, and is not dangerous. It is only painful at the epoch of 
the periodic inflammation, and is troublesome solely from its weight. 
When the affection becomes inveterate, the limb is apt to be covered 
with a number of small ulcers, which render the infirmity more 
unbearable. 

1360. Andrum, or endemic hydrocele, begins with an erysipelatous 
affection of the scrotum, which is renewed every month at the time 
of the new moon, and leaves a swelling behind it which is caused 
by the effusion of a quantity of serous fluid, the quantity of which 
increases from day to day, and distends the part to such a degree that 
it has at length to be evacuated by punctures and scarifications. This 
iluid is either thin and limpid, or viscid ; it is always reddish in colour, 
and differs in its qualities according to the temperaments of patients. 
The disease attacks the natives and Europeans ; a residence of a few 
years is enough to render any one subject to an attack. It is incurable 
in the country; but it is neither dangerous nor very troublesome. 
Still it sometimes happens that the testis is implicated and becomes 
scirrhous. If patients leave the country, the tumefaction abates gra- 
dually, unless it be complicated with sarcocele, a disease for which 
there is no remedy (Keempfer, Amcenit. Exoticse, 4to., Lemgo, 1712). 



1361. Senki is the name given by the natives of Japan toadisease 
which is very common among them, so common, indeed, that among 
ten adults, it is difficult to find one who has not been affected with it 
at one time or another. Strangers, too, after a short residence in the 
country, are liable to the disease. It begins with pain in the belly, 
and spasms, particularly in the abdominal muscles, when a sense of 
suffocation supervenes, from the tension which then occurs between 
the region of the pubes and that of the false ribs and ensiform car- 
tilage. The disease is sometimes fatal. When it abates, swellings 
are observed to occur here and there over the whole surface of the 
body; among men it often produces an enormous enlargement of the 
eyebrows ; among females, the labia majora are beset with a congeries 
of tubercular or fig-like enlargements. Enlargements of these parts 
in the two sexes are common in Japan, and may supervene without 
appearing to be consequences of colic (Ka?mpfer, op. cit, p. 552). 



MOUTH CANKER [LABRA-SULCATA (a)], OR CHEILOCACE OF IRELAND. 

1362. Boot describes a disease as prevailing in Ireland and even 
in England among children of four or five years old, characterized by 
a tumefaction of the lips, which become hard, and by projecting from 
the gums and teeth, give the countenance a hideous and unnatural 
expression. Occasionally they are divided by a deep chap or fissure 
into two parts, as it were, from whence there flows a sanious-looking 



(a) Labri — sulcium in the text. 



ALEPPO PUSTULE. 



411 



fluid, which chics up into a crust. The upper lip alone presents this 
anomalous enlargement in some cases, and when both are affected, 
the upper is always so in a much greater degree than the lower. This 
disease is mouth-canker, labra sulcata, or cheilocace. It is very gene- 
rally accompanied with ulcers in the mouth, on the palate, tongue, 
and gums. The best treatment, we are told, is to purge patients 
freely with calomel, and infusion of senna, to make them drink an 
infusion of fumitory, rumex, patientia, and endive ; to apply leeches 
to the lips and temples, and even to recur to general blood-letting if 
they be strong. The lips should be kept moistened from time to time 
with a decoction of honeysuckle, &c, or with a solution of sulphate 
of zinc, and then rubbed over with a liniment of the acetas plumbi 
and oil. A blister may be applied to the arm, if the disease be obsti- 
nate, and decoction of sarsaparilla, cinchona, &c, prescribed for all 
drink (Boot) ; Arnaud (Obs. Med. de affectibus omissis, 12mo. Lond., 
1649). 

Mercurialius and Bonetus (Sepulchret. anat., lib. i. sect. 21, obs. 
17), also speak of this disease, upon the nature and characters of 
which there still hangs great obscurity. I have frequently observed 
a hard and indolent tumefaction of the lips in children of scrofulous 
constitution, (a) 



SECOND GROUP. 
ENDEMIC TUMOURS. 

1363. This group includes tumours which are only known to occur 
in certain countries. 

ALEPPO PUSTULES (BOUTON d'aLEP.). 

1364. Symptoms. — The Aleppo pustule or spot is a disease ende- 
mical in Aleppo and several towns of Syria, which attacks almost all 
and sundry once in their lives. It is characterized by one or several 
pustules of tardy growth, which get well after having ulcerated, but 
leave ugly cicatrices behind them. It is denominated habbet el seneh 
(spot or pustule of a year), in Arabian, because a year is'required for 
it to run through the whole of its stages, that is to say, to be evolved, 
to suppurate, and cicatrize. It begins in the shape of a small promi- 
nence of a lenticular shape, without heat, pruritus or pain. This 
increases insensibly to the end of the fourth or fifth month, when it 
may have acquired from about six lines to several inches in diameter, 
and be found to project about three lines. At this time it becomes 
the seat of acute pain, the severity of which, however, varies accord- 
ing to the place of the affection. Its surface becomes covered with 
a whitish moist incrustation, which, when very firm, is either detached 
completely, or only cracks in different places, and allows a quantity 
of purulent matter, white or of a yellow colour, and inodorous at first, 
which is formed slowly in the interior of the tuberculation, to escape. 
When the crust falls off, the surface it covered is found uneven, 
granulating, and of the colour of raw meat; the place is surrounded 
with a red areola. The crust falls off entirely or in pieces at in- 
tervals; when it remains long adherent, the discharge becomes thick, 
of a dark colour, and extremely fetid. The period of suppuration 
lasts five or six months, and ends in the formation of a dry and ad- 
hering crust, which is complete by the end of the year when the 
disease has been left to itself, and the patient is in other respects 
well. The affected part, when first exposed, is at first of a vivid red, 
then becomes of a reddish-brown, and by and by approaches nearly to 
the natural colour of the skin. 

1365. All parts of the cutaneous surface may become the seat of 
the Aleppo pustule, but it is most generally developed on the face 
and extremities. The inhabitants of Aleppo have it more frequently 
on the face than on any other part. This is the mark which distin- 



(a) This disease of the lips is to be regarded as a part, merely, of 
canker or gangrene of the mouth. — Gangrenous Stomatitis. See 
Bell 8f Stokes's Lectures, vol. i. 



guishes them from the rest of the Syrians. Foreigners, on the con- 
trary, are seldom attacked with it on the face. When the pustule 
appears on the joints, over bony projections, and on regions which 
are but indifferently covered with soft parts, it occasions very severe 
pain. M. Guilhou relates a case of this disease occurring on the 
scrotum in a Frenchman; such an event is very rare. 

The inhabitants of Aleppo distinguish two species of this disease 
by the very objectionable names of male pustules, and female pustules. 
The former are single, whilst the latter occur in numbers together. 
Round several of the principal pustules, others of smaller size and in 
greater or smaller numbers, are frequently clustered; these may be so 
numerous, that the whole body becomes ulcerated by them. M. 
Guilhou once saw a Frenchman who had seventy-eight principal 
pustules, each surrounded by smaller ones in such numbers that the 
eruption at first sight had the appearance of confluent small-pox. The 
loss of substance which the pustule occasions is sufficient proof that 
the whole substance of the skin is implicated. This eruption con- 
stantly leaves an indelible cicatrice which is as various in its form as 
the ulcers which precede it; it is depressed, with the edges more or 
less oblique, sometimes rather deep, but in general superficial. The 
cicatrice is either smooth or rough, rarely brownish, more frequently 
white. 

1366. Causes. — This disease is endemical to Aleppo and its en- 
virons. M. Gilhou assures us that a similar eruption prevails in 
Bagdad, on the banks of the Tigris, and of the Euphrates, and in all 
the villages on the road from Bagdad to Aleppo, such as Mossal, 
Diarbekir, Medira, and" Orfa. At Aleppo, foreigners and natives, 
without distinction of race, sex, temperament, or profession, are 
affected by it. It rarely attacks infants at the breast; it is generally 
at the age of two or three years that it is developed. There is not 
a single instance of a child born in Aleppo, having reached the age 
of two years without having been affected with this disease. The 
time at which it attacks strangers is variable. It is very rarely that 
they suffer from the eruption till after a residence of some months. 
It is also often years before it shows itself; but it is the general 
opinion at Aleppo that it is enough to have passed some days in that 
city for the disease to be developed sooner or later, in whatever 
country the individual may afterwards happen to reside. Several 
facts in confirmation of this statement have been adduced. The 
Aleppo pustule is not contagious; it only attacks individuals once in 
the course of their lives. 

1367. Prognosis. — This disease is never fatal, but the face may be 
horribly disfigured by it, particularly when it is situated in the neigh- 
bourhood of the eyes, mouth or nose, &c. The ulcers often partially 
destroy the eyelids, and the ake of the nose; they divide the lips, 
cause gaps in the external ears, and always leave frightful cicatrices 
behind them. In fact, the cicatrices which the Aleppo pustule leaves, 
are the worst and most dreaded effects of the disease. 

1368. Treatment. — The various curative means tried in this disease 
have seldom appeared to exert any beneficial influence. It would 
indeed seem advisable to confine all treatment to the use of soothing 
washes, to great attention to cleanliness, and to keeping the ulcers 
from exposure to the air; still the ceratum minii camphoratum, or 
cerate of Nuremberg and the actual cautery, appear to have been 
employed with advantage before the period of suppuration, during 
the third or fourth month. 

Historical Notices. 

1369. We are indebted for the principal documents we possess on 
the Aleppo pustule to Russel [Alex.] (Natural History of Aleppo, 
and the Neighbouring Country, 2 vols.'4to.), to Dr. Hasselquist {Iter 
Palestinum (in Swedish), Stockholm, 1757, 8vo.), toVolney {Voyage 
en Egypte et en Syrie, 1787), to Bo (Memoire sur le bouton d'Alep., 
addressed to the Royal Society of Medicine, Journal de Midecine de 
Roux Destillets, vol. lviii. p. 411), to M. Alibert, who has himself 
seen the disease in two individuals who had lived at Aleppo, and has 
published several cases collected there by one of his pupils, (sur la 
pyrophlyctide endemique ou pustule d'Alep, Revue Medicale, Juillet, 
1820, p. 62), finally to M. Disant (Gazette Medicale, Paris, 1832, 
4to., p. 556), and to M. P. J.B. Guilhou, who have seen the disease 



4T2 



ELEPHANTOID DISEASES. 



in the countries thru,- [yes where it prevails, during a journey made 
through Syria, in 1829 [Essai sur le bouton d\dhp. Diss, inaug. 



TARA OF SIBERIA. 



1370. Gmelin, during his travels in Siberia, in 1740, 1741, 1742, 
1743, observed a contagious epidemic, which generally prevails during 
the months of June and July, in the city of Tara, and on the banks 
of the river Irtisch. This disease shows itself at first by a species of 
pustule of a pale colour, and hard to the touch, which appears on 
different parts of the body. In the course of four or five days these 
purfulcs attain the size of the fist, without changing colour or becom- 
ing less hard. The patient then experiences great weakness, with 
excessive thirst, loss of appetite, drowsiness, vertigo, precordial 
anxiety, difficulty of breathing, fetid breath, paleness of the face, 
excruciating internal pains, inexpressible anguish, and, if a copious 
sweat does not break out, death is inevitable from the ninth to the 
eleventh day. 

The treatment which is considered to be infallible is always under- 
taken by a Cossack, who kneads the tumour all around until the blood 
flows from it, or he plunges a needle into it until the patient complains 
of the pain of the operation. He then applies a cataplasm of chewed 
tobacco and sal-ammoniac, which is renewed three or four times in 
the course of twenty-four hours, and in the space of six or seven 
days the cure is accomplished. No other drink than warm quaas or 
quass, a liquor made of leaven or flour fermented in water, is gene- 
rally allowed during this interval, though chicken broth with horse- 
radish stewed in it, is occasionally prescribed instead. Milk, meat, 
fish and dry vegetables are interdicted. 

The parenchyma of these tumours is said to be a spongy bluish 
kind of flesh. Gmelin treated these tumours by opening them and 
powdering their interior with the red precipitate of mercury, whilst 
he prescribed calomel internally. 

Horses contract this disease; the tumours are treated in these ani- 
mals by the application of the actual cautery. (Gmelin, Travels in 
Siberia, from 1733 to 1743. Gcettingen, 1731-52, 4 vols. 8vo. fig., in 
German.) 



THIRD GROUP. 
ELEPHANTOID DISEASES. 

1371. In this third group several endemic diseases which are evi- 
dently varieties of Greek elephantiasis [the tubercular lepra of the 
middle ages], and others which evidently bear a greater analogy to 
elephantiasis than to syphilis, with which they have sometimes been 
assimilated. 

THE MAL ROUGE DE CAYENNE. 

1372. Under the name of the Mai Rouge de Cayenne, Bajon and 
Bergeron have described Greek elephantiasis, or tubercular lepra, 
which is more common in this island than in any other in the French 
colonies. See Dazille ( Obs. sur les maladies des negres, 8vo. Paris, 
1742, t. i. p. 300), Bajon (Mbnoires pour servir tl Vldstoire de Cay- 
enne et de la Guyane Frangaise. Paris, 1777, 1778, in 8vo. 2 vols.), 
the Rapport des commissaires de la sociHe royale de medecine sur le mal 
rouge de Cayenne ou elephantiasis. 8vo. Paris, 1786, and Bergeron's 
treatise (Mal rouge observe ci Cayenne. Diss, inaug. Paris, 1823). 

RADESVGE. 

1373. Radesyge is a Norwegian term, synonymous with the Latin 
phrase morbus atrox, by which the physicians of the country have 



designated a disease of the skin which is looked upon by some 8 
species of syphilis, and by others as a variety of elephantiasis; the 
latter opinion, according to the descriptions wc have of the symptoms, 
seems to me the more probable of the two. 

Radesyge shows itself in the cold and foggy season, by a feeling of 
weight over the whole body, lassitude of the limbs, and itchiness of 
the skin. Patients afflicted with this malady fly every kind of occu- 
pation; they experience a stiffness in the joints, and headache in the 
frontal region, accompanied with a sense of tightness in the chest, and 
dyspneea. The face has a pale, livid, leaden colour, followed by 
plethoric redness, and running at the nose, which renders the passage 
of the air into the nasal fossae difficult. The nose becomes red and 
swelled, the voice hoarse, the uvula elongated, and wandering pains 
in the limbs supervene, which subside towards morning after a very 
copious, viscid, and rather fetid perspiration. Some months, or some 
years afterwards, a dry, whitish, mealy, or furfuraceous eruption forms 
on the surface of the integuments, the scales of which fall off and are 
replaced by thicker ones which render the skin uneven, hard, and 
rugous. At other times an. extensive discharging eruption is thrown 
out, which occasions most distressing pruritus. Some patients present 
an eruption of small spots of various colours and the size of flea-bites, 
at first, on the face and then over the whole body, which appear and 
recede alternately, particularly under the influence of a damp atmo- 
sphere. These spots are mostly insensible, and may be pricked with a 
needle without causing the least pain. When they ulcerate a viscid 
matter runs from them, and they soon become covered with scabs or 
scales ; a serous ichor often flows from them which inflames and ul- 
cerates the neighbouring parts with which it comes in contact. These 
eruptions are accompanied or followed by coppery or lead-coloured 
tubercles, which are evolved, first on the face and afterwards over 
the whole body. By degrees the skin of the forehead thickens and 
wrinkles, the eyelids tumefy, the cheeks swell and assume a deep red 
colour, the lips, swelled and stretched out, give an unnatural size to 
the mouth. The external ear is folded and convoluted, the eyes are 
surrounded by a red circle, the look becomes oblique and menacing, 
in one word, the face is so hideous that it inspires universal disgust 
and horror. The tubercles, once formed, present scales, scabs, and 
ulcers, on their summits. On examining the posterior fauces tubercles 
are seen on the uvula, tonsils, and velum palati, to which foul ulcers 
succeed. These ulcers have callous, hard, uneven edges, from which 
a reddish and fetid matter is discharged, which dries up into reddish 
or brownish crusts. The skin situated between the ulcers is also 
often intersected with ridges or crevices, and the hair with which it 
is covered falls out. The violent pains in the limbs decrease, and 
sometimes cease entirely, as soon as the skin is affected. Arrived at 
this pitch, the disease still continues to advance. The ulcers, after 
having destroyed the integuments and soft parts, extend their ravages 
to the bones ; the discharge is now extremely copious and of a most 
unbearable odour. Flaps of fungous flesh are detached from the 
bottom of the ulcers, caries attacks the bony palate, vomer and ossa 
nasi, the voice changes and becomes weak, articulation is difficult, 
the hair of the head and of all the other parts of the body, eyebrows, 
&c, falls off; sometimes even the phalanges of the fingers drop. Pa- 
tients are at the same time said to have a most voracious appetite, and 
unquenchable thirst. These phenomena are regarded as the fore- 
runners of approaching death. This happens when the strength is 
entirely exhausted by night sweats and colliquative diarrhoea. 

As to the treatment of radesyge, much the same course has been 
recommended as that followed in elephantiasis, or in cases of syphi- 
litic affection, according as it has been held analogous to the first or 
to the second of these diseases. 

Historical JYotices. 

1370. Dr. Ludwig Hunefield, in his work on radesyge or Scandi- 
navian syphiloid (Die Radesyge oder Scandinavische Syphiloid. Leip- 
zig, 1828, Extract, in Bull, des sc. medic, de Ferussac, t. xviii. p. 387 ; 
t. xx. p. 410), has given an account of the principal researches made 
into the nature of the disease. Consult Hoist (Morbus quern radesyge 
vocant, quinam sit, quanamque ratione e Scandinavia tollendus, 8vo. 
Christianise, 1817), Munk, (Mimoire sur le radesyge, Act deV Ac. Roy. 



LEPRA OF HOLSTEIN— LEPRA TAURICA— LEPRA AN.ESTHESIACA OF INDIA— JEWISH LEPROSY. 



413 



des sc. de Stockholm, 1815). Arbo (Afhandl. om radesygens Kjen- 
detegn., Sfc, Copenhagen, 1793), and Vougt (Jac.) (Diss, inaug. sis- 
tens, obs. in exanthema arclicum vulgo radesyge dictum. Gryphiao, 
1811, &c.) 

LEPRA OF HOLSTEIN. (SPEDALSKED.) 

1374. Doctor Struve assigns the following characters to this dis- 
ease: the face swelled, sallow, and shining; loss of the hair, eye- 
brows and eyelashes ; swelling and change of colour in the nose ; the 
tongue tubercular ; the lips swelled and hard ; alteration of the voice, 
and difficulty of breathing. Struve looks upon the lepra of Holstein 
and radesyge as the same, or as mere varieties of the same affection; 
he assimilates them to the lepra of the middle ages. Struve (Ueber 
die aussatzartige Krankheit Holstein^s, allgemein daselbst die Marsch- 
Krunheit genannt, 8vo. 1820. Extract, in Edinb. Med. and Surg. 
Journ., vol. xviii. p. 92). 

LEPRA TAURICA. 
Disease of the Crimea, or Lepra of the Cossacks. 

1375. Pallas, Gautier and Von Martius have described, under this 
name, a disease which prevails extensively among the inhabitants of 
the Crimea, and which was introduced, as is said, by the Russian troops 
engaged in the war with Persia. 

According to Martius, the lepra taurica, with or without fever, is 
announced by the appearance of a great number of livid spots, or flat, 
indolent tubercles on the face, trunk and extremities, principally on 
the radial side of the wrist. At a later period (according to Martius, 
in the following year), the spots increase in number and size, and be- 
come of a blackish or brown colour ; every part of the body except 
the skin of the hands, and the bends of the joints, may become covered 
with these spots ; at this period the spots are not painful ; the voice 
is occasionally hoarse, and the patient is restless and depressed. Still 
later (about the third year), a feeling of itchiness arises in the parts 
of the skin affected, similar to that occasioned by the bites of ants. 
The tubercles now become true flattened tumours, some of which are 
indolent, whilst others are the seat of intolerable itchiness. The shape 
of the body and face alters ; the face swells ; the lymphatic glands 
tumefy ; and at this stage of the disease great weakness of the inter- 
nal organs and considerable prostration are observed. In the fourth 
year great pain in the limbs, and particularly in the joints, comes on ; 
the sleep and appetite, which, up to this time, were unaffected, fail; 
the strength decreases by degrees ; the spots and tumours assume a 
reddish-brown hue, become hard, rough, and covered with squamse. 
Scirrhous lumps are seen under the skin of the face and extremities, 
and under the tongue. In the fifth year the swellings begin to give 
way, and, particularly on the feet, are followed by ulcers of bad cha- 
racter, from which a foetid sanies is discharged, or which are covered 
with thick scabs. These ulcers have been seen to involve the loss 
of all the points of the fingers in succession. Tormented by a sense 
of insupportable heat in other parts, the patients, by scratching, give 
rise to ulcers, even of a more serious nature than the first. The man- 
ner in which the natives treat these ulcers, further, renders the slight- 
est wounds of the greatest consequence. Finally (sixth year), the 
cheeks, lips, velum palati, and tongue, are corroded by ulcers, which 
often form on the inside of the nose, and in the trachea, when they 
occasion great interruption to the breathing. The nails, by this time, 
have generally been lost or are much altered. The viscera become 
more and more diseased, and death at length concludes the patient's 
misery. (Martin's Henricus, de lepra taurica, specimen medico-prac- 
ticum, 8vo. Lipsise, 1806.) 



LEPRA ANJESTHHSIACA OF INDIA. 

1376. Robinson gives the characters of this disease in the following 
terms : 

One or two circumscribed spots or patches of a deeper colour than 
104 



that of the skin around them, appear on the feet or hands, and some- 
times on the trunk and face ; these spots are neither prominent nor 
depressed ; they are shining and wrinkled ; the wrinkles do not run 
into the surrounding healthy skin. The spots extend slowly until the 
skin of the legs and arms, and, by degrees, that of the whole body, 
.when the disease is so extensive, is totally deprived of feeling. No 
perspiration takes place from the surfaces affected, neither are they 
itchy nor painful, and it very seldom happens that they are swollen. 
In a more advanced stage of the disease the pulse becomes very slow, 
(fifty to sixty pulsations in a minute,) and soft without being small ; 
constipation of the bowels follows; the toes and fingers are benumbed 
as though with cold, shining, slightly swelled, and somewhat stiff. 
The patient is indolent, slow in understanding the questions put to 
him, and seems to be constantly half asleep. The soles of the feet, 
and palms of the hands present hard and dry cracks; a furfuraceous 
matter is deposited under the nails, which raises them, and occasions 
the skin around them to ulcerate. The legs and forearms swell; the 
skin is everywhere rough and chapped ; at the same time ulcers form 
on the metacarpal and metatarsal articulations of the fingers and toes, 
in the line of flexion, and in the corresponding parts of the articu- 
lations of the trunk, without any evident tumefaction or pain ; pieces 
of skin, half an inch in length, become gangrenous and fall off, leaving 
the pale and flaccid muscles bare; these, in their turn, mortify, and by 
and by are also cast off'. Different joints may be thus attacked, and 
destroyed in succession, by the slow but uninterrupted progress oi 
this terrible disease, which renders those who are affected with it 
objects of horror to all who approach them. The pains in this affec- 
tion are not insupportable ; the appetite is unaffected, and patients, 
horribly mutilated, sometimes live long, without appearing to be 
disgusted with life. They are finally carried off by dysentery and 
diarrhoea. Robinson assures us that, although tubercular elephan- 
tiasis sometimes shows itself during the course of elephantiasis anccs- 
thesiaca, it is not necessarily consequent on it. ( Transact, of the Medic. 
and Chirurg. Society of London, vol. 10.) 



JEWISH LEPROSY (SARAAT). 

1377. Moses (xiii. and xiv. chap, of Leviticus), in his laws con- 
cerning leprosy (Saraat), points out the signs or marks by which the 
Jewish priests might recognize it. Dora Calmet has given the fol- 
lowing summary of these : the first indication is an outward tumour ; 
the second is a pustule or abscess ; the third a whitish or red and 
shining spot, to which the epithets white, brilliant are often applied. 
Whoever presented one or more of these marks, was shut up for seven 
or fourteen days. The certain signs of leprosy w T ere, first, a whitish, 
reddish, and shining spot ; second, the hair pale and red on the same 
place ; third, the part more deeply sunk than the rest of the skin. 

A simple white spot was not sufficient to cause a man to be declared 
a leper ; it was necessary that this should grow and increase. When 
the whole body was white from the head to the feet, it was a pure 
leprosy; and when the flesh was covered with white tumours, and the 
hair, on the parts where these were seen, had changed colour and 
become white, it was an inveterate leprosy, and rooted in the skin. 

If, in a cicatrice or in a place which had been burned, a white tu- 
mour or a whitish spot was seen, shining or red, more depressed than 
the surrounding parts, and the hair of which had become fair or pale, 
it was a mark of a true leprosy. Finally, when any place was seen in 
the head of man or woman, more sunk than the rest, if the spot in- 
creased, it was leprosy, whether the hair changed colour or not. On 
the head of a bald person, spots, either whiter or redder and more 
shining than the surrounding parts, indicated leprosy. 

1378. The Jewish leprosy has been assimilated with several other 
diseases. Bartholinus, J. Leclerc, and others associate it with tuber- 
cular elephantiasis ; Hillary and Adams think that it was nothing 
more than the frambcesia of Africa ; Bateman believes it to correspond 
with the leuce of the Greeks, with the haras of the Arabians, and with 
the third species of vitiligo of Celsus ; Lorry and several others regard 
it as a distinct disease ; but at the present day, possessing these scanty 
accounts only, it is evidently impossible to form any thing like a defi- 
nite and just idea of the nature of this disease. 



4U 



SYPHILOID DISEASES. 



Historical Notices. 

1379. On tlic Jewish leprosy, consult Mead (Medica Sacra, Lon- 

' 19 , Dom. Calmel (Diss, ou recherches sur la nature et les 

la Snintc Bible, Latin et Francais, Svo. 1S20, t. 

iii. p. 19); Oussel | Diss. Philologico-medica de lepra cutis Hebraorum) i 

Schiilin >rd, p. 63), and Boussille-Chamseru (Recherches sur 

I veritable caractar <lc la l<pre des Hebreux. Mem. de la Soc. Med. 
ii'Kmulation, t. iii. p. 335). 



MALUM MORTUCM. 

13S0. The malum mortuum observed in the middle ages, has been 
described by Theodoric and Joannes de Vigo. " Qusedam infirmitas 
nascitur circa tibias et brachia, qua? mal morto appellatur. Sunt enim 
ulcera livid a et sicca modicae saniei generativa, quandoque fiunt de 
pura melancholia naturali ; quandoque e melancholia cum admissione 
phlegmatis salsi ; si illud, cognoscitur pernigras pustulas sine pruritu; 
si hoc, livescit locus cum pruritu e mordicationibus" (Theodoric, 
Chirurg.f lib. iii. c. 49). "Malum mortuum est squalida scabies 
maligna et corrupta in brachiis, coxis et tibiis, faciens pustulas crus- 

tosas cum saniositate subtus ad instar lupini Sumitur per viam 

contagionis. . . . In signis, curis et causisplurimum confert cum morbo 
gallico ; quae, uni conferunt, alteri conferre videntur .... Pustular 
sunt aliquantulum extra cutim elevatse cum colore mori semimaturi . . . 
i carificatione profunda usque ad os parum aut nihil patiens sentire vide- 
tur (De Vigo, Tract, in arte Chirurg., etc., c. v. p. 3). 

The malum mortuum has been assimilated with gangrenous ele- 
phantiasis and elephantiasis anaasthesiaca. 

M. Alibert (note on the genus spiloplaxia, malum mortuum of some 
pathologists, Revue Midicale, 1829, vol. iv. 169), has given the details 
of a case of disease which he met with in the course of his practice, 
and which he believes to be similar to the malum mortuum of the 
middle acres. 



FOURTH GROUP. 
SYPHILOID DISEASES. 

This group comprises epidemic syphilitic, and other analogous 
diseases. 

DISEASE OF THE DISTRICT OF CHAVANNE-LURE. 

{Department de la Haute Saone.) 

1381. M. Flamand writes as follows, on the 6th of October, 1829: 
" I have now satisfied myself that a disease having the reputation of 
being contagious, has existed in the district of Chavanne for the last 
eighteen months ; up to this time from twenty to five-and-twenty per- 
sons, and probably even more, have been affected with it ; for the 
inhabitants, from a sense of false shame, being unwilling to confess 
that they are its subjects, several have undoubtedly eluded my re- 
searches, and those of the mayor of the place. It begins with sen- 
sations of general weakness, followed by pain, more or less acute in 
its character, in the limbs, which increases during the night, and 
which the patients compare to that of rheumatism. These pains 
continue, in different cases, from a fortnight to four or five months, 
and successively attack several of the articulations. Afterwards an 
inflammatory swelling takes place on the lips, which become covered 
on the inside with whitish aphthae, and which crack, acquiring twice 
and even three times their usual size. The inflammation soon shows 
itself in the throat, attacks the uvula, the tonsils, and the velum palati, 
and occasions an extinction of voice, which, in some persons, is almost 
complete. As soon as these inflammatory symptoms appear, the pains 



in the limbs diminish, and entirely cease as they increase. In some 
persons a pustular eruption breaks out over the whole body, but more 
particularly upon the head. The pustules are accompanied with in- 
tolerable itchiness, which, however, ceases on their bursting and dis- 
charging a little purulent matter. These pustules are rather large, 
and of a livid red colour; they leave marks on the skin, tra 
which are seen long afterwards. One individual had the pustules on 
the head only, and in another the symptoms of the disease were ac- 
companied by a tedious ophthalmia, and a considerable flow of tears ; 
this second stage lasts several months, and even a year. 

In two-thirds of the persons who have been affected, the disease 
appeared to me to get well spontaneously ; others still retain some of 
the symptoms. It has not, as yet, been fatal to any one. A man, 
named Pierre Frangois Goudey, twenty-eight years of age, was the 
first who was attacked ; it is now twenty-eight months ago. The 
first symptoms were general weakness, and disinclination to work, 
then pains in the limbs, which lasted about two months ; afterwards, 
inflammatory and aphthous swellings of the lips and inside of the 
mouth, for nine months; at the same time inflammation occurred in 
the posterior fauces, and an extinction of the voice supervened, 
which lasted for three months ; an inflammatory affection also ap- 
peared on the scrotum, which the patient attributed to the rubbing 
of his drawers of coarse new linen cloth. No vestiges now remain 
of the disease, nor of any of its symptoms. Goudey communicated 
the affection under which he laboured to his three young children, 
all of whom suffered from the swelled and aphthous state of the lips ; 
one only from the inflammatory symptoms of the throat, and the hoarse- 
ness. His wife, with whom he cohabited, was the only individual 
of the family who did not catch the infection from him, which would 
seem to indicate that the union of the sexes is a means very little apt 
to communicate this disease, although it is regarded as a peculiar 
modification of syphilis. Goudey having been made prisoner, and 
detained for three days, by a troop of Austrians, at Montbeliard, at 
the time of the second invasion, pretends that he contracted the dis- 
ease by drinking out of the same glass immediately after a soldier of 
that nation, who, he said, had the disease on the lips. It was not 
until some time after his return home, that Goudey felt the first symp- 
toms of his malady. Elizabeth Goudey, fourteen years of age, assures 
me that she caught the infection from the children of the above-named 
Goudey, her relations, from having eaten with them ; she experienced 
the pains in the limbs, swelling of the lips, inflammation of the throat, 
and loss of voice. Her brother, Claude Francois Goudey, about fifteen 
years of age, contracted the disease sometime after his sister, and ex- 
perienced the same symptoms, with ophthalmia, in addition, which 
lasted several months ; the eyelids, indeed, are still slightly injected, and 
the eyes watery. The wife of Jean Baptiste Goudey thinks she caught 
the disease from Elizabeth Goudey, from her being so frequently in 
the house, and going often there to her meals. The disease showed 
itself in her by very intense pains in the limbs. These pains began 
in the lower limbs, and attacked, successively, the shoulders, elbows 
and wrists, and lasted about five months. She had had a general 
pustular eruption, though the head was the part more particularly 
affected ; the marks of this still exist in the shape of spots of a livid 
red. Her lips were not inflamed, but she had aphthae on the tongue, 
and inflammation of the throat, which, as well as the hoarseness, was 
still complained of. The husband of this woman took the disease 
six months after her ; he only suffered from pains in the limbs for a 
fortnight ; his throat is in a high state of inflammation, and this is 
accompanied by an almost complete extinction of voice. The inha- 
bitants of Chavanne are persuaded that this disease is particularly 
propagated through the medium of the implements used in taking 
food, which is the more likely to be the case, as it is known that 
country people make use of these one after another without any atten- 
tion to cleanliness. The following cases seem to strengthen these 
opinions 

" Since the month of March I have had those individuals under 
my care who still showed any of the symptoms of the disease ; I re- 
commended the use of the warm bath, and of tonics, and mercurial 
preparations, particularly the liquor of Van Swieten, internally. I 
had the satisfaction of finding that this treatment succeeded, and of 
seeing the disease entirely disappear from Chavanne, without having 



DISEASE OF THE BAY OF ST. PAUL— SCHERLIEVO. 



415 



been communicated to the adjoining districts." [Journal Compl. du 
Did. des Sci. .Med., t. v. p. 134.) 



DISEASE OF THE BAY OF ST. PAUL. (CANADA.) 

1382. Between the years 1776 and 1780, a disease which has been 
designated under the names of the disease of the Bay of Saint Paul, 
le mal de chicot, le mal des eboulemens, appeared in Canada, particu- 
larly in the Bay of St. Paul. According to Dr. Bowman, 1 who was 
sent by Governor Hamilton, to investigate the nature of the disease, 
it was announced by the appearance of a number of small pustules 
on the lips, tongue, and inside of the mouth. These pustules, which 
resembled small aphtha?, advanced rapidly; and children have been 
seen whose tongues were almost entirely destroyed by them. The 
whitish and puriform matter they contain communicates the infection 
to those who touch it. Patients are tormented with nocturnal pains 
in the bones, but these generally subside when ulcers appear on the 
skin and in the interior of the mouth ; cervical, axillary and inguinal 
buboes are often met with; at a more advanced stage, the body be- 
comes covered with pruriginous tetters, which soon disappear. The 
bones of the nose, palate, cranium, pelvis, thighs, arms, and hands, 
become affected with nodes and caries ; all the functions become 
greatly disordered ; the senses are disturbed, the patients die a prey 
to the most acute sufferings. Some individuals, however, are so 
robust that they stand out against this complication of infirmities for 
many years, dragging on a most miserable life ; entire limbs have 
been sometimes known to sphacelate and fall off. This frightful dis- 
ease spares no one, but it seems to rage with peculiar virulence 
among children. It is, above all, by the sexual act, that it is com- 
municated or transmitted from one individual to another. 

Decoctions of the roots of patientia, of arctium lappa, and sarsa- 
parilla, are the remedies usually employed to arrest its progress. A 
decoction of a species of fir, or beer, made with a decoction of the 
branches and bark of the pine of Canada (Pinus Canadensis) has also 
been approved. The inhabitants of some parts of Canada, and among 
others, those of the Bay of Saint Paul, where the disease spread ex- 
tensively, pretend that it was brought among them by the English. 
The peculiarity most worthy of remark connected with the history of 
this disease is, that it rarely attacks the organs of generation, and 
that it may be contracted without any actual intercourse with indi- 
viduals affected with it, even without touching them immediately. 

Swediaur observes that Dr. Bowman's description, however im- 
perfect it may be, recalls to his mind the account which the writers of 
the fifteenth century have given of syphilis. The similarity to scher- 
lievo is still more striking. 



DISEASE OF FIUME, OR SCHERLIEVO. 

1383. This epidemic disease, the origin of which was attributed to 
four sailors, who were supposed to have brought it from Turkey, ap- 
peared in 1800, in the districts Scherlievo, Gronemico, Fiurae, &c. 
It was supposed by others, again, to have been imported in 1790 
from Kukulianova, by a peasant named Kumzut. A short time 
after his return, his father and mother were affected by it, and after- 
wards propagated it in Scherlievo, &c. The disease spread with so 
much rapidity in 1801 in the provinces of Buccari, Fiume, Viccodal, 
and Fuccini, that in a population of from fourteen to fifteen thousand 
individuals, it was calculated that more than four thousand five hun- 
dred were affected with it. Messrs. Percy and Laurent assure us 
that a commission of physicians appointed in Sept. 1801, found more 
than thirteen thousand persons affected with this disease, out of a 
population of thirty-eight thousand. It reappeared in 1808 and 1809, 
raging especially in Scherlievo, where it seemed to be kept up by the 
filth of the lower orders of the people, whose damp cabins are shared 
with their domestic animals. 

1384. Symptoms. — This disease usually commences with lassitude 

1 These details are from Swediaur, who seems to have mistaken the name of Bow- 
man for that of Beaumont, and that of Hamilton for that of Haldiman (Adams, obs. 
on Morb. Poisons, p. 194). 



of the limbs, and pains in the bones of the arms, thighs, and spine, 
which increase during the night ; the voice soon becomes hoarse, and 
deglutition difficult ; the face is flushed ; the velum palati, the uvula, 
the tonsils, and sometimes the pharynx and larynx are red. Soon 
after, a species of aphthae burst, and discharge an ichor, which erodes 
the neighbouring parts; small ulcers are formed, which unite and 
create a sore of various dimensions, but always of a round shape, of 
an ashy colour, and with hard, raised, and dark red edges. These 
ulcers, which are in some cases evolved with great rapidity, cover 
the uvula, the tonsils, the velum palati, and the surface of the cheeks 
and lips ; caries affects the bones of the nose, when pus of unbeara- 
ble fetidness is discharged ; the voice changes more and more, and is 
at last entirely lost. The exostoses w r hich had appeared from the 
beginning, occasionally but rarely shrink and vanish, along with the 
pains which accompany them, as soon as a pustular eruption is evolved 
upon the skin. Dr. Lambini, however, relates four cases, which 
prove that the pains in the bones became more violent, notwithstand- 
ing the treatment employed, and lasted throughout the whole course 
of the disease. 

When scherlievo comm'ences by a pustular eruption, M. Boue says 
that it is announced by violent itchiness, which lessens as the eruption 
comes to an end. The pustules are of a coppery colour, round, and 
of various extent. They most frequently appear on the forehead and 
hairy scalp, but they are also seen on the inner surface of the thighs, 
legs, and arms, and round the anus and genital organs. An acrid ichor 
sometimes flows from them, which inflames the skin ; at other times 
this discharge dries and forms scabs ; the disease often remains sta- 
tionary in this state. After the scabs have fallen off, the skin retains 
marks of a coppery hue, which it is difficult to remove. 

Scherlievo has been known to begin with various sized blotches of 
a coppery colour, in the centre of which ulcers are seen, from which 
a matter is poured out, that by drying forms scabs similar to those 
wdiich cover the pustules. These blotches are generally surrounded 
by an areola of a coppery hue, and give the patient a most hideous 
aspect. It is related as a fact worthy of notice that the genital organs 
in w r omen are more frequently the seat of this disease than those of 
men. Doctor Cambieri, among the immense number of cases which 
came under his notice, only found one of gonorrhoea which came on 
after the desiccation of the pustules of the skin, and which disap- 
peared as soon as the eruption was restored. As for the ulcers which 
so frequently erode the scrotum they always appear as secondary to 
the general infection. 

1385. Causes. — The transmission of scherlievo is seldom the con- 
sequence of sexual intercourse, but is the effect of simple intermedi- 
ate contact ; the clothes, table utensils, such as glasses, spoons, forks, 
napkins, &c, and an atmosphere charged with the breath of those 
infected, are all sufficient to sow the seeds of it. Children have been 
known to bring the disease with them into the world, or to have it com- 
municated by the nurses who suckled them. It hardly ever appears by 
buboes in the groins, or enlargements of any of the other lymphatic 
glands. 

1387. Prognosis and treatment. — When this disease appears in the 
form of pustules, spots or ulcers in the mouth, it yields readily to anti- 
venereal remedies. The prognosis is more unfavourable when patients 
have been weakened by fruitless treatment, or by previous complaints ; 
when the ulcers have reached, and occasioned caries of the bones, or 
wdien the patients are debauched, indulging in intemperance and 
neglect of personal cleanliness. The treatment of scherlievo does 
not, in any particular, differ from that of syphilis. I have been assured 
that the bichloride of mercury, given in the syrup of Cuisinier, 
(comp. of senna and sarsaparilla,) has always proved the most effectual 
means of subduing it; and that, when caries had attacked the bones, 
the treatment might be concluded with advantage by ten or twelve 
mercurial frictions. Opium combined with mercury is employed with 
complete success against the pains in the bones. The protochloride 
of mercury, mixed in the cerate with which the ulcerated pustules 
are dressed, and the solution of corrosive sublimate diluted used as a 
gargle or wash to the ulcers of the mouth, always expedite the cure. 

Messrs. Percy and Laurent have proposed the establishment of a 
Lazaretto, and the disinfection of the dwellings and clothes of the 
poorer classes by chemical agency, as a means of getting rid of the 



416 



SYPHILOID DISEASES. 



e of scherlievp entirely (Percy and Laurent. Diet, des Set. Med., 
But if, as all seems to authorize us in believing, 
scherlievo be only syphilis under another name, this recommendation 
would require to be modified. 

Historical Notices. 

3. Scherlievo has been particularly studied by Cambieri, Mas- 

sich, Hensler, J. P. Frank and Bagneris, whose observations have 
been analyzed in a report read to the Soc. de Med., 6th Aug. 1811. 
(Journal de Mulct ine ct de Ckirurgie, t. xlii. p. 1.) M. Boue, in his 
inaugural dissertation, has related several cases of scherlievo (Essai 
sur la maladie de scherlievo, 4to. Paris, 1814). Eyerel has given a 
good description of the disease in his continuation of J. P. Frank's 
work, De curandis hom. morb. M. Amdee de Moulon has very 
recently published his Nouvelles Observations sur la nature et le traite- 
ment du Scherlievo, 8vo. Milan, 1834. 



FACALDINE. 

1389. Under this name is designated a variety of syphilis, which 
is said to have been introduced, in 1786, into the village ofFacaldo, 
in the province of Bellune, bordering on the Tyrol, by a female men- 
dicant labouring under venereal itch, and ulcers and warts on the 
vulva. The following characters are assigned to facaldine : Scabious 
eruption, of a syphilitic nature, which attacks adults and children, 
ulcers in the throat and nasal fossa?, destruction of the nose, serpi- 
ginous ulcers, which erode the skin in various directions; gummy 
tumours, are seldom seen; pains in the bones occur very rarely, and 
exostoses hardly ever. In adults blenorrhagic discharges take place 
from, and ulcers occur on the genital organs ; buboes, and several spe- 
cies of excrescences, are also frequent occurrences. Cure by means 
of mercurial medicines. 

Marcolini has related a case and given a representation of facaldine, 
which he considers as a variety of scherlievo. Marcolini, Mcmoire 
Medico- Chirurgiche. Milano, 1829, p. 18. See, besides, Zucchinelli, 
jinn. Univers. di Medicina. Milano. 



MORBUS BRUNN0-GALLICCIS (MORAVIA). 

1390. An epidemic appeared in Briinn, in 1578, which in the space 
of two or three months, attacked forty persons in the city, and almost 
a hundred in the suburbs; a considerable number of the country 
people were also affected. This disease presented symptoms similar 
to those of syphilis. The disease was generally supposed to have 
been propagated by baths, and the practice of cupping, which is in 
common use among the inhabitants. 

Thomas Jordan, the historian of this epidemic, thus describes its 
characters. "Interim insueta qu3dam ignavia, seu torpore gravati: 
pigri, segnes, inertes ad consueta munia obeunda, animo quoque ab- 
jecto, tristes vultu, cum nee mens neque manus et pedes ofHcium 
facerent, veluti umbra, non homines, passim oberrantes conspicie- 
bantur. Nativus faciei color in pallidum ; vigor ipse oculorum in 
torvum, circulo fusco sicut mulieribus menstruatis deformem, subito 
immutatus: frons exporrectior in caperatam et nubilam degeneraverat. 
Manitestis turn se prodidit indiciis. Vestigia cucurbitularum turges- 
centia, extemplo ardor invasit immensus et immedicabilis, quern feedi 
abscessus et ulcera excepere putrida, sanie taboque fluitantia ; circum- 
circa pustulae, palmum quoque latae, achoribus floridse, quibus dehis- 
centibus acu aut raedicamine discissis, profluxit pituita tenuis, serosa, 
marcida, sanieque mucosa: aliis etiam acris et erodens: turn caro 
cucurbits: ambitu circumsepta, corrosa, putrescens, tetrum ut e tele- 
phiis ac phagedaenicis ulceribus invexit fcetorem. Ubi admiratione 
dignum initio, quod h tot affixis cucurbitis, cum alii decern plus minus, 
tres quoque tantum nonnulli apponi jussissent, una duntaxat, aut ad 
summum duae (socrui Laurentiae sartoris e quindecim, tres) ex iis 
omnibus in feedam transiyerint vomicam. Nonnulis universum corpus 
pustulis compersum, facies informis, triste, supercilium, horrendus 
vultus, dorsum, pectus, abdomen, pedes, loci a suramo ad imum por- 



riginosa scabie, crus'aceis ulceribus supra cutcm paulum elevatis, 
duorum crirciatorum nummum, vel unguis pollicis amplitudine, am- 
bitu rubente, Candida superficie (ut tinea quam barbari vocant) pol- 
luta, et deturpata, cernerc erat. Manabant haec quoque pingui liquore, 
mucore lento, qui non pus, sed saniem referret luridam. Imo, scabie 
sublata et sanata, maculae atrae, diversaeque ab impetiginibus, aut 
vitiliginibus, plumbei etfusci coloris, remanserunt. Progressu morbi, 
in capite calli concrevere, qui summo cum dolore et ejullalu rupti 
vel dissecti, melleum quippiam, resinosura et tenax, seu ex coniferis 
arboribus laticem extillare videmus, lentum inquam et viscidum, ma- 
rescentis pituitae argumentum, exudabant. Abscessus hi sordidi 
vereque cacoethes, postquam magna difficultate expurgati, et non 
minore carne rursum producta, coaluissent, novum prorupit symp- 
toma. Universi corporis artus, brachia, scapulae, cubitus, humeri, 
surae, tibiae, pedes imi, puncturis quibusdam quasi aculeis, infensis- 
sime vellebantur, ac si ferris discinderentur, aut forcipibus ignitis 
laniarentur (sic aegri sensum doloris exprimebant) potissimum ubi 
tibia maxime excarnis, lacertorum non fulta thoris, a solo periosteo 

vestitur 'Nulla tamen quies, perpetua vociferatio, lachrymae, 

gemitus, indesinenter torquentibus doloribus, nocte potissimum, cum 
fessa membra sopore dulci reficiuntur, ill is noctes pervigiles, ob cru- 
ciatuum vehementiam,' " &c. 

Various remedies were tried for this disease ; but the following 
method seems to have been generally successful. After having bled 
the plethoric patients, and exhibited some purgative medicine, de- 
coctions of guaiacum, turpeth mineral in pills, and the expressed juices 
of wild endive and fumitory were administered, whilst the ulcers were 
dressed with mercurial ointment. 

Historical JYotices. 

1391. Consult Thomas Jordan (Brunno-gallicus, seu luis novae in 
Moravia exortce descriptio, Franckfort, 1577, 8vo.,ibid., 1783, 8vo.); 
Joannis Sporischii, tractatus, and Cratonis Epistolce, lib. ii. I have 
not been able to procure these last two works, which are quoted by 
Schenck, who has republished Jordan's memoir (Schenck, Obs. Me- 
dicar. Rarior., p. 792, lib. de Brunno-Gallico). 



