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PRACTICAL SYNOPSIS 



OF 



CUTANEOUS DISEASES, 

ACCORDING TO THE ARRANGEMFNT OF 

DR. WILLAN; 



EXHIBITING A CONCISE VIEW OF THE DIAGNOSTIC 
SYMPTOMS AND THE METHOD OF TREATMENT. 



BY THOMAS BATEMAN, M.D. F.L& 

FNTSICIAN TO THE PUBLIC DISPINSAKT, AND CONSULTINO PHTSICIAy 

TO THE FEVER IKSTITUTIOM. 



EDITED BT 

ANTHONY TODD THOMSON, M.D. F.L.S. 

MEMBER or THE &OTAL COLLEGE OF PHYSICIANS; 

PROFESSOR OF MATERIA MEDICA AND THERAPEUTICS, OF MEDICAL 

JURISPRUDENCE, AND OF CLINICAL MEDICINE IN THE UNIVERSITY OF LONDON ; 

PHTSICIAN TO THE NORTH LONDON HOSPITAL; 

ETC* ETC. 



LONDON: 

PRINTED FOR 

LONGMAN, REES, ORME, BROWN, GREEN, & LONGMAN, 

PATBRNOSTER-ROW, 
1836. 



* 



BOSTON MEDICAL LIBRARY 

WTHE 

FRANCIS A. COUNTWAY 

LIBW«Y OF MEDICINE 



ql(o- 



LOKDON : 

Printed by A. Spottiswoodb, 
New -StreeUSquare. 



ADVERTISEMENT. 



In putting forth a new edition of this work the Edi. 
tor, as in the last edition, has purposely refrained 
from altering the arrangement of the diseases of 
which it treats, except in three instances, which it will 
be readily seen are necessary ; from a desire that the 
work should still retain the stamp and impression 
given to it by its excellent Author* In stating his 
conviction that no arrangement is free from imper- 
fections, the Editor does not mean to enlist himself 
with those who affect to despise nosological arrange- 
ments : on the contrary, he accords with every sen- 
timent of the Author on this subject * \ and he believes 
that it is not by the loose manner of imparting in- 
formation, which has of late years prevailed in medi- 
cal writings, that a correct knowledge of the healing 
art can be communicated to the uninitiated, and the 
boundaries of the science of medicine extended. 

The chief object of the Editor has been to render 
the work as useful to the student as possible : with 
this view he has added the synonjrms of each genus 
and species ; and, by giving the definitions in a dis-^ 

* See the Preface. 
A 2 



IV ADVERTISEMENT. 

tinct form, he has endeavoured to impress on the 
whole a more definite character. The opportunities 
which have been afforded to him, from his connection 
with two extensive medical charitable institutions, 
have enabled him to add considerably to the prac- 
tical part of the work ; and he trusts that, in this 
respect, the present edition will be found not un- 
worthy of the confidence of the practitioner. It is 
the wish of the Editor still to improve the volume ; 
and he shall anKiousIy embrace every o^)ortunity 
i^hitk his bretliren may afford him of doing so, 
conscious that much may be done in advancing the 
treBtmetit (^ a class of diseases^ which have hitherta 
been regarded mare f^ affording c^portunities for 
em^rical experiments, than for the application of those 
prhiciples which are founded upoa an accurate knpw- 
ledge of physiology and pathology. He has aug-> 
minted greatly, at the close of each genus, the lists 
o£ the works which may be consulted on the diseases 
that constitute the genenu Much of tibe diffi.culty, 
indeed, which a young man has to encounter in the 
early pursuit of his profession, arises from his ignor. 
ance of the sources whence he c^n derive inform* 
lUion ) the Editor, therefore, is assured that this part 
€>[ his labours will be Justly appreciated. 

