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Full text of "A theoretical and practical treatise on the diseases of the skin"

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p.i iu,vcu, Lit* i j fm~ 



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