AMBOYNA PUSTULE, OR AMBOYNA POX. 

1392. J. Bontius (Medicina Indorum, 4to., Lugd. Batav., 1718; De 
tophis, gummatis ac exulcerationibus endemiis in insula Amboyna ac 
Moluccis prcccipul quas noslratas Amboynse pocken vocant), gives the 
following description of a disease, endemic in the island of Amboyna. 

" Endemius, seu popularis quidam morbus in Amboyna, ac Moluccis 
insulis pra;cipue oritur, qui symptomatis suis admodum similis est mor- 
bo venereo. Sed in his inter se differunt quod hie sine congressu vene- 
reo quoque nasci solet. Erumpunt in facie, brachiis, ac cruribus tophi, 
seu tumores, duri primum ac scirrhosi ac tam crebi per universum cor- 
pus, quam clavi ac verruca? oriuntur in manibus ac pedibus in patria ; 
si vero eos ulcerari contingat, materiam lentam, ac gummosam a se red- 
dunt, attamen tam acrem, ac mordacem, ut profunda, ac cava ulcera 
inde oriantur, cum labiis callosis, ac inversis ; foedum ac deforme ma- 
lum, et cum iue venerea conveniens, nisi quod hie tanti doloris non 
adsint, nee caries in ossibus tam facile oriatur, nisi per curantis incu- 
riam. Hie affectus originem trahit, primum ex peculiari cceli et soli 
istius genio ; turn ex aere, vaporibus salsis, 6 mari undique ascenden- 
tibus infecto ; cibis praterea crassis, ac melancholicis et pituitosis, ut 
sunt pisces marini, quorum hie magna captura est, quibus incolae assiduo 
escuntur, quod reliquae annonae sit satis indiga regio. Magnum etiam 
momentum huic malo adfert usus placentarum, quas vici panis, per 
totum istum tractum edunt, ac ab incolis sago vocatur, et est e corti- 
cibus arborum excussa farina. Ad haec confert potus importunus 
liquoris cujusdam saguer vocati, qui ferme eodem modo ex arbore 
elicitur, quo e palma indica seu coquos arbore liquor iste, quem incola; 
Towac, Lusitani Vinho de Palma vocant. Hie immoderate sumptus 
non secus ac vinum et cervisia inebriat ; caput ac nervos infestat, hinc 
etiam in his insulis crebrior est ista paralyseos species, quam Beriberii 
supra diximus appellari. Quantum ad curera attinet, ea, si recens sit 
hoc malum, non ad modum difficilis est. Sin inveteratum, jam mo- 



SIBBENS— PIAN DE NERAC— FRAMB(ESIA. 



417 



lestior est curatio. Porro iisdem fcrme remediis cedit, quibus lues 
venerea, obstructions lienis, leuco-phlegmatia, ac ipse hydrops, et 
caeteri chronici ac rebelles morbi. Decocta hie itaque parentu'r e 
China; radice, salsparilla, Guajaco et corticibus ejusdem, quibus inco- 
quantur anagalidis aquatieae, seu beccabungae, m. ij. Post peccans 
materia vehementioribus catharticis educendaest: nam levia hie non 
possunt. Talia sunt extract. Guttae cambodja, elaterium ; et si his non 
cedit, ad chymica, et mineralia deveniendum est: ut sunt mercurius 
vitae, seu butyrum antimonii, turpeth minerale, turn mercurius praeci- 
pitatus albus. Unguenta quoque mercurialia secundum artem parata 
hie externe adhibenda sunt." 

This disease very much resembles scherlievo, which, it would seem, 
ought to be assimilated with syphilis. 



1394. This disease has been observed in Scotland, particularly in 
the counties of Ayr, Galloway, and Dumfries. 

According to Gilchrist, sibbens shows itself under several forms. 
Sometimes inflammation of the velum palati and surrounding parts 
takes place, and is accompanied with a kind of white eschar, or a 
superficial ulcer of a bright red colour. At the same time, aphthae or 
small white spots or eschars often occur on the velum palati or insides 
of the cheeks. Small elevations, of a pearly or milky colour, also 
usually appear on the commissures of the lips. Often, too, a very small 
excrescence or fleshy growth is developed, resembling a raspberry, and 
which becomes covered with a scab. This growth is almost a certain 
indication of the disease, even when the sore throat does not exist. Dr. 
Trotter, who has also described this affection of the mouth, compares 
its appearance to that of toasted cheese. 

Another form of this disease is that of destructive ulceration, which 
may cause the entire loss of the velum palati, and the death, from 
inanition, of infants at the breast, deglutition becoming impossible. 

Sibbens appears in other cases on the s/cin, and under different 
aspects. Sometimes the whole surface of the body is spotted, and 
clouded with a coppery and dusky red blush. At other times, clus- 
ters of pustules appear, over which several successive desquamations 
of the epidermis take place. Scabby eruptions of the hairy scalp, 
forehead, inner sides of the thighs, &c, are accompanied with little 
hard lumps, in the thickness of the skin, and a feeling of unpleasant 
itchiness. At other times, a species of tumour, similar to furuncles, 
are seen on the arms, shoulders, face, legs and feet, which give rise 
to ulcers that perforate the whole thickness of the skin, and lay bare 
the muscles, which they sometimes also corrode. Adams is disposed 
to believe that these ulcers are the result of the immediate contact of 
the virulent matter proper to this disease. 

Finally, the soft and spongy raspberry tumours, which have been 
mentioned (whence the name of sibbens or sivvens, which is derived 
from sibbens frambcesia), are the last symptoms of the disease; they 
do not seem to occur in all places alike, for several other forms of 
the disease are observed, several, indeed, which Gilchrist himself had 
never seen. 

According to the same observer, the bones are not affected in this 
disease; Bell, on the contrary, speaks of nodes and caries. 

1396. Sibbens is rarely communicated by sexual intercourse ; the 
alterations which are sometimes seen in the genital organs take place 
consecutively. The disease is more frequently transmitted by nursing, 
and the common use of the same utensils, the use of the same pipe, 
for instance. 

The silence of cotemporary writers on this disease leads me to 
imagine that it is now extinct. 

The treatment adopted for sibbens, bears the greatest resemblance 
to that employed in syphilis. 

Historical Notices. 

1396. Since the publication of Doctor Gilchrist's paper {.fin ac- 
count of an infectious distemper prevailing in many places, &c. Essays 
and Observ. Physic, and Literary, by a Society in Edinburgh, vol. iii. 
p. 154), Doctor Adam Freer has treated of sibbens, which he believed 
105 



to be produced by an insect similar to acarus, in an appendix to his 
inaugural treatise (De syphilitide venerea). Adams gives an account 
of several additional researches made by Doctors Hope and Barry, 
and particularly by Dr. Hill. Adams made a journey to Scotland 
himself, expressly to study this disease, and gives several cases of it 
(Observat. on Morbid Poiso?is, p. 176, 4to. Lond., 1807). 



PIAN DE NftRAC, 



(Departement de Lot et Garonne.) 



1397. Raulin has described an epidemic disease which seemed fo 
be analogous to scherlievo and facaldine, under the objectionable 
name of Pian de JSTerac. 

" At the end of the month of June 1752, a singular epidemic dis- 
ease appeared at Nerac ; it was a species of lepra or framboesia (pian), 
similar to that which affects the negroes in the Gulf of Mexico. It 
spreads among children at the breast ; those affected by it begin to 
fall off; by degrees pustules appear on the face, mouth, neck, buttocks, 
and thighs. Nurses contract this eruption on the breasts, and it 
afterwards appears over the whole body. The pustules are generally 
round, hard, and rather callous; from some of them, a yellowish ichor 
is discharged; others are covered with a pulverulent crust; these 
pustules, covering the body, become confluent, and appear to form 
only a single incrustation ; they degenerate into deep ulcers which 
lay bare the bones, and occasion death ; towards the end of December 
it was calculated that more than forty infants had already been affected 
with this disease. The treatment that was most successful was the 
use of an ointment, made with one ounce of pure mercury, rubbed 
till the globules had disappeared in Venice turpentine, one ounce of 
lard, and one scruple of camphor, well mixed together. Mercurial 
frictions were tried upon several women, but mercury without cam- 
phor was often ineffectual. Children were cured in a fortnight, but 
it was necessary to continue the treatment for several days afterwards. 
The origin and cause of this disease were entirely unknown." 



FRAMBOZSIA OR YAWS (PIAN FRENCH). 

1398. The identity of yaws and pian seems to be demonstrated, 
although some differences appear in the exposition of the symptoms 
of the two diseases, given by the English observers who have studied 
yaws in Guinea and in Jamaica, and by the French physicians who have 
observed pian in Saint Domingo, Guadaloupe, Brazil, Jamaica, &c: 
these differences, however, seem at the most but to characterize two 
varieties of the same affection. 

1399. Yaws begin by a state of languor and weakness; with pains 
in the joints, and in most cases with fever, which runs highest among 
children. Before the eruption, the skin is often covered with a white dust 
(Thomson), as though it had been powdered. Some days afterwards 
spots similar to flea bites or small papulae appear on the skin, particu- 
larly on the forehead (Thomson). These elevations increase in size 
during from six to ten days ; at the end of this time, a scab is formed 
on their top, from under the edge of which a crude purulent matter is 
discharged. 

The size of the pustules still increases, and they become covered 
with irregular scabs not very adherent. Many of these pustules 
acquire the size of a shilling. On raising the scab an ulcer of a bad 
or gangrenous description is discovered. It does not assume the 
fungous appearance which it ultimately acquires, at any definite 
period of the disease ; this sometimes occurs a month after the break- 
ing out of the eruption, and sometimes three months afterwards ; the 
development of these fungous growths seems to depend very much 
on the constitution of patients, taking place earlier in those who are 
lusty and well fed. A second eruption sometimes makes its appear- 
ance preceded by fever, the progress of which is the same as of that 
which has gone before it, so that the eruption may occasionally be 
seen in different states in the same individual. The elevations are 
broader and more numerous on the face, groins, axilla?, verge of the 
anus, and labia majora than on any other part of the body. New erup- 
tions take place as soon as the first begin to dry off, so that after these 



418 



SYPHILOID DISEASES. 



ssive eruptions, the number of pustules existing together is 

sometimes very considerable. If the writers who have studied this 

are to be credited, there is always one pustule larger and 

more raised than the others, which it is more difficult to cure, and 

which is designated by the name of the mother yaw. 

This affection is said to be sometimes accompanied with nocturnal 

pains and swelling of the bones, ulcers in the pharynx, &c. In this 

tse the disease becomes very distressing ; the ulcers of the throat 

resemble toasted cheese ; they never become fungous, and a great 

part of the palate is very apt to be destroyed by them. 

The fungus of frambcesia, in patients of a good constitution, is red, 
like a piece of flesh ; in delicate or diseased subjects, it is white like 
a piece of cauliflower ; it bleeds on the slightest touch ; in the latter 
case it is less raised than in the former. After having continued 
some time in this state, the fungus gradually diminishes in dimensions 
and in height, shrinking and generally disappearing without leaving 
any scar, except in places where the inflammation has been very 
great (Thomson). The cicatrices that then result resemble those of 
cow-pox, only they are larger and more superficial. 

In the successive eruptions of yaws, there is often one pustule 
which does not heal like the rest ; left to itself it is apt to produce caries 
of the neighbouring bones. 

Yaws-appear under a different aspect in cachectic persons : the pus- 
tules are smaller, the eruption which is less copious is successive ; 
the fungous growths wdiich usually characterize the disease either do 
not exist at all, or are very small and watery. 

The length of time during which this disease continues is uncer- 
tain ; in some patients it lasts six months, in others a year ; in general, 
its term may be stated at about eight months. Fever and the symp- 
toms generally, are mostly very well marked in weakly and ill fed 
children. 

1400. Causes. — We are informed that frambcesia usually occurs 
among the ill fed negroes, whose skin is continually irritated by a 
burning sun, by the bites of insects, and by the rancid oils with which 
they are in the habit of anointing their bodies. This disease is con- 
tagious, is transmitted by the union of the sexes, by suckling or by 
the application of the matter of the pustules or cutaneous ulcers to 
any part of the excoriated skin; perhaps it is also transmitted in still 
other ways. 

It is difficult to determine the time of incubation. Thomson relates 
that a certain number of negroes in good health were sent with their 
children to a sugar farm in a mountainous district, and the healthy 
children having eaten and drunk with those at the farm who were 
affected with yaws, three of the former were, seven weeks afterwards, 
attacked with fever and pains followed by a general eruption ; the 
others were not affected until three weeks later ; at the end of eight 
months all were cured. Thomson inoculated a child in five places 
with the matter of an ulcer from which the scab had been removed. 
Three of the punctures healed ; the two others looked like simple 
scratches during three weeks, when they formed into small ulcers, 
which spread until they had assumed a gangrenous appearance with 
jagged edges, &c. Seven weeks afterwards papulae appeared on the 
forehead, and by and by extended over the whole body; the fungus 
now formed ; the patient had an abundant eruption which lasted nine 
months. The two ulcers which followed the punctures never became 
fungous, but they left deep scars. Thomson relates that variolous 
matter having been taken from a little negress affected with yaws, 
the child who was inoculated with this pus had the small-pox in a 
very mild form, and was afterwards attacked with yaws. The blood 
of a negro covered with yaws, was inoculated upon four children in 
five different places without producing the disease. 

The usual progress of cow-pox, small-pox and varicella is not 
impeded by the existence of yaws. 

The matter of yaws has not been found to occasion any eruption in 
rabbits or dogs, even after repeated inoculations. 

The disease can only be communicated once to the human subject. 
A woman, however, who suckles a child affected with yaws may 
have the breast excoriated ; death has even been known to follow 
this circumstance : phagedenic ulceration of the breasts which ex- 
tended to the axillae and was accompanied with great irritation, took 
place and proved fatal. 



If a person affected with an ulcer of considerable size, contracts 
yaws, it may happen that this ulcer continues and presents the granu- 
lated aspect characteristic of yaws without the eruption appearing. 
If this ulcer be healed, an eruption similar to that which occurs in the 
usual course of the malady is developed ; left to itself the ulcer gets 
into a progressively worse and worse condition. 

1401. jyiagnosis. — Thomson says, that an old Scotch physician, 
who had long been familiar with yaws in Jamaica, was struck, on his 
return to Scotland, with the identity of sibbens and this disease in 
most of their phenomena, (a) 

Yaws is regarded by some writers as a modification of syphilis, by 
others as a peculiar disease of the skin. (6) 

1402. Treatment. — According to Thomson the usual practice in 
the island of Jamaica is to leave the disease to the efforts of nature. 
Good food is recommended, and moderate work; sulphur, a decoc- 
tion of the sudorific woods, and antimonial preparations, are exhibited 
in the cases of children with success. A great many diseases are 
generally attributed to the dregs of yaws. Thomson thinks that the 
number of these has been greatly exaggerated. 

Finally, Thomson is convinced that though mercurial preparations 
may cause the symptoms to disappear in the course of a month, they 
generally reappear at a later period, and with greater violence than 
before. Hunter had already declared against the use of mercury in 
frambcesia. 

1403. The description given ofpian by the French physicians who 
have seen it in St. Domingo, Guadaloupe, Cayenne, &c, differs in 

(a) Dr. Kerr {Cyclopedia of Pract. Med., art. Yaws), establishes 
the diagnosis between the latter (frambcesia) and sibbens or sivvens, 
in the following terms. " The identity of many of the phenomena, 
as well as of the original signification of the names of the disease 
under our consideration, with sivvens or sibbens, (sibbens in the 
Erse dialect signifies a raspberry,) a malady well known in the western 
parts of Scotland, renders it a matter of interest, if not of importance, 
that we should notice their characteristic distinctions. The sivvens, 
it is remarked, at first seizes the throat and nose ; the yaws never, 
until after a length of time or improper treatment. The eruptions in 
sivvens are watery, of a dirty hue, and of intolerable fcetor ; those of 
the yaws are at first as small as a pin's head, hard, and without any 
peculiar odour. In sivvens boils appear here and there, forming 
deep and ill-disposed ulcers, a character which does not belong to 
yaws. In sivvens itchy tetters break out in form of ringworms, and 
occasion either a deep ulcer or a scabby large spot with inflam- 
mation ; the yaws have no such appearances. The sivvens rarely 
affect the bones, the yaws always unless well managed. In the yaws 
the excrescences succeed the pimples as well on the face and body 
as on the axillae and pudenda; in sivvens the fungi appear on the 
groin and perineum in a very advanced stage of the disease. The 
sivvens is highly contagious without sensible inoculation, the only 
mode, as it appears, by which yaws is propagated. The sivvens may 
be cured early by mercurials, but mercurials in the yaws, at least in 
the early stage, are pernicious. In constitutions otherwise healthy 
the yaws will usually run a definite course, be spontaneously exhausted, 
and terminate in health even without medicine; but if speedy and 
effectual means be not used to counteract sivvens, it will almost cer- 
tainly proceed to a fatal issue." 

(b) The distinction between yaws and syphilis is drawn by Dr. 
Kerr in the work just referred to. " The yaws and syphilis have 
frequently been considered as modifications of the same disease, but 
a comparison between the descriptions of the two will at once establish 
some important distinctions. It is true that the yaws will affect the 
bones, the cartilages of the nose, and the palate, like syphilis, and 
will admit of cure by similar means ; but in primary syphilis neither 
eruptions nor fungi appear as in the yaws, except on the pudenda, 
and then only in the form of warts. Syphilis will never cease spon- 
taneously, (c) like yaws, and, unlike yaws, it may be and is contracted 
repeatedly. Persons who are suffering from the yaws may contract 
gonorrhoea, and even syphilis; and it is very remarkable that the 
former may be cured independently of the yaws, but that the latter 
cannot until the yaws have begun to decline." 

(c) This averment is not sustained by the history of syphilis. 



PELLAGRA. 



419 



several respects from that which I have just sketched from the works 
of the English physicians who have studied this disease in the West 
Indies, and particularly in Jamaica. I shall, therefore, add a short 
abstract of the descriptions and opinions of the French physicians in 
the colonies. . 

Pian is announced by small red spots which appear on different 
parts of the body; the patient at the same time experiences a slight 
degree of fever, pains in the limbs, and even in the bones; the skin 
becomes scaly; the patient becomes sensibly thinner. By degrees 
the intensity of these symptoms decreases, the eruption is developed, 
and shows itself under three aspects: 1st, large picas, or white plans ; 
2d, small pians ; 3d, red plans. The first, of great size, sometimes 
as large as the hand, are formed of fungous flesh, from which a thick 
sanious matter exudes. The small pians, less in size than the former, 
are much more numerous; their excrescences are redder and less 
fungous. The red pians, larger than the latter, less than the former, 
round, and of a more marked flesh colour, developed slowly and suc- 
cessively, are accompanied and followed by much more serious symp- 
toms than those of the other two species, particularly than the first, 
which is the mildest of all. 

One of the pustules of pian generally becomes larger than any of 
the others, and takes the form of a deep ulcer of bad character, but 
without fungi, from whence a sanious matter is discharged. If this 
ulcer is dressed with the usual remedies, it becomes irritable, and 
assumes a worse appearance than it had before. This ulcer is called 
the mother plan. It is dangerous to attempt to dry it up, or to effect 
its cicatrization before the symptoms of the general infection are 
manifested. If a patient have an ulcer on any part of the body, the 
first pustules are generally developed upon it, and the ulcer itself 
sometimes becomes the mother plan. 

Several affections have been attached to the pianic eruption, as 
consecutive diseases: 1st, gulgnes, a species of excrescence which 
principally appears on the soles of the feet, palms of the hands, and 
tips of the fingers, which are so tender to the touch that the patients 
can neither walk nor lay hold of any thing without experiencing the 
greatest pain. 2d, certain whitish excrescences on the soles of the 
feet, named crabs from their shape, from which a purulent matter is 
discharged. 3d, Saouaouas, considerable thickenings of the skin of 
the soles of the feet, and of the insides of the hands; they are red, 
acutely sensible, and very painful in walking, without any exudation, 
but with simple increase and hardening of the parts. After plan, an 
affection of the bones, entitled mal aux os or bone evil, occurs, 
characterized by wandering pains in the bones, generally by the 
tumefaction of those that are spongy, and of the extremities of long 
bones, by exostoses, softening, caries, &c. These, as may be ima- 
gined, are serious symptoms, and being accompanied by the forma- 
tion of numerous ulcers, often reduce patients to a horrible state, (a) 

1404. Chopitre, Dazille, &c, think that mercurial preparations, 
frictions of mercurial ointment, the internal use of the bichloride of 
mercury, diluents of sarsaparilla, and guaiacum are the best remedies 
for pian. The diet should be mild and succulent; broths made from 
turtle, crabs, fresh vegetables, and white meats are recommended. 

1405. To conclude, in studying the documents published by the 
English and French physicians comparatively, it will be seen that 
the former have carefully described the elevations, pustules, scabs, 
and ulcers which precede the fungus of frambcesia, and that the latter 
have exclusively confined themselves to this latter appearance, and 
to several consecutive lesions (gulgnes, crabs, saouaouas, bone evil), 
which the English writers hardly mention. Besides, most of the 
latter think that yaws only attack the same individual once during 
the course of his life, whilst the French physicians maintain the con- 
trary, with regard to plan. Hunter and Thomson assure us that 
mercury is detrimental, whilst the French physicians recommend it 
as the most efficacious remedy. Notwithstanding this diversity of 
opinion, yaws and plan are generally regarded as the same disease. 
Sauvages, Lorry, and Sprengel, however, are agreed in considering 
them as distinct from each other. 

1406. Frambcesia differs from syphilis in several of its characters, 

(a) Pian or yaws is represented to be a common precursor of 
leprosy in Brazil. 



its progress, the time it lasts, the inefficacy of mercury in its cure, 
and above all, the constantly fungiform aspect of the ulcers. This 
latter appearance has been observed in some scrofulous ulcers, but 
they presented other distinct characters. (Martin. Obs. d'un ulcere 
scrofuleux simulant le frambcesia. — Bulletin des sc. medicales, t. vii. 
p. 217.) 



Historical Notices. 

1407. Yaws have been observed in Brazil, by Piso (De medlcina 
Brsesillum, lib. ii. chap. 9, 1643, in fob); in America, by Labat 
(Nouveau voyage en Amerlque, 1722, 6 vols, in 12); in Africa, by 
Winterbottom {Account of the native Africans of Sierra-Leone, vol. 
ii. chap. 8) ; by Hume (John) {A description of the African distemper 
called the Yaws, fyc, Medic. Essays and Obs. by a society in Edin- 
burgh, vol. v. pt. ii. p. 87) ; and by Bancroft (An Essay on the Natural 
History of Guiana, in 8vo. London, 1769) ; in Jamaica, by J. Thom- 
son (Obs. and Experiments on the Nature of the Morbid Poison called 
Yaws, fyc, Edin. Med. and Surg. Journ., v. xv. p. 321 ; and Remarks 
on Tropical Diseases, ibid., v. xviii. p. 31); in Barbadoes, by Hillary 
( Obs. on the changes of the air and the concomitant epidemical diseases 
in the Island of Barbadoes. London, 1759, in 8vo.) ; in St. Domingo, 
and in Cayenne, by Bajou (Mtmolre pour servlr a Phistolre de Ca- 
yenne et de la Gulane. Paris, 1777, 1778); in St. Domingo, by 
Dazille ( Obs. sur les maladies des negres, in 8vo. 2 vols. Paris, 1742); 
and Chopitre (Apercu sur le pian et sur les maladies dont 11 est sulvl, 
in 4to. Paris, 1804). Bern. Peyrilhe may also be consulted (PHcls 
theorique et pratique sur le pian et la maladie d?Ambolne, in 8vo. Paris, 
1783); as also Gomez (B. A.) (Mem. de VAcademle Royale des Sciences 
de Llsbonne, t. iv. p. i.); and Arthaud (Traite des pians au Cap Fran- 
cols, in 4to. 1776). Sprengel is decided in separating yaws from pian 
(Beltrage zur Geschichte der Medizln, Stuck, 3): see also several papers 
inserted in the Edln. Med. and Surg. Journal, (a) 



FIFTH GROUP. 
PELLAGROUS DISEASES. 

This group comprises pellagra and some squamous diseases. 

PELLAGRA. 

1408. Pellagra, dermotagra, colore del fegato, male delta spienza, 
mal de mlsere, scorbuto, alpino, &c, is a disease peculiar to certain 
parts of Italy, reappearing in an aggravated form every spring, charac- 
terized by chronic inflammation of the skin of an exanthematous and 
squamous description, confined to the parts exposed to the sun, pre- 
ceded, and often accompanied with very serious functional derange- 
ments of the digestive organs, and of the cerebro-spinal axis. 

1409. Symptoms. (Slight Pellagra). Pellagra is often preceded 
by lassitude, uneasiness, ennui, dislike to all kinds of occupation, and 
less frequently by nausea and vomiting. Some patients also experi- 
ence vertigo, and pains in the head : but pellagra generally shows 
itself without precursory symptoms. 

This disease most commonly appears first on the back of the hands 
and feet, on the chest, throat, nape of the neck, arms and legs of 



(a) M. Sigaud (Du Climat et des Maladies du Bresil), in his account 
of pian (frambcesia), refers to B. M. Gomes (Ensal dermosographico, 
Lisbon, 1820), J. V. Couto and J. Alves Carneiro (Revista medlca 
flumlneusc, 1833), and J. A. Carneiro (Memorla sobre as bobas), among 
Portuguese writers on pian, called, also, boubas of Brazil. It is 
described in that country as found in three species ; the moist, the 
dry and the crystalline. 



420 



PELLAGROUS DISEASES. 



persons whose clothes do not cover these parts. The face is seldom 
attacked. 

The eruption of pellagra presents three principal forms : in the first 
the back of the hands, the fingers, and feet become the seat of a sen- 
sation of heat, smarting or unpleasant pricking which exposure to the 
sun renders insupportable. These parts redden ; this redness is some- 
times pretty deep, at others paler, or livid, brownish or dusky ; some 
time afterwards the epidermis splits, is detached and falls off in the 
form of sqaamse, leaving the subjacent skin, which is reddish, shining, 
and rather swelled and rough, quite bare. In the second variety, 
this inflammation is sometimes still more intense ; the epidermis is 
raised in vesicles, or more frequently in large irregular bulla?, formed 
of a yellowish or reddish serum, which produces slight scabs in drying; 
excoriations and slight cracks are also sometimes, though very rarely, 
seen in this case. Thirdly, the epidermis thickens, undergoes change, 
becomes yellowish, brownish or blackish, dry and often hard, and 
scaly like the bodies of certain fish, without the skin smarting or 
becoming red. 

The morbid appearances of the skin are not at first very marked, 
and patients pay little attention to what is passing, considering all as 
the simple effect of exposure to the sun. In fact it almost always 
only requires the parts affected to be kept covered, for them to recover 
their natural appearance, and indeed the alterations all disappear 
spontaneously towards the end of summer, but reappear in the spring 
with fresh intensity, to vanish again, at least in great part, during the 
autumn. 

The patient may thus continue for a great number of years, to pre- 
sent symptoms of a local affection, disappearing in the winter, and 
reappearing in the summer, without any functional disturbance worth 
noticing. General symptoms and disorder of the digestive organs 
sometimes also happen along with the cutaneous affection ; a foul 
tongue, often red at the edges or point, heat in the mouth and throat, 
thirst, more or less pain in the epigastrium, loss of appetite, or an 
irregular and excessive appetite, nausea, sometimes vomiting, bad 
digestion, eructations, abdominal pains, either spontaneous or expe- 
rienced on pressure, and diarrhoea or obstinate constipation of the 
bowels. 

The nervous system frequently appears affected in a no less remark- 
able manner. Some patients are much dejected, take a disgust to 
their former occupation, and suffer from vertigo, giddiness, and pains 
in the head. These symptoms are in general aggravated in the same 
degree as the alterations of the skin make progress. 

1410. But pellagra may appear in a totally irregular manner instead 
of following this even tenour, and progressive increase in its symptoms. 
Serious symptoms, mostly secondary, occasionally occur without the 
skin being visibly, or, indeed, in any way affected ; sometimes, again, 
they take place only a very short time after the appearance of the 
cutaneous affection. These anomalies are more particularly observed 
in individuals born of parents who have died labouring under pella- 
gra. Pellagra is occasionally seen to commence by desquamation of 
the lips, accompanied by great heat of the mouth, and ardor urinae. 
Boe'rio has several times seen periodical ophthalmia appearing in the 
spring, followed by very severe and acute pellagra ; he makes the 
same remark with respect to some periodical rheumatisms, which he 
has known to appear in the spring, in persons whose parents had 
suffered from pellagra ; he has also seen several of the neuroses, such 
as hysteria and hypochondria, &c, occur at this season, in many indi- 
viduals in countries where pellagra was endemic, the external charac- 
ters of this disease appearing at a later period. 

1411. Severe Pellagra. — Pellagra often shows itself under more 
serious forms; and then the digestive and cerebro-spinal organs are 
deranged to a much greater degree, and other systems, and the con- 
stitution itself, are more or less deeply implicated. 

In these severe varieties of pellagra, the lips become pale and livid, 
dry and cracked ; the nostrils inflamed ; the gums red, swollen and 
bleeding (scorbuto alpino) ; the saliva flows abundantly from the 
mouth, and acquires a salt taste (salsadina); the tongue becomes red, 
sometimes brownish, and presents ulcers and cracks ; the mouth is 
painful, and there is a feeling of heat complained of in it which 
extends to the throat. Other symptoms are also observed : aphtha?, 
excessive thirst, pains in the pit of the stomach, nausea, vomiting of 



greenish or yellowish fluids, abdominal pains, liquid-greenish, yel- 
lowish, or grayish, and occasionally, though rarely, blackish evacu- 
tions, from the bowels, immediately after drinking or taking food, 
generally without pain, and still less frequently with tormina, tenes- 
mus, &c. 

The nervous system presents phenomena no less remarkable. Pa- 
tients are habitually in a state of the greatest dejection ; their look is 
sombre and melancholy ; their sight is disordered ; they see things 
double ; they are subject to giddiness or vertigo, to numbness, sing- 
ing, and noises in the ears, and experience the most singular hallu- 
cinations. They complain of feeling a heat in the head and spinal 
marrow, of tingling and darting along its course, and that of the 
nerves which proceed from it, of pains in the chest, in the belly and 
in the organs of the senses, which seem to them to be traversed from 
time to time by the electric spark. Besides this, they have a feeling 
of heat in the limbs, in the palms of the hands, and particularly in 
the soles of the feet, v r ery painful at times, and less frequently replaced 
by a sensation of coldness. 

These pains sometimes only affect one side of the body. Some 
patients suffer from distressing cramps ; and Strambio has seen a 
case of tetanic spasm of the whole body. Irregular muscular con- 
tractions are more frequently observed (Saint Vitus's dance, general 
trembling); continual motion of the lips ; involuntary movements of 
the head and body forwards ; convulsions, and sometimes epileptic fits. 

A general prostration of strength is also seen without any other 
serious symptom ; a great degree of debility in the limbs, particularly 
of the legs, with a feeling of weakness at the bottom of the back, to 
such an extent that the patients tremble when they stand up, and are 
sometimes even incapable of supporting themselves seated in their 
beds. Finally, true contractions of the lower limbs, by which the feet 
are drawn up to the buttocks, have occasionally been observed ; anaes- 
thesia and paralysis of the bladder sometimes take place. 

Pellagrous subjects often present all these symptoms, particularly 
the nervous pains and cramps, without being affected with delirium. 
This delirium is of two descriptions : acute and chronic. The first, 
which may prove fatal in a few days, is accompanied with a hard and 
full pulse. Some patients are melancholy, refuse to eat or drink, or 
answer any questions which are put to them ; others are boisterous 
and cry out ; some are even furious ; the greatest number in moving 
their heads backwards and forwards, imitate the sound of bells (Stram- 
bio). This acute delirium does not occur in the first stages of the 
disease. 

1412. The chronic delirium, or pellagrous mania appears under 
several forms : one of them is a sort of madness ; another is a loss of 
memory (amnesia), and of the faculty of attention ; a third and much 
more common one, is religious melancholy, with the desire to destroy 
themselves, particularly by drowning (hydromania), (Strambio): this 
chronic delirium is most frequently incurable ; sometimes, however, 
it is cured after lasting many years. In the hospitals for the insane 
in certain countries in Italy, pellagrous mania forms a considerable 
proportion of the cases. 

Strambio mentions cough as a frequent symptom among the pella- 
grous. He believes in the existence of a pulmonary phthisis of pella- 
grous origin. 

The menstrual flux is generally suppressed in women on the 
appearance of the serious symptoms of pellagra. Besides this the 
organs of generation often become the seat of inflammation and 
excoriation, which extend to the surrounding parts, and are kept up 
by a considerable whitish or yellowish discharge from the vagina. 
In men pains in the bladder, and great heat of the urine occur. 

Persons affected with pellagra are observed to have a very slow 
pulse (thirty pulsations in a minute) (Strambio), before the develop- 
ment of gastro-intestinal inflammation. Two descriptions of fever 
are also observed in pellagrous subjects ; in the one there is a strong, 
hard and unequal pulse, with prostration of strength and great heat of 
skin; the tongue is dry, red, blackish, the lips dry, and the teeth 
black; gangrene of the sacrum, picking at the bed-clothes, and other 
symptoms analogous to those which are observed in the acute dothin- 
enteritis, also occur, &c. This species of fever is constantly fatal. 
In another species, which, according to Strambio, is more connected 
than the former with the cause of the disease, and probably with the 



PELLAGRA. 



421 



internal lesions which accompany it, the fever continues with irreo-ular 
exacerbations. The pulse is frequent and hard, with heat of skin, 
followed by a sweating of a particular odour, and which does not 
afford any relief. This species of fever is tedious, and reduces 
patients to such a degree as is seldom seen in other chronic diseases : 
they become like real mummies, and die consumed with the most 
horrible of all consumptions. 

In other cases anasarca and ascites have been observed ; these 
symptoms occur rarely in the first stages of the disease, but pretty 
frequently towards its termination. Spontaneous ecchymosis of the 
skin is also sometimes seen, a phenomenon which, with the swelling 
of the gums, has induced many to give pellagra the name of Alpine 
scurvy. 

1413. Strambio has seen acute febrile delirium disappear after 
profuse sweats over the whole body. The sweating which occurs in 
hectic fever does not, on the contrary, afford any alleviation, but 
rather reduces the strength of the patient. Apyretic local sweating, 
particularly of the palms of the hands and soles of the feet, is often 
followed by an abatement of these symptoms (Strambio). The matter 
perspired, particularly in the fever with acute delirium, is of a very 
fetid and peculiar smell : Strambio compares it to that of the larvae of 
the silk worm, steeped in water, and half putrid; Jansen thought it 
similar to that of mouldy bread. 

Pellagra is always aggravated by the return of spring, when the 
patients remain under the influence of the causes which produced the 
disease ; profuse secretion of saliva with a salt taste, is added to the 
eruption on the skin, accompanied with heat of the mouth, diar- 
rhoea, &c. Dejection is changed to melancholy, and acute delirium 
supervenes, or otherwise various nervous symptoms, pains, cramps, 
trembling, &c, make their appearance. 

These last symptoms increase, becoming continually more and 
more violent; fever is lighted up, the diarrhoea becomes colliquative 
and involuntary, and death takes place, preceded by spasmodic stiff- 
ness or convulsions of the muscles, &c. 

1414. Some anomalies have been observed in the nature, progress 
and succession of the symptoms of pellagra. During its first ravages 
in Italy, this disease was remarkable for the intensity of its nervous 
symptoms, cramps, spinal pains, &c, and the trifling development of 
the cutaneous phenomena. At a later period, alterations of the skin 
became very prominent features of the disease, whilst affections of 
the digestive organs, and mania occurred only as secondary symptoms. 
Different symptoms have also been known to predominate ; in certain 
years ptyalism was very common, while in others it was not observed, 
or was replaced by heat in the mouth, aphthae, and an extremely 
disagreeable desquamation of the lips. Very recently, the various 
nervous symptoms, cramps, spinal pains, &c, on which former writers 
expatiate at such length, have been very little noticed, while pella- 
grous mania is spoken of as very common, and gastro-intestinal lesions 
as habitual. 

These symptoms have been known to declare themselves during 
winter, and to be the forerunners of pellagra, which did not appear 
till the spring. Pellagra has also been known to occur in a mild 
winter (1796), and to prevail longer than usual. 

1415. Pellagra may be complicated with other diseases of the skin, 
such as lepra, psoriasis, pityriasis, lichen, erysipelas, urticaria, prurigo, 
acne, eczema, purpura, syphilis, &c. The spots of ephelis which 
have been remarked on the forehead are, perhaps, an alteration of the 
epidermis similar to that which is seen in other parts of the body in 
pellagra. Other diseases, such as intermittent fever, scrofulous affec- 
tions, white swellings, peritonitis, phthisis, &c, may be complicated 
with pellagra. 

1416. Anatomical researches. — Gaetano Strambio sometimes found 
lesions in the head, at other times in the chest, and always in the 
abdomen of pellagrous subjects. Several of these lesions were proba- 
bly accidental. I have remarked in these post-mortem examinations, 
the frequency of local or general peritonitis either recent or of older 
date, and of bronchitis and pulmonary tubercles. Fantonetti has 
given a detail of the morbid alterations found in the body of a woman 
who had been affected with pellagra for twelve years. This patient 
had often been insane, and in the last stage of her disease became 
paralytic ; she died labouring under dementia, and in a state of maras- 

106 



mus. The skin of the back of the hands and feet was like leather; 
this alteration extended to the whole thickness of the skin; examined 
with the lens, it presented a great number of irregular cracks, very 
close together, crossing at acute angles, and sometimes implicating 
the whole thickness of the corion. At the edges of some of these 
cracks there were small, thin, yellow crusts. Between the cracks, 
furfuraceous lamellae of a dirty white, adhering very firmly, and of an 
irregular form, were seen. The epidermis was six or eight times 
thicker than usual, brownish, cracking, friable, and dry, and could 
not be readily detached from the skin ; the sub-epidermic layers were 
everywhere of a most singular appearance, and, once or twice, as thick 
again as in their natural state. 

The cutaneous branch of the radial nerve when laid bare, seemed 
a little larger than usual; on being divided, serum flowed from it; 
its pulp was reddish and of soft consistence. The membranes of the 
brain were injected with black blood. The dura-mater adhered very 
closely to the right parietal bone; the pia-mater adhered to the cere- 
bral convolutions, in which a slight degree of atrophy had taken 
place ; the substance of the brain was in general rather softer than 
usual ; there were about two ounces of serum in the ventricles ; the 
cerebellum was slightly injected and rather softer than in its natural 
state ; the spinal marrow was very soft and pulpy ; its membranes 
looked thinner than common, and contained a great quantity of serum. 

M. Brierre de Boismont has carefully examined the bodies of five 
individuals who had died of pellagrous affections. " The result," 
says he, " of ourresearches is that lesions always occur in the digest- 
ive organs; the mucous membrane of the stomach is often red, inter- 
sected with bluish or brownish vessels, soft, pultaceous, or easily 
removed with the nail. The redness may be confined to the great 
end of the stomach, or at least appear more marked in this region ; it 
is sometimes of an uniform red colour, sometimes of a brownish red, 
and sometimes bordering upon gray. The mucous membrane may 
farther be thinner, though in other cases it also occurs thicker than 
natural. The stomach, again, is sometimes distended and presents 
no alteration, but the redness is then found in the intestines. The 
valves of the duodenum partake of this colour ; the mucous membrane 
of the small intestines, and those of the great, are generally coloured 
red of a lighter or darker tint, and sometimes brown. Hypertrophv 
and softening ought to be classed among the number of the lesions of 
the mucous membrane. Ulcers are common ; they may be irregular, 
round, numerous, surrounded by an inflamed tissue, or one quite 
white. The subjacent cellular tissue and the muscular coat have 
been found hypertrqphied. In the five subjects that we opened, the 
intestines contained lumbrici. Dr. Carswell has met with a large 
perforation arising from the softening of the stomach, in two indi- 
viduals in whom there had been evident symptoms of chronic irritation 
of the digestive organs ; and in other parts the mucous membrane 
showed unequivocal traces of chronic inflammation." 

The nervous system presents alterations no less evident. The 
membranes of the brain, particularly the tunica arachnoides and pia- 
mater, are injected, infiltrated, adherent, thickened, and opalescent; 
the consistence of the brain is sometimes increased, the gray substance 
is more deeply coloured, fuller of blood, the Avhite substance is gritty 
[sablce], and dotted ; there is generally no serum in the ventricles. 
It is not uncommon to find the bones thickened, and a considerable 
quantity of blood at the base of the cranium. The lesions of the 
spinal marrow are also very remarkable ; the membranes, and par- 
ticularly the arachnoid and the pia-mater, are red, the vessels gorged 
with blood ; a frothy serum has sometimes been seen. The gray- 
substance is almost always hard to the touch, and injected ; the white, 
on the contrary, is soft, reduced to a pap or cream, along a greater or 
less extent, and infiltrated with pus ; its colour is commonly a yellow- 
ish or dirty gray. 

1417. Causes. — Pellagra is endemical in certain parts of Italy and 
Spain ; particularly in the environs of Milan, Pavia, Padua and in 
Piedmont, &c. It is not contagious. It is confined almost exclusively 
to the country among labourers, herdsmen, &c, is more frequent 
among women than men, and more frequent in full-grown persons 
than in young people and the aged. It is supposed that nervous, 
hypochondriacal, hysterical or melancholy persons, particularly those 
who have been weakened by privations, the depressing passions, 



122 



PELLAGROUS DISEASES. 



any previous disease, are more liable to be affected by 
pellagra than the generality of individuals. It has also been remarked 
that the children of pellagrous parents bring a peculiar disposition to 
this disease into the world with them, which generally passes as here- 
ditary. Pellagra has been attributed to the use of maize (Margari), 
to the abuse of common salt (Guereschi), to the habitual use of sour 
rye bread, or the want of good water in several parts; to dirty and 
ill ventilated dwellings (Aglietti), to fatigue and bad food, to depress- 
ing passions and misery among the unhappy peasantry, &c. The 
influence of exposure to the sun upon the production of the cutaneous 
affection in pellagra is incontestable ; ever since pellagra has been 
l ed, it has been well known that the eruption could be excited 
or caused to disappear at will in pellagrous subjects, by merely ex- 
posing various parts of the body to, or covering them from, the light 
of the sun. M. Aug. Spessa attributes pellagra to the habit which 
the poorer inhabitants of some parts of Italy have of passing the even- 
ings, and sometimes part of the day, in winter, in their dirty and 
unhealthy cow-houses, by way of escaping from the cold. He is per- 
suaded that pellagra is not endemical in countries where this habit 
does not exist; that where it is endemical it is only seen among those 
who inhabit stables ; finally, he adds, that pellagra has only attracted 
the attention of physicians since 1770, an epoch when fire- wood had 
already become exceedingly scarce in countries where this disease 
prevails. M. Spessa seems to think, besides, that exposure to the 
sun is the occasional cause of this disease. 

1418. Diagnosis — Pellagra is distinguished from acute erythema 
inasmuch as the latter, which may appear on any part of the body 
whether covered with the clothes or not, shows itself not only in the 
spring but at all other seasons, and generally terminates after con- 
tinuing for a week or two. As to chronic erythema, it is never accom- 
panied by serious symptoms, and the lesions of the digestive organs 
and nervous system which are observed in pellagra. These general 
symptoms, when they exist, also distinguish pellagra sufficiently from 
lepra, to prevent any mistake; the prominent rings of lepra, besides, 
covered with squama", heal from the centre, and appear indiscrimi- 
nately on parts either covered with clothing or not. This absence of 
general symptoms is also remarked in psoriasis, the white and pearly 
squamae of which differ from the generally embrowned state of the 
epidermis in pellagra. 

Pityriasis rubra, in a severe form, has more analogy with pellagra, 
on account of the gastro-intestinal symptoms which sometimes accom- 
pany it during its course ; but it differs from pellagra in never being 
accompanied with secondary lesions of the nervous system, and in the 
eruption being general. 

Of all the diseases seen in France, the epidemic which prevailed 
in Paris and its neighbourhood, in 1828 (acrodynia), is, without ex- 
ception, the one which bears the greatest resemblance to pellaora. 
In fact, as in pellagra, from the commencement of the disease, red- 
ness varying in tint from bright to dark red, was commonly seen on 
the feet and hands, less frequently on the legs, and more rarely still 
on other parts of the body ; vesicles and bullae also accompanied this 
first form of the eruption, and at other times the skin assumed a brown 
or blackish hue, particularly on the belly, neck and about the joints, 
a hue produced by an alteration of the epidermis, which falls off at a 
later period. Profuse, irregular, periodical local sweats also occurred 
in acrodynia as in pellegra. Disorder of the digestive functions, 
characterized in some by simple loss of appetite, and a feelin^ of full- 
ness and weight in the stomach, in others by nausea or vomitings, 
particularly after taking food or drink, by colic, and very frequently 
by a diarrhoea of longer or shorter duration, were almost always su- 
peradded to the other symptoms of acrodynia either in the commence- 
ment of this affection, or at some period during its course. As in 
pellagra, too, a sense of numbness, and of tingling, and occasionally 
smart shooting pains were felt in the hands and feet, extending some- 
times along the legs, thighs or arms to the trunk, and even to the 
hairy scalp ; the sense of touch was even affected in some cases (an- 
esthesia). Paralysis, and contractions, and shrinking of the limbs, 
tremblings and painful cramps were observed in the one as in the 
other disease. (Edema, mostly partial, but sometimes general was 
more frequently seen in acrodynia than in pellagra. As has been 
remarked in pellagrous epidemics, these various symptoms presented 



a very considerable number of anomalies in their progress and succes- 
sion in acrodynia. In some cases the redness and black discoloration 
of the skin were the principal phenomena of the disease; in others, 
lesions of the digestive passages seemed to predominate ; in others, 
again, such disorders of the nervous system were observed that it 
alone seemed to be affected. As in pellagra, also, the small number 
of bodies which have been examined, have exhibited alterations 
which were owing, perhaps, as much to accidental and intervening 
affections as to the disease itself. 

Jlcrodynia, like pellagra, broke out in the spring, prevailed particu- 
larly during the summer, and seemed to become extinct in the middle 
of the severe winter of 1829-1830. As for the differences between 
these two diseases, they are much less striking than the analogies 
which exist ; still it must be remarked that the pain in the feet and 
impossibility of walking were much more marked in the epidemic of 
Paris ; that exposure to the sun is an evident occasional cause of 
pellagra, and that this latter affection, which almost always reappears 
each year in an aggravated form, is more frequently fatal, and gives 
rise to a species of insanity which was not seen in the epidemic of 
Paris. 

The mal de la rosa, a disease epidemic in the Asturias, ought not, 
it would seem, to be separated from pellagra, of which it presents the 
principal symptoms. Some difference in the alterations of the skin 
only are remarked ; in the mal de la rosa it becomes covered with 
scabs sometimes followed by cicatrices, whilst in pellagra, the form 
of the cutaneous disease is exanthematous or squamous. 

Upon the whole, pellagra, the mal de la rosa, and the epidemic of 
Paris, seem to me to form one very natural group. 

There is, without doubt, much similarity between pellagra and the 
epidemic disease which prevailed at Briinn (Moravia), in 1578, and 
which has been assimilated with syphilis : after the cutaneous symp- 
toms, however, signs of melancholy, and other nervous phenomena, 
which are so commonly seen in pellagra, are known to have occurred 
(See Jordan (T.), Brunno-Gallicus, seu luis nova in Moravid exortce 
descriptio. Frankfort, 1577, 8vo.). 