The advantage of plates to aid the descriptions of 
cutaneous emptkms is undeniable i for without such 
«A appeal to the eye it is almost impossible for the 
student to form a correct idea of the most accurate 
description. The delineations of the Author of the 
Synopsis are admirably calculated to fulfil such an 
object ; but they are executed on a scale of expense 



ADVERTISEMENT, V 

which places them far beyond the reach of the stu- 
dent* To supply a remedy for this obstacle in the 
path of the student, the Atlas of Plates of the £di« 
tor has been constructed. It contains almost all 
that really relates to the diseases delineated in Dn 
Bateman's plates, with the addition of several original 
representations. To give them the character of de- 
monstrations, the different stages of the eruptions, and 
other peculiarities necessary to be pointed out, are 
marked upon the plates. By this plan the trouble- 
some method of examining plates by means of letters 
and figures of reference is avoided ; and without les- 
sening in any degree the beauty of the representations, 
the utility of the plates is greatly enhanced. 

The Editor is perfectly sensible that his part of the 
volume is not free from defects : he trusts, however, 
notwithstanding these, that the merit of having en- 
deavoured to improve a most useful work will not be 
denied to him. He is responsible for all the parts, 
in the text, contained within inverted commas, and 
for those notes marked with his initial. Such as this 
edition is, he commits it to the Public and to the 
Profession ; and is willing to abide by their award, 
whether it be favourable or adverse. 

A- T. T. 



3. Hinde-strcet, Manchester-square, 
2d February, 1836. 



A 3 



THE AUTHOR'S PREFACE. 



Xo prevent any misapprehension in regard to the 
nature and object of this volume, it may be necessary 
to state, that it is not brought forward with any pre- 
tensions to supply the deficiencies which have been 
left in the valuable treatise of Dr. Willan, or to be 
considered as the completion of that original work. 
Its sole purpose is to present an abstract of the clas- 
sification proposed by that respected author, toge- 
ther with a concise view of all the genera and species, 
which he intended that it should comprehend. The 
materials for the description of the first four Orders 
have been obtained principally from Dr. Willan's 
publication, of which the first part of this Synopsis 
may be regarded as an abridgment ; some additional 
facts, however, have been supplied from subsequent 
observation* The remainder of the matter has been 
derived partly from personal experience and research, 
but principally from a constant intercourse with Dr. 
Willan, upon the subject of these diseases, during a 
period of ten years, while his colleague at the Public 
Pispensary, and from his own communications in his 
last illness, before he departed for Madeira, when he 

A 4 



viii author's preface. 

kindly undertook a cursory perusal of his unfinished 
MSS. for my information, during which I made 
notes relative to those points with which I was least 
acquainted. For it was, in fact, his wish, that the 
Profession should possess a sketch of the whole of 
his arrangement, even when the completion of his 
own treatise, though distant, was not without hope. 
Were I capable of following my learned preceptor 
through the literary and historical researches which 
enriched his publication, it would be altogether in- 
compatible with my plan. I have, however, deemed 
it advisable to introduce into notes some brief illus- 
trations and references, which, without interrupting 
the practical details, may satisfy the reader that the 
principles of the classification and nomenclature were 
not adopted vnthout the sanction of reason and au- 
thority. 

I am far from maintaining that this arrangement 
of cutaneous diseases is altogether free from material 
imperfections ; (for what artificial arrangement of 
natural objects has yet been devised, to which imper- 
fections may not be imputed ?) but I apprehend it will 
be impossible to study it carefUly and practically, with- 
out deriving benefit from the exercise. I am aware, 
indeed, that there are many individuals professing 
themselves to be practical men, who affect a contempt 
for all nosological disquisitions, and deem the discus- 
sions relating to nomenclature, in particular, very idle 
and frivolous, or, at the best, a sort of literary amuse- 
ment, which is not conducive, in the smallest degree, 
to the improvement of the medical art. But this I 
conceive to be a mistaken view of the subject, origin- 
ating, perhaps, from indolence, or from a want of 
habitual precision in the use of language. The in- 



author's preface. ix 

ferences of slight and superficial observation may, 
indeed, be detailed without recourse to a very de- 
finite vocabulary ; for, where little discrimination is 
exercised, very little nicety can be requisite in regard 
to the import of the language employed. But it is 
not by such means that the boundaries of science are 
extended. 