Certain epidemics which have been observed in Europe, and par- 
ticularly in the north, from the middle of the sixteenth century till 
towards the end of the eighteenth, and which have generally been 
attributed to the use of damaged grain, as of spurred wheat or rye, 
may be assimilated to a certain point with pellagra. Ptyalism, func- 
tional disorders of the digestive organs, acute pains, a feeling of heat 
in the palms of the hands and soles of the feet, swellings and vesicles 
on the skin, cramps, tremblings of the body, and mania as a secondary 
phenomenon, have been remarked in these epidemics as in pellagra. 
Independently of the special cause assigned to these diseases, they 
are distinguished from pellagra by a variety of characters, and parti- 
cularly the development and reappearance of their symptoms under 
the form of fits or paroxysms. (See, for a history of these epidemics, 
Ozanam, Histoire des maladies epidemiques, in 8vo. t. v. p. 120.) 

1419. Prognosis. — Medical practitioners have distinguished three 
degrees of intensity in pellagra. In the first, local lesions are seen, 
produced by exposure to the sun, sometimes only with slight accom- 
panying indisposition ; in this case it is sufficient to remove the patient 
beyond the influence of the causes which have produced pellagra to 
accomplish a cure. The second degree is much more serious, still it 
is sometimes cured ; it embraces those cases in which the alterations 
of the skin, after several relapses, become of a more decided nature, 
and disorders of the digestive organs more apparent. Nervous symp- 
toms, vertigo, pains, cramps, slow pulse, &c, are added to ptyalism, 
heat in the throat, vomiting, and diarrhoea. The third degree, or con- 
firmed pellagra, is constantly fatal ; it is known by a constant febrile 
state, involuntary stools, and other phenomena, such as melancholy, 
pellagrous mania, stiffness of the body, convulsions, loss of flesh, &c. 

Acute delirium, although of a serious nature, is a less formidable 
symptom than chronic delirium. 

Upon the whole, the prognosis should be based, not upon the state 
of the skin, or the alterations it has undergone, but upon due appre- 
ciation of the disorders of the various systems of the body generally. 

The condition iniife of individuals affected with pellagra must also 
be considered in prognosticating in regard to the issue of the disease. 
The mischief is aggravated, and the affection generally proves fatal to 



ROSA. 



423 



those who are a prey to poverty and wretchedness, and obliged to re- 
main within the influences of the causes which produce it. The state 
of the constitution, previous diseases, and complication, must also be 
taken into the account. Pregnancy and lactation exercise a pernicious 
influence. Writers have particularly insisted upon the serious cha- 
racter which pellagra assumes in those whose parents have died of 
the disease. 

1420. Treatment. — Upon the first symptoms of the pellagrous affec- 
tion, the patient ought to change his habits and occupation, or at least, 
abstract himself from the influence of the causes which appear to have 
occasioned it. Change of climate, of regimen and habits, will be the 
most certain remedy ; unfortunately, those affected with pellagra, the 
poor inhabitants of the country, are scarcely ever in circumstances to 
follow this advice. 

In the slight forms of pellagra, physicians are agreed upon the 
necessity of avoiding exposure to the sun, and of placing patients in a 
healthy and well-aired dwelling. The food should be good and sub- 
stantial, consisting of animal and vegetable substances, in quantities 
proportionate to the wants of the system, and to the powers of the di- 
gestive organs. Milk sweetened, or old wine much diluted with water, 
are appropriate drinks. 

Fontanetti has advised, at the commencement of the disease, the 
moderate use of bleeding and purgatives, according to the state of the 
skin and the mucous membranes. Tepid baths, both general and local, 
fomentations, anointing the skin, dry friction, sudorific or slightly laxa- 
tive tisans, &c, may be made use of with advantage. 

1421. In the more serious forms of this disease the treatment should 
be modified according to the various symptoms which present them- 
selves. In pellagrous affections of the digestive passages, fomentations, 
emollient cataplasms, sometimes even the application of leeches to the 
pit of the stomach, to the abdomen or anus, should be had recourse 
to. Preparations of opium, rice water, barley water, emollient and 
narcotic injections will be useful in cases of obstinate diarrhoea. 

Serious affections of the brain and spinal marrow must be attacked 
by blisters, and issues in the nucha, or along the course of the spine ; 
a seton should be inserted in the nape of the neck, or several moxas 
applied along the back. 

Cold applications to the head, leeches behind the ears, or bleeding, 
should be had recourse to in cases of acute delirium. 

In general trembling, cold sulphureous baths, combined with anti- 
spasmodic remedies, are worthy of a trial. 

Opium seems to be of use in cramps, in pains and tetanic stiffenings 
of the limbs. 

Pellagrous mania requires treatment similar to that which is pur- 
sued in mental affections produced by other causes ; only in almost all 
cases, the strength should be supported by mild and nutritious diet, 
and the other symptoms of the disease treated with circumspection. 

Historical Notices. 

1422. Frappoli, of Milan, (animadversiones in morbum vulgo pella- 
gram diet. Mediolani, 1771,) was the first who published upon pel- 
lagra. Odoardi (Dissertazione di una specie particolare di scorbuto, 
Venezia, 1776), has assimilated the disease to scurvy, and has con- 
sidered its causes, symptoms, and treatment, in this point of view. 
Gherardini (Mich.), in his Descrizione della pellagra, Milano, 1780, 
has given a good description of pellagra : he has well appreciated 
the influence of exposure to the sun on the cutaneous eruption. Al- 
bera (G. M.) (Trattato teorico-practico delle maldttie deW insolato di 
primavera volgarmente detto della Pellagra, Venezia, 1784), is remark- 
able for his therapeutic views. Strambio (Gaetano) (de pellagra, Me- 
diolani, 1786, 1787, 1789; Dissertazione sulla pellagra, 1794), has 
given a very good description of pellagra, and particularly of the 
nervous forms which it presents. Fanzago has published a series of 
memoirs on pellagra ; he has studied its causes, its diagnosis, and 
treatment with care, and has related several particular cases : Me- 
mortf sopra la pellagra, Padova, 8vo. 1798 ; Paralelli tra la pellagra 
ed alcune malattie, Padova, 8vo. 1792 ; sulla Pellagra memorie, Pa- 
dova, 8vo. Videmar (De quadam impetiginis specie vulgo pellagra 
nuncupata disquisitio, Mediol. 1790), Jansen (de Pellagra morbo in Me- 
diolanensi ducatu endemico, in Dilect. opusc, vol. i. 325), and Boerio, 



Ant. (Storia della pellagra nel Camovese, Torino, 1811, 8vo.), have 
left a good summary of the information extant respecting pellagra, 
and some remarks on various symptoms of this disease. Jourdan 
has published a remarkable article on pellagra (Dictionnaire des Sci- 
ences Medicates). Strambio has insisted on the inflammatory cha- 
racter of the functional disorder of the digestive organs in pellagra 
(J\"atura, sede e cagioni della pellagra disunte dai libri di Gaetano 
Strambio, e della dottrina Brousseiana, Milano, 1820). Fantonetti 
has dissected the skin, with great care, of a man affected with pella- 
gra (Trattato dei mail della pelle di P. Rayer, art. Pellagra). Brierre 
de Boismont (de la Pellagra et de la folie pellagreuse, 8vo. Paris, 
1834), has published an interesting paper on pellagra, particularly in 
a therapeutical and anatomico-pathological point of view. And. Aug. 
Spessa (sulla Pellagra, Annali universili di medicina di Omodei. Mi- 
lano, 1832, vol. lxiv. p. 207), has attributed pellagra to inhabiting 
stables, &c. (a) 



ROSA ; OR DISEASE OF THE ASTURIAS. 

1423. Thierry has given the following description of la rosa: 

This disease generally appears at the spring equinox. It shows 
itself on different parts of the body by simple redness, and harshness 
of the skin. It then degenerates into rough, dry, blackish crusts, 
intersected with deep cracks, which often penetrate to the quick. 
These dry and fall off in summer, leaving reddish, very smooth and 
shining stains or marks behind them, devoid of hair, depressed below 
the level of the surrounding skin, and very similar to the cicatrices 
of burns. It is probably from the appearance of these marks that 
the disease has been denominated rosa. They remain through life. 
In the spring of every year they are covered anew with fresh crusts, 
which become ever more and more disgusting to look upon. Occa- 
sionally a large yellowish or ash-coloured crust occupies the forepart 
of the neck, and extends from thence over the clavicles and upper 
portion of the sternum, forming a band of two fingers breadth, and 
descending half way down the breast, like the collar of one of the 
orders of knighthood ; this appearance is quite characteristic. 

To these symptoms there is added a constant shaking or trembling 
of the head and upper parts of the body, which sometimes becomes 
so violent that patients experience great difficulty in keeping them- 
selves erect; there are also heat in the mouth, vesicles on the lips, 
foulness of tongue, extreme weakness of stomach and of the body 
generally, and a feeling of general heaviness. Through the night 
burning heat is complained of, insomnia, dejection, melancholy, 
groaning without any assignable reason, &c. Patients for the most 
part are in the entire possession of their intellectual faculties: several, 
however, suffer from slight delirium, hebetude, and a loss of the sense 
of taste, and particularly of touch. This state may be succeeded by 
erysipelas, ulcers and erratic fever. 

This disease may end in dropsy, in scrofulous affections, and in ma- 
rasmus ; at other times it terminates in mania, which is seldom of a 
violent kind; the patients sink into an undefinable state of dejection, 
which leads them to forsake their homes and to seek solitude, and their 
excess of depression and of suffering often reduces them to utter 
despair. This insanity, which does not generally show itself save 
about the summer solstice, commonly proves fatal. 

Rosa is particularly frequent in the province of Oviedo, where the 
sky is generally overcast, and the soil is barren (Thierry, Obs. de 
Physique et de Medecine,faites en Espagne, 8vo. Paris, 1791). 

Casal, who practised for thirty years in the Asturias, informs us 
that the rosa is extremely rebellious. Thierry cured one woman after 
two months of treatment with the aethiops mineral, crude antimony, 
saffron, and some of the balsams. 

All we have upon this disease is still too little to enable us to come 



(a) M. Rayer has omitted, in the preceding list, the work of Sig. 
Vincenzio Chiarugi, M. D., entitled Saggio di Ricerche sulla Pella- 
gra, Firenze, 1814: with two coloured drawings. The editor's first 
knowledge of pellagra was derived from this volume, which he pro- 
cured many years since, when in Italy. 



424 



PELLAGROUS DISEASES. 



to anv definitive opinion in regard to its character and proper treat- 
.dogy it bears to pellagra is nevertheless striking. 

Historical Notices. 

1424. The chief documents we possess upon la rosa, are con- 
tained in the work of Thierry, the title of which is given above, and 
in that by Casal, entitled Historia natural y medica de principado de 
jJsturias, 4to. Madrid, 1762. 



ACRODYNIA. 

1425. In the month of June, 1828, an epidemic disease, principally 
characterized by pain and numbness of the lower extremities, erythe- 
matous patches, and more rarely by a blackish discoloration of the 
cuticle, attracted the attention of the practitioners of Paris. This 
malady first appeared at the Hospice de Marie Thercse, and was soon 
afterwards observed in various quarters of the city. It made its way 
at the same time into several barracks; in one, 560 out of 700 indi- 
viduals were attacked with it. A great number of patients labouring 
under it were received into the different hospitals, and I had many 
under my charge in that of St. Antoine. During the following winter 
the disease abated; but in the month of March, it again made its 
appearance in the Barrack de la Courtille. The epidemic seemed to 
haye become completely extinct towards the midwinter of 1829-30. 

1426. Symptoms. — Some patients complained at first of simple loss 
of appetite ; others suffered with sickness and vomiting, colicky pains 
in the bowels, frequently with diarrhoea, and the eyes at the same 
time became inflamed and watery. From the very commencement a 
kind of puffing of the face was observed among many patients, which 
occasionally extended to other regions of the body. 

The skin of the palms of the hands and soles of the feet presented, 
often from the invasion of the disease, a red colour which frequently 
extended along their edges to other parts of the body, to the legs more 
especially, in the shape of patches of various shades of red, some- 
times very similar to ecchymoses. Pretty frequently, too, the skin 
assumed a blackish or brown appearance, as if it had been rubbed over 
with soot; this happened more particularly on the abdomen, neck, and 
about the bends of the joints ; it very rarely happened that this dis- 
coloration extended to the face. 

Numbers of small spots, pustules, phlyctenoo, coppery spots or 
patches, and even boils were evolved upon the hands and feet. A 
process of desquamation, assisted by profuse local sweats, ended by 
laying the corpus mucosum completely bare. This process was often 
renewed again and again upon the same place, and took place over 
all the regions affected. 

Occasionally an evident thickening of the cuticle was observed, 
especially over the articulations of the feet; this sometimes formed an 
elongated and painful roll between the nail and the pulp composing 
the point of the finger. 

Sensations of numbness, and of tingling, and occasionally painful 
shootings were felt in the hands and feet, more especially in the latter, 
and generally of greater severity through the night than during the 
day, and more intense at all times in the palms and soles than any- 
where else. They sometimes extended up the legs, thighs and arms, 
to the trunk. A feeling of cold, succeeded by one of burning heat, 
sometimes obliged patients to put their feet and hands out of their 
bed ; some complained of the slightest pressure made upon those 
parts as intolerably painful; in others the feet and hands were so 
much benumbed that sensation and touch were almost entirely abo- 
lished ; others, again, were affected with true paralysis of these parts, 
accompanied with contraction and wasting of the limbs, in which, 
nevertheless, occasional painful twitchings and shootings were expe- 
rienced. 

The symptoms presented very considerable variety at different 
periods of the epidemic; in one the alteration of the sensibility was 
one of the most marked ; in another the digestive organs were the 
parts principally implicated, and in a third, oedema and the brownish 
hue of the surface were the most striking peculiarities. In the Prison 
Montaigu, almost all who were affected presented the brown discolora- 



tion of the skin, whilst this symptom was not seen in the Barracks 
de l'Oursine and de la Courtille; in the latter, violent convulsive 

twitchings in the limbs were the principal phenomenon, in that de 
l'Oursine, after the numbness, oedema of the face, ophthalmia and 
vomiting were the most remarkable symptoms. 

The disease generally lasted for several months, sometimes it 
ceased after a few weeks. Many patients, after recovering completely 
to all appearance, had relapses which did not end but with the epide- 
mic. It rarely proved fatal except among the aged. The lesions of 
the viscera discovered after death were evidently owing to compli- 
cations. 

1427. Causes. — A variety of causes have been presumed for this 
disease, such as the adulteration of the articles used for food, bread, 
wine, &c, some change in the water, salt, potatoes, &c. ; a vitiated 
state of the atmosphere, &c. But the epidemic prevailed in the most 
healthy barracks, in the best ventilated apartments, and did not show 
itself in other places much less advantageously situated. It was 
observed, during its prevalence, that it attacked adults and the aged 
more particularly, that men were more liable to it than women, and 
the poor than the rich; it did not appear to be contagious. The dis- 
ease was viewed variously as rheumatic in its nature, as an inflamma- 
tion of the skin and mucous membranes, as the effect of a peculiar 
lesion of the nervous system, especially of the spinal marrow; lastly, 
as a new disease. 

1428. Diagnosis. — Pellagra, of all known diseases, is that with 
which acrodynia has the greatest analogy ; both are characterized by 
a triple manifestation of cutaneous symptoms, of gastro-intestinal 
symptoms, and of nervous symptoms, the similarity of which is cer- 
tainly striking. (Vide Pellagra.) In several epidemics attributed to 
indifferent qualities of the cerealia, the spurred rye, &c, the greater 
number of the symptoms of acrodynia will also be found noted, such 
as tinglings and numbness of the feet and hands, amounting some- 
times to paralysis, contraction of the fingers, cramps of tie le 
swelling of the feet, phlyctense on these parts, &c. These epidemics, 
like that of Paris of 1828, also occurred in cold and moist summers. 

1429. Treatment. — Uncertain of the actual nature of acrodynia, I, 
like the rest of the profession, tried a variety of means which I con- 
ceived calculated to abate the predominating symptoms, but without 
very marked success, the disease almost constantly proving very 
tedious and various in its phenomena. I generally prescribed Seltzer 
water and anodynes when the gastric symptoms were pressing. 
When the nervous symptoms appeared with great intensity from the 
first, I ordered a small bleeding, and the patient was put into the warm 
bath, and took a grain of opium at night. If these symptoms only 
occurred in the second or third stages of the disease, and when the 
general system had already suffered, I ordered the sulphureous water 
bath, and sometimes with good effect. As to the cutaneous symp- 
toms, I never treated them save with tepid baths and fomentations 
and emollient applications. 

Historical Notices. 

1430. First pointed out by M. Cayol, and subsequently by M. 
Chomel, acrodynia has since been the subject of numerous researches: 
Genest, Recherches sur V affection epidemique qui regne maintenant h 
Paris. (Arch. Gener. de Medec, 1828, t. xviii. p. 232, t. xix. p. 63, 
p. 357.) Constitution medical ou tableau des obs. meteorol. et med. 
recueillies en 1829, a la clinique de M. Cayol (Revue Med., 1830, t. ii. 
p. 48). Dalmas, Compte rendu de la clinique de M. Chomel (Journ. 
Hebdomad., t. i. p. 333). Chardon fils, De Vacrodynie ou de Pepidhnie 
qui a regne a Paris et dans ses environs, l'annee 1828, in 8vo., Pans. 
Dezeimeris, Sur Pepidhnie de Paris (Journal general des hopitaux, 
nos. 2, 4, 8, 17. — Dance, art. Acrodynic (Diction, de m6dec, 1832). 



DISEASE OF MELADA, 

(An Island in the Gulf of Venice). 

1431. In a village of the Isle of Melada, known for the slight deto- 
nations which are there heard, several of the inhabitants are subject 



CARATE— PINTA. 



425 



to a disease affecting the skin of the extremities which bears a certain 
resemblance to that of Anna Jackson (§ 1173), and of the brothers 
Lambert (§ 1102). 

Eleven individuals belonging to three families present a similar 
alteration of the skin of the palms of the hands and of the soles of the 
feet and toes. 

It is not above half a century ago since this alteration of the integu- 
ments was first described ; how long it may have existed previously 
is uncertain ; the accounts we have of it extend over no more than 
fifty years, and exhibit it as possessing the same features during the 
whole of this time. 

1432. Children at their birth present in the palms of their hands, 
unequivocal signs of this disease, which is developed as they advance 
in years. The skin of this region becomes gradually thicker and 
thicker and firmer, and extends so as to cover the whole superficies 
of the parts above mentioned. The alteration then spreads round 
upon both sides of the fingers and toes, and in the angles between 
them, and to the articulations of the metacarpus and metatarsus, so 
that the skin at length acquires the appearance of a long layer of yel- 
lowish tallow, but of the consistence of leather; it is rough and 
uneven in consequence of the fissures, with which it is traversed, 
which give it the look of the bark of the cork tree. The outermost 
layer of the skin is then transformed into a substance that is almost 
completely inorganic, through which neither cutaneous exhalation nor 
sweat ever finds its way. There is no longer the albuminous transu- 
dation by which the cuticle is renewed as it is worn away. 

The cuticle of the elbows is also thickened ; the corion and rete 
mucosum form but a single layer; the integuments of the carpus and 
tarsus are sallow and wrinkled ; the knees, too, are often covered with 
squama? and warty excrescences ; the hands, in addition to this, and 
feet, are impotent. The parts affected are entirely without sensation ; 
they never swell ; the epidermis over them seems never to be raised 
by the effusion of a fluid under it ; neither do they ever ulcerate. 

The feet of the persons affected diffuse a very fetid odour. The 
perspiration seems to be retained within the deep cracks of the skin, 
and there to acquire great fetor. The cause of the cracks appears to 
be entirely mechanical. 

This disease is an organic and hereditary defect or vice of confor- 
mation. It does not extend to the other parts of the body, and does 
not seem to influence the general health. 

The children who present this defect of conformation of the skin 
are occasionally born of parents who are free from it, but who were 
themselves the offspring of individuals who had laboured under it. It 
is common to both sexes. Some of the children of a family are born 
with the disease, others altogether free from it. Propagation by way 
of contagion is inadmissible. The disease bears some analogy to 
ichthyosis ; but it is followed by worse effects than this complaint, 
preventing the unfortunate persons who labour under it from earning 
their livelihood by their industry, the fingers, especially the ring and 
little finger being in a permanent state of forced flexion. (Letter of 
Dr. Stulli : Sur une espece de rnaladie cutanee. Bullet des sc. Med. 
de Feruss., t. xxi. p. 96.) 



SIXTH GROUP. 

ENDEMIC BLANCHING AND DISCOLORATION OF THE 

SKIN. 

1433. This group comprises the particular blanchings and dis- 
colorations of the skin endemical in certain countries. 



CARATE. 

1434. Under the name of Curate, a disease of the skin peculiar to 

the countries bordering the Cordilleras, and especially prevalent in the 

kingdom of New Granada, has been described. Bonpland observed 

it on the banks of the river Magdalena at Monpox, and onwards to 

107 



the confines of Peru. It was so common in some villages, that but 
few individuals were encountered altogether free from it. It is said, 
however, to attack negroes and mulattoes more particularly. 

Carate appears under the form of spots or patches spread over the 
whole body, but more abundantly over the arms and forearms, cheeks 
and breasts among women. These patches are, in some cases, of the 
colour of coffee, in others of a dull white, in others of a crimson red, 
and in others of a livid white; the skin, by the mingling and contrast 
of these different tints, often presents a marbled appearance. Amongst 
the natives, Carate is said to whiten the blacks, and to blacken the 
whites. The disease is not contagious. 

M. Daste assures us, that this affection is successfully treated by 
means of the corrosive sublimate. M. Zea says it is incurable when 
it has made a certain progress. It does not influence the general 
health ; it is only unpleasant to look upon. 

These accounts are extracted from a note, by M. Alibert, sur la 
carate ou taches endemiques des Cordiltieres, in the Revue Med., t. 
xxiii. p. 228, 1829. 



1435. M'Lellan states that a disease of the skin, known under the 
name of pinta, or blue spots, made its appearance in the neighbourhood 
of the volcano of Jorulla, in the northern part of the province of 
Valladolid, Mexico, and soon spread southwards as far as the town 
of Mascala, on the road from Mexico to Aispuello. The populace, 
whose skins are of a dark colour, were the principal sufferers. The 
disease began with slight shivering and nausea, followed by trifling 
fever. These symptoms lasted for a few days only ; when they sub- 
sided, pale and yellowish-coloured spots were observed over the face, 
chest, and extremities ; these spots grew paler and paler, till they 
became nearly white ; but they then began to deepen in their tint, 
and went on till they acquired the same depth of shade as the skin of 
the negro. The integuments, too, grew rough and squamous, ap- 
peared slightly inflamed, and fell readily into open ulcers. The 
cutaneous perspiration was fetid, but the general health was not much 
affected. M'Lellan informs us that in Mexico there was a regiment 
composed of individuals whose skin had undergone this singular 
change, and which was denominated the pinta regiment. The dis- 
ease appears to be contagious. Individuals born and brought up in 
districts where the pinta is only known by name, become affected 
with it after a residence of a few years, in parts where it prevails, and 
nurses have been known to communicate it to their nurslings. Persons 
in easy circumstances, nevertheless, live all their lives in the district 
of Pinta, and take into their service individuals affected with the 
spots in question, without contracting it themselves. They appear to 
enjoy immunity from its attacks, by the most sedulous attention to 
personal cleanliness, by using the bath continually, performing ablu- 
tions, &c. Although the individuals affected with pinta are to be 
met with all around Mexico, selling a variety of wares, &c, the dis- 
ease is only known by name on the coast of the Pacific Ocean and 
adjacent countries, divided by the mountains from the Tierra Caliente . 
The physicians of the country regard pinta as a specific and incurable 
disease {An acct. of the pinta or blue stain, a singular cutaneous 
disease prevailing in Mexico, by S. M'Lellan, Ed. Med. and Surg. 
Journ., 1826). 

Pinta must be looked upon as associated with the other morbid or 
accidental discolorations of the skin observed in Europe— cloasma, 
nigrities, &c. 



SEVENTH GROUP. 

ACUTE ENDEMIC ERUPTIONS. 

1436. This group comprises the acute diseases which are peculiar 
to certain countries. 






GANGRENOUS EPIDEMICS. 



lichen tropicus; prickly heat. 

3 . I have already noticed the chief observations made on this 
628) by Bontius in India [De Medicina Indorun, cap. 18), 
by Hillary in Barbadoes (Obs. on the Changes of the Air and concomi- 
tant Epidemical Diseases in the island of Barbadoes, 8vo., Lond. 

. in Africa by YVinterbottom, whose remarks are published by 
Willan (on Cutaneous Diseases, p. 57), and by Dr. James Johnson 
(the Influence of Tropical Climates, &c), who also mentions the re- 
searches of Dr. Moseley. 

ILLINOIS itch. 

1438. Horiatio Newhall states that four-fifths of the individuals 
who have lived for a year in the state of Illinois (United States), be- 
come affected with a disease known under the name of the Illinois itch. 

The disease begins with severe itching of the arms and thighs, 
without any eruption, which induces the individual affected to rub 
and scratch himself vigorously to appease the sensation. The effect 
of this indulgence, however, is to bring out in a few seconds an erup- 
tion of small papula 1 , of the same colour as the skin. These papulae 
are not pointed, and are not inflamed around their bases. One crop 
often disappears whilst another isevolved; the latter become vesicular 
after the lapse of a day or two. The vesicles are more pointed than 
the papulae, and are filled with a clear transparent fluid, which, in the 
course of a few days, changes into an opaque matter of a pale yellow 
colour. There is no inflammation around the vesicles until after a 
great deal of scratching, which seems to occasion the inflammation 
that subsequently occurs. 

If the vesicles are punctured at the first with the point of a needle, 
they disappear without leaving any traces of their presence ; but if 
their apices be torn off at a later period, a watery fluid, mixed with 
blood, exudes, and black or brownish crusts are formed, which vanish 
in the course of time, but leave small permanent cicatrices behind 
them. 

Where the affection has lasted long, the vesicles are occasionally 
intermingled with psydracious pustules containing a straw-coloured 
matter. These often become confluent, and by drying give rise to 
broad and irregular crusts. The crusts are commonly situated on 
the legs in men, on the legs and breasts of women, and on the head 
and a variety of other parts in children, among whom the disease 
might very well be confounded with crusta lactea. Occurring around 
the fingers, the eruption has sometimes caused the loss of the nails. 

In this affection, then, we have papulae without inflammation about 
their bases, papula? with inflammation round them, vesicles, pustules, 
minute squamae and broad crusts, external characters which prevent 
its being assigned to any particular place in the chart of cutaneous 
diseases. 

The eruption is most copious on the inner parts of the thighs, arms, 
wrists, between the fingers, and around the axillae and scrotum. In 
young children the sole of the foot is particularly affected ; the face 
is never implicated. The pruritus is intolerable, and is increased by 
heat ; the hands are occasionally swelled to such a degree as to force 
the individual to abstain from all kind of manual labour. There is 
not in general any fever; the disease is not contagious, and cannot 
be communicated by inoculation. Mr. Newhall has seen persons 
affected with this disease during four and five years at a time (New- 
hall, Rem. on the disease of the skin called Illinois Itch, New. Engl. 
Journal, vol. xviii. p. 134. Ext. in Bullet, des Sciences Med. de 
Ferussac, t. xviii. p. 65). 



EIGHTH GROUP. 
GANGRENOUS EPIDEMICS. 

1439. This eighth group comprises two gangrenous affections ; the 
Nome of Sweden and the Mai des Ardens or ignis sacer of the middle 
ages. 



NOME OF SWEDEN. 

1440. In the ninth volume of the Memoirs of the Academy of 
Stockholm, we read the following accounts : " Among the children of 
the poor in Sweden, from one to ten years of age, who live on salted 
meats and breathe a corrupt atmosphere, there prevails a species of 
ulcer denominated nome. This disease begins with uneasiness, lassi- 
tude, pallor, fetor of the breath, heat, thirst, diarrhoea, inappitence, 
restlessness, sleeplessness, and rambling, and transient swellings of 
the body. A black pustule or spot then makes its appearance on the 
face or neck ; the gums assume a dark green colour ; the teeth fall 
out; fetid saliva distils from the mouth ; the tongue, face and lips 
swell ; the whole body becomes painful ; the urine is brown ; the 
pulse small and quick; the respiration frequent;' trembling from 
weakness. From the second day the extremities become cold ; the 
black spot extends ; the crust falls off and exposes an ulcer covered 
with a grayish-black, thick and fetid pus ; the pulse becomes frequent, 
unequal and weak, and the patient soon dies. 

The disease consists in a scorbutic gangrene, which requires the 
most prompt measures for its relief. The. best internal medicine is 
the decoction of bark with sulphuric acid; externally, the gangrenous 
spot is bathed with diluted muriatic acid. When the eschar is de- 
tached, the sore is dressed with decoction of bark, some digestive 
ointment, with a solution of sublimate in alcohol, volatile alkali, 
myrrh, diluted sulphuric acid, &c. 

Change of air, exercise, and wholesome food, are necessary to 
complete the cure. The ulcer never bleeds ; the patients sometimes 
suffer from epistaxis, the blood being then watery and pale. 

It is worth while to compare this description with that of the vovat, 
of Hippocrates (Prcedict., lib. ii.), and of the gangrenous affection of 
the cheeks of children in France. 



IGNIS SACER OF THE MIDDLE AGES. 

1441. In the eleventh, twelfth, and thirteenth centuries a disease 
variously entitled ignis sacer, mal des ardens, and St. Anthony's fire, 
committed great ravages in France. Rudolphe {Hist., lib. 2, cap. 7, 
de incendiis), tells us, that when this fire attacked a limb, it was 
straightway detached from the body, after being burned. Sigebert, 
speaking of the St. Anthony' 's fire which prevailed in Basse Lorraine, 
assures us that the extremities, as black as charcoal, were detached 
from the body, and that the sufferers, having lost their feet and hands, 
died miserably, or dragged out a still more miserable existence. 

The Martyrologia has further, under the date of 1140, in the reign 
of Louis VII : "A disease showed itself in Paris which the physicians 
called ignis sacer, and which attacked persons on their genitals." 
(Consult Mezerai, Abrege Chronol. de PHist. de la France, and parti- 
cularly the learned memoir of Jussieu, Paulet, Saillant, and Tessier : 
Rech. sur lefeu Saint Antoine, lues le 31 Dec. 1776. Mem de VAcad. 
Royale de Medecine, t. i. p. 260.) 

This epidemic ignis sacer must not be confounded with the ignis 
sacer described by Celsus, which cannot certainly be assimilated to 
any disease known at the present day : " Sacer quoque ignis malis 
ulceribus annumerari debet. Ejus duae species sunt: alterum genus 
est subrubicundum aut mixtum rubore atque pallore, exasperatumque 
per pustulas continuas, quarum nulla altera major est, sed plurima; 
perexiguae. In his semper fere pus, et saepe rubor cum calore est, 
serpitque id nonnunquam, sanescente eo quod primum vitiatum est, 
nonnunquam etiam exulcerato, ubi ruptis pustulis ulcus continuatur, 
humorque exit qui esse inter saniem et pus videri potest. Fit maxime 
in pectore, aut lateribus, aut eminentibus partibus, praecipueque in 
plantis. Alterum autem est in summae cutis exulceratione, sed sine 
altitudine, latum, sublividum inaequalitertamen, mediumque sanescit, 
extremis procedentibus, ac saepe id quod jam sanum videbatur, interum 
exulceratur. At circa proxima cutis quae vitium receptura est, tumi- 
dior et durior est, coloremque habet ex rubro subnigrum. Atque hoc 
quoque malo fere corpora seniora tentantur, aut quae mali habitus sunt, 
sed in cruribus maxime. Omnis autem sacer ignis, aut minimum pen- 
culum habet ex his quae serpunt, sic prope difficillime tollitur. Medi- 
camentum ejus fortuitum est febris quae uno die humorem noxium 



CUTANEOUS DIPHTHERITIS— PLICA. 



427 



absuraat. Pus qud crassius et aibidius est, eu periculi minus est. 
Prodest etiam infra os ulcerum csedi, quo plus puris exeat, et id, quo 
ibi corruptum corpus est, extrahat. Sed tamen si febricula accessit, 
abstinentia, lcctulo, alvi ductione opus est. In omni vero saero igni, 
neque lenibus et glutinosis cibis, neque salsis et acribus utendurn est, 
sed his quae inter utrumque sunt, qualis est panis sine fermento, piscis, 
haedus, aves, exceptoque apro, omnis fere venatio. Si non est febri- 
cula, et gestatio utilis est, et ambulatio, et vinum, et balneum. Atque 
in hoc quoque genere potio magis liberalis esse quam cibus debet. 
Ipsa autem ulcera si mediocriter serpunt, aqua calida ; si vehementius, 
vino calido fovenda sunt ; deinde acu pustula?, quaecumque sunt, ape- 
riendae : turn imponenda ea quae putrem carnem exedant. Ubi inflam- 
matio sublata, ulcusque purgatum est, imponi lene medicamentum 
debet. In altera autem genere possunt proficere mala cotonea in vino 
cocta atque contrita; potest emplastrum vel Hierae, vel tetrapharmacum, 
cui quinta pars thuris adjecta sit: potest nigra edera ex vino austere 
cocta: ac, si celeriter malum serpit, non aliud magis proficit. Purgato 
ulcere quod in sum ma cute esse proposui, satis ad sanitatem eadem 
lenia medicamenta proficient." (Celsus. De Medicina., lib. v. sect, 
xxviii. 4.) 



NINTH GROUP. 
CONTAGIOUS PSEUDO-MEMBRANOUS DISEASES. 

1442. The skin excoriated by the action of blisters or accidental 
ulcers is liable to be attacked with two contagious diseases of a pseudo- 
membranous appearance, diphtheritis and hospital gangrene. For a 
particular account of the latter, I beg to refer to the works of Delpech. 
(Mem. sur la pourriture d'fiopital, 8vo. Paris, 1815.) 

CUTANEOUS DIPHTHERITIS. 

1443. From the researches of Messrs. Bretonneau and Trousseau, 
diphtheritis, angina maligna or angina membranacea, is occasionally 
accompanied with a pseudo-membranous inflammation of the skin of 
the same nature, and which, during the prevalence of epidemic 
diphtheritis may even display itself upon the skin, without there being 
any accompanying affection of the mouth or throat, in those who are 
exposed to the contagion. Not having myself had an opportunity of 
observing any epidemic angina membranacea, I shall here give an 
abstract of the remarks of M. Trousseau, and for further details, beg 
to refer to his memoir (Archives Gen. de Med., t. xxiii. Be la diph- 
therite cutane'e). 

Angina maligna prevailed epidemically in September, 1828, at 
Nouan-le-Fusilier, Cher et Loir. A blister having been applied to the 
nape of the neck of a young girl labouring under the above-mentioned 
pharyngeal diphtheritis, suppurated abundantly, and the excoriated 
surface became covered with false membranes, as did an ulcer also 
which this girl had long laboured under on her foot. The blister, which 
was but four inches in diameter at first, four days afterwards was more 
than six ; it was excessively painful, and discharged profusely. It 
spread down the back, throwing out irregular pointed rays like the 
scores of a backgammon-board, and was surrounded with a bread 
erysipelatous areola, much deeper in colour below than above. The 
part denuded of epidermis appeared depressed, and really was so, when 
the level of the tumefied surrounding parts was made the standard of 
reckoning. This part was covered with fibrinous superposed layers, 
of a more yellowish white towards the centre than about the circum- 
ference of the part. In the middle they were two, three, and even 
four lines in thickness, and bore a perfect resemblance to the dry 
pleuritic concretions found in the cavity of the chest when inflamma- 
tion is on the decline, and the serous fluid, which had also been 
effused, had almost entirely disappeared. On raising several of these 
layers with the blade of a knife, they were found to adhere so firmly 
to the tissue of the skin, that they could only be detached with a cer- 



tain difficulty. The blister had always been dressed with butter. The 
surrounding erysipelas had a peculiar appearance ; the redness was so 
much the deeper the nearer it was considered to the excoriated sur- 
faces. The cuticle was raised in multitudes of points by the effusion 
under it of small quantities of milky serum, so that the skin was covered 
with confluent vesicles in the vicinity of the sore, and with others, but 
fewer and fewer in number, as the healthy integument was neared. 
Some of the vesicles appeared to be formed by the fusion of several 
others; several, simple or agglomerated, had opened, and there the 
skin was seen covered with a whitish pseudo-membranous deposit ; 
these ulcers ran into others of smaller size, and this was the way in 
which the disease appeared to spread. 

M. Trousseau gives several other cases which go to prove that 
blistered surfaces and excoriations, in individuals labouring under 
diphtheritis of the throat and mouth, had a great tendency during the 
epidemic prevalence of this disease, to assume a peculiar appearance, 
and to undergo alterations analogous to those exhibited by the mucous 
membranes. Other facts have shown, that persons unaffected them- 
selves with diphtheritis, but in contact with those who were, and 
having an excoriated part about them, were very apt to have this 
covered with a false membrane. M. Trousseau mentions five cases 
of diphtheritic affection behind the ears, or of the scalp. In one, the 
affection extended to the nape of the neck ; in another, to this part 
and down the back; and in a third, to the back and loins. He also 
mentions instances of pseudo-membranous deposits upon an excoria- 
tion of the nape of the neck, of the side of the neck and face, of the 
lips, of the chin, two of the breasts, one of the abdomen, one of the 
prepuce, one of the scrotum, two of the anus, three of the vulva, one 
of the thigh, one of the foot, and two or three others on different parts 
of the body. 

The treatment of diphtheritis of the skin ought to be directed upon 
the same principles as that of the affection of the mucous membranes. 



TENTH GROUP. 
TRICHOMATOUS AFFECTIONS. 

1444. In Poland, the inhabitants, and several species of animals, 
are subject to an epidemic disease which attacks the hair especially, 
and the nails; this disease is denominated Plica; its influence, how- 
ever, does not always end there, but sometimes extends to other 
organs, and then gives rise to a variety of affections which are entitled 
trichomatous . 



1445. Plica is a chronic disease, peculiar to Poland, and charac- 
terized by the agglutination and anomalous development of the hair, 
and sometimes by an alteration of the nails, which become spongy 
and blackish. 

1446. Symptoms. — Plica often begins after an attack of acute fever, 
preceded by languor, pains like those of rheumatism in the head and 
extremities, occasionally vertigo, and a singular and invincible dispo- 
sition to sleep, tingling and rushing noises in the ears, pains in the 
orbits, ophthalmia, and coryza; plica also occurs occasionally after an 
attack of acute fever, with clammy sweats (sueurs gluantes); some- 
times, too, a kind of redness is observed over the thighs, and an 
alteration of the nails, which become black and rough. In other 
cases, however, plica makes its attack suddenly without precursory 
symptoms. 

When the head is the part affected, the scalp is sore to the touch 
and excessively itchy ; a clammy or agglutinating sweat of a disagree- 
able odour then occurs over part of the cranium ; the hair becomes 
unctuous, is stuck together, and appears altered ; the hairs affected 
appear distended with an adhesive or unctuous matter of a reddish or 
brownish colour, which has been believed to be sanguinolent in its 
nature by a great many observers. This matter is produced at the 



428 



DISEASES WHICH HAVE DISAPPEARED. 



extremity of the bulb, and ascends to the very end of the hair. The 
bail is so acutely sensible that the slightest touch occasions severe 
pain in the roots. A viscid matter of a very offensive smell, like 
spoiled vinegar, mice, or garlic, exudes from the whole surface of 
each affected hair. This matter glues the hairs together at first at 
their exit from their skin, and then along their entire length ; this 
matter, which also appears to be secreted from the whole surface of 
the scalp, congeals, and then dries into a kind of incrustation. If 
there be no exudation, as happens sometimes, though rarely, the 
disease is entitled plica sicca, or dry plica. 

The hair is matted and stuck together in a variety of ways, some- 
times in single locks of various thickness and length, so as to resem- 
ble ropes (plica multiformis, common male plica) ; sometimes these 
masses unite together and compose one very long and thick club, like 
the tail of a horse {plica caudiformis); and, again, the hair gets matted 
and glued together, without separating into locks, into one uniform 
intricate mass of various magnitudes (common female plica). The 
hair of the beard, axillae and pubes, is also liable to be attacked with 
this disease. 

Professor Kaltschmidt, of Jena, possesses the pubes of a woman, 
the hair of which is of such length that it must readily have gone 
round the body. The nails of the hands and feet generally become 
long, yellowish, livid, black, and sometimes hooked. 

Immense numbers of pediculi are occasionally developed, even 
among those who are most careful of their persons, in the course of 
this affection. 

1447. Anatomical observations. — We are informed by Joseph Frank, 
that the hair bulbs are enlarged, and that the surface of the scalp here 
and there presents running ulcers in this disease. In the museum of 
Meckel, at Halle, there are the scalps of two individuals who died 
whilst labouring under plica, which have been injected with the 
greatest minuteness, without the smallest particle of the injection 
having found its way into the stems of the hair. Lafontaine, having 
examined the piliferous bulbs of a patient affected with plica, after 
his death, found them excessively tumefied, and full of a glutinous 
matter of a yellowish- white colour, which they poured out when com- 
pressed. Gilibert has also seen the bulbs of the affected hairs dis- 
tended with a black and fetid matter. Rolfink and Vicat assure us 
that the hairs are often distended with a fluid which ultimately bursts 
them, and is discharged externally. Schlegel says, that in one case 
he found the whole hairs of the body enlarged, and some of them 
distended with a fluid of a yellowish-brown colour, to six times their 
natural size. Gasc saw a woman, whose body, about the seventh 
month of her pregnancy, assumed a blackish hue, and whose hair 
appeared enlarged and distended with a fluid of a darker colour than 
that which penetrates it generally. M. Blandin is of opinion that in 
plica, the papillae or bulbs of the hair rise above the level of the 
skin, within the infundibuliform cavity of the root of the hair, in the 
same manner as the papilla or bulb of the feather elongates and pro- 
duces the quill in the young bird. M. Sedillot, who removed five or 
six locks of hair affected with plica from the head of a child between 
seven and eight years of age, in Gallicia, examined these particularly 
with the microscope. The internal canal of each individual hair 
was found much larger than it is in healthy hair, and the cellular 
cavities, especially those near the canal, were much more distinct 
than usual. 

1448. Causes. — Hercules de Saxonia and Thomas Minadous speak, 
in 1610, of plica as a disease already long known. The greater number 
of writers fix the date of its first appearance in Poland about the year 
1285, under the reign of Nezek-le-Noir. This disease would seem 
to be getting rarer and rarer every year. Lafontaine states, that in 
the provinces of Cracow and Sandomir, plica attacks the peasantry, 
beggars, and Jews, in the proportion of one and a half in twenty, the 
nobility and the wealthy burghers in that of two in thirty or forty. 
At Warsaw and in the surrounding districts, the disease attacks the 
first classes in the proportion of four in from forty to forty-five, and 
the second classes in that of three in from ninety to a hundred. In 
Lithuania the same proportions are observed as at Warsaw ; in Vol- 
hynia and the Ukraine, the same as at Cracow. Schlegel, Gasc, and 
Hartmann, say that these ratios are too large, that the disease is not 
so frequent. 



Plica has always been more frequent on the banks of the Vistula and 
Borysthenes, in damp and marshy situations, than in any other parts 
of Poland. 

Plica attacks the human subject primarily. Some writers have 
imagined that it could be communicated from animals to man. 

The custom which prevails in Poland, of shaving the heads of the 
children, (a) neglect of cleanliness, the heat of the head-dress, and the 
exposure of the skin to cold subsequently, appear to favour the pro- 
duction of this disease. 

1449. Diagnosis. — The precursory symptoms of plica, the altera- 
tions of the nails which very commonly accompany it, the swelling 
of the hair, the glutinous fluid discharged from its roots, &c, are so 
many unequivocal characters which distinguish plica from simple 
felting of the hair, or any other affection of the hairy scalp. 

1450. Prognosis and treatment. — The occurrence of plica in indi- 
viduals labouring under paralysis, and a variety of serious diseases, 
has occasionally seemed to be beneficial. When plica is left to itself, 
the febrile or precursory symptoms disappear after a certain time; as 
an effect of the growth of the hair, the diseased portion extends to a 
distance from the skin ; in the course of several months or a year, the 
discharge diminishes, and ends in disappearing entirely ; it is now 
only that the generality of the Poles themselves, or of their phy- 
sicians, recommend the hair to be cut; Lafontaine, Schlegel, and 
Hartmann, all assure us, that the section of the affected masses before 
this time, has been known to be followed by amaurosis, convulsions, 
apoplexy, epilepsy, and even death. Alarmed or taught by such 
occurrences, the common people often go about with the plica till it 
drops off, and sometimes all their lives. 

Various measures have been tried to lessen the severity of this dis- 
ease, or to obtain its cure ; the results of such experiments as have 
been made with bitters and tonics, with antimonials, lotions of differ- 
ent kinds, baths and fumigations, appear to be little conclusive as to 
their worth or inefficacy. 

Historical Notices. 

1451. Among the works published on plica, those of Lafontaine 
(Traiit de la plique Polonaise, &c, trad, par A. J. L. Jourdan, 8vo. 
Paris, 1808), and of Schlegel, (Ueber die Ursachen des Weichsel- 
zopfes, 8vo. Jena, 1806,) are particularly worthy of notice. Dr. 
Burckhard Elbe (Die Lehre von den Huaren, 2 vols. 8vo. Wien, 
1831), has given a bibliographical note, which completes that of La- 
fontaine. Messrs. Sedillot (Nouv. considerations sur la Pligue, 8vo. 
Paris, 1832), and Brierre de Boismont (Archiv. Gen. de Medecine, t. 
xxxiii. p. 66), (b) have more recently published on the actual state of 
the disease. 



ELEVENTH GROUP. 
DISEASES WHICH HAVE DISAPPEARED. 

1452. In this group I have united several diseases which do not 
now occur, at least which never show themselves with the characters 
they presented in former times, when they prevailed often extensively. 

SUDOR ANGLICUS. [SWEATY SICKNESS.] 

1453. The description of this disease, by Dr. John Kaye, or Caius, 
is looked upon as the best we possess : 

(a) Is not the author mistaken here ? It was a religious custom in 
Poland, prevalent before the introduction of Christianity, to refrain 
from cutting the hair of children till they had reached their second year, 
when it was cut off with ceremony, and they received their names. 

(b) The paper of Brierre de Boismont is extracted from an unpub- 
lished memoir of Dr. Marcinkowske. A number of its chief details 
is given in the Edinb. Med. and Surg. Journ., 1834. 



EPINYCTIS. 



429 



"Ad dccimura septimura calendas maias anni quinquagesimi primi 
supra millesimum et quingentesimum a Christo nato, cum jam in alt 
pace omnia et tranquilla essent, nee ullis perturbata molestiis, subita 
et insueta nostris hominibus aegritudo, Salopice (clari munitique ad 
Sabrinam fiumen oppidi), irrepsit, cujus et nomen et natura primo suo 
ortu multos fefellerunt. Sed hi postea. malo docti, et veteris injuriae 
memores, sudorem, quern britannicum dicunt, esse tandem intellexe- 
runt. Is tamen inclementer populum habebat, ut prope dicam omnes 
per ea loca et vicina illis prosterneret. Quosdam enim in via, cum 
iter facerent, sustulit ; quosdam domi ostia et fenestras reserando 
interemit ; quosdam per lusum atque jocos pariim joculariter jugula- 
vit ; per jejunia quosdam, quosdam per saturitatem abripuit ; in somno 
aliquos, nonnullos vigiles interfecit : usque adeo, ut ex multis ejus- 
dem familiae, pauci a febre incolumes perstiterint : ex paucis, nulli 
plerumque intacti evaserint. Ex his alios brevi momento, alios unius, 
daurum aut trium, alios quatuor, aut eo amplius horarum spatio, post- 
quam sudare cceperant, de vita sustulit. Saepissime qui in prandio 
hilares erant, sub ccenam mortui fuerunt. Sed nemo qui devicto malo 
superfuerat, ante horas viginti quatuor quam citissime mali molestia 
et periculo liberatum se gloriari potuit. Itaque ex talibus initiis in 
dies ingravescentibus, ubi acerbiora incrementa, longius latiusque se 
fundente malo, subsecuta sunt vix credas quis pavor, quantus metus 
omnes Britannos invasit ; praesertim cum ejus conditionis miserandae, 
quae turn urgebat, contemplatio funestaque mortis imago nullis spem 
vitas (cujus usura omnibus solet esse carissima) non ademerit. Neque 
enim morbo ulla dementia fuit, nee ullum miseris mortalibus securum 
refugium. Etenim nusquam non populabatur, nusquam non sseviebat 
malum. Alios qui se vivos ab hominibus relegarunt, eosdem mortuos 
in publicum revocavit. Alios conclusos ac pene: abditos, contagione 
enectos in apertum reduxit. Neque sensere id malum faeminae aut 
servitia, plebesque humilis aut media solum, sed proceres etiam cum 
notum sit aequo pede nobiliumque turres humiliumque casas id pul 
sasse iniquis tamen modis, ut dicemus postea. In eo hie conquere 
batur se siti premi, ille ardoribus consumi, omnes sudore confici 
Hunc rursum amentia coepit, hunc gravis sopor oppressit, hunc in 
quietudo exagitavit. Hie moribundus ingemuit, ille animam expiravit 
Et qui valebat dudura jam febrescebat, versaque vice, qui ante morbo 
laborabat, nunc aiterius sanitatum procurabat. In summa, ita nulli 
fere hominum perpecit, ita in orbem crudele malum rediit, ut qui alios 
opera officioque juvissent prius, eos vicissim ab illis subsidium offici- 
umque mutuum petere ; et contra, qui ab aliis essent adjuti, eos sine 
quiete, magna fatigatione operam mutuam praebere, inque vices gravi 
periculo colla sub jugum mittere cogeret. Jam verd de fuga (quae 
alias in pestiferis morbis solet esse praesidio), cogitare au in alium 
locum commigrare, inane et supervacuum plane fuit. Nusquam enim 
tutus portus nostris, nulla ex mutato loco securitas erat, quod nulla 
malo oberranti omnia requies esset." 

The author then describes the frightful disorder occasioned by this 
dreadful epidemic. He says, "he knows not how many deaths it 
caused," but he adds (p. 15): "In una civitate pauculis diebus 
plus minus sexaginta supra noningintos crudeli morbo intercidisse." 

Farther on he expresses himself in the following terms in regard to 
the origin of the sudor anglicus : " Hie enim morbus, sic ut adventi- 
tius non est, ita novus non est. Si quidem ex historiis britannicis 
intelligo, malum hoc ex Britannia ortum esse (quantum scire licet), 
in exercitfl Henrici regis Angliae ejus nominis septimi, quem partim 
ex Gallia tunc nuper secum adduxerat, partim a Wallia propter Mil- 
fordiam, quo classe appulit conscripserat : exercuisseque nostros per 
anteacta tempora, afflixisseque eo quo dixi modo per intervalla quin- 
quies : anno scilicet 1485, primo ab Augusto mense inito, ad octobrem 
ultimum; iterum 1506, aestivo tempore; tertio 1517, a julio mense, 
ad decembrem medium; quarto 1528, per omnem acstatem ; quinto 
denique, anno hoc quinquagesimo et altero supra sesquimillesimum, 
ad menses quinque et eo amplius." 

1454. The picture he presents of the symptoms of the disease con- 
tains several remarkable passages (p. 23): "Primo insultu, aliis 
cervices aut scapulas, aliis crus aut brachium oecupavit. Aliis sensus 
erat veluti spiritus, aut flatus calidi per membra ea discurrentis. Una 
cum his subitus et sine manifests causa huic morbo insuetis, largus 
sudor manavit. Interiora calebant primo, postea ardebant, calore jam 
inde ad extimas corporis partes diffuso. Sitis ingens, jactatio inqui- 
108 



eta. Cor, jecur, atque stomachum male morbus habuit. Omnia 
subsecutus est gravis dolor capitis, vanum loquaxque delirium, post 
marcor, et inexpugnabilis pene dormiendi necessitas. 

" Rursum, aliis principio cohibitus sudor est, frigebant membra levi- 
ter. At postea erupit idem promotus, sed odore gravis, calore in alio 
alius pro humoris ratione, quantitate subinde diminutus, subinde 
copiosus, substantia crassus. Aliis nausea, aliis vomitus erat, sed 
perpaucis, et pene solis ex cibo saturis. Omnes spiritum gravem ac 
frequentem, vocem gemebundam expedivere. Urina colore tincta 
leviter, substantia crassior, levamento ambigua (nulla enim erat na- 
turae regula propter veneni impetum), caetera pro naturali. Pulsus, 
si quis praetentet, concitatior, frequentior; haec certa morbi indicia 
erant." (Joannis Caii Britanni De Ephemera Britannicd. Liber units 
summd curd recognitus. Londini, 1721, 8vo., p. 9.) Vide an ana- 
lysis of the investigations of Hecker on the sudor anglicus, by Ch. 
Martins. (Revue Medicate, aout, 1834.) (a) 



EPINYCTIS. 

1455. Hippocrates mentions numerous eruptions of epinyctis (xai 
IrtLwxrlBoi rtoM.^?; De aere, locis etaquis), and many ulcers consequent 
upon these epinyctides (Prorrhet., lib. ii. sect. 2. p. 95). 

Celsus expresses himself as follows : " Pessima pustula est quae en<.- 
wxtls vocatur: ea colore vel sublivida, vel subnigra, vel alba esse 
consuevit. Circa hanc autem vehemens inflammatio est; et cum 
adaperta est, reperituf intus exulceratio mucosa, colore humori suo 
similis. Dolor ex ea supra magnitudinem ejus est; neque enim ea 
faba major est. Atque haec quoque oritur in eminentibus partibus, et 
fere noctu unde nomen quoque a Graecis ei impositum est. In omni 
vero pustularum curatione primum est multum ambulare, atque exer- 
ceri; si quid ista prohibet, gestari. Secundem est cibum minuere, 
abstinere ab omnibus acribus, et extenuantibus; eadem quoque nu- 
trices facere opportet si lectens puer ita affectus est. Praeter haec is 
qui jam robustus est, si pustulae minutae sunt, desudare in balneo 
debet, simulque super eas nitrum inspergere, oleoque vinum miscere. 
et sic ungi ; turn descendere in solium. Si nihil sic proficitur, aut si 
majus pustularum genus oecupavit, imponenda lenticula est, detrac- 
taque summa pellicula, ad medicamenta lenia transeundum. Epi- 
nyctis post lenticulum recte herba quoque sanguinali vel viridi cori- 
andro curatur. Ulcera ex pustulis facta tollit spuma argenti cum 
semine fceni Graeci mixta, sic ut his in vicem rosa atque intubi succus 
adjiciatur, donee mellis crassitudo ei fiat. Proprie ad eas pustulus 
quae infantes male habent, lapidis quem pyriten Graeci vocant, cum 
quinquaginta amaris nucibus miscetur; adjiciunturque olei cyathi 
tres: sed prius ungi ex cerussa pustulae debent, turn hoc illini." (Cel- 
sus, De re medicd, lib. v. sect, xxviii. 15.) 

Lorry says he has never seen the epinyctis, such as it is described 
by the ancients : " Mihi vero epinyctidem qualem veteres medic"; 
describunt, sero periodice dolores concitantem atroces, de die ques- 
centem, videre rwnquam contigit." (Lorry, De morbis cutaneis, p. 
263.) Neither have I myself met with a similar combination or suc- 
cession of symptoms. Alibert, in his description of epinyctis, has 
included the itchy bites of various insects, and the nocturnal erup- 
tions which appear to be analogous to urticaria or to lichen urti- 
catus. 

(a) The work of Hecker, referred to by M. Raver, has been trans- 
lated by Dr. Babington, together with the essays by the same author 
on the Black Death and the Dancing Mania, under the title of the 
Epidemics of the Middle Ages. The three have recently been printed 
in one volume by the Sydenham Society. London, 1844. 

The strictly cutaneous symptoms, of an eruptive character, were 
few, and were not mentioned generally by the writers on the disease. 
Hecker quotes Tyengius in Forest., p. 158, " a respectable Dutch phy- 
sician," for the observation, that "after the perspiration was over 
there appeared on the limbs small vesicles, which were not confluent, 
but rendered the skin uneven." " Every thing," Hecker believes, 
"militates against the supposition that this phenomenon was consis- 
tent, or that the Sweating Sickness was an eruptive disorder." 



430 



COW-POX. 



\TAGRA OF THE LATINS. 

. Pliny 1ms described a kind of contagious mentagra which is 
v not seen in Italy at the present day: "Sensit et facies hominum 
novos, omnique aevo priore incognitos, non Italise mod6 verura etiam 
universal pr ope Europae, morbos : tunc quoque nee tota Italia, nee 
per Illyricum Galliasve aut Hispanias magnopere vagatos, aut alibi 
qaara Roma? circaque, sine dolore quidem illos, ac sine pernicie vitaa: 
sed tanta foeditate ut quaecumque mors prseferenda esset. Gravissi- 
nium ex his lichenas appellavere. Graeco nomine, latine, quoniam a 
iuento fere oriebatur joculari primum lascivia (ut est procax natura 
multorum in alienis miseriis), mox et usurpato vocabulo mentagram, 
occupantem in multis totos utique vultus, oculis tantum immunibus, 
descendentem verb et in colla pectusque ac manus, feedo cutis furfure. 
Non fuerat haec lues apud majores patresque nostros. Et primum 
Tiberii Claudii Cssaris principatu medio irrepsit in Italiam, quodam 
Perusino equite romano qua?storio scriba, cum in Asia apparuisset, 
inde contagionem ejus importante. Nee sensere id malum faeminse, 
aut servitia, plebisque humilis, aut media, sed proceres veloci transitu 
osculi maxime, fcediore multorum, qui perpeti medicinam toleraverant, 
cicatrice, quim morbo. Causticis namque curabatur, ni usque in 
ossa corpus exustum esset, rebellante taedio. Advenerunlque ex 
-Egypto genitrice talium vitiorum medici, hanc solam operam affe- 
rentes, magna sua prseda. Siquidem certum est, Manilium Cornutum 
ex prsetoriis legatum Aquitanicee provincial H-S CC. elocasse in eo 
morbo curandum sese." (C. Plini secundi Histories mimdi, lib. 
xxxvii. Lond., 1587, p. 641, fob) 

WAREN OF WESTPHALIA. 

1457. A disease formerly prevailed hereditarily in Westphalia, 
among several families, which was denominated Waren. The dis- 
ease, says Henricus a Bra, began with wandering and very acute 
pains over the whole body, and particularly in the back and loins, 
attacking one part first, and being then transferred with rapidity to 
others; leaving the feet, for instance, to fasten themselves in the 
shoulders, in the arms or in the hands. The pain is compared to 
what might be supposed to be produced by worms piercing and 
gnawing the flesh, and it is from this circumstance, indeed, that the 
disease received its title waren, (worms.) Two varieties of it were 
remarked : in the first, swellings succeeded the pains in the articula- 
tions, where they continued for a long time, and became covered with 
livid spots, like those of scorbutus ; these spots were apt to degene- 
rate into malignant ulcers, especially on the feet, and little worms 
were engendered in them similar to ascarides. These ulcers very 
frequently became fistulous. In the second variety, no swelling 
occurred, but general emaciation or marasmus followed the attack, 
and atrophy of some part which became paralyzed. 

The pains were generally more severe during tJie night than during 
the day; they were without fever, or accompanied with very slight 
slow fever. The bowels were constipated; small worms were fre- 
quently seen in the evacuations. 

Patients were treated with purgatives, alexipharmics, and anodynes 
in wine. The tumours were covered with cataplasms of plantago 
and salt; the ulcers were dressed with cicuta aquatica, bruised, mixed 
with honey or with a poultice of polypodium, &c., boiled in beer. 
(Vide Hen. a Bra de morbo quodam novo et incognito, Westphalis, 
Geldris et Frisis quasi endemico, Epist. ad Pet. Forestum, exhibita 
circa finem, lib. 20, Observationum ejusdem Foresti.) Schenckius 
quotes another important work upon this disease in his Obs. Med., 
lib. vi. : De novis aliquot morbis. 



TWELFTH GROUP. 

CUTANEOUS DISEASES OF ANIMALS SUSCEPTIBLE OF 
TRANSMISSION TO MAN. 

1458. Cow-pox, grease, glanders, scabies, and carbuncle, are the 



only external diseases of animals which appear capable of being 
transmitted to the human subject. 



1459. Cow-pox is an eruptive disease, which appears on the teats 
of cows, and is capable of being communicated to man, in whom it 
engenders vaccinia. Cow-pox in the animal presents four periods. 

1st period. (Infection.) Loss of appetite, repugnance to food ; the 
animals purse up their lips as a man does who blows tobacco smoke 
slowly out of his mouth ; the secretion of milk is diminished ; it is more 
watery than usual; the eye is dull; the creature becomes feverish. 

2d period. Three or four days after (period of the eruption), hard 
red elevations as large as a pea appear upon the udder, particularly 
around the teats; sometimes, but very rarely, others are observed 
upon the nostrils and eyelids. By and by a yellowish point is per- 
ceived on the summit of these elevations, about the size of a pin's 
head. In three or four days the elevations or spots have assumed 
the form of flat circular pustules, depressed in their centre and sur- 
rounded at their base by a red circle, the extent of which increases 
gradually. On the fourth and fifth days of the eruption, the animal 
becomes restless ; the pustules enlarge, and approach maturity, which 
occurs on the seventh and eighth days of the disease, the third or 
fourth of the eruption. If the pustules be pressed, the animal shows 
symptoms of great suffering. The pustules become still larger, always 
preserving a depression in their centre; they are diaphanous, and 
acquire a leaden or silver gray colour. 

In the fourth period (desiccation), the inflamed areola takes a livid 
colour; the udder becomes deeply indurated under the pustules; at 
the same time the restlessness of the creature increases ; the fluid 
contained in the pustules grows turbid, gets thicker insensibly, and 
begins to dry off towards the eleventh or twelfth day. The pustules 
become brown from the centre gradually towards the circumference ; 
they ultimately appear as dry crusts of a dusky red colour, thick and 
uniform, which are detached towards the twentieth day, leaving cir- 
cular cicatrices behind them, (a) 

1460. First particularly observed by Jenner, at Berkeley, in the 
great dairy county of Gloucester, cow-pox has since been seen in 
several other counties of England, as also in Holstein, Mecklenberg, 
Saxony, Norway, Prussia, Holland, Spain, Italy and France, (b) 



(a) Mr. Ceely ( Observations on the variola vaccince), has examined 
the anatomical structure of the A r esicle, and found that " its colour, 
indurated margin, and central depression, depend on the existence of 
an adventitious membrane, formed in the corium and secreted by the 
papilla;. It is raised in the form of a zone, and is intimately con- 
nected with the epidermis. It has a cellular structure, in which is 
secreted and contained a clear viscid lymph. The cells appear to be 
arranged in two concentric rows, and are separated from each other 
by whitish radiating partitions, which, at their converging extremities, 
are united by a central membranous band. The dusky central spot 
which marked the first change of the pimple into the vesicle, and 
which has now become darker and more distinct, seems to be caused 
by a greater or less degree of separation and desiccation of the epider- 
mis, stretched over a crypt-like recess, which contains a small quan- 
tity of semi-concrete lymph-like matter, occasionally a turbid opaque 
fluid. This cellular, adventitious, membranous conformation, though 
differing in texture and amount in different vesicles, is invariably 
present, and is not less essential than diagnostic. About the fourth 
or fifth day of the eruption, or two days before the decline of the 
vesicle, there often appears at its base a red circle, which gradually 
increases in extent till that event occurs. During this period, the 
lymph within the cells having become more abundant and less viscid, 
and somewdiat opaque, bursts and breaks up the cells and their con- 
necting band, separates the epidermis from its attachment to the sub- 
jacent adventitious membrane, and the vesicle, losing its central 
depression, becomes more or less acuminate, presenting a conoidal 
or semiglobular form." — p. 317. 

(b) Since M. Rayer wrote, the natural disease has been observed 
by M. Bousquet at Passy in 1836, M. Girard at Rambouillit in 1836, 



COW-POX. 



431 



Cows only contract the disease once. Neergaard, Luders, &c, have 
noticed vaccine epizooties. The disease is transmissible to man, 
when he has not had small-pox, from which it generally preserves 
him. 



Brown at Sylhet, in Bengal, in 1837, Mr. Eslin in Gloucestershire in 
1836, and by Mr. Ceely in Oxfordshire and Bedfordshire. 

The natural or casual cow-pox is represented by Mr. Ceely to 
appear most commonly during the spring, rarely in the heat of sum- 
mer, though he has observed the disease at all seasons. It is occa- 
sionally epizootic, more commonly sporadic, and extremely irregular 
in the periods of its occurrence, even in dairies situated in the same 
immediate vicinity, and apparently placed in circumstances in all 
respects similar. The disease is considered to be peculiar to the 
milch cow, occurring primarily wdiile the animal is in that condition, 
and being casually propagated to others by the hands of the milkers. 
Many intelligent dairymen are inclined to trace its origin to the equine 
vesicle, but Mr. Ceely has himself never been able to trace it to this 
source. Different from what is described by M. Rayer in the text, 
fever or other constitutional symptoms, either in the animals primarily 
affected or in those to which the disease has been conveyed, are very 
rarely observed ; heat, induration and tenderness of the udder being 
generally the first symptoms noticed. 

The regular duration of the disease would seem to be from twenty 
to twenty-three days ; the eruption appearing about the third or fourth 
day after exposure, reaching its full development in from six to seven 
days, and declining in five or six more ; the crust separates in about 
five or six days from its formation, leaving a cicatrix behind. 

Mr. Ceely treats of variola; vaccina;, 1st, as they appear naturally 
or are produced casually in the cow by the manipulations of the 
milkers ; 2d, as they are produced by vaccination ; 3d, by retro-vacci- 
nation ; 4th, by variolation. 

Of the casual cow-pox notice has been already taken. Vaccination 
of the cow with primary lymph, requires a few words of explanation. 
" The process followed by Mr. Ceely for the effecting of this object 
differs from the casual vaccination of the cow by the milkers, in the 
designated application of the lymph through punctures artificially made 
on parts selected as being appropriate for its reception. The animals 
chosen were sturks (young heifers), with a view of ascertaining how 
far other than milch cows were susceptible. Some of these, about 
ten months old, were vaccinated with lymph taken from a milch cow 
in the inside of the ear, on the teats, and near the vulva. The 
punctures in general were early inflamed, but the papular stage was 
not well marked, and appeared postponed ; the vesicles were normal, 
but declining on the eleventh day. The only constitutional affection 
observed was a slight acceleration of the pulse. The lymph taken 
from these vesicles on the tenth day, when transferred to man, pro- 
duced an affection which differed in no respect from that produced 
by primary lymph from the milch cow, with the exception that the. 
inflammation and induration at the base of the vesicles were less 
considerable, and the subsequent scars, though well defined, rather 
less deep." 

Retro-vaccination is the vaccination of the cow with humanized 
lymph. The animals selected for these experiments were sturks 
under twelve months old, as cows were difficult to be had for that 
purpose. The parts selected for the operation were those in close 
proximity to the vulva, as most easy of access and most suitable in 
every respect. The lymph used was either dry, or liquid in capillary 
tubes; and no precautions were taken further than excluding the 
animals from cold and moisture immediately after the operation for a 
few hours, or occasionally for a night. Scarcely one-half of the 
operations succeeded. In the majority of instances, where the vacci- 
nation succeeded, the vesicles ran their normal course, and declined 
on the eleventh day. Four different kinds of lymph were used, each 
having been current in man for a longer or shorter period. Four of 
these experiments are given in detail, in order the better to illustrate 
the particular attendant phenomena ; and as one will serve as an 
example, we give it in the author's words. 

" Retro-vaccination with lymph which had been several years in use. 
— It appeared sufficiently active, and from arm to arm was attended 
with satisfactory results. Subject: a small ill-conditioned sturk, 



1461. Observation has shown that there exists a false cow-pox, 
as well as a false or spurious variola, and vaccinia. 

C. G. Kiihn {Be morbo varioloso, 4to. Lips., 1801, p. 82), has col- 
lected the chief documents published on these eruptions. He admits 

strawberry coloured, thin skin. Seven punctures were made near 
the vulva, and eight points inserted recently charged with fifth-day 
lymph from a fine child on the 1st of February, 1839. 
" ' Second day: Nothing remarkable. 
" ' Fourth day: Some of the lower punctures rather red. 
" ' Fifth day: Scarcely any traces of punctures left. 
" ' Sixth day : Punctures appear perfectly passive. 
" ' Seventh day: Two punctures rather elevated and inflamed. 
"'Ninth day: All the punctures raised in the normal form, but 
in different degrees, the vaccine tumours being of different sizes ; 
tried to procure lymph, but failed, both on the surface of the tumid 
margins, which yielded only blood, and in the centres, where there 
is a slight crust. 

" ' Tenth day: There are four fine large and three small vesicles, 
from two of which were charged one hundred points, abundantly, 
with clear adhesive lymph, some of which was used on the same and 
subsequent days. The punctures made yesterday had given rise to 
the exudation of lymph which is now visible in the form of light 
amber-coloured concretions on the parts. 

"'Eleventh day: The vesicles appear diminishing, and amber- 
coloured lymphatic concretions are formed in their centres. Vespere : 
Crusts enlarging ; vesicles subsiding. 

" ' Twelfth day : Upper vesicles have a pustular appearance in 
places; others have a yellowish-brown crust; others flattening. 
" ' Thirteenth day: All subsiding ; crusts larger. 
"' Fourteenth day: Subsiding. 

" ' Fifteenth day: Crusts more elevated; margins flatter. 
" ' Sixteenth day: Declining. 

" ' Seventeenth day: Intumescent ring nearly disappeared ; black 
crusts alone remaining. 

"' Eighteenth day : Every thing diminishing. 
" 'Nineteenth day: Small elevations in the site of the vesicles, 
still lighter than the ground. 

"'Twentieth and twenty-second days: Some crusts prematurely- 
removed by accident; others spontaneously fell on the twenty-second 
and twenty-third days, leaving small pale rose-coloured smooth scars 
slightly depressed in the centre. 

" ' February 26th : Inoculated with liquid small-pox lymph (variola 
discreta, seventh day), in five punctures, from capillary tubes, on 
right side of labium pudendi, the wounds being at the same time 
deluged with fluid. 

" ' Third day: Slight tumidity around the punctures. 
"'Fourth day: A shining glassy tumidity around the punctures, 
which are larger. 

" ' Fifth day: In statu quo. 
" ' Seventh day : All subsiding ; no result. 

" < March 12th : Re-inoculated with dry sixth-day confluent small- 
pox lymph, inside and outside the left labium pudendi, with several 
points; four punctures. Re-vaccinated with seventh-day "variola 
vaccine" lymph, two removes, inside and outside of the right labium 
pudendi ; several points ; four punctures. No result from either.' "— 
pp. 355-357. 

In one of his experiments, no apparent effect was produced on 
the fourth day, but on opening the punctures, and re-vaccinating 
with the same matter, vesicles suddenly became developed, without 
havino- passed through a palpable and progressive state of papulation, 
and attained their full development by the tenth day. Analogous 
occurrences, he remarks, from various causes, take place in man, 
especially in using primary retro-vaccine and unassimilated lymph ; 
and similar phenomena are noticed in the natural and casual disease 
in the cow. 

The retro-vaccine lymph from these experiments, when taken on 
points thoroughly and trebly charged, and immediately used, produced 
perfect vesicles in man. The papular stage, however, was late, being 
not till the sixth or seventh day. This matter was vaccinated on 
subjects of different ages, and excepting in respect of the lateness 






COW-POX. 



species. The firs! ol a deep colour, broader than a Holstein 
shilling, and depressed in its rent re, is filled with thick pus. Trans- 
mitted to milkers by inoculation it occasions slight lever, with head- 
ache, and pains in the axillary glands. The pustules are painful, 

of the papular stage, and in the vesicles themselves being somewhat 
smaller, did not appear to differ from the matter which had nof 
undergone the transit through the system of the cow ; no difference 
noticed in local or constitutional symptoms. Even the slight 
■ which it had undergone in its transit through the system of 
the cow was not apparent after the third remove. 

Mr. Ceely concludes, from these experiments, that it is more dif- 
ficult to vaccinate the cow with humanized than with primary lymph, 
and that, when vaccination is successful, the disease is milder ; that 
vaccine lymph, therefore, in passing from the cow to man, undergoes 
a change which renders it less acceptable and less energetic on being 
r< turned to the animals of the class which produced it ; some, indeed, 
being incapable altogether of being affected by it. He also remarks 
that this difficulty of infecting the cow with humanized lymph is not, 
however, so great as that experienced in passing primary lymph from 
the cow to man. His experiments also demonstrate that the age of 
the humanized lymph did not appear to influence its reception in the 
system of the cow ; for provided the lymph was of ordinary activity, 
and possessed its normal qualities, it succeeded equally well in its 
operation, whether it had been current in man for only a few weeks, 
or for many years ; exciting in both cases equally perfect and pro- 
ductive vesicles. 

As to the question whether the practice of retro-vaccination is of 
any real value, as a means of renovating humanized vaccine lymph, 
Mr. Ceely says, " I confess, that from rny limited experience, (these 
few observations and experiments,) I am unable to discover its ad- 
vantages, or to admit more than its questionable utility, from one 
transit through the cow. What humanized vaccine might acquire 
by repeated and indefinite transmissions, I am not prepared to say." 

Mr. Ceely, whose opinion is highly valuable, in this alleged degene- 
ration of the vaccine lymph in its passing through many individuals, 
as he has had frequent opportunities of comparing the primary with the 
old lymph, coincides in opinion with the correspondents of the French 
Academy of Medicine, and also with Dr. Griva, of Turin, and his cor- 
respondents, and the report of the National Vaccine Establishment, 
that the vaccine virus has not degenerated. He states that his " own 
repeated applications to the cow have been chiefly for the purpose of 
experiment, for the satisfaction of his patients or the accommodation 
of friends, not from any belief in its superior protective efficacy over- 
active humanized lymph." 

On the other hand we are very properly told: " But when lymph 
is found uniformly deficient in infecting property, vesicles abnormally 
rapid in their course, at their greatest development on the seventh 
day, yellowish in appearance on the eighth, with turbid lymph, central 
desiccation on the ninth, and a miserably small crust falling on the 
fifteenth or eighteenth day, common prudence dictates its discontinu- 
ance, and urges the adoption of a new supply, although constitutional 
symptoms may not be absent, for toeak lymph mav not be better than 
late lymph." (p. 376.) 

To the last source of variolar vaccinae, viz., variolation, or the 
introduction of the virus of small-pox of the human subject in the 
cow, great interest naturally attaches, as showing the identity of 
variolous and vaccine matter, — the latter being the former, only modi- 
fied in its passage through the system of the cow. Of the different 
experiments performed by Mr. Ceely, the second is the more conclu- 
sive. It is detailed as follows : 

" Experiment secontj. White sturk, thin skin, [which had been 
inoculated with small-pox matter fourteen days previously without 
effect,] February 15th, reinoculated with small-pox virus of the 
seventh and eighth day (variola discreta), on the left side of the vulva 
and under fold thereof, as before, and near the verge of the anus. 
Virus liquid, some pellucid, some opaque and puriform, in capillary 
tubes, was forced into eight punctures, which were deluged with it ; 
the punctures being afterwards irritated with points deeply charged 
with the same, which were suffered to remain in the punctures. 
Third day, nothing remarkable. Fifth day, four upper punctures 



ulcerate, and get well with difficulty. The pustules of the second 
species arc not so large, of an amber colour, and filled with a yellow- 
ish fetid ichor. The animals suffer more from these than from the 
former pustules, and the secretion of milk is lessened. Transmitted 

near the verge of the anus enlarged and elevated ; four on the under 
fold of the labium, elevated and red, but less enlarged. Sixth day, 
all present the appearance of the vaccine vesicle. The four upper 
are larger, but seem only tubercular ; four lower on the under fold of 
the labium have a deep damask hue, and appear like oval or circular 
solid elevated rings, with central depressions ; from one of these took 
clear lymph with much difficulty, and scantily charged thirty-nine 
points. Seventh day, upper tubercles seem diminishing, lower vesi- 
cles seem flatter but broader. Eighth day, four upper still appear 
tubercular, of a lighter colour than their ground ; four lower vesicles 
rather augmented, have a light damask hue. Took lymph again from 
one of them ; the other three, not readily yielding lymph on a careful 
puncturing, were not further disturbed, from a desire to witness their 
progress ; slight central crusts. Ninth day, the four vesicles enlarg- 
ing ; again opened the inner margin under the daily increasing central 
crust of the vesicle first opened, and charged twenty points ; tubercles 
diminishing. Tenth day, one of the tubercles rather larger ; four 
lower vesicles increasing. Charged twenty-seven points. Vesicles 
have a bluish, reddish, glistening appearance ; two of them rather 
red at the base ; one or two rather raw on each side. Eleventh day, 
brown crusts over the centre of the vesicles, which appear declining. 
Twelfth day, declining, with increasing crusts of a blackish-brown 
colour, within a slightly elevated margin. Vaccinated in several 
punctures on the margin of the right labium with many points, well 
charged with sixth-day retro-vaccine lymph ; two removes. Punc- 
tures slightly tumid for a day or two, but quickly subsided. No result. 
March 12th, four scars as large as peas, in the situation of the four 
vesicles, depressed, pale rose colour. Re-inoculated with small-pox 
virus (confluent), fifth day, in four punctures, on inside of left labium. 
Re-vaccinated in three punctures, many points, of fifth and seventh day 
lymph from a child. No result." (pp. 385-7.) 

" The third experiment was a failure. Every precaution to avoid 
error seems to have been adopted in these experiments ; the small-pox 
virus was taken by Mr. Ceely himself on newly-prepared points 
which had never been used before ; and for the second experiment 
new capillary tubes were charged : the subjects from which the virus 
was taken were healthy young men, the pocks being remarkably fine, 
large, plump, and numerous. The first experiment, which, in conse- 
quence of vaccination having been performed on the ninth day of 
variolation, presents, as Mr. Ceely observes, the application of Bryce's 
test in the cow, is illustrated by six beautiful coloured plates, in 
which the simultaneous progress of the variolous vesicle, and of the 
subsequent vaccine vesicles rapidly overtaking it, is faithfully deline- 
ated. The drawings are taken on the tenth, eleventh, twelfth, thir- 
teenth, fifteenth, and sixteenth days of variolation, corresponding 
with the second, third, fourth, fifth, seventh, and eighth of vaccination, 
the whole of the vaccine vesicles, as well as the variolous one, being 
at their height on the fifteenth day of variolation, and manifestly on 
the decline on the sixteenth. The second experiment is illustrated 
by seven plates, representing the appearances respectively observed 
on the fifth, sixth, eighth, ninth, tenth, twelfth, and twenty-sixth 
days, the last plate showing the smooth pale marks left after the fall 
of the crusts. Both animals were re-inoculated and re-vaccinated 
without effect. No indisposition was observed during the progress 
of the disease ; and increased heat and redness of the mucous mem- 
brane of the vulva, with slight acceleration of the pulse, were the only 
symptoms noticed." 

Mr. Ceely then proceeds to relate the effects of the lymph, illustrat- 
ing his remarks by examples and plates. But we shall best convey 
an idea of his first experiments on this point in his own words. " ' I 
had inserted twenty points, charged from the variolous vesicle, on 
the tenth day, into five children, making four punctures in the left 
arm of each child, viz., James Bryant, aged two years, in delicate 
health, dark complexion ; Ann Nicholson, aged one year, healthy, fat, 
florid, but phlegmatic ; Henry Gibbs, aged one year and three-quarters, 
very fair, healthy ; Joseph Woodbridge, aged three years, robust and 



COW-POX. 



433 



to the human subject, this false cow-pox, produces more serious 
symptoms than the preceding. These two species were observed by 
Nissen,a practitioner at Segebert. A third species has been described 
by Helwag, under the name of yellow false cow-pox. It differs from 

remarkably florid ; George Woodbridge, aged five months, plump and 
healthy. In all, the punctures were early inflamed ; but the inflam- 
mation subsided, and the papular stage was late in all — the sixth, 
seventh, or eighth day before it was possible to determine the proba- 
bility of any result, when a dark dull red pimple occupied the place 
of some of the punctures, for many of them failed. Vesicles with 
areolae were formed at different periods in each. 

" 'Bryant, becoming ill with diarrhoea soon after vaccination, pro- 
duced only one vesicle, with an areola at the height on the fifteenth 
day ; the vesicle bluish and remarkably large. Nicholson yielded 
two fine vesicles with full areolae, and two papulse on the thirteenth 
day. Gibbs had but one vesicle, fine and pearl-like, with fully de- 
veloped areola on the eleventh day. Joseph Woodbridge had two 
vesicles, attended with areolae on the tenth day, which were very 
extensive on the twelfth, and did not decline till the fourteenth day. 
George Woodbridge entirely failed. Thus twenty punctures yielded 
but six vesicles. In all these cases the primary constitutional symptoms 
were very slight; the secondary proportioned to the extent and cha- 
racter of the areola ; hence Joseph Woodbridge suffered severely, 
had vomiting and delirium. No eruption was observed in any of 
the cases except his ; he had extensive roseola. 

" ' On three subjects, aged respectively eleven years, ten months, 
and two years and a-half, some of the remaining points were em- 
ployed ; into these, also were inserted, at the same time, points 
charged with ordinary vaccine lymph. In all three subjects the latter 
took effect in every puncture ; while only five out of eight punctures 
with the new lymph answered, papulation being tardy as before ; 
while the old lymph advanced as usual. As the areolae of the vesicles 
from this lymph began to form, the sluggish vesicles from the new 
began rapidly to advance, and ultimately ran the same course, but did 
not eventually attain the same size, though perfectly well developed. 

" ' Six points, charged with lymph taken from the vaccine vesicle 
of the fifth day, on the variolated sturk, were inserted into two sub- 
jects at the same time as points charged with lymph from the variolous 
vesicle of the tenth day. One Emma Churchill, aged five years, 
produced, from three punctures with the latter, two papulae only ; but 
from three punctures on the right arm, with the former lymph, two 
very fine active vesicles, in which the areolae began on the ninth day, 
and was fully developed on the eleventh. In the other case, Richard 
Tompkins, aged four years, both sets of punctures took effect, but 
those with the retro-vaccine lymph were more early developed ; the 
areolae of both commenced on the ninth day, and declined after the 
eleventh. The symptoms in both subjects appeared on the approach 
of the areolae, and were rather severe during its activity. In the 
subsequent removes of the lymph from the variolous vesicle and the 
retro-vaccine vesicles, and when propagated from arm to arm, it 
appeared rather more energetic than the ordinary lymph. Trials 
were made of both on the same and on separate subjects. In the 
subsequent removes of the new lymph, in the liquid state, by trials 
on the same and on different subjects at the same time, it was impos- 
sible to discover the slightest difference in its course and effects, 
whether derived from the variolous vesicle of the tenth day, or the 
retro-vaccine vesicles of the fifth or seventh day.' " — pp. 404-406. 

The phenomena presented by the lymph taken from the vesicles 
produced on the second variolated heifer, were very analogous to 
those above quoted. It is only necessary to mention that it was 
found that after the fourth remove " the vesicles were every thing that 
could be desired, even on a puny, sickly, rickety child, aged two 
years and a-half." 

In the case of his assistant, Mr. Taylor, who had accidentally 
inoculated himself from the matter of the single variolous vesicle de- 
veloped in the first experiment on the cow, he had in consequence 
modified vaccine with a general eruption of roseola and vesicular or 
vaccine lichen. This gentleman had been vaccinated in infancy, 
and had subsequently modified small-pox. With the exception of 
this case, no attendant eruption was observed by Mr. Ceelyin adults; 
109 



the two preceding species in its colour, in the nature of the fluid 
included in the pustules, and in not being contagious. A fourth 
species signalized by Jenner, differs from the preceding in the absence 
of erysipelatous inflammation, in the slight degree in which the secre- 
tion of milk is affected, and the rapid formation of the crusts. Viborg 
admits all these species, and describes several others. One of them 
of a fiery red colour is transmissible to map, and extremely benign ; 
another (warty vaccinia) shows itself first upon the teats under the 
form of small hard white bodies, like mustard seeds, which increase 
in size, become reddish on the flesh-coloured teats, and livid on the 
black, and secrete from their bottom matter of a yellowish colour. 
The fever accompanying this species is not very intense ; and the 
milk does not decrease in quantity unless the eruption be extremely 
abundant. At the height of the disease the teats become inflamed 
and painful, and the animal will hardly suffer itself to be milked. 
The disease is transmitted from one cow to another, but not to man. 

A. F. Luders (Rem. sur la Vaccine des Vaches de Holstein, Journ. 
Complementaire des Sciences Med., t. xxi. p. 53), has also published 
interesting observations upon epizootic cow-pox, and upon spurious 
cow-pox. 

1462. I have myself met with an eruption which I conceive ought 
rather to be ranked among the spurious than the true cow-pox. Still 
it may have been the true disease, the accidental inoculation of which 
upon the person of a woman who had had the small-pox, produced 
a modified vaccinia, followed by secondary eruption. I showed the 
case to M. Bonnet, now Professor of Anatomy at Poitiers, and to M. 
Leblanc, the distinguished veterinary surgeon, who agreed in opinion 
as to the vaccinal character of the eruption. Here is the case : 

I was consulted at Bellevue, in the month of June, 1829, by a 
woman, aged thirty-eight, of good constitution, and who had had 
small-pox, the marks of which she bore about her, who had been 
attacked during the last few days with an eruption of large pustules 
upon the corresponding sides of the index and medius fingers of both 
hands, which she employed to milk the cows she tended, seizing the 
teats between these two fingers. Three pustules were observed on 
the ulnar edge of the forefinger of the left hand. Another pustule 
existed on the same side of the right forefinger, and one upon the 
radial side of the right middle finger. These pustules, rather distant 
from one another, prominent, and of the size of a pea, were inflamed 
at their base, which was of a violet red colour. The broadest of the 
pustules was somewhat flattened in its centre. The epidermis being 
detached from the surface of one of these spots, a little blood was 
discharged, but neither pus nor serum. The spot thus denuded, 
examined with the lens presented four or five transparent, rounded 
points like globules of blood, divided from each other by a kind of 
septa, somewhat opaque. These spots had not been painful on their 
first appearance ; but by and by the patient felt shootings in them as 
if (as she said), they were going to fester. 

I saw the patient three days afterwards. The pustules had in- 
creased in size, and now contained a transparent serous fluid, depo- 
sited within cells or compartments. I collected some of this fluid, 
with which I next day inoculated three children, none of whom had 
any eruption. Three days later, the hands of the patient were tumefied; 
the fingers especially were excessively swollen ; the bases of the pus- 
tules were of deeper red and had extended, and the serum they now 
contained looked sanguinolent. The patient had still gone on milking 



nor in any child was there the slightest approach to any thing of a 
varioloid character. In one case true varicella appeared six days 
after vaccination at the sixth remove. Roseola, strophulus and 
lichen were the principal eruptions observed. Supernumerary vac- 
cine vesicles were frequently observed in the proximity of the punc- 
tures. This lymph has been extensively used both at the Small-pox 
and Vaccination Hospital at London, at the Cow-pox Institution at 
Dublin, at Cheltenham and at Bristol, and found equal to any at 
present in use. 

Not having had access to Mr. Ceely's paper, which is published 
in the Transactions of the Provincial Medical and Surgical Association, 
1840, we have made use of the full analyses in the British and 
Foreign Medical Review, October, 1840, and the Edinburgh Medical 
und Surgical Journal, October, 1840. 



434 



GREASE— CARBUNCLE. 



her cows. The deep red colour of the pustules gave them a pretty 
mblance to strawberries, though they were smooth and even 
on the surface. One of the pustules, situated on the middle finger, had 
rged its contents almost completely, and the cuticle, loosened 
and whitish, was still kept moist by the excretion of a small quantity 
oi thick and purulent serum. The patient complained greatly of pain, 
and was very unwell. During the last two days a secondary eruption 
had made its appearance over the forearms, hands, legs, and several 
other regions of the body. This eruption was vesicular, generally of 
the size of millet-seeds, and scattered, nowhere appearing clustered. 
The vesicles were transparent; their base was not inflamed, and the 
skin in the spaces between them was not red. They occasioned con- 
siderable pruritus, especially during the night. These vesicles, in their 
interior, presented numbers of small reddish inequalities, similar to 
what were observed in the pustules of the fingers. On the twenty- 
fourth day the pustules of the fingers were nearly well ; the small 
vesicles, of the secondary eruption, w r ere opaque and yellowish ; a 
very considerable number were wrinkled on their surface; a few days 
afterwards the recovery was perfect. 

The appearance of these pustules, and their seat upon the edges 
of the fingers, which were the parts more particularly brought into 
contact with the teats of the cows, excited my attention, and on the very 
day when I first observed this eruption, I examined the cows belong- 
ing to the family, and on one I discovered an eruption having the 
appearance of cow-pox. On the four teats there existed pustules of a 
circular form, and of the size of a large lentil. The base of one of 
these pustules, evolved on the point of the teat where there was no 
pigmentum, was of a citron-yellow colour, and its centre contained a 
purulent fluid. This pustule was not umbilicated, but a small black 
point was perceived on its summit; its base was but very slightly in- 
flamed. The citrine-coloured fluid it contained was rather thick. A 
second pustule, of larger size than the preceding, contained less serum 
and more pus. Others were already partially dry. (a) 



1463. Under the name of grease is designated a pustular or vesi- 
cular eruption of the lower parts of the legs, and particularly of the 

(a) Mr. Ceely points out various eruptive diseases, and spurious 
pocks, as they are termed, to which milch cows are subject, in ad- 
dition to the variola; vaccinae. Among these are the yellow pock, 
the bluish or black pock, and the white pock. Cases of spurious 
eruptive disease, communicated from the cow, and mistaken for 
genuine cow-pock, are frequent in dairy districts, a circumstance 
meriting the attention of the practitioner residing in them, since by 
leading to the neglect of correct and efficient vaccination, fatal con- 
sequences have ultimately resulted from subsequent exposure to the 
infection of small-pox. 

Of the spurious eruptions liable to be confounded with the genuine 
vaccine, the w r hite pock would seem to lead to the most frequent mis- 
takes. "On very thick skins, about the sixth or seventh day of its 
existence, it sometimes appears as a raised, circular, well-defined, 
firm vesicle, with a small violet or pink areola, and a slight central 
depression, with a light brown discoloration." On close examination, 
however, it will be found to be neither cellular in its structure, nor 
possessed of fluid contents. 

The cow, like children, is described as being subject to a purely 
vesicular eruption, consequent upon vaccine fever, which often bears 
a striking resemblance to vesicular varicella. This usually occurs 
about the ninth or tenth day of the vaccine, in the form of erythe- 
mato-papular elevations of different sizes, solitary, or in groups, 
evidently of sub-epidermic origin, which, within twenty-four hours, 
contains a pellucid serous fluid, which raises the epidermis. On the 
second day the fluid is straw-coloured and turbid ; and before the 
fifth the vesicles are desiccated with brown and black thin, brittle 
crusts, which speedily fall. They often continued to form and desic- 
cate for three or four weeks. Several eruptions were noticed as oc- 
curring at this period ; but none of them so liable to be mistaken for 
the vaccine as the white pock. 



pastern, of several species of animals, but more particularly of the 
horse. 

This affection is ushered in by symptoms of uneasiness and of fever. 
The eruption then makes its appearance. The hair of the parts affected 
looks bristly; the size of the limb is increased, and has a great tend- 
ency to enlarge ; the animal rubs the diseased leg against the others, 
and tries to bite it; he often lifts the affected member, especially if 
it be a hind leg. Examined closely, vesicular or pustular elevations 
may commonly be perceived, but still more frequently a discharge of 
a serous fluid having a peculiar smell, from a number of small orifices 
situated at the roots of the hairs. The redness and the discharge in- 
crease ; the hair is thrown out, excoriations and chaps are formed, to 
which sores succeed, that pour out a faint smelling or fcetid discharge, 
and upon the edges of which soft and fungous-looking excrescences 
sprout up. 

Jenner was of opinion that the accidental inoculation of the matter 
discharged in this disease, was the determining cause of cow-pox among 
cows. This idea was combated by Woodville, Simmons, Coleman, 
Buniva, Luciano, Bertholini, and others, who all tried, but in vain, 
to inoculate the virus of grease upon the teats of the cow. Other 
observers, Godine, Tanner, Lupton, Loy, Laffont, and Sacco, from 
repeated experiments, have held themselves bound to adopt the views 
of Jenner. But several of them, and particularly Saco, maintain that 
the virus of grease is not the only cause of cow-pox, and that it may 
be evolved spontaneously among cattle. The following fact, observed 
by M. Husson, appears conclusive. A coachman, who had never had 
small-pox, and who had, within a few days, dressed the leg of a horse 
affected with grease, came to consult the surgeons of one of the dis- 
pensaries of Paris, on account of a number of spots or pustules which 
had been evolved on his wrists, and were exactly like those of vac- 
cinia. This resemblance struck the surgeons, who immediately inocu- 
lated two children with the fluid from the pustules of this coachman's 
wrists. Vaccinia, of the most regular kind, ensued in both of these 
children, and the virus was used again and again to transmit this 
disease. A third child was afterwards inoculated with the matter of 
one of the crusts from the coachman's wrist, and had regular vaccinia, 
which, eight days afterwards, served to commence an indefinite series 
of vaccinations. 

1464. I think it right to observe that in all probability the whole 
of the affections designated as grease are not of the same nature. 
Several cases of grease which I have examined bore a stronger resem- 
blance to impetiginous eczema than to any other disease. 

1465. On this subject, — the relation of grease to cow-pox, consult 
Jenner's Inquiry into the Causes and Effects of Variola Vaccina, 8vo. 
Lond., 1798; Loy's account of some experiments on the origin of cow- 
pox, 8vo. Lond., 1802 ; Sacco's Trattato di vaccinazione, con osserva- 
zioni suH giavardo e vajuolo pecorino, con quattro tavole miniate, 4to. 
Milan, 1829 ; and Husson's article: Eaux aux Jambes, in Diet, des 
Sc. Medicares, (a) 



CARBUNCLE (CHARBON). 

1466. M. Hurtel d'Arboval relates (Diet, de M$.d. et Chirurg. Veter., 
in art. Typhus charbonneux), that a veterinary surgeon, opening the 
body of an ox which had died of typhus charbonneux, imprudently 
carried his hand soiled with blood to his face naturally covered with 
spots ; on this there followed an erysypele charbonneux accompanied 
with shivering fits, nausea, syncope, &c, so that the man died. A 
woman who had introduced her arm into the rectum of a horse, 
labouring under carbuncle (charbon), to remove the accumulated 
excrement, died very shortly afterwards of the same disease. A 
veterinary surgeon having removed a tumeur charbonneuse whilst suf- 
fering with a wound on his hand, contracted the disease and died. 