Among the manifest advantages of a copious and 
definite nomenclature, may be mentioned, in the 
first place, the necessity, which it demands, of an 
accurate investigation of phenomena, or, in other 
words, the habitual analytic turn which it tends to 
give to our inquiries, and therefore the general im- 
provement of the talent of observation, which it must 
ultimately produce. Secendly, it contributes to faci- 
litate the means of discrimination, by multiplying, as 
it were, the instruments of distinct conception ; for 
from a deficiency of terms we are apt to think and 
even to observe indistinctly. But, above all, a definite 
nomenclature supplies us with the means of communi- 
cating, with precision, the information which we 
acquire, and therefore contributes directly to the ad- 
vancement of knowledge, or, at least, removes an 
otherwise insurmountable impediment to its progress. 

In this view, such a nomenclature, as &r as re- 
gards the diseases of the skin, is obviously a great 
desideratum. For, while the language taught us by 
the fathers of medicine, relative to all other classes of 
disease, is clear and intelligible, the names of cutaneous 
disorders have been used in various acceptations, and 
without much discrimination, from the days of Hip- 
pocrates, and still more vaguely since the revival of 
learning in modem times. From that period, in- 
deed, the diseases of the skin have been generally 



X author's preface. 

designated by some few terms of universal import, 
which therefore carried no import at all. Hence the 
words Leprosy, Scurvy, Herpes, Scabies, Dartres, 
and some other appellations, have become so inde- 
finite, as to be merely synonyms of cvianeous dis^ 
ease. Even the more scientific inquirers, whose 
knowledge of diseases was not always equal to their 
learning, or whose learning fell short of their patho- 
logical skill, have inteipreted the generic and specific 
appellations of the ancients in various senses. They 
have not only differed, for instance, in their accept- 
ation of general terms, such 'as of the words, picstule^ 
phlyctcma^ exanthema^ erythema^ pht/ma^ phlyza- 
cium, &c.; but the particular appellations Lichen^ 
Psora^ HerpeSy Impetigo^ Porrigo^ ScabieSy and 
many others, have been arbitrarily appropriated to 
very different genera of disease. The practical 
errors, which must necessarily have resulted from 
such a confusion in the use of terms, are very nu- 
merous, as every one must be satisfied, who has 
attempted to study the subject in books. It may 
be sufficient to allude to the gross misapplication 
of the remedies of the petechial or sea-scurvy, which 
have been prescribed for the cure of inflammatory, 
scaly, and pustular diseases, merely because the epi- 
thet scorbutic has been vaguely assigned to them all; 
and to specify the single instance of the adminis- 
tration of tincture of cantharides in the scaly Lepra, 
on the recommendation of Dr. Mead, who, however, 
seems to have spoken of the tubercular Elephantiasis, 
or the non-squamous Leuce ; although it would be 
very difficult to ascertain his meaning. 

Most of the writers, who have composed express 
treatises on cutaneous diseasesi in modern times, 



author's preface. xi 

have implicitly adopted the nomenclature of the 
ancients, without attempting to render it more defi- 
nite, or to improve upon the diagnosis which they 
had pointed out. The essays of Mercurialis, Hafen- 
reflfer, Bonacursius, and Turner, were written after 
this manner ; and even Lorry, in his able and elegant 
woric, does not step far out of the ancient path. 
About the year I78O, however, an elaborate classi- 
fication of the diseases of the skin was published by 
Prof. Plenck, of the university of Buda ; and subse- 
quently to the commencement of Dr. Willan's pub- 
lication, a sort of arrangement has been proposed, 
in the splendid and pompous perfonnance of M. 
Alibert, which, however, is altogether destitute of 
method. 

The arrangement of Plenck is founded upon the 
same principles as that of Dr. Willan, namely, upon 
the external appearances of the eruptions : but, in 
filling up the scheme, he has deviated widely from 
the strict laws of classification which naturalists have 
established. Nine of his fourteen classes very nearly 
correspond with the eight orders of Dr. Willan.* 
These are, 1 . Maculae ; *2. Pustulae j 3. Vesiculae j 
4. Bullae ; 5. Papulae 5 6. Crustae ; 7. Squamae ; 
8. Callositates ; and 9* Excrescentiae. But the five 
remaining classes comprise, 10. Ulcera; 11. Vul- 
nera ; IS. Insecta cutanea ; 13. Morbi Unguium ; 
and 14. Morbi Capillorum, which are less judici- 
ously devised. But such a classification must fail to 
answer its end, because it requires the different stages 

f It sesms probable, indeed, that Dr, Willan was indebted to tbb 
work of Professor Plenck for the groundwork of his classification ; 
since his definitions, as well as his terms, accord accurately with those 
of the Hungarian nomologist. 