(a) Numerous cases are recorded of a similar kind to the one men- 
tioned in the text, of the propagation of vaccinia from the pustules 
of the lower part of the legs of a horse. But it must be borne in 
mind that this result can only follow the inoculation with the matter 
from one specific kind, of the many varieties of eruption, designated 
vaguely by the term grease. 



SCABIES— GLANDERS. 



435 



Two men having bled a bull from the neck affected with a charbon, 
of the nature of those which are held very malignant, were after- 
wards affected with a considerable swelling of the right arm, and a 
number of livid spots, in consequence of the contact of the blood 
with this part. Shortly afterwards they complained of weight about 
the heart, [maux de cccur,) and violent fever, and became exceedingly 
ill. A woman, after having bled a sheep which died of charbon, 
having let two drops of blood fall on her hand, two malignant pus- 
tules were evolved on the places. Petit instances the production of 
an affection charbonneuse in two children, by the intermedium of a 
cloth which had been used to cover the skins of some animals dead 
of charbon. 



SCABIES OF ANIMALS. 

1467. According to the testimony of several writers worthy of 
credit, the itch of animals, a contagious disease in which a species of 
acarus is observed, may occasionally be propagated to man. We are 
even informed that these cases of itch are much more severe than 
ordinary scabies, and the same remark has been made in regard to 
scabies transmitted from one species of animal to another. 

1468. The itch of the horse {roux vieux) is principally situated upon 
the neck, especially on its upper part near the insertion of the mane. 
It is characterized by the evolution of small spots hard at their base, 
vesicular on their apices, extremely numerous and very closely crowded 
together. Incessant itching leads the animals to rub themselves one 
against another, or against their stalls, trees, &c; by this means they 
sometimes excite excoriations, which in healing become covered with 
dry crusts, or with squama? which are detached in the shape of dust. 
In examining this dust in the sun or in a warm place, a number of 
shining transparent insects, which move with rapidity, may be per- 
ceived in it even with the naked eye. This is a species of the genus 
acarus of which Raspail has given an accurate figure and an excellent 
description (vide his JVouv. syst. de chimie organique, p. 509, 8vo. 
Paris, 1833, and the Lancette Fran$aise, 13me Aout, 1831). 

R. Fauvet gives the following case : In the month of January, 1820, 
a farmer bought a horse affected with the itch (cheval galeux) at the 
market of Bergamo, which he mounted to return to his home. The 
day after his arrival he experienced great itchiness over almost the 
whole of his body ; the same symptom was farther complained of by 
his son and a friend who had accompanied him to market. The stable 
boy, too, to whom the horse was given in charge, began to scratch 
himself incessantly within two days ; so did a labourer who had used 
the brute in some field work during a few hours, and this went on till 
more than thirty persons and several other horses attached to the farm 
were infected with itch. The mangy animal was, therefore, got rid 
of, and being sold to a miller, he and his men were forthwith attacked 
with itch merely from having put their hands on the back of the pur- 
chase; a cow, also, which had rubbed her neck against the manger 
of the horse, contracted the itch like the rest. 

The scabious character (caract'ere psorique) of the eruption com- 
municated, was ascertained by several distinguished physicians and 
surgeons (Revue Medicale, t. x.). 

Messrs. Dumeril, Geoffroy St. Hilaire, Bosc and other naturalists 
have borne testimony to the fact of a quadruped (un phascolome) which 
was affected with itch when placed in the Jardin du Roi, having 
infected the man who was ordered to preserve the skin (the animal 
having been accidentally killed by the elephant), with a very decided 
scabies. 

The vesicles which characterized the disease of the phascolome con- 
tained insects of much larger dimensions than the acarus scabei of the 
human subject ; neither did they degenerate transferred to the man who 
has been mentioned ; they occasioned vesicles of greater magnitude 
than common, which were attended with pruritus of the most intole- 
rable kind, and considerable redness of the skin. Sulphur, the true 
specific in ordinary scabies, was found equally efficacious in the present 
instance, and soon restored the individual to health. 

Several instances of the itch of dogs having been communicated to 
man have been mentioned, but unaccompanied with perfectly irrefra- 
gable proofs. 



ERUPTION FROM TOUCHING THE SKIN OF A LIONESS AFFECTED WITH A 
DISEASE OF THE SKIN. 

1469. Captain Nonencourt, of the Echo, arrived at Brest, from 
Senegal, having on board a young lioness, labouring under a scabious 
affection of the skin, and a chronic diarrhoea which before long proved 
fatal. A man of the name of Dupont, who skinned the animal, was 
attacked, the night after the operation, with an insupportable itchiness 
which was followed, by and by, by the appearance over the back, 
shoulders and legs, of a considerable eruption of little red, pyramidal 
elevations containing a serous sanguinolent fluid. The eruption on 
the back disappeared under the use of certain remedies, and that on 
the other parts was in a state of desquamation, when the treatment 
was discontinued. On the 23d of September, Dupont felt a consi- 
derable degree of itchiness in the head during the night, and next 
morning he found his forehead, eyebrows and ears covered with pus- 
tules, similar to millet seeds. The face, too, was so thickly beset, and 
so much swelled that the nostrils were obstructed. The eruption con- 
tinued for three or four days in this state. The pustules then burst, 
and poured out a sharp fluid, which dried up into a thick crust, that 
covered the face like a mask. The desquamation commenced on the 
sixth day ; the crust fell off in large flakes ; the denuded skin looked 
red, and only recovered its natural colour slowly. 

A person of the name of Bertin stuffed the skin of this lioness. 
Two days afterwards his eyelids swelled during the night, and a pus- 
tular eruption broke out which spread over the whole of the face, the 
skin of which generally presented an erysipelatous redness. The 
eruption disappeared from the face by and by, but attacked the hands 
and shortly afterwards the soles of the feet ; on the fourth day it fast- 
ened on the thighs. It was accompanied with violent and incessant 
itchiness. The thighs were covered with broad pustules. They 
burst, and were succeeded by thick crusts which fell off after a time. 
Shortly after this, Capt. Nonencourt himself began to complain of 
being affected with a scabious eruption. The formation and detach- 
ment of the incrustations put an end to this disease in the three persons 
affected. The skin, after this process, continued red and shining, but 
without ulceration. 

Drs. Duval and Coxil Saint Vincent made use of the same remedies 
in these cases, namely, sudorifics, bitters, sulphur, sulphureous baths 
and purgative medicines, with success. Dr. Saint Vincent at the same 
time made use of mucilaginous anodyne and saturnine lotions to ap- 
pease the pruritus and lessen the irritation of the skin. 



GLANDERS. 

1470. Acute glanders occurs in the horse and the ass with the fol- 
lowing characters: — the pituitary membrane is very red, and highly 
inflamed ; small eroded points soon appear and spread into foul and 
cankery sores with thick and raised edges ; the lips and point of the 
nose are sometimes swelled ; the ulcers extend, and discharge a fetid 
purulent matter, with which a quantity of sanguinolent sanies is from 
time to time mingled. The mucous membrane becomes gangrenous. 
The discharge continues in greater quantity than ever ; the sublingual 
glands are painful ; the conjunctivae and eyelids, at first inflamed and 
injected, assume a violet colour, swell, and a discharge takes place 
from between the eyelids ; the inflammation then extends to the sur- 
rounding parts, the breathing becomes laborious, and the animal dies 
within a few days. If the disease has not now this termination, the 
inflammation declines and passes into the chronic state. Pustules and 
gangrenous spots then occur over the face, the extremities swell, and 
ulcers and abscesses are formed in their substance. In a stable of 
eighteen horses and three asses attacked with glanders, Dr. Elliotson 
informs us that ten horses died within the few first days of the disease ; 
four after the first violence of the symptoms had subsided, and the 
disease had continued apparently stationary for two months ; the seven 
others which survived, presented all the symptoms of chronic glanders. 
They were sent into the country where they worked for nearly a year, 
at the end of which time they were killed. 

It is long since glanders was familiarly known to be a highly con- 
tagious disease among animals of the same species ; but it has only 



436 



GLANDERS. 



recently been discovered thai acute glanders accidentally inoculated 
upon the human body, give rise to very serious symptoms, to a dis- 
ease, in feet, analogous to the glanders of the horse. 

j)r. Clliotson has studied this point of pathology particularly, and 
lias thrown much light upon it by his researches. He reminds us of 
the case related by Mr. Travers, of a student who lost his life from 
accidentally puncturing his linger whilst engaged in dissecting the 
head of an ass affected with glanders. He died with abscesses in 
the arm, lungs, kidneys and knee-joints. An ass inoculated with the 
matter from the abscess in the arm, by Professor Coleman, contracted 
glanders, and died twelve, days afterwards. 

Two other cases, the particulars of which Dr. Elliotson has de- 
tailed, are still more remarkable : 

Thomas Maskall, aged seventeen, presented the following symp- 
toms : — The upper half of the face, including the eyelids and the nose. 
with the portion of the cheek on each side, especially on the right, 
was greatly tumefied, so that the eyes were closed. The eyelids and 
swollen portions of the cheeks were red and hot, dry and shining, 
but the nose was dark-coloured, and on its right half, black, cold, and 
senseless. From around the gangrened portion of the nose and some 
other points a little pus was oozing, as well as a thin dark-coloured 
fluid, and from the nostrils a thick discharge of a deep yellow colour, 
here and there a Utile bloody, was taking place, exceedingly copious 
from the right nostril. Several hard phlyzacious pustules existed on 
and immediately around the nose, still principally on the right side, 
and in various parts of the trunk and extremities. Tumefactions were 
observed in both forearms and in the back of the right hand. Some of 
these were hard, others softening into suppuration. The temperature 
was high; the pulse 136, and sharp: the tongue white, and rather 
dry. The respiratory murmur was indistinct on the right lower part 
of the chest, and the respiration quick and difficult. The gums were 
slightly turgid. He died next day; on opening the body there were 
proofs of a violent pleuroperipneumonia in the lower part of the right 
side, and two ounces of healthy pus were found between the adherent 
lung and diaphragm. A dark red patch existed in the stomach, and 
several at irregular distances throughout the intestines. The mucous 
membrane of the stomach was very lacerable at that spot. The other 
viscera, and all the contents of the head as well as the veins of the 
extremities, were reported healthy : but the mucous membrane of the 
nostrils was not examined. The abscess w r hich had been opened in 
the back of the right hand communicated with the joint of the meta- 
carpal bone of the middle finger, but those on the arm did not com- 
municate with the elbow. 

On Friday, the 26th of the following June, it being my week to 
admit patients, I was surprised to find another young man, named 
Thomas Dixon, and twenty-one years of age, lying in bed in Wil- 
liam's ward, with the same symptoms as the former. 

The nose and surrounding parts were exceedingly swollen, so that 
the left eye was closed completely, and the right nearly. The tume- 
fied parts were hot, and of a bright red, with the exception of an inch 
of the left half of the nose, which was of a mulberry colour : a pro- 
fusion of deep-yellow tenacious mucus, with a few streaks of blood, ex- 
uded from each nostril, but particularly from the left. Several hard 
phlyzacious pustules existed on the nose and adjacent parts, on the 
arms, thighs, and legs, and each was surrounded in the latter situa- 
tions by a blush of red. A patch of the same colour was observed on 
the left elbow. The temperature of the surface of the abdomen was 
107°. The pulse 144, broad, soft, and weak, so as to be rather an 
undulation than a pulsation. The respiration 30, and so shallow that 
the chest scarcely appeared to move. The tongue was dry and rough, 
and of a brownish red. The skin sweated copiously. He gave 
rational answers in a fluttering voice, but immediately afterwards 
always fell into a little incoherence. His movements were tremulous, 
and though otherwise exceedingly tranquil, he tossed his arms about, 
and requested that his wrists might be tied together to prevent this 
involuntary action. He complained of coldness in the lower extremi- 
ties, which, however, were sufficiently w^arm, though cooler than the 
rest of the body. This patient also died. On opening the body, 
many parts of the lungs were gorged with blood and frothy fluid, and 
the corresponding bronchial branches w^ere very dark ; numerous pa- 
pillae, with pointed black summits, were seen at the end of the ilium, 



and clusters of minute grayish-black points throughout the small in- 
testines, and most abundantly at the commencement of the duode- 
num ; the walls of the left ventricle of the heart were very thick : but 
nothing was detected, either peculiar or important, or calculated to 
throw the faintest light upon the disease. 

1471. Dr. Elliotson having contrasted the symptoms of these two 
cases with those presented in a young soldier, the detail of which is 
given by Mr. Brown, surgeon of the second regiment of Dragoons, 
under the title of, A fatal case of acute glanders in the human subject 
{London Medical Gazette, vol. iv. p. 134), was immediately struck 
with the resemblance which the whole of the three cases bore to one 
another, and forthwith instituted inquiries to ascertain whether or not 
his own patients could have had any intercourse with glandered 
horses. The result of these inquiries were next to certain evidence 
that they had. Some time afterwards Dr. Elliotson had a case com- 
municated to him by Mr. John Parrot, in which there was no doubt 
of the patient having been in contact with a glandered horse. Mr. 
Brown's case, moreover, was quite decisive upon this point. The cir- 
cumstances are as follows: — A fine healthy corporal in the 2d regi- 
ment of Dragoons, aged thirty-eight, suddenly awoke, while stationed 
at Caher, in Ireland, in the night of the 16th of April, with rigors, 
headache, and slight irritability of stomach, which in the morning 
were joined by depression of spirits, general disturbance, and stiffness 
and severe and constant pains of all the large joints, aggravated on 
the slightest motion. The pains increased to an alarming degree, 
but especially in the left shoulder, which was somewhat tumefied at 
the scapula, but not inflamed. On the 24th, the tumefaction was 
considerable, and of a livid hue. Similar swellings, but smaller, 
took place on the arms, legs, thighs and sacrum; all, like it, hard, 
insensible, and of a chocolate colour, and at first a slightly discoloured 
puffiness only, but becoming, after twelve or fifteen hours, of a deep 
vermilion, and soon of a dark brown; the integuments growing thick 
and callous, slightly cracking, and exuding a thin and acrid sanies. 
One precisely similar, and of large size, appeared upon the left 
temple, and the eyelids became tumefied. " The right nostril was 
gummed with an inspissated discharge." The " posterior fauces" 
were much inflamed, and nearly of a purple hue. On the 28th, 
several " warty pustules," acquiring about the size of a pea, rose high 
above the skin, in various situations around each of the tumefac- 
tions, particularly numerous and large over the right side of the neck 
and shoulders, and on the inside of the arms and thighs, and were 
found after death to be filled " with a violet-coloured inspissated 
lymph." The thirst was always great, the tongue foul and parched: 
the pulse from eighty-eight to ninety-six, full, but easily compressed; 
the blood, abstracted at the commencement, buffed, but much attenu- 
ated ; the urinary and alvine excretions "always natural in every 
respect." " The copious exhibition of tonics and antiseptics" had 
not the slightest effect.- and at the date last mentioned, — the 28th, 
many of the tumours, particularly that upon the shoulders, were 
rapidly running into gangrene ; the pulse was scarcely percepti- 
ble, the surface bathed with a cold, clammy sweat; imperfect stupor, 
and mild muttering delirium occurred, and he died upon the morning 
of the 30th. 

Neither the thoracic nor abdominal viscera presented any vestige 
of disease, but, as there was in this case no impediment to a full exa- 
mination, the head, extremities, and walls of the trunk were carefully 
inspected. A cluster of tubercles was found in the cellular mem- 
brane, exterior to the pericranium of the left supercilliary ridge, and 
in the right frontal sinus, according to the veterinary surgeon of the 
regiment, exactly similar to those observed in the frontal and other 
sinuses of the horse after acute glanders. On dividing the various 
livid tumours of the surface down to the bone, " the muscles appeared 
perfectly decomposed, and of a dark liver colour, exhaling a peculi- 
arly fetid odour, with points of purulent matter, as it were infiltrated 
everywhere through their entire substance, resembling much a hepa- 
tized or tuberculated lung;" and under each " was a cluster of gray 
circular tubercles, the whole composed of fine cellular tissues, en- 
closed in small cysts, proportionate in size and consistence to the 
extent and duration of the tumour, and firmly attached to the perios- 
teum." The muscles generally, even perhaps the heart, appeared 



GLANDERS. 



437 



pale and flabby, " and the cellular membrane infiltrated with a yellow 
serosity." 

" It appeared that the patient had had the sole charge of a glan- 
dered horse for some time, which had been destroyed on the very 
evening of his attack; and that he had skinned him, and exerted 
himself a good deal in cutting up and burying the carcass. But these 
circumstances did not at first create the least suspicion, and his com- 
plaint was considered a very severe case of acute rheumatism, and 
treated as such." 

1472. These data on glanders in man are derived from Dr. Elliot- 
son's first paper on this subject inserted in the sixteenth volume of 
the Medico-Chirurgical Transactions, published in 1830. In 1833 the 
same gentleman gave to the public an additional number of observa- 
tions on the subject. [Additional facts respecting glanders in the 
human subject, 7th March 1823, which were republished in two of 
the French periodicals, Journ. de Med. Veterinaire, 1832, p. 124; 
1833, p. 427; and in the Lancette Frangaise, 1833, p. 384.) 

Dr. Elliotson was afterwards informed that two cases, similar to 
those he had seen, were recorded in the eleventh and seventeenth 
volumes of Rust's Magazin fur die gesammte Heilkunde, 8vo. 1821, 
1824, to which he refers particularly. The cases in the first of these 
volumes are noticed in the Journal der Praktischen Heilkunde, for 
March, 1822. 

M. Vogeli, of Lyons, has also given several cases, one of which 
particularly, that, namely, of Pierre Couderac, appears to me analo- 
gous to those seen and related by Dr. Elliotson ( Quelques faits ten- 
dant a etablir la contagion du farcin du cheval d, Phomme. Journ. de 
Med. Veterin., January, 1825). 

It would, therefore, appear satisfactorily demonstrated, that glan- 
ders is communicable to man ; first, by the perfect similitude and 
uniformity of the symptoms in all the cases in which inoculation was 
ascertained ; by the peculiarity of the symptoms, and their distinct- 
ness from those of every other disease; by the exact correspondence 
of the morbid alterations discovered after death, with those encoun- 
tered in the bodies of horses labouring under acute glanders ; and, 
finally, by the actual excitement of glanders in asses, inoculated with 
matter taken from the sores of two different individuals, who died with 
the peculiar symptoms mentioned. 

This rare disease is represented in the Atlas, after drawings, for the 
correctness of which Dr. Elliotson vouches. The cases, the experi- 
ments, and the learned researches of this gentleman, on glanders, are 
replete with interest, (a) 

(a) Within the short period that has elapsed since M. Rayer wrote 
the above brief notice of Glanders, large contributions have been made 
to a better knowledge of the disease, and by few with more effect 
than the author himself; first, in a paper entitled De la Morve et du 
Farcin chez P Homme, 1837, in the Memoires de PAcademie de Medi- 
cine, and afterwards in an essay, jointly by him and M. Breschet, De 
la Morve chez P Homme, chez les Solipedes, fyc. ( Compte rendu de PAca- 
demie des Sciences, 1840). 

Among the German writers on this disease may be mentioned Dr. 
Eck (Beitrc'ig zu den Erfahrungen iiber die Schildliche Einwirkung des 
Rotzgifts auf Menschen . , 1837). Dr. Graves, also, makes glanders and 
button farcy the subject of one of his clinical lectures ( Graves and Ger- 
hard, p. 313, Philad. edit). Several cases of the disease in the human 
species have been recorded of late years in the Medical Journals, 
some of which I shall soon notice more particularly. I must men- 
tion, however, at this time, two valuable papers, containing much 
valuable information on the subject, in the British and Foreign Medi- 
cal Review, vol. vi. 1838, and the Edinburgh Medical and Surgical 
Journal, 1840. But the fullest monograph of glanders and farcy 
which has yet come under my notice, is the essay of M. Tardieu (De 
la Morve et du Farcin Chroniques chez P Homme et chez les Solipedes. 
Paris, 1843), dedicated to his former preceptor, M. Rayer. 

It was while preparing to make an analysis of this last work that 
I was induced to write a short monograph of the disease for my Bul- 
letin of Medical Science, July, 1843. This article will constitute the 
staple of my remarks on the present occasion. Now, as then, I shall 
refer to the admirable work on the Horse, by M. Youatt, whose clini- 
110 



cal experience in glanders and farcy, as they attack this animal, have 
a direct application to those diseases, when transmitted to man. 

Close connection between glanders and farcy. — First, we would de- 
vote a few words to the connection between glanders and farcy, and 
the reason for their being regarded varieties of the same disease ; 
attacking, indeed, different tissues, but acknowledging a community 
of origin : 

"'Farcy,' says Mr. Youatt, 'is intimately connected with glanders; 
they will run into each other, or their symptoms will mingle together, 
and before either arrives at its fatal termination, its associate will 
almost invariably appear. An animal, inoculated with the matter of 
farcy, will often be affected with glanders, while the matter of glan- 
ders will frequently produce farcy. They are different types or stages 
of the same disease. There is, however, a very material difference 
in their symptoms and progress, and this most important one of all, 
that while glanders are generally incurable, farcy, in its early stage 
and mild form, may be successfully treated.' 

"M. Tardieu (p. 13) adduces many experiments performed by Al- 
bigaard and Viborg, of the veterinary school at Copenhagen, Coleman 
and White among the English, and Jolivet and Gerard among the 
French veterinarians, all proving the identity of origin, in their inter- 
communicableness by inoculation, of glanders and farcy. Wherein, 
then, consists the differences of these morbid states ? M. Tardieu 
replies, by saying, that the lesion of the nasal fossae is the character- 
istic feature of glanders, Morve of the French, Rotz Rotzkrankheii 
of the Germans. All the cases in which this is wanting are those of 
farcy. Mr. Youatt holds an identical opinion, in his declaring that 
'glanders is an inflammation of the membrane of the nose, producing 
an altered and poisonous secretion ; and when sufficient of this viti- 
ated secretion has been taken up to produce inflammation and ulcer- 
ation of the absorbents, farcy is established.' — p. 137. 

" Post-mortem appearances clearly point out the anatomical seat of 
lesions in glanders. ' The nostril is generally more or less blanched 
with spots or lines of inflammation of considerable intensity. Ulcer- 
ation is almost invariably found, and of a chancrous character, in the 
septum, and also on the ethmoid and turbinated bones. The ulcers 
evidently follow the course of the absorbents, sometimes almost con- 
fined to the trunk of the main vessel, or, if scattered over the mem- 
branes generally, thickest over the path of the lymphatic. The ethmoid 
and turbinated bones are often filled with pus, and sometimes eaten 
through and carious ; but, in the majority of cases, the ulceration is 
confined to the external membrane, although there may be pus within. 
In aggravated cases the disease extends through all the cells of the 
face and head.' (Youatt, p. 132.) The extension of the disease to 
the larynx and trachea, and even, in aggravated cases, down to the 
lungs, is easily traced ; but, as in other cases, there is no morbid affec- 
tion whatever of these organs, we cannot regard pulmonic alterations 
as distinctive of glanders. In the chronic variety of this disease, 
miliary granulations are met with, which have been viewed, errone- 
ously, as analogous and even identical with tubercles in the lungs of 
the human subject. M. Rayer, in his examination of this point of 
comparative pathology, affirms that the. granulations in glanders are 
different in their origin, progress and termination, from the true tuber- 
culous granules in man (Tardieu, p. 42). 

" Among the symptoms of glanders, the earliest is ' an increased 
discharge from the nostril, generally the left, small in quantity, con- 
stantly flowing, of an aqueous character, and a little mucous con- 
stantly mingling with it.' Mr. Youatt, who gives this definition, 
adds, with earnestness, a caution not to wait until the discharge as- 
sumes a viscid or gluey character, before the disease is pronounced 
glanders, or before suspicion even is excited of its indicating the 
first stage. He admits, however, ' that, in a majority of cases, some 
degree of stickiness does characterize the discharge of glanders from 
a very early period.' Swelling of the submaxillary glands follows 
the discharge, but at an uncertain interval : these are distinct from 
adjacent tissue, and adhere closely to the affected side The mem- 
brane of the nose is of a dark purplish hue, or almost of a leaden 
colour, or of some shade between the two, or, if there is some redness 
of inflammation, it will have a purplish tinge. Spots of ulceration 
appear in the membrane covering the cartilage of the nose, which 



438 



GLANDERS. 



usually approach to a circular form, are deep, and with the edges 
abrupt ami prominent. 

" The farther progress of the disease is thus described by Mr. 
Vouatt : 

•• • When ulcers begin to appear on the membrane of the nose, 
the constitution of the horse is soon c\ idently affected. The patient 
lesh — his belly is tucked up — his coat unthrifty, and readily 
coming off — the appetite is impaired — the strength fails — cough, more 
or less urgent, may be heard — the discharge from the nose will in- 
crease in quantity; it will be discoloured, bloody, offensive to the 
smell — the ulcers in the nose will become larger and more numerous, 
and the air-passages being obstructed, a grating, choking noise will 
be heard at every act of breathing. There is now a peculiar tender- 
ness about the forehead. The membrane lining the frontal sinuses is 
inflamed and ulcerated, and the integument of the forehead becomes 
thickened and somewhat swelled. Farcy is now superadded to glan- 
ders, or glanders has degenerated into farcy, and more or less of the 
absorbents are involved. 

" 'At or before this time, little tumours appear about the muscles, 
and face, and neck, following the course of the veins and the absorb- 
ents, for they run side by side ; and these, the tumours, soon ulcer- 
ate. Tumours or buds, still pursuing the path of the absorbents, soon 
appear on the inside of the thighs. They are connected together by 
a corded substance. This is the inflamed and enlarged lymphatic ; 
and ulceration quickly follows the appearance of these buds. The 
deeper-seated absorbents are next affected ; and one or both of the 
hind-legs swell to a great size, and become stiff, and hot, and tender. 
The loss of rest and strength is more marked every day. The mem- 
brane of a dirty livid colour. The membrane of the mouth is strangely 
pallid. The eye is infiltrated with a yellow fluid ; and the discharge 
from the nose becomes more profuse, and insufferably offensive. The 
animal presents one mass of putrefaction, and at last dies exhausted.' 
—pp. 130-1. 

"Farcy (Farcin of the French, Warm of the Germans, Rogna del 
Cavalli of the Italians, and Lamparones del Cavallo of the Spaniards), 
as may have been already inferred from a quotation from Mr. Youatt, 
is, he thinks, always necessarily preceded by glanders, however slight 
the latter may be. Few things, says Mr. Youatt, are more unlike, or 
more perplexing than the different forms which farcy assumes at dif- 
ferent times. ' One of the legs, and particularly one of the hinder 
legs, will suddenly swell to an enormous size. At night the horse 
will appear to be perfectly well, and in the morning one leg will be 
three times the size of the other, with considerable fever, and scarcely 
the power of moving the limb.' 

" ' At other times the head will be subject to this enlargement, the 
muzzle particularly will swell, and an offensive discharge will pro- 
ceed from the nose. Sometimes the horse will gradually lose flesh 
and strength ; he will be hide-bound ; many eruptions will appear 
in different parts; the legs will swell; cracks will be seen at the 
heels, and an inexperienced person may conceive it to be a mere 
want of condition, combined with grease.' 

" Multiplied hard knots and cords, owing to inflammation of the 
absorbents, are formed in different parts of the skin ; some quite super- 
ficial, others deeper seated. Abscesses running into each other ap- 
pear also on the skin, and open into ulcers ; but some of them consist 
of blood. 

"As to the etiology of glanders and farcy, it has been already dis- 
tinctly stated, that contagion is an undoubted cause; but it is not the 
only one. There are two modes of direct transmission ; the one by 
inoculation, or the application of the glanderous matter to an abraded 
or absorbing surface of a healthy animal, by which it finds entrance 
into the system, and produces the specific taint and its characteristic 
effects: the other is by a contaminated air or fomes, caused by the 
emanations from the glandered animal, acting on the Schneiderian 
and pulmonary mucous membrane of a healthy one shut up in the 
same stable. Some may qualify the latter mode of transmission by 
the term infection. The French minister of war appointed a com- 
mission in 1836 to investigate the subject, both of the cause and 
treatment of glanders. A report of the conclusions arrived at has 
not yet been made. M. Barthelemv, a member of the commission, 
relates, however, the following experiment on the question of conta- 



gion. Ten horses, chosen by the commission from among the horses 
of two effective cavalry regiments in garrison at Paris, were put into 
a clean and healthy stable, with horses affected with chronic glan- 
ders : nine out of ten of the first set of horses exhibited symptoms of 
the disease ; and two of four, in which the disease had reached its 
third stage, have been killed." Coleman, Vibourg and Renaut have 
shown that the blood of a glandered horse will communicate the dis- 
ease to a healthy one. 

"Still more frequently than from contagion, does glanders originate 
from general causes acting on the health of the horse ; and this, in the 
history and inquiries into contagious diseases in the human subject, is 
a fact of deep importance. We have, in glanders, irrefragable proof 
that the disease originates spontaneously in the animal ; but yet, that 
in its progress virus of a specific nature is formed, capable of propa- 
gating the disease, by contagion, to another animal, previously quite 
healthy, and in which no causes of constitutional disturbance or de- 
terioration had been in action. 'Improper stable management, we 
believe,' says Mr. Youatt, 'to be a far more frequent cause of glan- 
ders than contagion.' The air, changed and deteriorated by respira- 
tion of many horses kept together in small and illy ventilated stables, 
becomes an irritant, or rather a poison, to the nasal membrane. Pro- 
fessor Coleman, of veterinary fame, relates a circumstance in point, 
which shows also the rapid and fatal agency of the cause in question. 
In the expedition to Quiberon, the horses had not been long on board 
the transports before it became necessary to shut down the hatchways 
for a few hours ; the consequence of this was, that some of them were 
suffocated, and that all the rest were disembarked either glandered or 
farcied. Glanders may be produced by any thing that injures, or for 
a length of time acts upon or weakens the vital energy of the nasal 
membrane ; hence the disease has followed fractures of the bones of the 
nose, violent catarrh, the injection of acrid and stimulating substances 
into the nostril. Whatever weakens the constitution generally, such 
as bad stable management, either excessive labour or defective exer- 
cise, want of wholesome food, will give rise to glanders. Mr. Youatt 
very properly remarks : 

" ' Every exciting cause of disease exerts its chief and its worst 
influence on this membrane. At the close of a severe campaign, the 
horses are more than decimated by this pest. At the termination of 
the Peninsular war, the ravages of this disease were dreadful. Every 
disease will predispose the membrane of the nose to take on the 
inflammation of glanders, and with many, as shingles, catarrh, bron- 
chitis, and pneumonia, there is a continuity of membrane, an associ- 
ation of function, and a thousand sympathies.' 

" Among the hygienic agents, the excess or prolonged application 
of which has been found to be frequently productive of glanders, 
moisture, or moist exhalations, deserve particular notice. New stables 
are, on this account, unhealthy, and sometimes give rise to the disease 
in horses placed in them too early. M. Tardieu, in this part of his 
subject, refers with great confidence to the opinions of M. Youatt, as 
recorded in the lectures by the latter, published in the London Lancet. 

" Hereditary predisposition is referred to by Mr. Youatt among the 
causes of glanders : 

" 'There is scarcely a disease which does not run in the stock. 
There is that in the structure of various parts, or their disposition to 
be affected by certain influences, which perpetuates in the offspring 
the diseases of the sire ; and thus contraction, ophthalmia, roaring, 
are decidedly hereditary, and so is glanders. M. Dupuy relates some 
decisive cases. A mare, on dissection, exhibited every appearance 
of glanders ; her filly, who resembled her in form and in her vicious 
propensities, died glandered at six years old. A second and a third 
mare, and their foals, presented the same fatal proof that glanders are 
hereditary.' 

" M. Latour cites a case, showing direct transmission of the disease 
from parent to offspring. A foal from a glandered mare exhibited, at 
birth, two hard glands adhering to the jaw, and it had a whitish flux 
from the right nostril. Its health was not particularly affected for 
four months, after which period it was killed ; but on dissection deep 
ulcerations were found in the right frontal and maxillary sinuses, and 
the cornets were almost completely destroyed. 

" The two species of disease now described, have each been divided 
into two varieties, — acute and chronic ; so that we have acute and 



GLANDERS. 



439 



chronic glanders, and acute and chronic farcy. This division is ap- 
plicable to the disease as it occurs in man as well as in the horse." 

In proceeding next to describe glanders and farcy in the human 
subject, we repeat the division already made of both these species, 
into acute and chronic, but without insisting much on its practical 
value. The proportion of the first variety is much greater than that 
of the second. Of 132 cases, of all kinds in man, collected by M. 
Tardieu, he found that 89 were of the acute, and 43 of the chronic 
form, or, rather, more than two of the former to one of the latter. 
M. Rayer (op. cit.) indicates three varieties of the acute form of the 
disease, regarding it (farcy and glanders) as one in its essential cha- 
racters. These are, the pustular, the gangrenous, and the pustulo- 
gangrenous. 

" 'In some cases, the most striking phenomena consist of a pus- 
tular cutaneous eruption, a thick and glutinous nasal discharge, and 
a typhoid aspect. In others, the symptoms of nasal lesion are ob- 
scure, while the external characteristics (the pustular eruption and 
gangrenous affection of the skin), predominate. Again, pains in the 
limbs, purulent deposition in various parts of the body, and inflam- 
mation of the lymphatic vessels and glands, form, in the outset, the 
most striking features of another set of cases, still more strictly ana- 
logous in character to the acute farcy glanders of the horse. Lastly, 
there are others more violent and promptly fatal, in which all these 
morbid changes and symptoms appear rapidly, and at once, a few 
days after vague initiatory phenomena.' — p. 642. 

"His classification, founded on another view of the subject, viz.: 
the cases caused by inoculation and those by infection, without con- 
tact, cannot, as yet, rest on a firm basis, since we are unable to say 
whether the disease in man has arisen without the positive contact of 
glanderous matter of the horse with some portion of the skin. But, 
even though this theory of the causation of the disease should not be 
tenable, a division depending on the physiognomy which would be 
supposed to indicate the two forms, may still be found convenient ; 
and hence we shall have a disease distinguished from the very begin- 
ning by local symptoms, and another variety in which the whole sys- 
tem is affected. 

"In acute glanders, caused by inoculation, a short period of incu- 
bation occurs, similar to that which follows the application of the 
variolous or other animal poison, to an abraded surface or wound. 
This period varies from two to eight days; after which, pain, heat, 
and swelling occur; the pain soon becomes lancinating; and red 
lines, or inflamed, painful hard cords extend up the limb, constituting 
angeioleucitis, or inflammation of the lymphatic vessels and glands, 
with which are associated diffuse inflammation of the subcutaneous 
cellular tissue, and active feverish symptoms. Often, at this time, 
there is a lull in the disease, which, so far, may be called farcy, but 
it is only to be followed by the symptoms peculiar to, and character- 
istic of, glanders. 

" When infection was supposed to originate the disease ; that is, 
when no local sore could be discovered, we find feverish symptoms, 
rigors, quick pulse and gastric affection or diarrhoea, and pain in the 
limbs. After the period of invasion, whatever had been the cause of 
the disease, whether inoculation or infection, its progress was the 
same, and marked by the following symptoms: 

" 'Articular or muscular pains, in some cases simulating rheuma- 
tism, followed by subcutaneous, circumscribed painful swellings (the 
probable result of angeioleucitis), which either undergo superficial 
mortification, or are converted into abscesses, containing laudable or 
sanious pus ; a yellowish, viscous, nasal discharge, of limited quantity, 
issuing, in the great majority of cases, from both nares, and first ob- 
served from the fourth to the sixteenth day, accompanied, in some 
instances, by a similar excretion from the mouth or eyelids ; occa- 
sional tumefaction of the nose and adjoining parts, followed by gan- 
grene in one-eighth of the cases ; in very rare examples, swelling of 
the submaxillary lymphatic glands, or depositions of pus therein; and 
pretty frequently inflammation of the throat and tonsils ; a peculiar 
pustular eruption, differing from all varieties hitherto observed, viz.: 
gangrenous bulla? appearing towards the twelfth day of infection, on 
the face, arms, thighs, and anterior surface of the trunk, and some- 
limes preceded or accompanied by profuse fetid sweats ; rapid and 
full pulse at the outset, subsequently weak, depressible, and some- 



times intermittent, and, as death approaches, extremely small and 
frequent ; diarrhoea, with watery stools of cadaverous smell, and oc- 
casionally containing dark-coloured blood ; dental sordes ; dry, brown 
tongue; tympanitic abdomen, with hardly any abdominal tenderness ; 
thirst in a few cases; difficult deglutition; occasional vomiting, espe- 
cially towards the close ; no typhoid macula on the surface ; violent 
cerebral symptoms, terminating in delirium, coma, and death.' — Brit, 
and For. Med. Rev., vol. vi. 

" The post-mortem appearances in subjects dead of glanders, though 
not very minutely described in many cases, demonstrate their perfect 
similarity in man and the horse. Whenever the nasal cavities have 
been examined, they have presented the characteristic peculiarities 
found in the glandered horse. These consisted of ecchymosed and 
gangrenous spots, a peculiar miliary eruption, compared to minute 
abscesses of the size of a grain of millet-seed, ulceration, and a de- 
posit of granular tubercles in the sinuses. The nasal membrane itself 
was usually thickened, infiltrated, and studded with numerous granu- 
lar tubercles, and covered with a thick, tenacious, puriform discharge. 
The bones of the nose were sometimes found corroded. 

" The larynx and trachea have occasionally exhibited marks of 
disease, in the mucous membrane being softened, injected and livid, 
and occasionally covered with a peculiar confluent pustular eruption 
and a glutinous mucous secretion. In the lungs the appearances are 
analogous to those met with in lobular pneumonia : they are, also, 
filled with innumerable brownish or whitish tubercles, varying in size 
from a hemp-seed to a hazelnut. Small abscesses are occasionally 
met with in the substance of the lungs. Ecchymosed spots have 
been noticed on the surface of the heart, liver, stomach, and intes- 
tinal canal. The liver has been the seat of abscesses. 

"The lymphatic ganglia were usually enlarged, often presenting a 
red and injected appearance ; or they were of a brown colour, soft 
and friable. Those chiefly affected were under the jaw, along the 
neck, in the axilla, elbow-joint, and groin. The bronchial lymphatic 
glands were also very commonly affected. The cellular tissue was 
always much diseased, being gangrenous in some places, and very 
generally infiltrated with turbid serous fluid. Here and there small 
collections of purulent matter had taken place. 

"In summing up the diagnosis of the disease, as laid down by M. 
Rayer, but divested of needless detail and collateral matter, we find 
that acute glanders may be distinguished from the results of dissection 
wounds, absorption of pus after capital operations, from ordinary phle- 
bitis, angeioleucitis, malignant pustule, carbuncular affections, putrid 
variola, &c, by the peculiar nasal discharge, pustular eruption, and 
the property the secreted pus possesses of producing the specific dis- 
ease in sound animals. 

" The treatment of this terrible disease is most unsatisfactory. M. 
Rayer's statement cannot be formally contradicted, when he says that 
acute glanders in the human subject has hitherto invariably terminated 
in death (one doubtful case excepted). Two-thirds of the patients 
perished before the seventeenth day; two died from the twenty-first 
to the twenty-eighth day; one only survived to the fifty-ninth. In 
the latter case the symptoms were those of farcy, on which those of 
acute glanders supervened, in the same manner as has sometimes 
been observed in horses. This writer suggests, if the lymphatic 
vessels and glands are swollen, the immediate incision of the latter; 
and if the local inflammation following this operation be intense, free 
incisions and mercurial frictions might, he believes, be serviceable. 
Excision, however, is seldom practicable to any extent, and the safer 
practice is that adopted in veterinary surgery, viz. : to cauterize the 
diseased glands, or other parts, by the red-hot iron. Whatever be 
the number of abscesses formed, they should be incised, and the cuta- 
neous pustules and bulla? opened and cauterized ; while the patient's 
strength is supported by tonic drinks and generous wine, diluted with 
gaseous water. M. Rayer is averse to blood-letting, either topical or 
general ; and, on the other hand, he has no opinion of the efficacy of 
bark, serpentaria, and other alleged tonic antiseptics. He gives a pre- 
ference to repeated purging, and the exhibition of large doses of acetate 
of ammonia. 

"Not more successful is the treatment of the acute glanders in 
horses. Marked, as the disease is, in both man and horse, by the 
same symptoms, and anatomical seat and changes, whatever remedy 






GLANDERS. 



is discovered to be serviceable in the one, may, with some degree of 
confidence, be relied on in the other; and, hence, we watch with 
interest, all the improvements, in this particular at least, of veteri- 
nary medicine. 

u Acute or button farcy differs from acute glanders, only, in the ab- 
sence of the nasal affection. The chief symptoms of acute farcy in 
man are the local inflammation, swelling of the lymphatic glands and 
3, and finally of the whole limb. Numerous small tumours 
extend, in lines, along the limbs, and terminate in suppuration or 
gangrene, whilst the inflamed cord-like lymphatics are seen extend- 
ing from one to the other. Abscesses form over the surface of the 
body and limbs; gangrenous patches occur here and there; and there 
is frequently attendant inflammation of the superficial veins. In every 
case, the peculiar pustular eruption, so characteristic in glanders, is 
observed. The post-mortem appearances correspond precisely with 
those seen in glanders. 

" Chronic glanders, in man, is described by M. Tardieu to be a 
disease resulting from the transmission of the glanders or farcy of the 
solipedes, characterized by peculiar ulcerations of the nasal fossae and 
air-passages, pains of the joints and muscles, general symptoms of 
cachexia, accompanied most commonly by farcy, and terminating in 
acute glanders or death. The patient complains, for some time, of 
weakness, prostration, acute pains in the limbs and joints, sometimes 
excessively painful pleurodynia, and cough, sore throat, and a trou- 
blesome stuffing of the nose. When the glanders is consecutive to 
the farcy, as is generally the case, after a period of two, four, six, or 
even ten months, during which the latter affection has undergone but 
slight changes, symptoms of disorder in the nasal fossae and air-pas- 
sages appear. In either case, the sore throat and cough generally 
precede the disturbance in the nasal fossa?. Pain is felt in the trachea, 
with a feeling of imminent suffocation, and alteration, and almost ex- 
tinction of the voice. These last symptoms sometimes disappear after 
a time ; there is then cough with dyspnoea, and a somewhat copious 
expectoration, which often is suppressed. Occasionally, the disorder 
of the respiratory apparatus is carried to the extent of (rue bronchitis 
or pneumonia, giving rise to considerable febrile reaction. The sen- 
sation of fulness in the nose increases, and breathing through it causes 
a perceptible snuffle. There is little or no pain of the nose, although 
sometimes patients complain in this way, and refer their distress espe- 
cially to the root of the nose, and between the eyes, and to the sinuses. 
At times, blood is blown from the nose in clots ; sometimes crusts are 
detached, or a simple grayish puriform mucus is discharged, which, 
in some rare cases, constitutes a regular flow. There may now be 
detected, on careful examination, ulcerations causing inequalities of 
surface, felt by a probe, or even perforations of the septum. In the 
mouth, similar inspection will reveal the existence, either in the pala- 
tine arch or in the pharynx, of ulcers, which we are allowed to infer 
extend to the larynx and trachea. Engorgement of the submaxillary 
glands is rarely met with. The skin is not affected with any erup- 
tion ; but it sometimes becomes cedematous at the hands and feet. To 
this list of special symptoms are sometimes joined the general ones, 
which are also met with in farcy, viz. : pains of the muscles and joints, 
diarrhoea, nausea, fever, with paroxysms at irregular intervals, sweats 
alternating with dryness of the skin ; the skin of an earthy and a sallow 
hue, emaciation, exhaustion, wakefulness, and all the symptoms of 
great cachexia. 

" But, in contrast with this picture, cases are seen in which there 
is no external character, except farcy, from the very beginning of the 
disease ; no pain, no discharge from the nose, and only a slight cough 
to indicate disturbance in the respiratory functions ; but yet autopsy 
will reveal lesions of the most serious and distinctive nature, either 
in the pituitary membrane or trachea, leaving no doubt of the real 
character of the disease. 

" The period of duration of chronic glanders is long, almost as much 
so as that of chronic farcy. Coming on after several months' duration 
of this latter, it may, in its turn, last as long. Commonly, however, 
chronic farcy-glanders runs its course in less time than that which 
occurs without farcy. In this latter state it may last for a period of 
six years. During this time the patient enjoys intervals of ease, but 
rarely is the health re-established even in appearance. The consti- 
tution, once compromised, rarely rallies entirely. As respects the 



mode of termination of chronic glanders, one case only of cure for- 
bids our seeing any other than that of death for the great majority of 
those unfortunate persons who are victims of the dis< 

" Chronic farcy, in man, is a morbid condition, produced by the 
transmission of glanders or farcy from the solipedes. It is distin- 
guished chiefly by numerous abscesses running into fistulous ulcers, 
specific angeioleucitis, and an entire change in the constitution; and 
it terminates commonly in acute glanders. Chronic farcy may exist 
alone or in conjunction with chronic glanders; but is of much more 
frequent occurrence than the latter. Of the 43 cases of contagion 
in man, in which the disease appeared in a chronic form, and which 
have been made public, 33 belong to farcy and its varieties. 

"In looking over an account of the symptoms of chronic farcy, we 
do not find that its invasion indicates the manner in which the con- 
tagion has been applied. More generally, however, local lesions 
follow immediate contagion, or the inoculation of the glanderous or 
farcinous matter, and then the disease is ushered in by symptoms of 
acute angeioleucitis or phlegmon ; but even in this respect there is 
no uniformity — the local lesions being sometimes wanting, although 
there had been inoculation. At onetime the disease makes its attack 
with violence — at another, its approach is quite insidious. After the 
common precursors of disease, such as languor, want of appetite, 
&c, symptoms resembling those of chronic rheumatism appear, and 
general weakness, without adequate cause, is complained of. In six 
weeks or so afterwards, numerous abscesses form rapidly, and, as it 
were, at one growth. Tumours make their appearance in a part 
already predisposed on account of a contusion or other local cause, 
and more frequently in the limbs than elsewhere. In a case of acute 
glanders, detailed by Mr. Denham, at Guy's Hospital, Mr. Morgan 
being the surgeon at the time, the patient, a carman, was attacked 
with glanders consequent to an injury of the left knee, by its being 
jammed between two barrels. This part continued to be the seat of 
such organic changes, as the formation of an abscess, during the whole 
course of the disease, which terminated about eighteen days after the 
injury to the knee. 

" Engorgements of the lymphatic glands in the groin and axilla 
are only observed as consecutive to local angeioleucitis, or to an ab- 
scess in an adjoining region. As new tumours form, they continue, 
after being opened, to distil a serous or ichorous matter, and are con- 
verted into indolent and ill-conditioned ulcers which cannot be healed. 
The more superficial bones in which these ulcers appear are denuded 
and become necrosed; the articulations are deformed, and lose all 
power of motion ; the skin is dry, and of an earthy hue ; the hair is 
matted on the temples ; the eyes are sunken ; the face of a yellow or 
a livid colour; the pulse small and irregular; repeated chills prelude 
a fever which returns every evening. The nights, during which the 
body is bathed in sweat, are passed without sleep, and sometimes in 
much dreaming, which precedes delirium. The appetite may last 
for some time, but an intractable diarrhoea supervenes, and completes 
the breaking down of the system. Sometimes a dry hacking cough 
harasses the patient, whose intellect finally becomes weakened ; and 
his body covered with ulcers, and all the springs of life nearly dried 
up, he falls into a state of frightful marasmus. 

" The duration of chronic farcy varies from four months to three years ; 
the mean period being from ten to fifteen months. Sometimes there is 
a deceitful remission and a seeming convalescence ; but a renewal of 
the symptoms is the signal for the persistence in disease, which com- 
monly has a fatal termination. Of 22 cases, collected by M. Tardieu, 
he knows but of 6 which have been cured ; and he asks whether, to 
a certainty, the restoration to health was permanent in all of the latter. 

" The seat of the abscesses in chronic farcy is for the most part in 
the extremities, and generally in the lower rather than the upper ones ; 
and in the vicinity of the joints. The matter of the abscesses varies 
in appearance ; sometimes it is sanguinolent or sanious, and sometimes 
purulent, or of a grayish colour, and viscous, — occasionally without 
odour, and again extremely fetid. Microscopical examination does 
not reveal any distinctive appearances. But, after all, the most im- 
portant consideration is the fact, that the matter of farcy abscesses 
has the property, when applied, by inoculation, to a healthy subject, 
of generating the disease, whether it be in a man or horse. 

"In the treatment of chronic glanders and farcy, we cannot place 



GLANDERS. 



441 



much reliance. More is to be expected from preventive measures 
against the disease being contracted; and, perhaps, a due appre- 
ciation of the early symptoms, or of the stage of incubation, even, 
may point out a course of remedies which, after the disease is fully 
formed, by the whole system being poisoned, will be of little avail. 
When there has been obvious inoculation, by the application of the 
glandered matter of a diseased horse, measures ought to be promptly 
adopted, similar to those after the bite of a rabid animal, viz. : abla- 
tion of the poisoned part, either by the knife, or by cauterization, and 
the use, afterwards, of stimulating washes, such as of chlorine water, 
strong solution of iodine, &c. In the early stage of the disease, ab- 
scesses, as they appear, ought to be opened, and either cauterized 
with heated iron or dressed with stimulating washes and ointments, 
and the healing process, which, in these cases, is very slow and diffi- 
cult, aided by compresses and moderate pressure. 

" The actual cautery is, and long has been, a favourite remedy in 
veterinary surgery, and its tried advantages, in the cure of glandered 
horses ought, even if direct clinical experience were wanting, to en- 
courage its use in the glandered human subject. 

"As an application to the diseased mucous membrane of the nose, 
creasote, recommended strongly by Dr. Elliotson, still enjoys the 
greatest reputation. He cured two cases of chronic glanders by in- 
jecting a watery solution of creasote up the nostrils. Mr. Ions, also, 
veterinary surgeon, in Waterford (Ireland), relates the cure of his own 
son, who had been, while yet suffering from a bad cold, and with a 
small sore on one of the alae nasi, poisoned with the glandered mat- 
ter, snorted in his face by a horse labouring under acute glanders. 
In two days afterwards there was a profuse discharge from the nostril, 
of a ropy, glairy appearance. Solution of nitrate of silver to the ulcer 
in the nose, and internal remedies were used without effect ; and at 
length creasote was employed by the medical attendants, at the urgent 
solicitation of Mr. Ions, sen., himself. The ointment was the pre- 
paration first used, but the slightest application produced the most 
dreadful pain, and in its stead Mr. Ions, who now took charge of the 
case himself, employed a solution of two minims of creasote in an 
ounce of water. 

" 'The disease had now assumed the most fearful character; there 
was profuse nasal discharge, accompanied by the most offensive smell, 
and ulcerations extending into, and seemingly occupying, the whole of 
the nasal cavities. There was great prostration of strength, cold per- 
spiration, pulse 112, laborious breathing, and every appearance of 
approaching death.' 

"The solution, as above, was injected 'as high up and as univer- 
sally' as possible, and its use repeated three times a day. ' I pledge 
my honour,' says Mr. Ion, 'that after the third injection a change 
almost magical took place. The discharge, in a great measure, ceased, 
and, two days afterwards, the ulcers began to assume a healthy ap- 
pearance, and have rapidly improved ever since.' The communi- 
cation was made Feb. 28th, 1839. The poisoning took place on the 
20th Jan. The ulcers had all lost their chancrous character, and 
were assuming a healthy granulating appearance. [Lancet, vol. ii., 
1 838-, pp. 111-15.) 

"Of the internal remedies, most stress has been laid on iodine and 
sulphur. M. Delaharpe recommends the ioduret of starch, with a 
slight excess of iodine ; and M. Andral used, in a case of farcy, re- 
ported as cured, the ioduretted iodide of potassium. M. Tardieu 
would prefer the tincture of the iodine, in doses increasing gradually 
from two to twenty drops. Thomson reports the successful use of this 
preparation in a case of chronic disease in the horse. Sulphur has long 
and generally been used in veterinary medicine in this disease ; exter- 
nally by vapour to the nostrils and by ointment to the ulcers, and in- 
ternally mixed with the food. In man, an advantageous method of 
employing it is in mineral waters, which should be drank freely, and 
applied externally as a wash to the ulcerous sores. As suggestive 
knowledge, it may be well to say that M. Youatt, although laying 
little stress on any curative plan for the disease in horses, tells us that 
blue vitriol and Spanish flies have held out the longest, among those 
which, at different times, enjoyed reputation in the disease in ques- 
tion. The deutiodide of copper has, also, he adds, been of great 
service in farcy, but it is not to be depended on in glanders. The 
tonic treatment, in all its details, should be carried out, and more 
111 



especially in the use of good substantial and nourishing food. Absti- 
nence, or any rigidness in diet must, in the present state of our know- 
ledge of this subject, be regarded as very prejudicial in any case of 
chronic glanders or farcy. Fresh and pure air are always to be in- 
cluded among the hygienic agents of a tonic nature, which can never 
be dispensed with; and if the change of climate, from a variable to 
a mild and equable temperature, can be procured for the patient, 
the probability of restoration will be increased. Pure air is relied on 
among the foremost remedial measures by scientific and experienced 
veterinary surgeons, in their treatment of glandered horses. 

" Where treatment is so uncertain in its results and so often of no 
avail, it becomes more imperative on us to adopt all possible measures 
of prophylaxis. Fortunately, the poison of glanders is not generated 
spontaneously in the human subject as it is in the solipedes, in which 
alone it originates, and from which originally the poison always pro- 
ceeds with which man and some other animals, as the cat and the 
dog, have become affected. The poison once developed in man is 
transmissible to other men, as well as to horses, by inoculation. The 
average susceptibility, as Dr. Graves has remarked, (Clinical Lec- 
tures, ut supra,) to the poison of glanders must be small, ' for grooms 
and veterinary surgeons take few or no precautions for examining the 
diseased animals, and yet the proportion infected, compared with the 
number exposed, is by no means considerable.' This writer tells us, 
however, that from the notices which he has been able to collect, it 
appears that glanders in man is of very frequent occurrence in Ireland ; 
so frequent, indeed, that he thinks the legislature called on to imitate 
the wise example of the Prussian government, in placing glandered 
horses under the surveillance of the police. M. Tardieu (p. 178) 
inserts the regulations of the French police on this point, which have 
been approved of by the Board of Health (conseil de salubrit'e). By • 
these, all persons are forbidden to sleep, or to allow grooms to sleep, 
in a stable in which there is a horse, even suspected to be glanderous. 
The like prohibition extends to sleeping in the stables used as infir- 
maries for sick horses, or in any place used for lodging sick animals 
of any kind. Those who are allowed to take charge of glandered 
horses, or of horses supposed to have the disease, or who have horse 
infirmaries, and who are desirous of watching their animals during 
the night, are enjoined so to contrive it that the room of the stable- 
keeper or groom shall not communicate with the stable, but that the 
supervision shall be made through a glass window." 

In the symptoms of eruption in glanders and farcy, there is no uni- 
formity. It is chiefly pustular, and of carbuncles resembling anthracion. 
I shall conclude by introducing a few cases of this terrible disease. 

Cases related by Dr. Graves [op. cit., pp. 314-19) : 

I. Communicated by Dr. McDonnell to Dr. Graves. — " Patrick 
Wallace, a healthy muscular man, aged twenty, was admitted into 
the Richmond Surgical Hospital on the 6th October, 1836. It was 
stated that he had been in care of a glandered horse — driving, clean- 
ing, &c. — and that he had been in the habit of drinking out of the 
vessel from which the horse drank. It appeared, also, that he had 
had an abrasion on one of his ears. On admission he had much of 
the appearance of a person labouring under cynanche tonsillaris; he 
could only open his mouth to the extent of half an inch ; this was the 
only uneasiness complained of. The left tonsil was very much en- 
larged, red, hard, and projecting towards the middle line ; no fluctu- 
ation could be felt ; there was a general fulness about the angle of 
the jaw, extending upwards nearly as far as the zygoma. The sub- 
maxillary gland on the same side was also enlarged and indurated. 
These symptoms had been ushered in by feverishness, a few days pre- 
vious to admission. He was ordered to have eight leeches to the 
throat, to be followed by a poultice, and a bolus composed of calomel 
and jalap. 

"Next day the external swelling was found to be increased ; greater 
difficulty of opening the mouth; the tonsil still hard and swollen. 
Twelve leeches were applied to the fauces, and the patient took the 
tartar emetic mixture of the hospital, with sulphate of magnesia. 

" On the 15th of October the disease is reported to be on the in- 
crease. Tonsil still hard, but no fluctuation; left side of the face 
greatly swollen ; eye of the same side nearly closed, from tumefac- 
tion of the lids; general inflammatory appearance over the cheeks, 
and great hardness of the tissues about the angle of the jaw of the 



142 



GLANDERS. 



same side, extending towards the chin; several circumscribed spots 
of redness, varying in extent from the size of a sixpence to that of a 
halfpenny, with irregular margins, scattered over different parts of the 
body ; two pustules observable on the left leg. 

" 16th. — A vesicle, containing a yellowish serum, observable on 
the left tonsil; the same inability of opening the mouth continues; 
increase of swelling over the left side of the face ; a small abscess 
has formed on the posterior part of the left forearm ; some delirium 
during the night; three evacuations from the bowels. The tonsil to 
be brushed over with a solution of nitrate of silver; a blister to the 
fauces ; the tartar emetic mixture to be continued. 

" 17th. — Some sleep during the night, interrupted by delirium of 
a low muttering character. Patient appears willing to answer ques- 
tions, but cannot, from obstruction in the mouth. This, however, 
lasts but for a moment, and he then lapses into a state of incoherency. 
Mouth open to the extent of half an inch ; left eye closed ; considera- 
ble swelling of the left side of the face, which is indurated, hot, 
tense, and shining; all the glands on both sides of the jaw, but par- 
ticularly on the left, are swollen and hard ; same state of tonsil ; nares 
dilated; breathing stertorous, somewhat hurried, about 28 in the 
minute, and interrupted by frequent sighs. Pulse very small, rapid, 
intermitted, and cannot be counted ; skin hot, tongue furred, teeth 
covered with sordes. He complains of great thirst, but says he feels 
no pain ; it is evident, however, that he feels great uneasiness in the 
joints and limbs when moved. There is, however, no swelling or 
redness of the joints; there is no discharge from the nostrils, nor is 
there any perceptible ulceration of the mucous membrane of the nose. 
No apparent affection of the absorbent glands in any other part of the 
body. 

"During this period, vesicles and pustules of various sizes, and at 
various stages of growth, had made their appearance on different parts 
of the body, particularly on the back. They varied in size, from the 
head of a pin to the section of an almond. In the first stage they re- 
sembled very minute vesicles, scarcely surrounded by any inflamma- 
tory border, and containing a limpid serum. In the second stage the 
serum was replaced by pus ; there was a considerable blush of redness 
around each pustule, which, at this period, became greatly increased 
in size. When one of the vesicles was punctured the serum appeared 
to come from a single cavity under the cuticle: this operation did not 
produce any subsidence of the tumour, a considerable hardness still 
remaining in the cutis or beneath it, with a cavity in the centre in 
which the -serum was contained. A number of achores existed in 
various parts, congregated together, and not much larger than the 
head of a pin. These clusters were surrounded by white raised mar- 
gins, having much the appearance of wheals, and about a line and a 
half or two lines in breadth ; between these margins and the achores 
there existed a line of redness. The whole taken together are rather 
of an oval shape. There also existed numerous inflammatory spots 
on the right shoulder, left arm, and other parts of the body. These 
were of a dark brown, approaching to a livid colour ; when pressure 
is made on them the colour disappears, but returns immediately when 
it is removed. On running the finger over them, a small hard tumour 
w r as felt in the centre ; the margins of these spots were irregular. 

"On the 17th the character of the disease became more plainly 
developed ; at three o'clock, P. M., pus, in considerable quantity, 
was observed to issue from both nostrils. The patient was ordered 
to take the solution of chlorate of soda internally, in drachm doses, 
three times a day ; and also a mixture composed of carbonate of am- 
monia, liquor a:theris oleosus, and camphor mixture. At five o'clock, 
P. M., he was found half out of bed, his head resting on the pillow ; 
still able to express his wants ; pulse not to be counted ; legs and feet 
cold ; breathing stertorous ; numerous stigmata scattered over the sur- 
face of the body. The purulent discharge from the nostrils had ceased, 
but there is a discharge of mucus from the mouth, with considerable 
fetor of breath. 

" 8 o'clock, P. M. — A copious perspiration has broken out over 
the body ; face red, tense, shining, and very much swelled ; swelling 
has now extended to the right side of the face ; right eye nearly closed; 
can open the left better ; a few pustules have made their appearance 
at the inner canthus of the eye. Pulse, tongue, and skin, as in last 
report ; delirium and muttering continue. 

" Died at 4 o'clock, A. M., October 18th. 



" On examining the body ten hours after death, the redness was 
found to have disappeared from the face ; the glands about the left 
angle of the lower jaw as before mentioned ; they were found matted 
to the surrounding parts. The cellular tissue covering the submax- 
illary and parotid glands was infiltrated with serum, and indurated; 
numerous depositions of pus were found in the tissue of the submax- 
illary and parotid glands. The brain was firm, but its ventricles con- 
tained a considerable quantity of fluid ; the arachnoid membrane was 
opaque in many places ; several patches of vascularity were observed 
on the pia mater. The lungs presented a congested appearance; 
numerous pustules were scattered over their surface — some separate, 
yellow in the centre, and surrounded by an ecchymosed border; others 
existing in clusters. They resembled, in every respect, those found 
on the surface of the body. The lining membrane of the larynx was 
very much inflamed, especially about its upper part and about the 
epiglottis. The inflamed parts, in this situation, were of a livid hue. 
There was some appearance of vesicles in the trachea, but this could 
not be satisfactorily ascertained. The bronchial tubes were filled with 
mucus. The stomach contained a quantity of yellowish-green mu- 
cus ; its lining membrane presented an ecchymosed and inflamed 
appearance. The liver was somewhat enlarged, and adhered, by its 
inferior margin, to a few folds of intestine. The periosteum did not 
exhibit any appreciable deviation from the normal state. 

" One of the chief things to be noticed in the foregoing case is the 
variety of inflammatory affections observed in the skin as the result 
of the introduction of an animal poison into the system. There was, 
in the first place, the general diffused redness of the face, then super- 
ficial inflammatory spots on the shoulders and arms, resembling ery- 
thema nodosum ; in the next place, scattered pustules, of various sizes, 
commencing in the form of a vesicle, which afterwards became a pus- 
tule surrounded by an inflammatory zone ; and, lastly, achores congre- 
gated together, and surrounded by an elevated white margin, within 
which there existed an inflammatory ring of a red colour. Another 
point worthy of notice, is the state of the lungs and bronchial mucous 
membrane. The lining membrane of the larynx, particularly in the 
vicinity of the epiglottis, was inflamed, and of a livid colour, and 
there was an indistinct appearance of vesicles in the trachea. But 
what was particularly deserving of note in the lungs, was the exist- 
ence of pustules on their surface, bearing the closest resemblance to 
those found on the surface of the body. It is not stated whether there 
was any appearance of vesicles or pustules in the nose, pharynx, or 
oesophagus, but we are told that the stomach was ecchymosed and 
inflamed. 

" II. The following case, says Dr. Graves, was witnessed by my- 
self and Dr. Halahan, and seems more nearly allied to the variety of 
glanders termed button farcy. I regret that want of time has pre- 
vented me from arranging its details in a form more worthy of your 
attention ; and were not the disease one of comparatively rare occur- 
rence, I should not have ventured to lay the case before you in its 
present imperfect state. 

" The subject of this case was a gentleman residing at Rathmines, 
an extensive proprietor of horses, and who, having originally graduated 
as a surgeon, exhibited much skill in the veterinary art. About the 
time of his illness he had had some horses in his establishment labouring 
under glanders and button farcy, to which he paid particular attention. 
After having laboured for some days under considerable lassitude and 
derangement of the stomach and bowels, he was attacked, on the 8th 
of July, with rigors, followed by great thirst, excessive heat of skin, 
and pains in his limbs. The moment he felt himself attacked in this 
way, he said he was sure that he had got some dangerous infection 
from the horses, and would never recover. He took some blue pill 
and colocynth, which produced a few dark and very fetid evacuations. 
On the 9th, his pulse was 94, his urine very high coloured, his thirst 
and feverish symptoms rather increased, and he suffered greatly from 
constant nausea and vomiting. A tumour now began to appear about 
three inches above the inner ankle of the right foot. He applied a 
poultice over it, but was obliged to remove it in a short time, in con- 
sequence of the pain occasioned by its weight. The tumour was about 
the size of half a walnut, of a dull red colour, tense, shining, and 
exquisitely painful. Its external aspect w r as peculiar, and might be 
compared to something intermediate between a boil and a spot of 
erythema nodosum. On the 10th, another tumour of the same cha- 



GLANDERS. 



443 



racter appeared near the outer ankle of the same leg ; and in this way 
the disease went on, tumour after tumour appearing on different parts 
of the body, with an increase of the feverish symptoms, until the 20th 
of July, when he was first seen by Dr. Halahan. At this time several 
tumours had appeared on different parts of his body; there was one 
of an extremely painful character on his head, and he complained of 
great tenderness and pain along the right clavicle. His thirst was 
still urgent, his restlessness excessive ; the slightest motion gave him 
exquisite pain, and sleep had completely abandoned him. He had 
endeavoured to regulate his bowels by purgative medicines, and had 
applied leeches to the tumours and to the clavicle at various times, 
but without any decided benefit. There were eight or nine tumours 
on different parts of the body, of the character before mentioned, with- 
out any tendency to suppuration, and so exquisitely painful that he 
could only bear a single sheet over him. The inflammation about 
the clavicle, which was of a diffuse character, had extended up the 
neck and over the right shoulder; there was not much swelling, ex- 
cept about the clavicle ; the colour of the affected parts was a peculiar 
dusty red. Immediately over the clavicle two vesicles were observ- 
able, filled with a transparent fluid. Three dozen leeches were ordered 
to be applied over the clavicle and shoulder, and the patient was di- 
rected to use chicken-broth, beef-tea, and other light nutritious articles. 

" On the 21st all symptoms are stated to be on the increase. His 
fever, thirst, and sleeplessness are undiminished ; his tongue furred 
and dry; his teeth covered with sordes; his pulse small, weak, and 
rapid ; his nausea and vomiting not so troublesome. He had received 
no benefit from the application of the leeches ; the swelling and stiff- 
ness of his neck were increased, and he had now some difficulty of 
swallowing. The erysipelatous surface of the neck, clavicle, and 
shoulder, were lightly brushed over with lunar caustic, which gave 
the patient an agreeable sensation, and from which he stated that he 
derived much relief. This was repeated the next day at his own 
request, and with equal benefit ; the difficulty of deglutition dimi- 
nished, and for two days he went on pretty well. On the 25th there 
was an evident increase of fever; the tumours over the body and 
limbs were increasing in size and number; and his anxiety, restless- 
ness, and sufferings unabated. He had taken alterative doses of 
calomel and James's powder, and his bowels had been regulated by 
mild aperients and enemata. I saw him for the first time on the 28th. 
His pulse was then 98, small, and easily compressed ; his thirst ex- 
cessive ; his restlessness and agony such as would strongly excite the 
pity of persons most conversant with scenes of human suffering. He 
had several tumours over different parts of his body, all exquisitely 
painful, and in their aspect something between boil and erythema 
nodosum. Some of them were hard to the touch; others, which ap- 
peared more advanced, were softer, and had a boggy feel. There 
was, however, no appearance of any thing like suppuration. He was 
ordered sulphate of quinine, chicken-broth, ale, and other light nour- 
ishment, and an opiate at night. On the 31st, a tumour appeared on 
the right side of his forehead, larger and more painful than any of the 
rest. Another of a similar character showed itself on the right cla- 
vicle, which had been previously affected. Shortly after their appear- 
ance vesicles were observable on their surfaces, such as generally 
precede mortification in cases of anthrax and malignant carbuncle. 
Next day he was evidently worse ; his pulse was 108 ; his fever, pain, 
and restlessness, unabated ; and a miliary eruption began to make its 
appearance over his chest and abdomen. The vesicles now began to 
increase on the surface of the tumour ; his fever and restlessness were 
aggravated ; and his mind, whicb had been hitherto collected, began 
to wander. His restlessness was so excessive that he could not remain 
for a moment in the same position ; and being a person of much me- 
chanical ingenuity, he had a set of pullies constructed and fastened 
to his bedstead, so that he could move himself in various directions. 
His medicines and diet, with the addition of claret, and opiates at 
night, were continued as before. 

" On the 6th of August he was still worse ; the tumour on the head 
continued to enlarge, and decided sloughing had taken place. The 
tumour on the clavicle presented the same aggravation in appearance 
and character, and a fresh tumour had appeared on the back of his 
head. A pustular eruption now began to make its appearance over 
his body, chiefly over the abdomen and limbs ; his symptoms became 



aggravated in every respect ; the delirium and watchfulness increased; 
and he died on the 10th of August, about thirty-three days from the 
commencement of the disease. He attributed his illness to attending 
horses, four of which had died of button farcy ; and what is also curious, 
his nephew, who had been also engaged about the diseased animals, 
had fever of a typhoid character, with petechia? of a larger sort than 
usual, but ultimately recovered." 

Case showing the transmission of the glanderous poison from man 
to the horse— related by M. Nonat. (Med. Chir. Rev., 1840.) 

" In February, 1839, a young man, 21 years of age, was admitted 
into the Hotel Dieu, under the care, of M. Nonat. He was in a state 
of great prostration of strength, and highly feverish ; his breathing 
was rapid and oppressed ; the skin was hot, the face flushed, the 
eyelids swollen, and the eyes themselves glazed. The right side of 
the forehead was red, painful and puffy ; further back there was a 
swelling on the scalp, which, when pressed upon, conveyed to the 
finger a sense of fluctuation. Other two abscesses existed; one on 
the right thigh, and the other on the left leg. Next day several pus- 
tules made their appearance on several parts of the body ; and now 7 , 
when the nostrils were compressed, a sanguineous frothy fluid ex- 
uded out. This pressure caused pain; and at the root of the nose 
the integuments began to exhibit a red and swollen appearance. 
During the night a purging came on, and the patient was excessively 
restless and uneasy. 

" On the following morning there was a drowsiness, which was 
speedily followed by a state of complete coma ; different portions of 
the scalp and face had become of a livid aspect ; other abscesses had 
made their appearance in various parts of the body, and there were 
fresh pustules on the arms, legs, and chest ; a thick yellowish-white 
discharge also oozed from both nostrils. All these symptoms con- 
tinued to increase until next day, when death took place. 

" Dissection. — The body was covered with pustules, which were 
depressed on the surface (affaisstes), without any redness at their 
base, and of a dull white aspect: some were ulcerated. 

"The alterations of the lymphatic system were in strict relation 
w T ith the pustular eruption on the surface. The ganglia, which were 
the most diseased, were those in the armpits and groins. 

" In addition to the abscesses noticed above, there were found 
many others in various states of maturity ; some having the appear- 
ance of diffused purulent collections, but the greater number being 
very similar to what are well known under the name of metastatic 
abscesses. The veins of the dura mater and the cells of the diploe 
presented many traces of marked inflammation. 

" The mucous membrane on the septum narium was swollen and 
highly injected with blood: here and there dark patches of ulcera- 
tion, and several pustules, also, were observed. On the floor of the 
nostrils the mucous membrane was found thickened, very much soft- 
ened, and covered with a gray-coloured detritus : the maxillary sinus 
was full of a yellowish viscid mucus. 

" On the surface of the lungs there were numerous ecchymosed 
spots; and imbedded within their parenchyma were several abscesses 
— under the form of circumscribed pulmonary haemorrhages, having 
a purulent infiltration in their centre. The largest of these were of 
the size of a walnut, the smallest of that of a hazelnut. 

" Remark. — It was with the matter taken from one of the abscesses 
of this patient that M. Boulay inoculated two horses: it was inserted 
at the margin of the nasal passages. 

" In one of them the acute form of the disease very quickly showed 
itself, and the animal died on the eighteenth day, after having exhi- 
bited all the usual symptoms of decided glanders. 

" The other horse lived for twenty-eight days, and then died very 
suddenly ; the immediate cause of death being certainly a rupture of 
the aorta ; although many of the symptoms of acute glanders had been 
manifested during life, and also some of the most pathognomonic 
traces of this disease also were discovered on dissection. 

" To add further weight to this conclusion — that the glanderous 
principle may be communicated from man to the horse, we may state 
that MM. Nonat and Bouley inserted some matter taken from one of 
the horses, which had been inoculated from their patient, into another 
horse, and that this last animal quickly sickened, and eventually died 
with all the symptoms of the genuine disease." — Revue Medicate. 



444 



GLANDERS. 



n exhibiting varieties assumed by the disease (Edinb. .Month. 
Joitni., June, 1841 . 

" Cask 1. — Report of a case, by J. B. Tytler, Esq. — Charles Higgs, 
a stout young cab-driver, was admitted into the Westminster Hospital 
on the 1 fit ti June, having been ill for live weeks, with severe rheu- 
matism, pains of the legs and arms, increased at night, but without 
redness or swelling of the joints ; the tongue furred in the centre ; 
pulse very frequent ; bowels rather confined. About three weeks ago 
he was bled and blistered, and felt some relief. He had three several 
abscesses in the lower extremities. He w T as treated by warm bathing, 
diaphoretics, and regulation of the bowels, and appeared to be making 
some progress toward recovery, until 23d June, when he complained 
of severe pain in the left leg, and swelling of the knee, with muscular 
pains of the chest unaccompanied by any marked constitutional symp- 
toms. Relief was obtained from mustard cataplasms to the knee, and 
he continued under the former treatment, without marked alteration, 
till the 29th. He complains of violent pain in the head, and has had 
a rigor, followed by heat and fever. Ordered eight leeches to the nape 
of the neck, and saline purgatives, with antimony, every six hours. 

" July 2d. He has again experienced some relief: the head has been 
shaved, and is easier ; some patches of inflammation appear on the 
scalp. Ordered to continue the saline purgatives. 

" 4th. An extensive but very flat carbuncle has formed on the 
vertex, and having been freely incised, is dressed with resinous oint- 
ment, and poulticed. There is considerable fever. 

" 5th. Another carbuncle has formed on the left eyebrow. The 
right eyelid and cheek are much swollen and cracked in several places, 
discharging an extremely fetid sanies. The scalp looks erysipelatous, 
and is dusted with flour, and covered with cotton wool. The pulse 
is quick and weak ; and the breathing hurried. He complains of sore 
throat. He takes wine and cinchona. 

" 6th. The throat is now extremely sore : the tongue, which had 
been usually pretty moist, is parched and red ; breath fetid ; some 
offensive discharge from the right nostril ; pulse very rapid and small. 
On examining the throat, many irregular yellow ulcerated patches are 
seen. Wine and bark continued. 

" 7th. A number of pustules have appeared on the arms and legs ; 
the throat is more ulcerated, and the right eye closed by the swelling ; 
the sanious discharge continues. He has fallen into a low muttering 
delirium. 

" 8th. All the symptoms are aggravated ; and his occupation having 
given rise to suspicions of glanders, which were confirmed by persons 
who had seen the disease in the human subject, his friends were 
minutely examined, and now acknowledged that not only had he been 
working about a glandered horse, but that a fellow-servant had died 
recently from the disease, by infection from the same animal. The 
horse also died. The patient himself died at 3 A. M. On exami- 
nation ten hours after death, the fauces were found coated with sanious 
matter, which had collected about the angle of the jaws, and flowed 
into the trachea and gullet. The palate and fauces, with the posterior 
nares, were sloughy ; a small ulcerated patch existed in the lining 
membrane of the trachea, just opposite the cricoid cartilage, and the 
larynx was generally much inflamed. The thoracic and abdominal 
viscera w r ere healthy; the brain was not examined. 

" This case seems to have lasted long, and, for forty-eight days, 
the symptoms were very ill defined. 

" Case 2. — Report of a case of glanders in the human subject, by 
.Alexander Graham, Esq. — J. S., a carter, aged seventeen, consulted 
me on the 2d February, 1840, about a pain he had felt for some days 
previous in the index finger of the right hand, which was swelled, and 
slightly inflamed. The skin covering the first phalanx was of a livid 
colour, and there was fluctuation underneath. He had a considerable 
degree of febrile irritation. On opening the finger, a very small 
quantity of thin grayish-coloured fluid escaped, without affording any 
relief from pain. The soft parts appeared dead, but no line of separa- 
tion was observable, nor indeed for many days after were there any 
symptoms of impending danger. He continued in nearly the same 
state till the evening of the fifth day from the time I first saw him, 
when the soft parts covering the first phalanx came off" during the 
dressing, leaving the bone exposed. On removing the bone, which 
was easily done, without causing the least pain to the patient, the part 
presented the appearance of a very healthy-looking sore, and the red- 



ness and swelling of the hand and finger entirely disappeared. On 
the following day, however, a new and more alarming train of phe- 
nomena presented themselves. During the preceding night, he expe- 
rienced a great tendency to rigors; there was increased pyrexia, and 
he complained of a pain over the spine of the left tibia, near its distal 
extremity. At this place there was a small circumscribed tumour, 
which was very painful to the touch. The integuments were slightly 
inflamed, and an obscure fluctuation was also observed. On interro- 
gating him and his friends closely regarding the sore on his finger, it 
was discovered that he had been driving a glandered horse, and that 
it was possible it might have been produced by his finger, which was 
scratched, coming into contact with the diseased animal. 

"On the eighth day the tumour over the spine of the tibia had nearly 
disappeared, but he experienced severe and constant pain from the 
site of the swelling along the inside of his leg, as far as the middle of 
the thigh, which was tense and swelled. He showed much restless- 
ness and anxiety ; his stools were of a darkish-green colour, thin, and 
fetid ; his tongue was loaded, and he had great thirst. The pulse was 
quick and small. 

" On the following day (the ninth) his finger appeared to be healing ; 
but he informed me that he had passed a very restless night, without 
sleep, and that the pain of his leg was more severe. The absorbents 
now became red and hard, and their course could be traced distinctly 
as far as the knee joint. The leg and thigh were more swelled, and 
the tumour was hardly perceptible. The pulse was 120, and small, 
the skin hot and dry, and the tongue very foul. 

" Next day I found the leg and thigh more swelled, and found it 
necessary to make several incisions on the inside of the leg. They 
did not bleed much, but nevertheless afforded the patient some relief. 
His bowels were open, and the stools were fetid. From this time he 
became gradually worse ; and on the evening of the day before that on 
which he died, (the twelfth,) when I visited him in company with a 
professional friend, we found a general tumefaction of the whole body, 
but mostly of the left side. His head and face were much enlarged, 
and, in addition to this increased swelling, there were all over his 
body and face several distinct and prominent pustules, resembling 
variola, none of which were visible the preceding day. The inside 
of the leg and thigh was also covered with a great number of gan- 
grenous spots, of irregular size and shape, ranging from the bulk of a 
split pea to that of a shilling, but without vesication, or the least 
appearance of separation. These gradually increased in size and 
number until he died, on the 13th February. 

" During the whole course of his disease, and even up to the very 
close of it, there was not the least manifestation of any disturbance in 
the sensorial functions." 

Case of acute glanders following a bite from a horse, and where 
new symptoms were seen, by M. Landouzy (Med. Gaz., 816). — "A 
vine-grower, fifteen days after buying a horse, in July, 1843, perceived 
that it was labouring under glanders. The disease was communicated 
to an ass living in the same stable. In order to make the horse take 
the drinks, the proprietor used to open his jaws with the help of a 
rope. One day the rope broke, and the jaws closing suddenly, he 
received a bite on his cheek. On the 20th of December, being two 
days after this, symptoms of acute glanders manifested themselves. A 
pustular eruption, abundant discharge from the nares, dyspnoea, dimi- 
nution of the respiratory murmur, abscesses, &c. ; and in addition to 
these symptoms, there appeared one that has not yet been described — 
opacity of the cornea. 

" The man died on the 2d of January. At the autopsy an abundant 
eruption was found on the thorax and the abdomen : the bronchi were 
covered by a miliary eruption ; the lung was filled with abscesses ; the 
liver and spleen were evidently increased in size ; in the intestines 
there was a miliary eruption above and below the caecum, and in the 
caecum seven ulcerations, a lesion that has not yet been mentioned. 
The principal features of interest which the case presents are, its inocu- 
lation by a bite, the opacity of the cornea, and the ulcerations of the 
caecum. 

"M. Barthelemy remarked, that the horse had been five months ill, 
and that, consequently, as the case was one of acute glanders, com- 
municated by a bite from an animal chronically diseased, the distinction 
which some persons had attempted to establish between acute and 
chronic glanders was not warranted." — Veterinarian, Sept. 1844. 



FORMULARY. 



BATHS. 

Baths ought to be prepared with soft or river water. A bath is 
generally taken at about blood heat, 97 of Fahrenheit ; but it may be 
prescribed at a lower or a higher temperature according to the indica- 
tions to be fulfilled. The time of remaining in a bath extends from 
half an hour to an hour or several hours. 



Acid Bath. 
Water .... 

Hydrochloric or sulphuric acid 

Alkaline Bath. 
Water .... 

Subcarbonate of potash 



Bath of Bran Water. 



Water 
Bran 



galls, xxx. 
Jii to j|iv. 



galls, xxx. 



galls, xxx. 
lbs. iv. 



Boil the bran in ten or twelve quarts of water for half an hour, pass the decoc- 
tion through a hair sieve with squeezing, and add it to the bath. 

Emollient Bath. 
Emollient herbs, (althea, marshmallow, elder flowers, 
parietaria, &c.) ..... lbs. iv. 

Linseed ...... Bss. 

Tie the linseed and herbs loosely in a cloth; boil them in 30 lbs. of water, 
express, and add the decoction to a tepid bath. 

Gelatinous Bath. 
Purified gelatine ..... !bi. 

Dissolve in lutts. of water, by boiling, and add the solution to a bath. 



Iodurated Baths, (Lugol.) 
Water ..... 

Add to this for baths of increasing strength. 





Iodine. 


No. 1. 


3ii. 


" 2. 


£llSS 


" 3. 


3111. 


" 4. 


3iv. 



galls, xxx. 



Ioduret of potassium. 
3iv. 
3v. 

3 V1 - 
3viii. 



Sublimate or Bichloride of Mercury Bath. 
Water ...... 

Bichloride of mercury .... 

This bath should be taken in a wooden bathing tub. 



Water 
Soap 



Soap Bath. 
Sulphureous Water Bath. 



galls, xxx. 
3" ^ Si- 



galls, xxx. 
Bi. 



Water .... . galls, xxx. 

Sulphuret of potash .... giv. 

With the addition of a pound of gelatine the gelatino-sulphureous bath, in such 
frequent use, is prepared, (a.) 



CATAPLASMS. 



Cataplasms are generally applied warm ; cool or cold they are some- 
times more effectual in relieving pruritus and subduing heat of skin. 

(a) See recipes for sulphureous washes, at p. 138. Also, imitation of Bareges 
water for bathinir, at p. 57. 
112 



Soothing Cataplasm. 
Cram of bread . . . . . Jiv. 

Milk ....... )bi. 

Bring to the boiling point over a slow fire, stirring the mixture. 
[The poultice made by pouring boiling water over a sufficient quantity of cram 
of bread, letting it stand for a few minutes, and then draining off the super- 
fluous moisture, is generally a much better application than the poultice of 
bread and milk.] 

Narcotic Emollient Cataplasm. 
Linseed ...... ^iv. 

Boiling decoction of poppyheads a sufficient quantity ; 

add of Extract of Hyoscyamus . . iji. 



Caustics or escharotics are in familiar use for the destruction of the 
skin and subcutaneous tissues when affected with disease, or for the 
purpose of changing the mode, the form, or the nature of an inflam- 
matory affection of the integuments. 

Burned Alum. 
Burned or desiccated alum is used in powder to a variety of ulcers of the skin ; 
the quantity employed varies with the extent of surface to be stimulated. It is 
either sprinkled upon the parts with the fingers, or dusted over them with a dossil 
of lint. 

Nitrate of Silver. 
The nitrate of silver melted and run into moulds is one of the caustics most 
frequently employed of all. The point of the caustic is dipped into water and 
applied to the part affected, during a longer or shorter space of lime, according to 
the effect intended to be produced. If the application have been lengthened, a 
thin grayish and superficial eschar is produced. When minute points of the 
skin only require to be touched with the caustic, the stick may be shapened like 
a black-lead pencil. 

Potassa Fusa. 
A piece of potassa fusa or of potassa cumcalce, weighing a grain, and about a 
line and a half in diameter, applied to the skin, will, in the course of from three 
to four hours, occasion a grayish eschar of about half an inch in diameter, impli- 
cating the whole substance of the skin. 

Muriate or Butter of Antimony. 
This caustic from being fluid has the advantage of penetrating readily into all 
the windings and inequalities of the sores or diseased surfaces to which it is 
applied. It causes eschars that are drier and better defined than those that result 
from the application of the potassa fusa. 

Acids. 
The concentrated mineral acids, the sulphuric, nitric and hydrochloric, are all 
used in the same manner. Applied pure, they occasion deep eschars ; diluted 
with water, they may be used to stimulate certain chronic inflammations. The 
concentrated mineral acids are frequently employed to cauterize malignant pus- 
tule in its early stages, warts, tubercles, &c. 

Acid Nitrate of Mercury. 
Nitric acid . . . . . . §i. 

Proto-nitrate of mercury 3i. 

This caustic is frequently and beneficially used in the treatment of certain 
ulcers. A piece of lint is dipped in the solution and applied to the affected sur- 
face, either continuously for as long a time as may be deemed necessary, <>v is 
simply dabbed repeatedly upon the part. If the object be to produce a deep 
eschar, a quantity of scraped lint is spread upon the part, and being then imbibed 
with the caustic solution, is kept in its place by means of a bandage. A single 
application of any caustic may suffice in some cases, several may be found ne- 
cessary in others. 



446 



FORMULARY. 



Arsenical Pasta, and Chlorwet of Zinc. 
(For these caustics vide sub. Powders.) 



Cerate of the Subacctate of Lead. 
Simple cerate . . . . . §i- 

[White wax one part, oil of .sweet almonds four parts; 
melt with a gentle heat, and as they are cooling stir 
in three parts of rose water.] 
Solution of subacetate <>t lead (Extract. Saturni) . 3i. 

Mix in a marble mortar. The quantity of the mineral solution may be vari- 
ously increased, an ounce being in some cases not too much. 

Cerate of the Acetate of Morphia. 
Cerate . . . • 3"i- 

Acetate of morphia ..... gr. iv. 

Dissolve the acetate in a little alcohol, and mix it well with the cerate. 



Sulphur Cerate. 
Cerate (without the addition of water) 
Sublimed sulphur 



3iv. 



DOUCHES. 



Douches, to their action of simple lotions, add percussion to a greater 
or less degree of the parts against which they are directed. The jet 
is either made to ascend or to descend. It is administered during 
ten, fifteen or twenty minutes. 'After the douche, patients are often 
directed to take a bath for half an hour. 



FOMENTATIONS. 



All the compounds employed as baths and douches may be used 
as fomentations. 

Cool or cold fomentations are usefully employed in several of the 
acute and chronic inflammations of the skin. 



Of the Subacctate of Lead. 
Water ..... 

Solut. of subacetate of lead, from 



3ii to §i. 



FUMIGATIONS. 

Fumigations or fumigating baths are prepared with substances sus- 
ceptible of being converted into vapour, which, by means of a suitable 
apparatus, is applied to the whole or to a portion only of the body. 

Of Calomel. 
Proto-chloride of mercury (calomel) . . gii. 

Of Cinnabar. 
Red sulphuret of mercury .... 3iss to 3iii. 

Local fumigations of this substance are readily applied by means of a hot tile 
and a funnel. 

Of Sulphur. 

Sulphur ...... 31V to gi. 

LINIMENTS. 
Mercurial. 
Olive oil ...... |i. 

Liquor of ammonia gi. 

Strong mercurial ointment . . . 3b. 

Useful in the treatment of the syphilitic eruptions. 

Chlorine. 
Water saturated with chlorine 3L 

Oil of sweet almonds .... gi. 

I feed to disperse the dark stains consecutive on syphilitic pustules, tubercles, &c. 

Hydrochloric Acid. 
Balsam of Fioravanti . . . . giv. 

[Alcohol distilled over a host of aromatics ; cloves, cinna- 
mon, nutmeg, styrax balsam, Venice turpentine, &c, 
&c. Eau de Cologne or proof spirit with a drop or two 
of any essential oil, may be substituted for it.] 
Hydrochloric (muriatic) acid . . . gtts. xxxii. 

Useful in recent and unexcoriated chilblains. The parts affected are rubbed 
night and morning with a little of the mixture. 



As lotions, plain water, and decoctions or infusions of various 
emollient, narcotic and astringent vegetables are employed. Cool or 
cold they are very useful in a great variety of acute arid chronic in- 
flammations of the integuments. 



Spirituous Mercurial. 
Rose water ...... Ibi. 

K;iu de Cologne £i, 

bichloride of mercury (corrosive sublimate) . grs. viii. 

Very useful in old cases of rosacea. The quantity of bichloride may be in- 
creased till it amounts to 3ss. 

Mercurial 

Almond emulsion ..... Ibi. 

Bichloride of mercury .... grs. xii. 

Eau de Cologne . . . • • |i. 

This is similar to but not so active as the Gowland's lotion. 

Phagedenic Mercurial. 
Bichloride of mercury .... grs. xxx. 

Lime water ..... Ibi. 

The corrosive sublimate is decomposed, a chlorate of lime or chloride of calcium, 
and an oxide of mercury being formed ; it should always be well shaken before 
being used. 

Mercurial. 
Rose water ...... Jiiss. 

Mercurial water of the codex, [a compound of the liquor 
of subacetate of lead, alum, corrosive sublimate, sal 
ammoniac, and water] . . . . |ss. 

Used to destroy pediculi pubis. 

Sulphate of Copper. 
Sulphate of copper . . . • • 3SS to 3L 

Distilled water . . • • • Ibi. 

Hydrocyanic. 
Distilled water of the lettuce . . . tbsii. 

Medicinal prussic acid . . • • 3 U t0 3> v - 

Used in impetigo and ulcerated cancer. 



Asiatic, (Arsenical.) 
English. 
Arsenious acid . . 55 grs. troy 

Powdered black pepper 9 drachms 

Gum Arabic . . q. s. 

Water . q. s. 



French. 
66 grs. 

9 drs. (gros.) 

2 drs. 

q. s. 



aa 3i. 
q. s. 



The arsenious acid and black pepper powder are triturated for a long time 
together in an iron mortar. The gum Arabic is then added, and in a marble 
mortar, water is added in sufficient quantity to make a mass which is divided 
into 800 pills. 

These pills contain nearly 1-1 4th of a grain English, of arsenious acid in each. 

Arsenical. 
Arsenious acid . . . . • 1 gr. 

Gum Arabic and mucilage, q. s. to make 12 pills. 
The dose is one a day for adults. 

Plummerh Pills, (Mercurial.) 

Protochloride of mercury, (calomel) 

Golden sulphuret of antimony 

Mucilage .... 
Make pills of 3 grs. each. 
The recipes for these pills vary. 

Of Dulcamara and Sulphuret of Antimony. 
Extract of dulcamara .... ftss. 

Sulphuret of antimony .... 3ii. 

Powder of dulcamara . . . . q. s. 

To form a mass to be divided into pills weighing 4 grs. each. 
These pills are the same as those denominated Kunckel's, in all but the addition 
of the powder of dulcamara. They vary in their effects with the sulphuret of 
antimony with which they are prepared, and the quantity of arsenic it contains. 

Of Dulcamara and Arsenic. 
Extract of dulcamara .... 31- 

Arsenious acid . . . . . gr. i. 

Mix and make eighteen pills. 
Dose, one daily. 

Of Protochloride of Mercury, (Calomel.) 
Protochloride of mercury, (calomel) . . 3*- 

Gum guaiacum . . . . 3ii. 

Syrup of buckthorn . . . . q- s. 

Make into seventy pills. 

Two for a dose, night and morning, drinking a glass of infusion of hops after 
each dose, and taking a purgative draught occasionally. 



Of Protoioduret of Mercury. 

Protoioduret of mercury 

Gum guaiacum .... 

Starch and mucilage 
To make six pills. 
Dose, one a day. 



gr. 11. 
gr. xii. 

q. s. 



FORMULARY. 



447 



OfSedillot, (Mercurial.) 

Strong mercurial ointment .... 

Spanish soap ..... 

Allium root and mucilage .... 
To make 36 pills, weighing 4 grs. each. 
Dose, two or three a day. 

Of Mercurial Ointment and Opium. 
Mercurial ointment ..... 
Extract of opium ..... 
Powder of althea root _ . . 

Syrup . • • 

To make 72 pills, each containing a grain of mercury, and half a grain of 
watery extract of opium. 

Dose, same as Sedillot's pills, and may be substituted for these advantageously 
in the syphilides which are accompanied with nocturnal pains in the bones and 
joints. 



3i- 
9ii. 

q. s. 



gu. 
gss. 

3"}- 

q. s. 



• 3i- («) 

gr. xv. 

gtts. x. 



3> 



UNGUENTS. 

Alkaline. 
Slaked quick lime ) 
Subcarbonate of soda J 
Watery extract of opium 
Lard . 

Essence of bergamot 
Prescribed in prurigo. 

Strong Mercurial. 
Lird ) 

Mercury ' '. '. J ec * ual P arts b y wei S ht 
Rub till the mercury is extinguished. 

Of the Protochloride of Mercury, (Calomel.) 
Calomel ...... 

Lard ...... 

tJsed in various pustular and squamous inflammations of the skin. 

Of the Ammoniacal Protochloride of Mercury. 
Ammon. pr. chlor. of mere. . . . 3L 

Lard ...... gii. 

Prescribed in Rosacea and Sycosis, when the inflammation is no longer acute. 

Of the Proto-chloride of Mercury and Sulphur. 

Lard ...... gi. 

Calomel ...... 3L 

Sublimed sulphur ..... giss. 

Essence of bergamot .... gtts. x. 

Of the Cyanuret of Mercury. 
Cyanuret of mercury .... gss. 

Lard . 3"i. 

Ess. of bergam. ..... gtts. x. 

Used in chronic lichen and eczema in quantities of half a drachm, gradually 
increased. 

Of the Protoioduret of Mercury. 
Protoiod. of mere. gr. xx. 

Lard ...... gi. 

Ess. of bergam. ..... gtts. x. 

This salve expedites the cicatrization of cutaneous syphilitic sores. The quan- 
tity of the protoioduret should be increased or diminished, according to its effects, 
and as the parts are inflamed in a greater or less degree. 

Of the Deutoioduret of Mercury. 
Deuto-iod. of mer. .... 

Lard ...... 

For the discussion of tubercles and syphilitic ulcers. 

Of the Ioduret of Sulphur. 
Ioduret of sulphur ..... 

Lard ...... 