Xii AUTHOR^S PREFACE. 



of the same disease to be considered as so many dis- 
tinct maladies, and to be arranged in several classes. 
For example, the Crust®, and the Ulcera cutanea are 
equally the result of Pustules, Vesicles, and Bulbs, 
and sometimes even of Scales : hence, while Small* 
pox and Scabies are arranged among the Pustules, 
and Lepra (by which he underst^ds Elephantiasis) 
among the Papulae, the Crusts, which succeed them, 
are all brought together ^s species of one genus, 
in the class of Crustas. In like manner, particular 
symptoms are classed as distinct genera : thus the 
"Rugositas" and the "Rhagades** of the same 
Elephantiasis are found in the classes of Squams dnd 
Ulcera respectively. In short, this Elephantiasis is 
divided into no less than four genera, and its parts 
arranged under four different classes-*-an eiTor, which 
renders the purposes of the classification almost nu- 
gatory, 

M. Alibert, with loud pretensions to superior 
skill, and much vaunting of the services which he 
has rendered in this department of medicine, has, in 
fact, contributed nothing to the elucidation of the 
obscurity ii^ which it is veiled. The merit of his 
publication belongs principally to the artists, whom 
he has had the good fortune to employ : for he ha» 
adopted the ancient confusiofi of terms, without a 
single definition to fix their acceptation ; and he has 
not scrupled to borrow the nomenclature of the vul* 
gar, in its most vague and indeterminate sense. He 
has, moreover, thrown together his genera, without 
any attention to their affinity or dissimilarity, making 
an arbitrary whole of disjointed parts. Thus his 
arrangement commences with, ** Les Teignes" (Por- 
rigo), which are followed by " Les Pliques" (Plica 



author's preface. Xlll 

or Trichiasis)^ and by ** Les Dartres" (which seems 
to be equivalent to our vulgar and indefinite term 
Scurvt/) ; and he then passes to the discolorations, 
called «• Ephelides/'*— to some eruptions, which he 
chooses to call " Cwicroides," but which are not 
intelligibly described,— • to the eomprehenssve Lepra 
— ^ to FramboBsia, «— and to Ichthyosis. 

But the total defect of discrimination and (^ me* 
thod is still more obvious in M. Alibert's distribution 
of the species* The Dartres, for instance, are said 
to be erf* seven kinds, — furfuraceous, scaly, crustace^ 
dus, phagedenici pustular, vesicular, and erydemoid ; 
so that, in fact, the appellati(m has an universal 
fitness to almost every form of cutaneous disease ; it 
includes, at least, the Pityriasis, Psoriasis, Lepra, 
Impetigo, Ecth3rm3, Herpes, Acne, Sycosis, Lupus, 
and Erythema of this classification. In like man- 
ner, the L^ra includes some forms of the scaly 
disease properly so called, together with Leuce or 
Vitiiligo^ the tubercular Elephantiasis, and the Bar- 
badoes leg* Thus he unites, under the same gene- 
ric namC) diseases which have no affinity with each 
other. 

From these gross errors the classification of Dr. 
Willan ^>pears to be entirely free ; and the imper- 
fections, which confessedly belong to it, are probfd)ly 
inseparable from the nature of the subject. The 
truth is, that the various genera of cutaneous dis- 
ease, as characterised by their external ^pearances, 
do not differ in the same essential d^ree in which 
the diseases of ot^ans of various structure differ from 
each other. The same exciting cause will produce 
different kinds of cutaneous disorder in different 
individuals: thus, certain substances, which suddenly 



xiv author's preface. 