Dose, a scrapie by way of friction. 

Of the Nitrate of Mercury. 

Nitrate of mercury ..... 
Spermaceti ointment .... 

Used in prurigo, sycosis, &c. (b) 

Of the Sub-deutosulphate of Mercury. 
Sub-deutosulph. of mere, (turpefh mineral) 
Lard ..... 

Ess. of bergamot ..... 
Useful in inveterate psoriasis. 

(a) Of anthrokokali, and of fuligokali, see pp. 301-2. 

(b) See formula; of various anti-pruriginous ointments in note to p. 231. 



gr. vi to xn. 
5i- 



gr. 111. 
Si- 



9i- 
§i- 



grs. xxx. 

Si- 

jrtts. x. 



giii. 

3111. 

aa ^iss. 



Of the Red Oxide of Mercury. 
Fresh butter .... 

White wax melted 
Red ox. of mere, (red precipitate) 
Camphor 
Used in Rosacea. 

Of the Bichloride of Mercury. 
Lard ...... 31. 

Bichlor. of mercury (corrosive sublimate) . 31. 

Rub them well together in a glass mortar for six hours : and during the last 
hour add of hydrochlorate of ammonia . . grs. x. 

Used in the way of friction, in doses of a drachm, to the soles of the feet. 

'Of Pitch or Tar. 
Pitch melted by means of heat ) 
Lard, also melted . . ) 

Mix and pass through a piece of fine rag. (a) 



aagi. 



Of the Subacetate of Lead. 
Liquor of the subacetate of lead 
Olive oil . 

Yellow wax .... 

Camphor ..... 



3ii. 

§"ss. 
gr. x. 



Of the Subcarbonate of Potash and Sulphur, (Helmerich's ointment.) 
Lard . . . . . gi. 

Sublimed sulphur . . . , . 3H. 

Sub-carbonate of potash . . . . 3i. 

Use. In scabies, in the dose of an ounce in friction daily. (6) 



Olive oil 
White wax 
Spermaceti . 
Used in chaps of the lips, &c. 



Of Spermaceti. 



3iv. 

§i- 

3ii. 



Of White Hellebore. 
Powder of white hellebore . . . 3L 

Hydrochlorate of ammonia . . . 9i. 

Lard ...... ^i. 

Used as a stimulant in various chronic diseases of the skin, such as inveterate 
psoriasis, lepra, &c. (c) 



Of Cacao Butter. 






Cacao butter .... 
Oil of sweet almonds 
Mucilage of quince seeds . 
Used in chapping of the nipples, &c. 


Jss. 

3"- 
3ii. 




Of Oxide of Zinc. 
Oxide of zinc .... 
Lard ..... 


3i. 
|vi. 


00 


Depilatory. 
Lard ..... 
Sub-carb. of Soda of commerce 
Slaked quick lime 
Used in favus. 


gii. 

3m. 
3ii. 




POWDERS. 







Of the Sulphur et of Antimony. 
Sulphuret of antimony j .._ 

Sugar . . ) . & 

To be divided into twelve doses. The effects of the medicine vary according 
as the sulphuret of antimony contains a larger or smaller proportion of arsenic. 

Of Calomel and Arsenious Acid. 
Calomel prepared by sublimation . . . 199 parts. 

Arsenious acid ..... 1 part. 

Use. In ulcerated lupus and cancer. 



(a) In note to p. 237, see formula for naphthaline ointment. 

(fc) See also note to p. 138. 

(c) The following is advantageously used to stimulate sebaceous secretion: 
Elderflower ointment .... gi. 

White of egg ..... 3L 

Croton oil . . . . . TT[x. 

To be used night and morning. 

(r/) Sulphuret of Copper and Zinc. 
Elder flower ointment . . . . ^i. 

Sulphate of copper or zinc . . . J)i. 

To be used twice or thrice in the day. 
Useful in sebaceous flux. 



448 



FORMULARY. 



O/Sulphurct of Lime. (Of Pyhorcl.) 
Sulphuret oflime ..... 3Ji. 

Rubbed on the palms of the hands with a little oil, in scabies 
The sulphurets of potash and soda may be used in the same manner. 

Depilatory. 

Lime ...... %i. 

Sub-carb. of potash of commerce . . . §ii. 

Charcoal powder ..... 3i. 

1 in favus. 

Depilatory ofPlenck, of (lie Sulphuret of Arsenic. 
Quicklime ..... §iss. 

Starch ...... 3x. 

Sulphuret of Arsenic . . . . 3i- 

It is made into a soft paste with water, and applied to the parts to be denuded. 

Of the Hydrochlorate of Gold. 
Hydro-chlor. of gold and soda gr. i. 

Powder of lycopodium .... gr. ii. 

To be divided into fifteen parts, and one used daily, being rubbed on the tongue 
and gums in syphilis. The dose to be gradually increased. The preparation 
exposed to the air is rapidly decomposed. It is also given in the shape of pills, 
each containing 1-loth of a grain. 

Of Sulphuret of Mercury and White Oxide of Arsenic (of Rousselot) . 



Sulphuret of Mercury 
White oxide of Arsenic 
Dragon's blood 



Arsenical of Dubois. 



White oxide of arsenic 
Dutch vermilion 
Dragon's blood 



Si- 

3ss. 

3 SS - 



3ss. 

Ii- 

3iv. 



A little of this powder is made into a thick paste with water or mucilage, and 
applied to the surface of open cancers, freed from incrustations. 

Arsenical ofFrb'e Come. 
Arsenious acid . . . . . gr. x. 

Cinnabar ...... Qii. 

Charcoal of an old shoe .... a pinch. 

Applied in the same way as the last. It must be used very cautiously, and 
only to limited portions of the ulcerated surface at the time. 

Of Chloride of Zinc. 
Chloride of Zinc ..... 1 part. 

Flour ...... 3 parts. 

Use. Same as the arsenical powders. It must be very slightly moistened, and 
left to attract moisture from the atmosphere for some time before it is applied. 

SYRUPS. 



Compound of Sarsaparilla (of Larrey) . 

Sarsaparilla . 

Dried elder berries 

Guaiacum 

China-china 

Sassafras 

Senna leaves 

Borrage 

Sugar 

Water 
Mix and add to each pound of syrup 

Watery extract of opium 

Bichloride of mercury 

Hydrochlorate of ammonia 
Used in syphilis. Dose, one or two tablespoonfuls daily 
The following is the formula used in the Hospitals of Paris : 

Bichloride of mercury ' 

Hydrochl. of ammon 

Extract of opium 

Hoffman's anodyne liquor 

Syrup of sarsaparilla 



fti. 

ibss. 

§iv- 

aa gii. 

aa Jss. 

ftvi. 
q. s. 

aa grs. v. 



aa grs. xx. 



311. 
ftiv. 



Of Mercurial Ethei\ 
Simple syrup ..... fti. 

Mercurial ether (sulphur, ether, ifi. Corros. sublim. grs. 
xvi.) ...... §i. 

Used in syphilis. Dose, from one to four drops daily. 

Antisyphilitic of Laffecteur. 



Sarsaparilla .... 


fti. 


Guaiacum ) 




China-china > . . . 


aa ft. vi. 


Sassafras ) 




Yellow cinchona bark 


ftiii. 


Borrage flowers 


fti. 


Anise seeds .... 


giv. 

Bs. xxx 


Purified molasses . 



A simple compound decoction is first to be made with a sufficient quantity of 
water, after maceration for forty-eight hours. Add the molasses at last, and bring 
the decoction to the consistence of syrup. («) 

Of Fumitory. 
Expressed juice of fumitory, depurated by heat . Ibii. 

White sugar . . . . Ibii. 

Make a syrup. 

Of wild Pansy. 
Expressed juice of the leaves, depurated . . Ibii. 

White sugar ... . . ftii. 

Make a syrup. 

SOLUTIONS. 
Of Arscnite of Potash (Fowler's Solution). 
Protoxide of arsenic, in powder \ 
Subcarbonate of potash 

Distilled water . . jfiv. 

Digest in a sand bath in a flask, till the oxide is dissolved. When cold, add 
two drachms of the compound spirit of lavender, and a sufficiency of water to 
bring the whole to a pound. A very active medicine, to be used with great dis- 
cretion; five or six drops gradually increased to twenty. 

Of Arseniate of Soda (Pearson's solution). 

Arsen. of soda 

Distilled water 
Dose, twenty drops to half a drachm, daily. 
Used in chronic eczema, lichen agrius, fyc. 



aa 32 grs. 



gr. iv. 
|iv. 



Of Arseniate of Ammonia. 
Arseniate of ammonia .... gr. vi. 

Distilled water . . . . ftss. 

Used in chronic eczema with discharge, but little inflammation. Dose, same 
as last formula. 

Of the Bichloride of Mercury (of Van Swieten). 
Bichl. of mercury ..... gr. viii. 

Alcohol . ... . . . 3i. 

Distilled water ..... fti. 

Dose, a tablespoonful daily in a glass of water, or of milk, or of decoction of 
sarsaparilla. 

Of Subcarbonate of Potash. 
Subcarb. of potash ..... grs. xxiv. 

Decoction of dogs-tooth grass . . . Ibii. 

The dose of subcarb. of potash may be carried the length of half a drachm. 

TINCTURES. 

Of Camphorated Cantharides, 
Tinct. of cantharides .... giv. 

Camphor ...... gi. 

Dose, 4, 6, 8, 10, 15, 20, and 30 drops gradually increased. This acts less 
powerfully on the urinary organs than the common tincture. 

TISANS. 

Of Daphne Mezereum and Sarsaparilla. 
Sarsaparilla root . . ». . . ^ii. 

Bark of the mezereon root . . . . 3i to 3ii. 

Boil in three quarts of water till a third is wasted; add near the end, 
Coriander seeds ' 
Liquorice root. 

Of Ormus Pyramidalis. 
Bark of ormus pyram. . . . . %i. 

Water ...... ftiiss. 

Reduce to ftii. by boiling. 

Of Muriatic Acid. 
Water ...... ftii. 

Simple syrup . . . . ^ii. 

Muriatic acid q. s. to make the liquor pleasantly acid. 

Of Sulphuric Acid. 

Water ...... ftii. 

Sulphuric acid ..... 3SS. 

White sugar ... . gii. 

Essential oil of lemon peel .... gtts. ii. 

The mixture is more energetic without the sugar. 

(a) M. Gibert has lately directed the attention of the Academy of Medicine to 
a formula which he terms syrup of ioduretted deutoioduret of mercury (sirop de 
deuto-iodure-iodure) . The formula for this syrup is the following : — 

Deutoioduret of mercury .... 1 part 

Ioduret of potassium .... 50 parts. 

Water 50 " 

Dissolve, filter, and add of simple syrup . . 2400 " 

The average dose is from four to six drachms. 



aa 3i. 



FORMULARY. 



449 



Of Sarsaparitta. 



3"- 
ftiiss. 



Sarsaparilla root . • 

Macerate for twelve hours in 

water • • 

Which are reduced to ffisii. by boiling. 

Of Sarsaparilla and Sulphuret of Antimony (Tisari de Feltz). 
Root of sarsaparilla 3"i- 

Sulphuret of antimony (tied up in a bag) . gl. 

Isinglass . • • . •. .• 3 1V - 

Boil the sarsaparilla and sulphuret of antimony m a pint and a hall ot water ; 
add the isinglass already dissolved in a little water ; reduce to a pint by boiling, 
which the patient will take during the course of the day. 



Of Sarsaparilla and Arseniovs Acid. 

Tisan of sarsaparilla .... 

Arsenious acid ... 

Used in the same way as the last. 

Compound of Sarsaparilla (Tis. de Vinache). 



teii. 

gr. l-16th. 



3»- 



Sulphuret of antimony 

Sarsaparilla . 

China-china . 

Guaiacum 

Sassafras 

Senna leaves 

Tie up the sulphuret of antimony in a bag; boil with the three first articles in 
three quarts of water. When reduced to a third, add the senna and sassafras, 
which are only to be infused. W T hen cold, decant and allow to settle. 



aa 3*iiss. 
aa §ss. 



Of Walnut husks, Sarsaparilla, <$r., (of Pollini) 
Green walnut husks 
Sarsaparilla . 
China-china . 



aa 3SS. 



Pumice stone pulverized 

Sulphuret of antimony 
Boil in two quarts of water till reduced to one half. 
Dose, a spoonful every hour. 

Of Sarsaparilla, Alum, Senna, fyc. (Decoction of Zittman.) 
[A purgative compound decoction of sarsaparilla, which has been vaunted in 
syphilitic complaints] . 

• Zittman 's Decoction modified. 



No. 1. 

Sarsaparilla . 
Liquorice root 
Senna leaves 
Anise seeds . 
Sulphate of alumina 
Calomel 



3x11. 

§iss. 
3 m. 
5ss. 
31SS. 
|ss. 



Boiled in a sufficient quantity of water to fill sixteen bottles after the decoction 
is complete. 
No. 2. Residue of the above. 

Sarsaparilla . 

Liquorice root 

Cinnamon 

Lemon-peel . 

Cardamom seeds 
After decoction, fill sixteen bottles, (a) 



3m. 
oiii- 
giii. 



(a) For an enumeration of remedies in chronic cutaneous diseases, see "Pre- 
liminary Considerations" by the author from p. 32 to 65, and " outlines &c," by 
the editor, p. 56 to 58. 



113 



EXANTHEMATA. 



The exanthemata are characterized, when at their height, by red spots or surfaces, which disappear for a short time under the 
pressure of the finger. There are seven of them, viz :— measles, scarlet rash, scarlet fever, erysipelas, erythema, urticaria and the 
syphilitic exantheme. 

FIRST GROUP. 

This comprises the febrile exanthemata — rubeola, roseola, scarlatina and erysipelas. 

Rubeola (or measles) is characterized by blotches, sometimes slightly elevated, developed on the skin, leaving the interspaces 
of a natural colour, or presenting a faint blush. The form of these blotches is occasionally irregularly lunated. The eyes are 
generally red and filled with tears. 

In Roseola (or scarlet rash) there is less fever ; the spots are large and round or oval, and there is no injection of the conjunctivas. 

Scarlatina presents a scarlet-red or strawberry-coloured eruption, diffused and consisting of small dots close together. The 
tongue, towards the last, sheds its epithelium, and is of a vivid red. Sore throat most frequently attends, but the eyes are not injected. 

Erysipelas shows itself on various parts of the body by a violet or yellowish-red, in patches slightly swelled. It is often confined 
to one side. There is neither sore throat nor redness of the eyes. 

PLATE I. 

Fig. 1. — Roseola, or scarlet rash, developed on the face and body of an infant. 

Fig. 2. — Rubeola, or measles, in its ordinary form. 

Fig. 3. — Measles, attended with extravasation of blood in the cutis, called rubeola hemorrhagica. This appearance is observed 

under two circumstances : — 1st, in severe cases of common measles attended with congestion ; 2d, in malignant cases, 

attended with hemorrhage from the mucous membranes. 
Fig. 4. — Appearance presented by the decline of hemorrhagic rubeola, in which the petechias are left, (tenth day.) 
Fig. 5. — Eruption of scarlatina, with small white points on the neck. 

Fig. 6. — Sanguineous effusion into the skin in scarlet fever, constituting scarlatina hemorrhagica. 
Fig. 7. — The appearance presented by the tongue in scarlet fever. 



EXANTHEMATA. 



PLATE II. 



Fig. I.— Erysipelas of the face, with oedema of the eyelids in an old subject. The diffuse redness of erysipelas is easily distin- 
guished from the spotted appearance of other eruptions. 
Fig. 2. — Bullse and vesicles developed on an erysipelatous surface. They are seldom, numerous. 

SECOND GKOUP. 

The second group comprises the exanthemata which are seldom preceded or accompanied by a febrile movement. It is composed 
of Erythema and Urticaria. 

Fig. 3. — Rheumatic erythema. This variety is sometimes preceded by fever, and has been described as rheumatic roseola 

and eruptive rheumatic fever. 
Fig. 4. — Erythema nodosum. A very painful variety involving the cellular tissue. 
Fig. 5. — Erythema papulosa. This variety resembles lichen urticatus, but is distinguished by the colour and the absence of 

itching. 
Fig. 6.— Erythema annulala. This may be confounded with lepra with the scales rubbed off; but, besides other distinguishing 
traits, litis disappears in a week or two. 



OLA 



RUBEOLA. SCARLATINA 



PL 1 



jseols 



2 




gfc 








t 



Af 



i 



| 







3 ft 4 

limb..- ;tfeira 



■HjrTtatiiraa 









wsaun 






..-.ijfaljLith ' 



ERYSIPELAS , ERYTHEMA. 



PI. II 



3. Bjaewmatic Erythema. 



icles o: 
Erysipelas , 






I- .mswrn, 



5 . ErvlIThieiinia. "pawul<E>sa 



6. ExTflkenniiia 














EXANTHEMATA. 



PLATE III. 

Fig. 1. — Erythema iris. A rare variety resembling herpes iris, but wanting the vesicles. 

Fig. 2. — Chronic erythema. Distinguished by red spots, superficial, irregular at the margins and destitute of heat or itching. 

Fig. 3. — Urticaria (nettle rash). On the face. 

Fig. 4. — Urticaria alba (porcelaine). White prominent wheals, like the cuts of a whip. 

BULLJ. 

Bullae are large elevations of the cuticle distended by a serous, or sero-purulent fluid. 
The First Group of Bullae comprises Pemphigus, Rupia and Bullar Syphilis. 

Pig, 5. — Pemphigus. The bulke discreet and scattered irregularly. This is the most frequent variety. Observe the bulla? 
but slightly inflamed and the lamellated crusts which take their places when they are broken. 

Fig. 6. — Pemphigus in groups, forming a sort of transition or intermediate link between it and herpes. 

Fig. 7. — «/2 large bulla. Occasionally seen distended with a milky fluid ; the skin is much inflamed. 



114 



BULL^. 



PLATE IV. 

Fig. 1. — Pemphigus pruriginosus. A rare variety, distinguished by small bullae, mixed with the papulae of prurigo. 

Fig. 2. — Pemj)higus infantilis. Often attended with white ulcerations, and forming a link between pemphigus and rupia. 

Fig. 3. — Scabs of pemphigus, left after the breaking of the bullae. 

Fig. 4. — Rupia simplex. Ulcerations and scabs surrounded by a kind of ring formed of the detached epidermis 

Fig. 5. — Rupia prominens. Elevated conical scabs, surrounded with pus. 

Fig. 6. — Rupia cachectica. Bullae sanguinolent, scabs black, and shaped like a shell. 

Fig. 7. — Rupia gangrenosa. A deep slough with a livid tint of the surrounding skin. 



PEMPHIGUS. — RUPIA 



PI. IV 



1. :!>rnph«4«» prur»t' MmslJS ' 



4. Rnpia simplex 






* 
# * 






t> 








S. Crusts <n>f ii'i 







5. M.tu 








6 . Mmpia Cacledica . 



7. Rupia Ctiiifcrciiosa. 



« ';■ Starts by S Daxre. 



P/UlaeULpkia Fublished by farey i-Hart 



P 5 Duval. Lith r\W 



HEBPJES 



ri.v. 



rpea Zoster on face 



2. Herpes Zoster (Shingles ) 





5, H Zoster in the inpiatumtlh , 




4. H. Zoster. 3. 





7. Herpes Urns . 



6.H. Zosteir ©t Suma 













% 



(M Stone by A Jfiwsam- 



ThtladelpTua., Fublishjed 7>jr Care.}' &Xart. 



rSJ}u-val,XUA J'KU ' 



YE SICULjE. 



Vesicles are small elevations of the cuticle, filled with serosity, at first transparent, afterwards becoming muddy or sero-purulent 
previous to desiccation ; and they comprise, Herpes, Miliaria, Sudamina, Itch, Eczema, Mercurial Eczema and Vesicular 
Svphilis. 

The vesicles of Herpes are developed in groups on a red ground, and terminate in little scales or crusts. 

The vesicles of Sudamina are minute, and resemble drops of water. 

The vesicles of Miliaria are red or white, minute and mixed with papulae, accompanied by fever and profuse sweating. 



PLATE V. 



Fig. 1. — Herpes zoster, on the face ; this variety almost always extends upon the scalp. 

Fig 2. — Herpes zoster, on the body (shingles), at the commencement. 

Fig. 3 and 4. — Consecutive ulcerations, and 4th, cicatrices following zona, fig. 6. 

Fig. 5. — Herpes zoster, extending from the face into the month. 

Fig. 6. — Zona. Herpes zoster of the trunk, presenting irregular bullae and crusts. 



VESICUL.E. 



PLATE VI. 



Fig. 1. — Herpes phtyctenodes. Scattered groups of vesicles without symmetry, on various parts of the body. 
Fig. 2. — Herpes circmatus (ring-worm). Commencing in a point and spreading in an irregular circle; as the old vesicles disap- 
pear, new ones arise outside of them. 
Fig. 3. — Herpes prasputia lis, on the prepuce. 
Fig. 4. — Herpes labialis, on the lips, often seen after fevers. 
Fig. 5. — Herpes digitorum, whitish on its palmar aspect. 
Fig. 6. — Sudamina. 
Fig. 7. — Miliaria. 
Fig. 8 — Mercurial eruption resembling eczema. 



HERPES — STOAMOTA . 



PL VI 



1. H. F Myctemrodl.es . 










_> 








sB 




4> 







2. M. Circiinia.tiuis . (ring worm.) 










J 



3. II. Fracpuiialii 





5 . H. di^itoruLmii 



1-. M. L 




8. XVii ■■ 



7. § . "miMaxia 



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PLATE VII. 



Fig. 1. — Scabies or itch of long standing. 

Fig. 2. — Scabies purulent a, with the burrows running out from them. 

Fig. 3. — Scabies on the foot of an infant. 

Fig. 4. — Conoidal form of the vesicles seen through a magnifier. 

Fig. 5. — Acarus scabei or itch-insect magnified. (Ventral aspect.) 

Fig. 6. — Do. dorsal aspect. 

Fig. 7. — Eczema simplex in the vesicular stage. 

Fig. 8. — Eczema impetiginodes. Large, moist, yellowish, flattened scales, covering a great portion of the body. 



115 



ECZEMA. 



PLATE VIII. 



Fig. i. — Eczema of the scalp, and of the ear, which alter being chronic has suddenly assumed an acute character. 
Fig. 2. — Eczema of the face in the acute form, presenting here and there whitish pellicles like false membranes. 
Fig. 3. — Curious appearance of the leg of an old woman suffering from chronic eczema. 
Fig. 4. — Affection of the nails accompanying general eczema. 

Fig. 5. — Chronic eczema of the penis attended with redness and swelling of the prepuce. 

Fig. 6. — Inveterate chronic eczema complicated with varices in an old man. The skin is ulcerated in many places during an 
exacerbation. 



ECZEMA, 



PI VIII, 



of face. 



I 





3. lBcaesimatwras fissures 




6. Ckroinic rraciiuffl 
Eoriatioais . 



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4". B . of the mails 



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5 . E . of ilk© p ewis 





On Stone by .4 . Vrirsam. 



Philadelphia, Published by Carey <&■ Hurt 



/'.•> Davat.Zith Phil' 



KCZEMA. 



PI IX 



1. EcKPina impeti^cnodrs. 



2. Ecienma mvetcraia. 









■\. !K- . lurfuracea 



4. Eczema a-uArmm. 



5 . E c z emma of the mippl© . 






7. Eczema 



6. Eczema of the lips. 







£>H Slont hr H f)a.r. 



Phtlcuir/pAia., PuMlskid &y Carey 4-Ma.rt 



PSJ)u.val, LitA ■ Phi/' 



ECZEMA. 



PLATE IX. 



Fig. 1. — Chronic eczema impetiginodes presenting a mixture of scabs and epidermoid scales. 

Fig, 2.— Remarkable state of the face after a long continued eczema impetiginodes. 

Fig. 3. — Scaly condition following a chronic eczema of the scalp. 

Fig. 4. — Eczema rubrum of the bend of the arm. The cuticle is abraded in several points. 

Fig. 5. — Chronic eczema of the nipple in the scaly stage. 

Fig. 6. — A rare variety of eczema impetiginodes on the lips. 

Fig. 7. — Moist eczema of the navel in an acute stage. 



ECZEMA. 



PLATE X. 

Fig. 1. — Chronic eczema affecting the toe-nails. 

Fig, 2. — Inveterate eczema of the anus with fissures and abraded cuticle in patches. 

PUST-TJLE S. 

Pustules are little deposits of pus in the skin, which is deeply inflamed. Pustular diseases are ten in number, viz : — Variola, 
Varicella, Vaccine, Vaccinella, Favus, Impetigo, Acne, Rosacea, Ecthyma and Pustular Syphilis. 

They are divided into three groups : — 

The first group comprises variola, varicella, vaccine, and vaccinella. 

The second group com prises fa vns and impetigo. 

The third group contains acne, rosacea, sycosis, and other follicular diseases. Ecthyma forms the transition between pustular 
diseases and furunculous inflammations. 

VARIOLA, (SMALL-POX.) 

Fig. 3. — Discrete small-pox, commencing stage. 

Fig. 4. — Variola in groups— red elevated patches with depressed pustules. 

Fig. 5. — The same in an advanced stage. 

Fig. 6. — Confluent small-pox, pustules purulent. 

Fig. 7. — Confluent variola in its worst form. 

Fig. 8. — Hemorrhagic variola. 

Fig. 9. — Pseudo-membranous discs in the trachea, the mucous membrane of a lively red in the intervals. 



ECZEMA 



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2. IRcaeina pwdlicis 



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8. HsemorrTka^ic V. 




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Philadelphia, Published f>_y Carey fHart 



P.SJ>ural,£ith PhW 



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PJ. XI 



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PUSTULES. 



PLATE XI. 



Fig. 1. — Pseudo-membranous discs in an annular form found under the cuticle of the sole of the foot. ( Variola.) 

Fig. 2. — Similar discs concave, and more perfect. 

Fig. 3. — Variola as it appears in the foetus. 

Fig. 4. — Sections of pustules in various stages, a. The papula, b. Pseudo-membranous pustule, c. Purulent pustule with ulcer- 
ation of the cutis-vera. d. Papula magnified, e. Magnified view of b. f. Magnified view of c. g. Section of a 
scab of variola, h. Section of a varioloid scab. i. Magnified view of g. k. A pseudo-membranous disc, dried under 
the cuticle of the sole of the foot. I. Magnified view of h. 

Fig. 5. — Progress of variola, the days are marked on the plate. 

Fig. 6.— Corresponding progress of varioloid. 

Fig. 7. — Cow-pox on the animal's teat. 

Fig. 8. — Progress of vaccine. 

Fig. 9. — Scab and cicatrix of vaccine. 

Fig. 10. — Progress of vaccinella or imperfect vaccine. 

Fig. 11. — Various appearances of spurious vaccine. 

Fig. 12. — Vaccine which has failed or become spurious. 

Fig. 13. — Simultaneous development of variola and vaccine ; the eighth day of vaccination ; three vaccine pustules. 



116 



PUSTULES. 



PLATE XII. 



Fig. 1. — Conoidal varicella in its early stage. 

Fig. 2. — Globular varicella — pseudo-membranous discs on the centre of the pustules ; one of the discs being open, shows the 

central papilla. 
Fig. 3. — Vesicular varicella, or chicken-pox. 
Fig. 4. — Common varicella, vesicles in various stages. 
Fig. 5. — Progress of varicella. 

FAVUS. 

Fig. 6. — Favus disseminata principally in the scalp. 

Fig. 7.— Follicles and hair-bulbs filled with favous matter, seen from the under side of the scalp. 

Fig. 8. — Favus aggregata in an infant, with partial alopecia. 

Fig. 9. — Ulcerations of the scalp following a long case of favus. 

Fig. 10. — Healthy hair-bulb magnified. 

Fig. 11. — Similar bulb, affected with favus, magnified. 









1. Coiioidal V. 

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2. IFavus in mass. 





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3 . Iirmpeti^ffl fi^uurata , 




4-. Imottoeti^© ecaenmatosa. 







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On Ston* hy J -tVtM'sam 



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PUSTULES. 



PLATE XIII. 

Fig. i. — Favons crusts of a sulphur yellow colour and a large size, on the knee of an individual who was affected in every region 

of the body. 
Fig. 2.—Favous crusts in which the peculiar characters are lost. 

IMPETIGO. 

Fig. 3. — Impetigo figuraia, mixed with the hair. 

Fig. 4. — Impetigo eczematosa. A very rare form, a central crust surrounded by psydraceous pustules. 

Fig. 5. — Impetigo scabida. Crusts, covering the leg and filled with fissures. 

Fig. 6. — Impetigo facei. A mass of scabs projecting irregularly with desquamation of the cuticle at its margins. 



PUSTULES. 



PLATE XIV. 



Fig. 1. — Impetigo sparsa. Pustules and scabs. 

Fig. 2. — Impetigo in a chronic form, affecting the scalp. 

Fig. 3. — Impetigo annulala in a scrofulous individual. 

Fig. 4.— Impetigo Jigurata in various states. 

Fig. 5. — Impetigo Jigurata after the scabs were detached. 

Fig. 6. — Chronic impetigo affecting the beard on the upper lip. 

Fig. 1.— Annular variety of impetigo remarkable for its shape, and the swelling of the skin under the pustules. 



IMFETK&© 



PI XIV. 



2. Impetigo capillifi 



1. ImrupetijS© sparsa. 




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4 . Imnrpcfiy o fiip^mra-ta , 



3.Imwpetiiiimin>iiLS rid^»e. 




5. Hmripptii 



6 . .Chromic impcii^© 



7. Inipeii^o armula. 
(T us hilar Ringworm,.) 





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PSDural^ZUhPhU' 



lMPUTIfcl) - SYC ©SIS ~ FUMjILICUIiAM BISBA&E 



PL XV. 



1. Impetigo annulata 







7 Follicular tumor. 



2. Impetigo marioim. 



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9. Piliferous 
follicular tmnwtr. 



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5. Sycosis invelerata 



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10. Section of a 
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•i'i'iu by .4 . \ in/saja 



PhilaUdfi/iui., Published by t'arey & Eartr 



J'S.PwtU, Lith ful' 



PUSTULES. 



PLATE XV. 



Fig. 1. — A rare variety of impetigo annulata. 

Fig. 2. — Complete closure of the nostrils by the scabs of impetigo, without ulceration of the mucous membrane. 

Fig. 3. — The form of impetigo usually seen in infants ; (crustea lactea, or milky scall.) 

Fig. 4. — Impetigo, accompanied by erysipelas. 

Fig. 5. — Sycosis inveterata on the upper lip. 

EOLLICULAK DISEASES. 

Fig. 6. — Plates formed of altered and dried follicular secretion on the surface of the skin. 

Fig. 7. — A follicle whose mouth has become obstructed; distended by its own secretion in the form of a tumour. 

Fig. S. — Yellow follicular plates on the upper eyelid. 

Fig. 9. — Section of a distended follicle containing hair. 

jPV.gr. 10. — Section of a common follicular tumour. 



117 



PUSTULES. 



PLATE XVI. 



Fig. l, — Hypertrophy of the follicles on the corona glandis. 

Fig, 2. — Minute pearly cartilaginous granules under the cuticle. 

Fig. 3. — Minute follicular elevations presenting a black point in the centre. (Acne punctata.) 

Fig. 4. — Hairs developed on the arm of a child after the application of a blister. 

Fig. 5.— Follicular granulations arising under the same circumstances. 

Fig. 6.— Acne indurata on the back, in various stages. 

Fig. 7. — Acne on the scrotum. 

Fig. 8.— Acne rosacea— consisting of pustules, tubercles, redness of skin, and dilatation of the capillary veins. 

Fig. 9. — Sycosis of the beard. (Mentagra.) 

Fig. 10. — Consecutive vegetations in sycosis. 

Fig. 11.— Fungous vegetations on the scalp. (From Alibert.) 



FOLLICULAR DISEASE .MYCOSIS —ACNE . 



PI. XVI 



1. Follicular hypertrophy. 
2Co 




2. Pearly Granulations, 



3. Follicular Elevation* 

/ Actia punctata ' 



4. "Pilaus productions 



7. Acne ©n the Scrotum, 



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6. Acme on the hack 



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INFLAMMATIONS - GAKT GREW ©ITS & IFURIWCinijlDHIIS 



ri. xvii 



1. (Gr 11 a to nil cits . 



4- . Malignant pustule 
in the stomach . 




2. G landers 
(pituitary incmb ) 







6. (Gran ^r en® us 
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\S . Malilaami pustule 



5. Boil & Caribnunnole 



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FURUNCULOUS AND GANGRENOUS INFLAMMATION. 



PLATE XVII. 



Fig. 1. — A case of glanders in the human subject. Gangrene of the skin on the forehead, a group of tubercles in the corner of the 

eye. Scattered do. on the cheeks, and puriform matter flowing from the nostrils. 
Fig. 2. — The mucous membrane from the frontal sinus in a glandered subject. 
Fig. 3. — Malignant pustule on the upper eyelid, slough »in the centre, the cuticle around elevated by bloody serum and diffuse 

inflammation outside of that. 
Fig. 4. — Gangrenous spots in the stomach of a subject who died of malignant pustule. 
Fig. 5. — Boil, carbunculous boil and anthrax, or carbuncle — all in the suppurating stage. 
Fig. 6. — Deep-seated ecchymoses which precede typhoid gangrene. 



FIMJNCULOUS AND GANGRENOUS INFLAMMATION. 



PLATE XVIII. 

Fig. i. Typhoid gangrene with abrasion of the cuticle. 

Fi<r. 2.— Deep mortification of the skin and subjacent cellular tissue. 

Fig. 3. — Common ecthyma. 

Flo-. 4.— Pustules of cachectic ecthyma surrounded by a livid areola. 

PAPULA. 

Papula; arc small, solid, itchy elevations of the skin, either reddish, or of the natural colour of the skin, usually terminating by a 

scaly desquamation. 

The papular diseases are Lichen, Strophulus, Prurigo and Papular Syphilis. 

LICHEN. 

Fig. 5.— Simple acute lichen on the breast. (Prickly-heat.) 

Fi«. 6.—J2cute lichen arranged in circles and arcs mixed with patches of various forms over the whole body. 

Fig. 7.— Lichen pilaris affecting the hair-bulbs of the fore-arm. 

Fig. 8. — Margin of a large annulus of lichen from the thigh. 

Ft". 9.— Lichen agrius in the ham, deep alteration of the skin surrounded by the papuke. 

Fig. 10.— Lichen simplex in a chronic form with successive crops of papulae. 



d^A^CBEMM - ECTHYMA - MCHE^ . 



PI. XVILl 



1. Typkoid Gangrene 




4f. C a eke ctic E ctky m a 




2. Typkeid &am£xene 



3.Ectkyma 



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8 .Lichen linearis 



9. Lichen a^rius 



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10. Lick em simj 

( chronic J 




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LICHEE — STftOPHimiTS — PI 



n xix 



1. Lichen urticatus 



2. Lichen circumscrifrtus 



3. Lichen lividus 








4- . Lichen lividus 



5. Strophulus 










8 . Fruri§ © uniiis 




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6 . Strophulus 
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7. Strophulus 
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PS.VuvnJ.LiU, Phil: 



PAPULA. 



PLATE XIX. 

Fig. 1. — Lichen urticatus on the bend of the arm. 

Fig. 2. — Lichen circumscriptus in a chronic form, groups of papula? bounded by a sort of ring. 

Fig. 3. — Lichenoas eruption on the leg of an old woman labouring under a hemorrhagic fever, accompanied by an ecchymosis 

under the skin. 
Fig. 4. — Lichen lividus. 

STROPHULUS. 

Fig. 5.. — Strophulus in very active condition ; it is usually more mild. 

Fig. 6. — Strophulus candidus. 

Fig. 7. — Small papulae of strophulus albidus. 

PRURIGO. 

Fig. 8. — Prurigo mitis. Scattered papula? and minute black scabs. 

Fig. 9. — Prurigo for micans. Small crusts, dry and bloody, numerous and scattered. 

Fig. 10. — Pediculus capitis magnified. 

Fig. 11. — Pediculus corporis do. 

Fig. 12. — Pediculus pubis do. 



118 



SQU AMiE. 



The scaly diseases are recognized by scales or plates of altered cuticle, dry, of a dead-white colour, which are rapidly reproduced. 
The subjacent skin is always more or less inflamed. The Squamae are preceded by red spots or papular elevations surmounted by a 
minute scale. 

They comprise Psoriasis, Lepra, Pityriasis and Scaly Syphilis. 

PLATE XX. 

PSORIASIS. 

Fig. 1. — Part of the skin of the fore-arm of an individual affected with acute psoriasis. Single points and confluent patches. 

Fig. 2. — Psoriasis guttata. A chronic eruption of scaly papulse without redness at the base, several patches as white as chalk. 

Fig. 3. — Psoriasis inveterata. Large and old plates divided by fissures and irritated by the friction of the clothes. 

Fig. 4. — Psoriasis annulata et imbricata. This form of eruption is rare. 

Fig. 5. — Psoriasis gyrata from Willan. 

Fig. 6. — Confluent psoriasis of the scalp. 

Fig. 7. — Skin of the elbow in an acute case of psoriasis. 

Figs. 8 and 9. — Two varieties of acute psoriasis, one white and the other red. 



SQUAMA 

PSORIASIS. 

2. Psoriasis guttata . 



Pl.XX 



1. "Psoriasis acuta 



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6. Confluent Psoriasis. 






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7. Coherent plates fir;M?*, 






3 . Psunxiasis iuveterata 



Psoriasis 






White variety 

QnStoJU /n.7-i ''•<■<'"" 



5 . Psoriasis 
jiyxaia . 







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Red variety 



Fluhid-e/pfiui. Published by Carey ,{■ Jlurt 




f> S Ihn *f Lif/t J 1 ////' 



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PSORIASIS LEPRA 

1. Psoriasis palmaris. 



IM.XXI 





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3. Psoriasis leprosa 




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5. Lepra <r.«n.pilllliti 



4. Lepra vulgaris. 




6. Lepra nigricans 





7. Li epnra 









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'FhUadUphia, Puilished fy Gu-e_y &Mart 



f S l>u*a Ir, / rth f'h 1 1 " 



SQUAMA. 



PLATE XXI. 



Fig. 1. — Psoriasis palmaris. Papular elevations, scales, and irregular desquamation of the palm of the hand. 
Fig. 2. — A very remarkable case of palmar psoriasis in which the desquamation proceeds regularly and in a circle. 
Fig. 3. — Psoriasis leprosa. A variety which approaches lepra. 

LEPRA. 

Fig. 4. — Lepra vulgaris. Leprous plates in progress of cure on the belly of an adult. 
Fig. 5. — Peculiar appearance of lepra on the scalp. 

Fig. 6. — Lepra nigricans, Willan. A ring of lepra with a thick black scale in the centre. 

Fig. 7. — A variety of lepra very difficult to distinguish from lichen circumscriptus, it differs in the absence of pruritus, and the 
leprous arc has no appearance of papulas. 



SQUAMA. 



PLATE XXII. 

PITYRIASIS. 

Fig. 1. — Desquamation of the cuticle of the neck and head from pityriasis, resembling asbestos. 

Fig. 2. — Pityriasis furfuracea. Smaller scales and separate. 

Fig. 3. — Pityriasis rubra. Desquamation foliated, rendered yellow in spots by the exudation of a thin serous fluid; scales dead 

white. 
Fig. 4. — Pityriasis affecting the lips. 

Fig. 5. — Pityriasis as it appears on the sole of the foot, cuticle yellow and rose-coloured in patches. 
Fisr. 6 — A npearance of the nails in a case of general psoriasis. (See PI. XXI.) 

PELLAGRA. 

.Fig-. 7. — Appearance of Pellagra. (From JHibert.) 



PITYRIASIS 



(MTXIS 



JPEJLLAGrEA 



pi. xxit 



1. Pityriasis des«piamaiiis 




6 . fflmysis sqmaiiwsa. 




*: 







5. Pityriasis plantaris 










4- . Pityriasis iaMalis . 




3. pityriasis rubra 








7. PelRa|Tra 





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TSDwval. LUh PAiif 



1. Lupus exedem® 



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pus 
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'Hiillalioiriis . \ I scale; 



LUPUS. 



H.XXHI. 




4*. Lupus tiom exedens.. 




5. Lupus tt©n exedems 
serpi|in©stns . 








fi. L . jULffln raedeims(Tiui!i. 



7 . L .no n e x e dl e in s ( c i c afarix 






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;,, 



wstun 



Philadelphia . Published by Carey £. //,/>/ 



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TIT BERCUL^. 



Tubercles are solid elevations, developed in the thickness of the skin, of which the size" varies from that of a small bean to an 
olive and which almost always terminate in suppuration or ulceration. 

The Tuberculae are six in number, viz: — Lupus, Scrofula Elephantiasis, Frambossia, Cancer and Syphilitic Tubercles. 

PLATE XXIII. 

I UP u s. 

Fig. 1. — Lupus exedens. Brown scabs strongly adherent, slight desquamation at the edges and oval, violet, tubercles. 

Fig. 2. — Lupus exedens. Ulcerations. 

Fig. 3. — Lupus exedens. Partial destruction of the end of the nose and scaly appearance of the rest of the organ. 

Fig. 4. — Lupus non-exedens. Patches of small tubercles of a yellowish red, covered with scales. 

Fig. 5. — Lupus serpiginosus. Presenting a singular appearance, as if covered by a sleeve. 

Fig. 6. — Lupus non-exedens. A subcutaneous tubercle. 

Fig. 7. — A portion of the skin of the thigh covered by small tubercles and resembling a cicatrix. 



119 



TUBERCUL^. 



PLATE XXIV. 



Fig. 1. — Lupus non-exedens. Developed on the scalp. 

Fig. 2. — Lupus vorax. (From Mibert.) 

Fig, 3. — Scrofula. Cutaneous ulcerations, scaly crusts, and scattered cicatrices. 

Fig. 4. — Section of a scrofulous tubercle. 

Fig. 5.— Scrofulous ulcer, following inflammation of a gland. 

Fig. 6.— Scrofulous inflammation of the root of the nail with a fistulous opening. 

Fig. 7.— Scrofulous ulcer. (From Lugol.) 

ELEPHANTIASIS. 

Fig. 8. — Elephantiasis. Cutaneous and subcutaneous tubercles, some blotches and a few ulcers on the face of an adult. 



' >, .vr.'R'IDFITlLA, EUEFHAWTIASRS 



IM.XXIV 



f . Alopecia J 







3 . iScrofuilla - 
/ Cutaneous tubercles J 







2.L 



vorax. . 






<5 



1 




l. Mjd'^tidiiii mi IT a I mi b «-. ir c II e 




5 . S croftda (ulcer . ) 



m, 



6. Scrofula (oroyxis . ) 




7. § crofula I ce^cl a 





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ft . Klephaniia.s'iiR , /■ (Jfcerafions J 





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BliEFHA^TllASlIS FRAME© SI A 



I'l.XXV 



of theAreUfS 



I 

, ' tubercle* 




T> fcaasis 

of ///< Scrotum 




2 

Ihfurtrtiphud Ear 




le-jpkaitutaaisis , Ulcer 
qf ike Epiglottis 




V . El ephamtiasis 
Palatini tubercles 








aws) 
/iV tubercles 




i\ . Fi amliioesia 

#v$zife tubercles. 




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TUBEKCUL^. 



PLATE XXV. 



Fig. 1. — A rare variety of Elephantiasis (From Adams.) 

Fig. 2. — Elephantiasis affecting the ear. 

Fig. 3. — Epiglottic ulcers in an Elephantiac subject. 

Fig. 4. — Tubercles, some of which are ulcerated on the palate. 

Fig. 5. — Elephantiasis of the scrotum. (From Delpech.) 

Fig. 6. — Elephantiasis of the Arabs. 



FKAMBCESIA, OB THE YAWS 

Fig. 7. — Framboesia. Red elevations, scabs and fungous ulcers. (From J. Thompson.) 
Fig. 8. — Frambcesia. Fungous whitish ulcers. (From Gomes.) 



TUBERCULiE, 



PLATE XXVI. 

CANCEROUS AFFECTIONS OE THE SKIN. 

Fig. \.—Mollusciform cancer. Tumours of the same colour as the skin, covered with convoluted fissures, in a woman who had 

a cancer of the breast. 
Fig. 2. — A section of the above, showing the amount of the elevation. 
Fig. 3.— White cancer. Small tumours of a milky white on the skin of the abdomen. 
Fig. 4. — A subcutaneous tumour, rounded and red. 

Fi". 5.— Subcutaneous cancer. A mass of cerebriform matter, divided into several lobes, their surface covered with small veins. 
Fig. 6. — Subcutaneous cancerous tubercles. 
Fig. 7. — Mulberry cancer from the cheek near the upper lip. 
Fig. 8. — Cancer of the penis. (From Wadd.) 
Fig. 9. — Fungous cancer in the ham of a woman. 

Fig. \0. — Melanoid cancer. A tubercle of an irregular form and a dark colour. 
Fig. 11 and 12.— Bleeding tumour, in the centre of which clots of blood are found. 



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1. Nliillu.'Ji'ifoniii 




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TUBERCUL.E. 



PLATE XXVII. 



Fig. 1. — An ulcerated cancerous tumour situated in the corner of the eye. 

Fig. 2. — Small cancerous tumours in the scalp, causing the fall of the hair. 

Fig. 3. — Corroding ulcer of the face ; dilated veins at the base which is indurated. 

Fig. 4. — Cancerous ulcer of the scrotum ; the glands of the groin carcinomatous. 

Fig. 5. — Small melanotic mass on the forehead. 

Fig. 6. — A melanotic eruption in the form of grains, in an old woman. 

Fig. 7. — A melanotic mass in the rectus muscle of the thigh. 

Fig. 8. — A mixture of cancer and melanosis found in the lung. 

Fig, 9. — Melanotic tumour developed on the sole of the foot ; it has the colour of a truffle covered with whitish plates. 

Fig. 10. — Melanosis in an ovary. 



120 



TUBERCULjE. 



PLATE XXVIII. 



Fig. 1. — Sections of the tumour in the sole of the foot. (Fig. 9, PI. XXVII.) 

Fig. 2. — Melanotic and cerebriform tumours in the liver. 

Fig. 3. — Melanotic masses in the skin. 

Fig. 4. — A melanotic mass from the substance of the heart. 

Fig. 5. — A keloid tumour developed on the cicatrix of a burn. 

Fig. 6. — Hypertrophy of the skin of the abdomen. 

Fig. 7. — A section of do. showing the thickness. 

Fig. 8. — Sarcomatous tumour on the nose, cutaneous veins much expanded. 

Fig. 9. — A verrucous or warty tumour, developed in the larynx. 

Fig. 10. — Mollusciform tumour, developed on the shoulder. 

Fig. U. — A remarkable piliferous neevus. (From Walter.) 



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SYPHILIS. 



The appearances presented by primary syphilis are very various. They are Blennorrhagia, Balanitis, and Common, Indurated, 
Phagedenic, and Gangrenous Chancre. All these symptoms are produced by a morbid virus, capable of being inoculated, and when 
inoculated, of being followed by general or secondary syphilitic diseases. 

These secondary affections comprise many affections of the skin, and may be made to include, Vegetations, Onyxis and Alopecia. 



PLATE XXIX. 



Fig. 1. — Ordinary chancre on the corona- gland is, yellow at the bottom, but no induration. 

Fig. 2. — A Hunterian chancre with indurated base. 

Fig. 3. — Superficial primary sores. 

Fig. 4. — A fungous primitive sore on the skin of the prepuce. 

Fig. 5. — Fungous ulcers inside of the prepuce. 

Fig. 6. — Phagedenic ulcer of the glans. 

Fig. 7.— Do. of the skin of the penis. 

Fig. 8. — Superficial primary sores. 

Fig. 9. — Primary sores with elevated margins. 

Fig. 10. — Balanitis, or inflammation of the glans. 

Fig. 11. — A corroding syphilitic ulcer on the soft palate. 

Fig. 12. — A corroding ulcer at the angle of the mouth. 

Fig. 13. — Destruction of the nose by a syphilitic sore. 

Fig. 14. — A sloughing or gangrenous ulcer of the penis. 

Fig. 15. — A rare variety of ulcer of the gums. 

Fig. 16. — Simple consecutive ulcer. 

Fig. 17. — Consecutive ulcer on the tongue. 

Fig. 18. — A scabby ulcer of the cheek. 



SYPHILIS. 



PLATE XXX. 



Fig. 1.— A face almost destroyed by a serpiginous phagedenic syphilitic ulcer ; it has cicatrized on the chin and is covered in 

other parts by scabs of a dark colour. 
Fig. 2. — A curious excentric serpiginous ulcer which extends over nearly half the trunk. 
Fig. 3. — A remarkable form of serpiginous tilcer caused by a collection of ulcers in the form of the letter C. 
Fig. 4. — Ulcers and cicatrices on the palate. 
Fig. 5. — A serpigi?ious ulcer cicatrized at one end. 
Fig. 6. — A curious ulcer filled with fissures on the ala of the nose of a syphilitic patient. 






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SYPHILIS. 



PLATE XXXI. 




C of a violet tint. 
Syphilitic blotches < of a red or coppery tint. 

rof a yellow tint. 
Scaly plates of a violet tint, formed by the aggregation of several blotches. 
Large scaly blotches of a violet red and a deeper colour in the centre. 
Yellow blotches of a uniform tint of colour. 
A yellowish scaly band filled with fissures. 

Lenticular copper-coloured blotches scattered over the palm of the hand. 
Confluent blotches on the sole of the foot detaching the cuticle. 
— Blotches with a scab in the centre. 



121 



SYPHILIS. 



PLATE XXXII. 



Fig. 1. — Small yellowish syphilitic pupulse on the back. 

Fig. 2. — Small groups of yellowish-brown papulae. 

Fig. 3. — Large papulae looking almost like tubercles. 

Fig. 4. — Syphilitic lichen circumscripta. 

Fig. 5. — Papulae and yellowish tubercles on the breast. 

Fig. 6. — A papulous arc surrounding a cicatrix. 

Fig. 7. — A portion of the skin of the shoulder exhibiting groups of papulae. 

Fig. 8. — An eruption of vesicles on the back of the forearm of a man affected with syphilis. 

Fig. 9. — Ordinary appearance of a syphilitic psydraceous eruption. 

Fig. 10. — Phlyzaceous pustular syphilis. 

Fig. 11. — Large conoidal pustules on the breast and face. 






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SYPHILIS. 



PLATE XXXIII. 



Fig. 1. — A group of agglomerated tubercles, of a copper-red colour, near the ala of the nose. 

Fig. 2. — Large projecting tubercles on the skin of the thigh. 

Fig. 3. — A part of the skin of the back showing chaplets of tubercles. 

Fig. 4. — Flattened tubercles presenting fissures in the direction of the folds of the anus. 

Fig. 5. — Tubercles above and at the corners of the mouth. 

Fig. 6. — Flat moist tubercles on the scrotum ; the upper part of the raphe is swelled and hardened. 

Fig. 7. — Tubercles on the thigh without any change in the colour of the skin. 

Fig. 8. — Ulcerated tubercles on the nipple of an infected nurse. 

Fig. 9. — An arc of ulcerated tubercles on the nose of a syphilitic patient. 



SYPHILIS. 



PLATE XXXIV. 



Fig, i. — An eruption of flat tubercles on the thighs and genitals. 

Fig. 2. — Tubercles on the back of the neck. 

Fig, 3. — Groups of little ulcers with subcutaneous indurations. 

Fig. 4. — Small masses of vegetations, traversed by hairs, cut from the verge of the anus. 

Fig. 5. — Same vegetations seen in section. 

Fig. 6. — Flat scaly tubercles in the axilla. 

Fig. 7. — Red indolent tubercles accompanying syphilitic ozcena. 

Fig. s. — Vegetating tubercles on the thighs and vulva. 

Fig, 9. — An arc of tubercles surmounted by triangular ulcerations. 



SYPHILIS . 



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SYPHILIS. 



PLATE XXXV. 

Fig. 1. — A bullar syphilitic eruption on the back of the forearm. 

Fig. 2. — A similar eruption on the palm of the hand. 

Fig. 3.— A large bulla ulcerated and covered by a black adherent crust in the palm of the hand. 

Fig. 4.__Upper lip elevated to show a deep ulcerated fissure, and a small grayish tubercle. 

Fig. 5.— Obstruction of the larynx by a voluminous vegetation. 

Fig. 6. — Vegetations on the corona glandis. 

Fig. 7. — Vegetation in the form of a horn on the corona glandis. 

Fig. 8.— Syphilitic onyxis on two of the toes and a grayish tubercle in their commissure. 

Fig. 9.— Section of a tumour from the forehead of a syphilitic patient. 

Fig. 10.— A large tubercle or tumour on the cheek. 

Fig. 11.— Confluent syphilitic pustules on the end of the nose. 

Fig. 12. — Syphilitic alopecia. 



122 



SYPHILIS. 



PLATE XXXVI. 

Fig. 1. — Reddish-brown blotches on a new-born child affected with gonorrhoea! ophthalmia. 
Fig. 2. — An eruption of tubercles on the thighs of a new-born child. 

VASCULAR ALTERATIONS. 

These are produced by the morbid alterations of the capillaries of the skin, and are characterized by permanent red spots, without 
morbid heat, and disappear for the moment under the pressure of the finger. They are divided into cutaneous and subcutaneous. 
Fig. 3. — A varicose tumour on the thumb. 
Fig. 4. — A small vascular naevus commonly called a strawberry. 
Fig. 5. — Small vascular papular vegetations, around the mouth and on the nose. 
Fig. 6.— Small petechise, scattered over the face of a child of 12 years affected with purpura. 






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VASCULAR ALTERATIONS. 



PLATE XXXVII. 

Fig. i. — Purpura urticans; an eruption of rose-red, itching, lenticular spots, slightly prominent, disappearing partially under 

pressure, mixed with yellowish or brownish blotches, which bear pressure without altering. 
Fig. 2. — The lower part of the leg of an adult covered with purpura and rupia mingled. 
Fig. 3. — Purpura ; large ecchymoses, such as are produced by a blow. 
Fig. 4. — A small portion of intestine presenting ecchymoses. 

Fig. 5. — A portion of the right lung, presenting sub-pleural petechias and an ecchymosis in the substance of the lung. 
Fig. 6. — A congenital vascular tumour. (Nasvus.) 
Fig. 8. — A vascular nasvus which has taken on the ulcerative process. 
Fig. 9. — A portion of a vascular nasvus which has no distinct arborizations. 



DISEASES OF THE CORNEOUS TISSUES. 



PLATE XXXVIII. 



Fig. 1. — Onychia of the root of the nail consequent upon a bruise. 

Fig. 2. — Lateral onyxis, or the nail growing into the flesh. 

Fig, 3. — A deformed, blackened nail, following onyxis. 

Fig. 4. — Deformed nail, following a chronic onyxis. 

Fig. 5. — A wart under the nail elevating the edge. 

Fig. 6. — Alteration of the nails in plica-polonica. 

Fig. 7. — A horn developed on a large wart in an old woman. 

Fig. s. — A horn on the scrotum. 

Fig. 9. — Toe-nail altered and elongated. 

Fig. 10. — A hand totally deformed by horny excrescences. 

Fig. 11. — Spots of lentigo or nasvus pilaris. 

Fig. 12. — Warty vegetations on the wrist.' 

Fig. 1 3. — Warts on the finger. 

Fig, 14. — Hordeolum or stye, followed by a wart. 

Fig. 15. — Excessive development of the papillae of the skin. 

Fig 16. — Do. of the tongue. 



©HYXirS - 3MSEASES W TEE • MORE Y TISSUES 



PI. XXXVIII 



1. 



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ALTERATIONS OF THE EPIDERMIS, &c. 



PLATE XXXIX. 

Fig. 1. — Corn on the little toe. 

Fig. 2. — Corn which had been a long time freed from pressure. 

Fig. 3. — Internal face of fig. 2. 

Fig. 4. — Section of a corn. 

Fig. 5. — Simple ichthyosis on the elbow. 

Fig. 6. — Bend of the knee covered with brown mosaic plates of ichthyosis. 

Fig. 7. — Appearance of the thumb of one of the brothers by the name of Lambert, who were called porcupines, accompanied by 

two magnified views of the spines. 
Fig. 3. — Dead white spots deprived of their hair. {Alopecia.) 
Fig. 9. — Spots of chloasma, some small, others large and irregular. 
Fig. 10. — Plica-polonica, or trichoma. (From Lafontaine.) 
Fi%. 11. — Chloasma in the form of little blotches. 



123 



ALTERATIONS OF THE PIGMENT. 



PLATE XL. 



Fig. 1. — Dark discoloration of the skin, which followed articular rheumatism. {Melasma.) 

Fig. 2. — Melasma in an individual affected with pellagra. 

Fig. 3. — Same affection on the hand. 

Fig. 4. — Small white blotches on the upper eyelid. (Canities.) 

Fig. 5. — An old woman with bunches of white hair growing on the face. 

Fig. 6. — Albinism in a negro. 

Fig. 7. — Partial albinism; congenital. 

Fig. 8. — Partial leucopathia or albinism. 

Fig. 9. — Nigrities; a part of the shoulder, which became as dark as that of a mulatto. 

Fig. 10. — Tint of the skin produced by the internal use of nitrate of silver. 

Fig. 11. — Black spots on the tongue. 

Fig. 12. — Yellow spots symmetrically disposed on the eyelids. 



ALTERATION'S OF HUE PIIMENT 

2. Pellagrous melatoia . 



PI. XI 



1. Melasma. 






3. Pellagrous melasma 



5 . C aniti e § . 









6. Albinism. 



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7. Partial A lib 




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12. Yellow spots on the eyelids 






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INDEX AND YOCABULABY. 



Acarus scabiei, 136-7 and append. 397. 

Achor, 195. 

Acne, 180. 

Acne Rosacea v. Rosacea. 

Syphilitica, see syphilida, psydraceous pustules. 

Acrodynia, 424. 

Albaras, Baras, Lepra, q. v. 

Albinism,' 337. 

Albohak, Lepra, q. v. 

Aleppo pustule, 411. 

Alopecia or Baldness, 379; porrigo decalvans, 380; tinea tondans, 380. 

Alphos, Lepra, q. v. 

Amboyna pustule or pox, 416. 

Ambustio or Burn, 318; erythematous, 318; vesicated or bullous, 318; 
gangrenous, 318. 

Ampullae, 100. 

Anemia, 322. 

Anaesthesia, 335. 

Andrum, a form of Arabian Elephantiasis, 410. 

Angiectasia, 356. 

Animals, parasitic, infesting the body of man, 393. 

Anomalous rosy Eruption v. Roseola. 

Anthracion seu Pustula maligna, 214. 

Anthrax, 212. 

Aphthae praeputii v. Herpes praputialis. 

Appendix, 393. 

Area, Alopecia, q. v. 

Aspredo, Aspretudo, Urticaria, q. v. 

Atheromatous tumours, 375. 

Atonic Ulcers, consequences of Rupia. q. v. 

Bacchia v. Rosacea. 

Baker's Itch, Psoriasis of the hand v. Psoriasis. 

Baldness v. Alopecia. 

Baras v. Elephantiasis Greecorum. 

Barbadoes Leg, 410. 

Blactiffi v. Rubeola. 

Blanching, Endemic, of the Skin, 425; Carate, 425; Pinta, 425. 

. of the Hair v. Canities. 

Blebs v. Bulke. 

Boil v. Furunculus. 

Bricklayer's Itch, impetiginous Eczema and Impetigo of the hands v. Ec- 
zema and Impetigo. 

Brunno-gallicus Morbus (syphiloid), 416. 

Bullae, 91. 

accidental, ampulla, blisters, 100. 

Bulla, Pemphigus, q. v. 

Burn, 318. 

Calculi of the sebaceous follicles, 376. 

Cancer, 265; vulgaris, 265 ; melanic, 266; leucoid, 267; globose, 267; 
mollusciform, 267 ; chimney sweepers, 268 ; local varieties, 268. 

Cancroid v. Cheloid formation. 

Canities, 378. 

Carate, 425. 

Carbo or malignant pustule, 434. 

Carbuncle v. Anthracion and Anthrax. 

Cheilocace, 410. 

Cheloid formation, 360. 

Chicken-pox, 148, 163 v. Varicella. 



Chilblain v. Pernio. 

Chin-welk v. Sycosis. 

Chloasma, 342. 

Cingulum. Herpes zoster. 

Classification of Diseases of the Skin, 21, 47. 

Cnesmos. Prurigo. 

Colour of the Skin, alterations of the, 337; Albinism, 337; Nigrities, 339; 
Ephelis, 341 ; Lentigo, 342 ; Chloasma, 342 ; Melasma, 34:3 ; Pigment- 
ary nasvi, 344 ; Blue colour, 345 ; Yellow colour, 345 ; Slate colour from 
use of Nit. Argenti, 346; Artificial Staining v. Skin, 347. 

Colour, slate, of the Skin from using Nitras Argenti internally, 346. 

Colour, (yellow,) 345. 

Corion, hypertrophy of the, 363. 

Corn v. Tylosis. 

Crusted-tetter v. Impetigo. 

Cow-pox v. Vaccinia, 172, 430. 

Crusta lactea, Eczema and Impetigo of the face v. Eczema and Impetigo. 

Crystalli, Vaccinia. 

Crystallina, Herpes praputialis. 

Cuticle v. Epidermis. 

Dandruff v. Pityriasis. 

Degenerationes,364; fibrous 364; Melanosis, 365; Tubercular matter, 366. 

Dermis, diseases of the, 54. 

suppurative inflammation of, 147. 

depositive inflammation of, 218. 

disordered chromatogenous functions of, 337. 

Diffuse cellular inflammations, see Gangrene. 
Diphtheritis of the Skin, 427. 

Discolorations of the skin, artificial or accidental, 346. 

Djuzam v. Elephantiasis Grascorum. 

Diseases which have disappeared, 428 ; of Animals susceptible of commu- 
nication to the human subject ; Cow-pox, 430; Grease, 434; Carbuncle 
or malignant pustule, 434 ; Scabies, 435 ; Glanders, 435. 

Dracunculus v. Filiaria. 

Dry-scall, Psoriasis. 

Dysodia, impeded perspiration. 

Ecthyma, 205 ; acutum, 205 ; chronicum, 205 ; cachecticum, 207. 

Eczema, 114; Simplex, 114; rubrum,115; impetiginodes, 115, 190; Chro- 
nic Eczema, various local forms of, on the scalp, face, ear, &c, 116; et 
sequent complications, 118; diagnosis, 118; treatment, 121. 

Eczema mercuriale v. Hydrargyria. 

Efflorescence. Erythema. 

Elephantiasis Arabica, 401; generally attacks lower extremities, 404; 
of the scrotum, 405 ; geographical distribution of, 407. 

Elephantiasis Brazilian, 406. 

Grascorum, 273. 

Elephantoid affections, modifications of tubercular or Greek elephantiasis, 

412. 
Ephelis, 341. 
Ephidrosis, 334. 
Epidermis, structure of, 46. 

morbid secretions of the, 333. 

Epinyctis, 429. 

Epinyctis pruriginosa v. Urticaria. 

Eruptions, Endemic acute, 425; Lichen tropicus, 426; Itch of the Illinois, 

426. 
Eruptive fevers, are general diseases, 13. 
variety of character of, in different epidemics, 14. 



492 



INDEX. 



Eruptive i bvers, writers on, 14. 

Erysipelas, 65; causes of, 65; simplex, 65; symptoms of, G5; miliaris, ti(i: 
phlyc el bullosa, 66; erratica, 66i metastatica, 66; phlegmo- 

nous, lii) ; gangrenous, 66; cederaatous, 66; Erysipelas of the face, GO; 
scalp, 67; mamma and umbilicus, 67; groin, scrotum, prepuce, and 
extremities, tu : ( reneral Erysipelas, 07; diagnosis, prognosis and treat- 
ment, 68; history and cases, 70. 
Erysipelas zoster, Herpes zc 
Erysipelatous efflorescence v. Roseola. 

Erythema, 00; intertrigo, 60; paratrimma, GO; a punctura, GO; papula- 
tnm, 60; tuberculatum, 60; nodosum, 00; marginatum, 60; circinatum, 
60; fugax, 60; Chronic, of the feet, 00; lips, nipple, abdomen, anus, 
prepuce, and vulva, 00; fiery spots of the face, 00; diagnosis, 61 ; prog- 
nosis, 62; treatment, 02; cases of, 03. 
Essera v. Urticaria. 
Exanthema labiale v. Herpes labialis. 
Exanthemata, progress of, 58. 

associated with internal disease, 59. 

changes of skin in, 59. 

artificial, 90. 

E* RESCENCES, syphilitic. 
Excrescences, vascular, 357. 
Fa< alpine, (syphiloid,) 410. 
False measles, Roseola. 
Farcv, 438. 

chronic, 440. 

Favus, 195 dispersus (Porrigo lupinosa, Wil.) 196; confertus (Porr. scu- 
tulata, Wil.) 197; organic nature of, 196; probably a modification of 
tubercle, 199. 
Febris bullosa v. Pemphigus. 
Febris pemphigoides v. Pemphigus. 
Febris urticata v. Urticaria. 
Fiery spots of the face — Erythema, 61. 
Filiaria Medinensis or Guinea-worm, 398. 
Fish-skin disease, Ichthyosis. 
Fleas v. Pulices. 

Follicles sebaceous, diseases of the, 367. 
Follicular grubs or worms, 370; elevations, 371; tumours, 375; calculi, 

370. 
Formica. Herpes phlyctenodes. 
Formica corrosiva. Lupus. 
FrambjEsia, Yaws, or pian, 417. 

diagnosis between, and sibbens, 418. 

Freckle. Ephelis. 

Furunculi, 210. 

Furunculus or Boil, 210. 

( rANOREN.£, 214; simple of the skin, 387. ! 

Gangrenous diseases, epidemic or endemic, 426; Nome, 426; Ignis sacer 

of the middle ages, 420. 
Glanders, 435 ; acute, 439 ; chronic, 440 ; connection between Glanders 

and Farcy, 437; transmission from man to horse, 443. 
Glandular disease of Barbadoes. Elephantiasis Arabum. 
Grease of the horse, 434. 
Grutum vultus, Acne. 

Grocer's Itch. Impetigo of the hands, Psoriasis of the hands. 
Guinea-worm v. Filiaria Medinensis. 
Gum v. Strophulus. 
Gutta rosea v. Rosacea. 
Ha?macelinosis v. Purpura. 
Hemorrhagica?, 323. 
Hamorrhcea petechiale v. Purpura. 
Hair v. sub Piliferous follicles. 
Herpes Esthiomenes. Lupus. 

Herpes, 103; Herpes zoster, 104; of the trunk, face and mouth, 104; is 
generally complicated, 105; causes, diagnosis, and prognosis, 106 ; treat- 
ment, 107; phlyctenodes, 109; circinatus, 110; labialis, 111; praspu- 
tiahs, 112; vulvaris, auricularis, palpebralis, 113; iris, 113. 
Herpetic affections depend on constitutional causes, 13. 
Hives, Globular variety of Varicella. 
Hordeolum or Sty, 211. 
Horn-pox v. Varicella. 
Horns or horny productions, 354. 
Hydatis. Pemphigus. 
Hydrcea febrile. Herpes labialis, 410. 
Hydrocele, Endemic, a form of Elephantiasis Arabum. 
Hydrargyria mitis, 130, febrilis, 130; maligna, 131. 
Hyperesthesia. 330. 
Hypertrophic, 348. 



Hypertrophy of the corion, 303; of the nose, 868. 

of the Papillae and Epidermic layers of the skin, 31 s ". 

of the subcutaneous cellular and adipose tissues, 863. 

of the vascular elements of the skin, 866; Phlebectasia, 

350; capillary angiectasia, 350; Noevus araneus, 856; flammeus, 856; 
vascular excrescences, 357 ; Cutaneous vascular navus, 357; subcuta- 
neous vascular namis, 357; congenital cutaneous and subcutaneous vas- 
cular naBvus, 358 ; of erectile tisfeue, 358 ; of dilated veins, 359. 

Ichthyosis, 348 ; simplex, cornea, spuria, 308. 
sebacea, 307, 370. 



Ignis Persica v. Anthracion. 
Ignis sacer v. Erysipelas. 

Herpes zoster. 



Ignis sacer of the middle ages, 426. 

Illinois itch, 426. 

Impetigo figurata, 189; Sparsa, 190; of the scalp, (tinea granulata), 190 
eczematosa, 190. 

Inflammatory affections of the Skin, 22. Effects of these: ulcers 23 
crusts, 23; local symptoms, 23; general symptoms, 23; complications 
24 ; etiology, 26 ; diagnosis, 29 ; prognosis, 29 ; influence of on the gene 
ral health, 30; treatment, 31 ; of the acute forms, 31 ; of the chronic 
32; effects of various therapeutic agents and means— medicines, baths 
etc., 33, 45, 56. 

Inflammatory affections of the Skin, having a single elementary form, 58. 

Intertrigo — Erythema intertrigo, q. v. 

Intumescentle, diseases at first foreign to the Skin, but implicating it at 
length, 401. 

Ionthos v. Acne. 

Itch v. Scabies. 

Insect v. Acarus scabiei. 

Bakers' — Grocers' v. Psoriasis ; psor. palmaris. 

Jewish Leprosy, 413. 

Labri-sulci Hibernige, 410. 

Lentigo, 342. 

Lepra medii a?vi v. Elephantiasis Gracorum. 

Lepra of Holstein, (Spedalsked,) 413. 

Taurica, (Lep. Crimea?,) 413. 

Judaica, 413 



anaesthesiaca Indorum, 413. All these Lepras are varieties of tuber- 
cular Elephantiasis. 

Lepra, (scaly lepra,) 233; (vulgaris,) 234; its frequency in England, 234. 

Leuce Lepra. 

Leucopathia seu Albinismus, 337 ; general, 337; partial or accidental, 337. 

Leontiasis. Elephantiasis Groecorum. 

Lichen simplex, 220; pilaris, 221; circumscriptus, 221; agrius, 221: 
urticatus, 221 ; lividus, 221 ; tropicus, 221 ; local varieties, 222. 

Liver-spot v. Chloasma. 

Lupus exedens, 253; non exedens, 255. 

Lymphatic system, disease of in Arabian Elephantiasis, 404. 

Macula? volaticas. Erythema. 

hepatica?. Chloasma. 

Mal rouge de Cayenne, 412. 

Mal de Rosa, 423. 

Malum mortuum, 414. 

Measles v. Rubeola. 

Melada, disease of, 424. 

Melanosis, 365 ; in grains, in mass, of the forehead, cancerous of the heart, 
of the liver, cancerous of the muscles, cancerous of the lung. See 
plates. 

Melas v. Lepra. 

Melasma, 343 ; (acrodynia ; pellagra.) 

Mentagra v. Sycosis. 

Mentagra of the Latins, 430. 

Mentagrophyte, 180. 

Metastasis of cutaneous diseases, 14. 

Miliaris Sudatoria, 139; Cases of, 143. 

Milium, Acne. 

Mole, Neevus, Spilus. 

Molluscum contagiosum, 371 ; structure of, 372-4. 

Morbilli v. Rubeola. 

Morbilli confluentes v. Scarlatina. 

Morbus maculosus hemorrhagicus. Purpura. 

Mother marks. Nasvi of different kinds. 

Mouth Canker, 410. 

Mucous membranes, diseases of Skin in contrast with_those of the, 389. 

morbid states of the, in cutaneous" diseases, 29, 55. 

Nevus araneus, 350. Nawus flammeus, 356. 

, varieties of, 358. 



INDEX. 



493 



N^evus, mollusciforrn. piliferous. 

pilaris. 

cutaneo-vascular, 357; subcutaneo-vascular, 358 ; congenital-cuta- 

neo and subcutaneo-vascular, 358; of erectile tissue, 358; of dilated 
veins, 359; ulcerated naevus. 

N*:vus, pigmentary, 344. 

■ verrucous, 353. 

structure of, 358. 

Nails, faulty conformation of, 385; excessive growth of, 386; anomalous situ- 
ation, 386; ficus unguium, 386; anomalous form, 386; defaedatio unguium, 
386 ; Reproduction, 387. Vide subunguial matrices, and onychia. 

Nails in the form of horns, 386. 

Nettle rash v. Urticaria. 

Neuroses of the Skin, 335. 

NlGRITIES, 339. 

Nitrate of silver, effect of, on the Skin, 345. 

Noli me tangere v. Cancer. 

Noli me tangere v. Lupus. 

Nome, of Sweden, 426. 

CEstrus, 400; a supposed cause of cancerous fungus of the uterus, 401. 

Onychia from an outward cause, 382; from the nail growing into the 
flesh, (lateral onychia,) 383 ; from an internal cause, 383 ; chronic ; of the 
root of the nail ; Eczematosa, 383 ; Squamosa ; Scrofulosa ; Syphilitica, 
384; maligna, 384. 

Papillae, Hypertrophy of the, 348. 

of the tongue, hypertrophy of the, 348. 

Papula, 219. 

artificial, 232. 

Parasitic vegetable structure, cause of certain cutaneous diseases, 393. 

Pedarthorace, a name for Arabian Elephantiasis, 401. 

Pediculi, 394 ; pediculus capitis, 394 ; corporis, 394 ; pubis, 395. 

Pellagra, 419. 

Pellagrous diseases, 419; (melasma) mania, 420; Mai de Rosa, 420; 
Acrodynia, 424; disease of Melada, 424. 

Pelliosis rheumatica v. Roseola rheumatica. 

Pemphigus acutus, (febris bullosa, feb. synocha c. vesiculis, feb. pemphi- 
goides, pompholyx solitarius,) 91 ; chronicus, (pompholyx diutinus,) 92; 
associated with inflammation of mucous membranes, 92; with herpes 
and prurigo, 92 ; treatment, 93 ; of pemphigoid inflammation of mucous 
membranes, 94. 

Pemphigoid fever. Acute pemphigus. 

Perical, a form of Elephantiasis Arabum, 410. 

Pernio orchilblain, 321 ; erythematous, 321 ; bullous, 321; gangrenous. 321. 

Perspiration, morbidly increased, 334. 

Petechias, Petechias sine fibre. Purpura. 

Phlebectasia, 356. 

Phlyctena. Bulla. 

Phlyzacia, 144, 195, 205. 

v. Ecthyma. 

Phyma. Furunculus. 

Pian, frambaesia. q. v. 

Pian de nerac, (syphiloid,) 417. 

Pigment, diminution of, 337. 

Pigmentary naevus, 344. 

Piliferous follicles, special diseases of the, 376; Atrophy, 376; congenital 
deficiency of the hair, 376; tufts of hair, 376; unusual growth of the 
hair, 376 ; felting of the hair, 377 ; changes of colour of the hair, 378 ; 
Canities, 378 ; accidental, 378 ; of the beard, 379 ; Alopecia, 379 ; (por- 
rigo decalvans, Wil. 380, tinea tondans ;) partial alopecia of the beard, 
380; Syphilitic, 380; general, 381 ; summary of treatment, 381. 

Pimple. Pustula, Papula. 

PlNTA, 425. 

Pityriasis, 247; general, 247; capitis, 248; palpebrarum, 248 ; labrum, 

249; palmaris et plantaris, 249; oris, 249; praeputii, &c, 249. 
Pityriasis versicolor. Chloasma. 

nigra. Chloasma. 

Plica, 427. 

Pompholyx v. Pemphigus. 
Porcelana v. Urticaria. 
Porcupine men v. Ichthyosis. 
Porrigo decalvans v. Alopecia. 

v. Favus and Impetigo. 

favosa v. Impetigo. 

scutulata v. Favus confertus. 

lupinosa v. Favus dispersus. 

Prickly-heat v. Lichen tropicus. 

Prurigo, 227; mitis, 227; formicans, 228; senilis, 228; podicis, 228; 
scroti, 228; plantaris, 229. 
1'24 



Pseudo-membranous affections of the Skin, 427 ; Diphtheritis, 427. 

Psora v. Scabies. 

Psoriasis, 240; discreta, (guttata,) 240; confluens, (diffusa,) 241 ; invete- 
rata, 242; gyrata, 242; of the scalp, 242; of the face, 242; of the 
trunk, scrotum, and prepuce, 242; palmaris, 242; palmaris centrifuga, 
242. 

Psydracia, 146, 195. 

Psydracia v. Impetigo. 

Pulices, 396 ; varieties of, 396. 

Purpura, 323; sine fibre, 323; simplex, 323; urticans, 324: hemorrhagica, 
324; febrilis, 326; senilis, 326. 

Purpura v. Scarlatina. 

Purpura urticata v. Urticaria. 

Pustula mahgnav. Anthracion. 

Pustule, 146, varieties of, 195. 

Pustules, artificial, 209. 

Radesyge, 412. 

Rash v. Roseola. 

Red gum v. Strophulus. 

Retro-vaccination, 431. 

Ringworm, vesicular. Herpes circinatus. 

Ringworm. Porrigo scutulata, Herpes circinatus, and Impetigo figurata are 
so denominated. 

Rosa, mal de, 423. 

Rosacea, 182. 

Rosa volatica v. Roseola, Erysipelas. 

Rossalia v. Rossania. Scarlatina. 

Rose. Erysipelas, Roseola. 

Roseola, 84; aestiva, 84; autumnalis, 84; annulata, 84; infantilis, 84; va- 
riolosa, 84; vaccina, 85; miliaris, 85; febrilis, 85; rheumatica, 85; 
Cholerica, 86 ; Cases, 86. 

Rubeola vulgaris, measles, 71 ; sine catarrho, 71 ; nigra seu haemorrha- 
gica, 72; sine efflorescentia (febris morbillosa) 72; Anomalous, 72; Con- 
secutive diseases, 72; causes, diagnosis, 73; Prognosis, treatment, 74 ; 
Historical Notices and Cases, 76. 

Running Tetter, Impetigo, Eczema. 

Rupia simplex, 98 ; prominens, 98 ; escharotica seu gangrenosa, 99. 

St. Anthony's Fire. Erysipelas. 

Sanguineous congestions of the skin, 323. 

Scabies, 135. Causes, 135; experiments with acarus scabiei, 137, 

Scabies of animals, 435. 

Scabies sicca. Psoriasis. 

Scall v. Psoriasis. 

Scarlatina simplex, 77 ; anginosa, 78 ; maligna, 78 ; sine exanthemata, 
77; Secondary diseases, 79; Treatment, 81; prophylaxis, 82. 

Scarlatina urticata v. Urticaria. 

Scarlet fever. Scarlatina. 

Scalled-head. Favus and Impetigo of the scalp. 

Scaly Tetter. Psoriasis. 

Scherlievo, (syphiloid,) 415. 

Scrofula, 261. 

Sebaceous follicles, diseases of the, 367; increased secretion, 367; 
worms or grubs, 370 ; follicular elevations, 371 ; tumours, 375 ; contain- 
ing hair, 375; calculi, 376. ■'*?*? 

Secreting functions of the skin, morbid states of the, 333. 

Senki, a Japanese word for a variety of Elephantiasis Arabica, 410. 

Serpedo and Serpigo-Psoriasis. 

Shingles v. Herpes zoster. 

Sibbens, (syphiloid,) 417. 

Skin, anatomy of the, 25, 45. 

morbid secretions of, 333. 

neuroses of, 335. 

alterations in the colour of, 337. 

blue colour of, 345. 

yellow colour of, 345. 

artificial discolorations of, 346. 

artificial staining of, 347. 

hypertrophy of vascular elements of, 356. 

vascular growths of, 357. 

increase of morbid secretion of, 367. 

gangrene of, 387. 

cicatrices of, 388. 

endemic blanching and discoloration of, 425. 

anomalous formation of the, 388 ; congenital deficiency of the, 388 ; 

remarkable extension of portions of the, 389. 

Skin, outlines of pathology of, contrasted with that of the mucous mem- 
branes, 389. 

classification of diseases of the, 21, 47, 54. 



494 



INDEX. 



.Skin Diseases, symptoms of, 23. 
1 complications, 24. 

anatomical lesions, 25. 

etiology of, 26, 47. 

herecGtariness of, 28. 

diagnosis, 29. 

prognosis, 39. 

treatment of, 31, 47. 

Small-pox v. Variola. 

Spbdalsked, or Lepra of Holstein, 413. 

Spihis. Najvus pilaris. 

Syt \m.*:. 283. 

Squamous inflammations, artificial, 253. 

States, unusual, of the elements of the skin, 336. 

Steakuii(i:\. 'M'u. 

Strophulus, 226; intertinctus, 226; albidus, 226; candidus, 226; con- 
fertus, 226. 

Structure, faulty, of the skin. 

Struma v. Scrofula. 

Sty v. Hordeolum. 

Sycosis seu Mentagra, 185; with excrescences, 186; contagiosum, 186. 

S\ cmi.iDA.Syphilidesor Syphilitic eruptions, 282, 296. Primary symptoms 
of Syphilis : Gonorrhoea, 283 ; Chancre and its varieties, 283 ; Syphili- 
tic ulcers, 285; Bubo, 288; Secondary symptoms, 290; Syphilitic erup- 
tions, 290 ; exanthematous, 291 ; maculae syphilitica?, 292 ; bullous, 292 ; 
vesicular, 292 ; psydracious pustular, 293 ; phlyzacious pustular, 293 ; 
Rupia syphilitica, 294 ; papular, 295 ; squamous, 295 ; subcutaneous 
gummy tubercles (gummata) 997 ; serpiginous syphilide, 299. Ulcers. 
Ulcers of the mucous membranes, 300 ; Syphilitic excrescences, 301 ; 
S. alopecia, 302; S. onychia, 302. 

Syphilis, 282. 

Syphiloid diseases, — various epidemic or endemic varieties of syphilis, 
414 ; of Chavanne-Lure, 414; of the Bay of St. Paul, 415; of Fiume, 
or scherlievo, 415; Facaldine, 416 ; morbus Brunno-Gallicus, 416; tophi 
Amboinenses,416 ; sibbens, 416 ; pian de Nerac,417 ; Framboesia, 416. 

SuDAMINA, 144. 

Sudor Anglicus, 428. 

Sweating-sickness, 428. 

Swine-pox, conoidal varicella, 169. 

Tara of Siberia, 412. 

Tetter v. Herpes. Impetigo. Eczema. 

Tetter, humid, Impetigo ;, scaly Psoriasis. 

Tinea annularis v. Impetigo figurata. 



Tinea. Species referred to Favus, Impetigo, or Eczema of the scalp. 

Tinea favosa v. Impetigo. 

Tinea tondans v. Alopecia. 

Tooth rash v. Strophulus. 

Triciiomatous affections, 427 ; Plica, 427. 

Tumour, vascular, 253. 

Tumours, endemic, 411. 

Tubercula, 253. 

artificially produced, 281. 

Tylosis or Corn, o\">.">. 

Ulcuscula praeputii v. Herpes praeputialis. 

Qnguiax matrices, special diseases of the, and alterations of the nails. 882.J 
onychia, 382; v. onychia. Subunguial ecchymosis, 385; faulty con- 
formations and texture of the nails, 385. 

Urticaria, 87 ; acuta: vulgaris ab ingestis, 87; sine causa, 88 ; perstans, 
88; chronica, 88 ; evanida, 88 ; subcutanea, 88 ; tuberosa, 88 ; with in- 
termittent fevers and rheumatism, 88. 

Uredo v. Urticaria. 

Vaccinia, (Cow-pox,) 172; Progress of the pustule, 173, 431 ; Modified 
vaccina, 174, 434; Vac. spuria, 175; origin of, 175, 431 ; from small- 
pox, 432. 

Vaccinella, (horn-pox,) 178. 

VaricelljE, (variola spuria?,) 148, 163 ; umbilicated pustular (varioloid) 
164 ; conoidal pustular, 169; globose pustular, 169 ; papular, 170 ; vesi- 
cular, (chicken pox,) 170 ; sine varicellis, 172. 

Variola, 147 ; two series of, 147 ; affinity of, 147 ; periods of variola, 
confluentes, 150; discretae, 152; corymbosae, 152; cohaerentes, 152; 
progress of variola, 151; inoculated variola, 152; anomalies of, 153; 
diagnosis of, prognosis, 155 ; treatment, 156 ; epidemic mortality from, 
163 ; per insitionem, (inoculated,) 152. 

Variola? spuria? v. Varicella?. 

Varioloid v. Varicella?. 

Varus v. Acne. 

Vegetations, a cause of favus, &c, 393. 

Verruca, wart, 352. 

Verrucous n^vus, 353. 

VESicuLiE, or Vesicular Inflammations, 103. 

Vesicular eruptions, artificial or accidental, 145. 

Vitiligo, partial Leucopathia, also Greek Elephantiasis. 

Waren of Westphalia, 430. 

Wart v. Verruca. 

Whelk v. Acne. 

Zona v. Herpes zoster. 



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Uniform with " Quain's Anatomy" " Pantoast's Surgery" and " Moreau's Midwifery." 

" We do not possess a modern work on Dental Surgery, written by a British author, which equals 
that of Dr. Goddard. One reason for this may arise from the circumstance, that the learned author is 
a practical anatomist, whose knowledge is on a level with the modern discoveries, and who has him- 
self authenticated the latest researches into the minute anatomy of the dental structure. It is quite 
apparent that such knowledge must prove of immense value in enabling any one to arrive at just 
conclusions relative to the diseases of the teeth; and it is chiefly to be attributed to the want of such 
knowledge that most writers on Dental Surgery have erred so much relative to the causes and nature 
of these diseases.— This work may confidently be recommended, as containing the best and most 
approved methods of performing all the operations connected with Dental Surgery. 

" We cannot close our remarks without adverting to the thirty very beautiful lithographs which 
illustrare the text. They render it quite impossible to misunderstand the author, and afford a very 
favourable example of the advanced state of the Art on the American Continent." — Edinburgh Me- 
dical and Surgical Journal, 1844. 



MOREAU'S GREAT WORK ON MIDWIFERY. 
A PRACTICAL TREATISE ON MIDWIFERY: 

EXHIBITING 

THE PRESENT ADVANCED STATE OF THE SCIENCE. 
By F. G. MOREAU. 

Translated from the French by T. FORREST BETTON, M.D., and Edited by 
PAUL BECK GODDARD, M.D. 

THE WHOLE ILLUSTRATED BY 

EIGHTY SPLENDID QUARTO PLATES, 

WHICH ARE EITHER 

THE SIZE OF LIFE 



EXACTLY HALF THE SIZE. 

Upon which the first artists have been employed, and which are fully equal, 

if not superior, to the original, and the publishers 

can safely pronounce it 

THE MOST SPLENDID WORK ON MIDWIFERY 

EVER PUBLISHED. 

ISow complete in one large Ho. volume, of the size of " Quain's Anatomy," " Pancoast's 
Surgery," and " Goddard on (he Teeth." 

Price TEN DOLLARS, full bound in cloth. 

"The work of Professor Moreau is a treasure of Obstetrical science and practice, 
and the American edition of it an elegant specimen of the arts." — Medical Examiner, 
August, 1844. 

"A splendid 4to., containing eighty lithographic plates, true to the life, has been 
some weeks before us — but we are groping our way through a mass of new works, 
with a full expectation of soon doing justice to the merits of this elaborate and truly 
beautiful work." — Boston Med. and Surg. Journal. 

" Moreau's treatise is another valuable work upon ihe science of Midwifery, with 
eighty of the most splendid lithographic plates we have ever seen. These illustra- 
tions ARE ENGRAVED WITH SO MUCH BEAUTY AND ACCURACY AND ITIIS SO LARUE A 

scale, that they cannot fail to present to the eye the precise relation of ihe foetus and 
of the parts engaged in labour, under every condition and circumstance, from the 
commencement of the state of natural parturiiion, to ihe most difficult and compli- 
cated labour. The profession are greatly indebted to French industry in pathological 
and special anatomy for the continued advance in the science of Obstetrics: and ihe 
work before us may be regarded as the completion of all ihat has accumulated in this 
department of medical science, greatly enhanced in value by many valuable original 
suggestions, to the proper arrangement of which the author has devoted a great 
amount of labour. The translation is faithfully and elegantly done and the work will 
be a valuable addition to the medical literature of our country." — The New York 
Journal of Medicine. 



PRINCIPLES AND PRACTICE OF MEDICINE. 

BY 

JOHN ELLIOTSON, M.D., F.1LS. 

COMPLETE IN ONE VOLUME. 

WITH NOTES AND ADDITIONS ADAPTING IT TO THE UNITED STATES. 

BY 

THOMAS STEWARDSON, M.D., 

THYSICIAN TO THE PENNSYLVANIA HOSPITAL. 

Among other additions, the American Editor has introduced entirely new 
articles upon 

REMITTENT FEVER AND YELLOW FEVER, 

AS WELL AS CONSIDERABLE ADDITIONS TO THE ARTICLE ON 

CONTINUED FEVER. 

" Under such circumstances, we cannot but congratulate the profession 
in this country that it has now been placed within their reach, under the 
auspices of an editor whose ample experience and especial study of fevers 
have enabled him to add several chapters and notes, which materially en- 
hance the usefulness of this treatise. We refer, in particular, to Dr. 
Stewardson's chapter on Remittent and Yellow Fevers, diseases so preva- 
lent in many sections of this country, and which had received. but very 
cursory notices in the original work. Dr. Stewardson has given an account 
of Cholera Infantum, a disease peculiar to this country, and which, there- 
fore, rarely attracts the attention of European writers." — American Medi- 
cal Journal, January, 1844. 



PRACTICAL TREATISE 

ON THE 

DISEASES OF THE TESTIS, 

AND OF THE 

SPERMATIC CORD AND SCROTUM. 



BY 

J. B. CURLING. 

EDITED BY 

P. B. GODDARD, M. D. 

" We have another instance of it in the work of Mr. Curling, a diligent labourer, 
who has carefully collected every fact within his reach, relative to the diseases of the 
testis and spermatic cord, producing a Volume that mat for mast tears be the 
Standard Work ox those Diseases. We shall conclude our notice with an extract 
relative to a new and promising method of treating varicose veins, and take leave 
of the volume by warmly recommending that it be added to the library of every sur- 
geon." — London Lancet, August, 1843. 

"A work on these diseases, not only superior to any yet published, but which, we 
imagine, is not likely to be soon superseded by a better." — British and Foreign Medi- 
cal Review. 

" Goddard's Curling. — Messrs. Carey & Hart, Philadelphia, have unquestionably 
the credit of publishing the most beautifully executed Surgical work that has yet 
appeared on this side of the Atlantic. The printer, Mr. Sherman, has proved that 
wood engravings may be as well printed here as in Europe. 

"This faithful reprint of Curling's admirable volume supplies a desideratum to 
the surgical literature of the day, having been carefully revised and enriched by 
several judicious notes by Dr. Goddard. AH surgeons and practitioners who have 
occasion to treat patients suffering from hydrocele, orchitis, or other diseases of the 
same locality, will be glad to possess this volume, being filled as it is, with practical 
instruction for the management of some of the most afflicting diseases man is 
heir to. 

" This intimation of the existence of a valuable and beautiful surgical book ought 
to be sufficient to induce practitioners, as well as students, to seek for, and examine 
it themselves." — North American. 



ENCYCLOPEDIA OF CHEMISTRY. 

Wow Ready, Parts 1 to 9, Price 25 Cents. 

THE 

ENCYCLOPEDIA OF CHEMISTRY, 

THEORETICAL AND PRACTICAL. 

Presenting a complete and extended view of the present state of Chemical Science, 
with its numerous and important applications to Medical Science, Agriculture, the 
Arts, and Manufactures; based upon the plan of the Dictionary of Chemistry, by Dr. 
Ure, and the Dictionary of Theoretical and Practical Chemistry, now publishing by 
Liebig, Poggendorf, Woehler, &c. 

BY JAMES C. BOOTH, 

Member of the American Philosophical Society, and of the Academy of Natural Sciences, 
Professor of Technical Chemistry in the Franllin Institute, and of Ele- 
mentary Chemistry in the Philadelphia High School. 

The facility for easy reference offered by the Dictionary, (rendering that form pre- 
ferable to any other for works on science and the arts,) has induced the author to 
adopt it in'the publication of an 

ENCYCLOPEDIA OF PRACTICAL AND THEORETICAL CHEMISTRY, 

which, while it will embrace all the latest discoveries in the pure science of chemis- 
try, shall at the same time exhibit the manifold applications of chemical principles 
and theories to every department of the useful arts. 

The rapid advancement of chemical science in the path of discovery within a 
few years, has created a demand for treatises upon this subject which has not been 
fully answered by the several elementary works lately issued from the English press. 

While these works must be mentioned with unqualified praise as text-books for the 
student of chemistry, it must at the same time be acknowledged that since they offer 
little more than an outline of the science, they cannot satisfy the thirst for more 
extended treatises, which may be employed as valuable works of reference by the 
advanced scholar, while their practical tendency shall enable the uninitiated to enter 
actively into the vast field of research. 

The ENCYCLOPEDIA OF CHEMISTRY is designed to meet the varied 
wants of the student of science, the physician, the agriculturist, and the manu- 
facturer. The first and second will find the whole theory of chemistry fully deve- 
loped, as contained in the original essays of all the great and leading chemists, 
among whom we place Berzelius, Liebig, Woehler, Rose, Mitscherlich, Zeisse, &c, 
Dumas, Pelouze, Fremy, &c, Graham, Kane, Hare, and many others in Europe, 
and in our own country. They will find all the important recent discoveries in 
organic and inorganic chemistry, and practical treatises on the several branches of 
analysis. 

The sciences of Mineralogy and Geology will receive their full share of attention, 
more especially in their chemical relations, and where they admit of such applica- 
tion. 

It will be seen from the hasty sketch of the design of the work presented above, 
that it is intended as a complete Encyclopedia of Chemistry both in theory and prac- 
tice, and that while the pure theoretic nomenclature will be adopted in the one part, 
the second shall be so developed as to bring it within the reach of those not fully con- 
versant with chemical principles. 

TERMS OF PUBLICATION. 

This work will appear in semi-monthly numbers, and in addition to numerous wood 
cuts, will contain many beautifully engraved plates, and will be completed in Twenty 
Numbers, at 25 cents each. 

CAREY & HART, Publishers. 
Extract from the Edinburgh New Philosophical Journal, October, 1844. 

"The Encyclopedia of Chemistry, Theoretical and Practical; presenting a com- 
plete and extended view of the present state of Chemical Science. By James C. 
Booth, Member of the Am. Phil. Society, &c; and Martin H. Boye, Member of the 
Am. Phil. Society. Carey & Hart, Philadelphia. Six Nos. of this work have reached 
us. Judging from the industry, research, and accuracy of the authors, we anticipate 
that when finished it will contribute to the advancement of Chemical Science, and 

FIND A. PLACE IN EVERT CHEMICAL LaBORATORT AND LlRRART. The Style tOO, in 

which it is got up is very creditable to the American publishers." 



IN PRESS, 

A WORK ON SURGICAL DISEASES. 

With about seventy finely engraved Plates, illustrative of the Pathology, 
and various methods of Treatment. 

IN ONE QUARTO VOLUME. 



. 



* * ARMY * * 
MEDICAL LIBRARY 

Cleveland Branch