* 

derange the organs of digestion, sometimes produce 
Urticaria, sometimes Erythema and Koseola, and 
sometimes even Lepra and Psoriasis ; yet each of 
these shall retain its specific chai^acter, and follow its 
peculiar course: thus also certain external irritants 
will, in one case, excite the pustulgs of Impetigo, 
and in another the vesicles of Eczema. Again, the 
diseases which commence with one generic character 
are liable occasionally to assume another, in the 
course of their progress : — thus, some of the papu- 
lar eruptions become scaly, and still more frequently 
pustular, if their duration be long protracted ; the 
Lichen simplex and circumscriptus, for instance, 
sometimes pass into Psoriasis; the Lichen agrius 
and Prurigo formicans are occasionally converted 
into Impetigo ; and the Prurigo mitis is changed to 
Scabies. Moreover, it frequently happens, that the 
characteristic forms of eruptive diseases are not pure 
and unmixed, but with the more predominant ap- 
pearance there is combined a partial eruption of 
another character ; thus, with the papular Stro- 
phulus, with the rashes of Measles and Scarlet 
Fever, and with the pustular Impetigo and Scabies, 
there is occasionally an intermixture of lymphatic 
vesicles. And, lastly, the natural progress of many 
eruptions is to assume a considerable variety of 
aspect; so that it is only at some particular period 
of their course that their character is to be unequi- 
vocally decided. Thus in the commencement of 
Scabies papuliformis and lymphatica, the eruption is 
of a vesicular character, although its final tendency 
is to the pustular form : and, on the contrary, in all 
the varieties of Herpes, the general character of the 
eruption is purely vesicular: yet, as it advances in 



AUTHOR^S PREFACE. XV 



its progress, the enclosed lymph of the vesicles ac- 
quires a considerable degree of opacity, and might 
be deemed purulent by cursory observers. In like 
manner, the original pustular character of some of 
the forms of Porrigo is frequently lost in the accu- 
mulating crusts, the confluent ulcerations, and the 
furfuraceous exfoliations, which ensue, and which 
conceal its true nature from those who have not seen, 
and are unacquainted with, the whole course of its 
advancement. 

These circumstances constitute a series of natural 
impediments to every attempt at a methodical ar- 
rangement of cutaneous diseases. But it is more 
philosophical, as well as practically useful, to com- 
promise these difficulties, by retaining in the same 
station the different appearances of a disease, in its 
different stages and circumstances, when our know- 
ledge of the causes and remedies, as well as of the 
natural progress and termination of it, is sufficient 
to establish its identity, — than to separate the vary-, 
ing symptoms of the same disorder, and to distribute 
the disjecta memhra^ not only under different genera, 
but into different classes of the system, after the 
manner of Prof. Plenck. Such was the method 
adopted by Dr. Willan; and although it may 
sometimes diminish the facility of referring individual 
appearances to their place in the nosological system, 
yet it greatly simplifies the classification, as well as 
the practical indications to which it conducts us. 

If, then, the adoption of the arrangement and 
nomenclature, of which a Synopsis is here given, 
should lead to more clear and definite views of the 
various forms of cutaneous disease, and should enable 
practitioners to write and converse respecting them 



XVi AtJTHOR's PREFACE. 

with perspicuity, by fixing the meaning of the terms 
which they employ, we may consider this as an im- 
portant object gained : and it will at length, perhaps, 
be found, that, for the successful treatment of these 
diseases, the discovery of new medicines is less ne- 
cessary than a discriminate appropriation of those 
which we already possess. 

I am fully aware that it is very difficult to convey 
by words, used in an acceptation that is not familiar, 
distinct notions of many of the minute changes of 
appearance in the i^in; and that one great defici- 
ency, which Dr. Willan's large work was calculated 
to supply, by means of the engravings which ac- 
companied it, will be left unprovided for by this 
Synopsis. Perhaps, however, this defect will be 
partially obviated ' by the plate prefixed to this 
volume, in which I have endeavoured to convey an 
idea of the fundamental principles of the classifica- 
tion, as well as to designate the characters of some 
of the more remarkable genera of cutaneous disease. 

T. B. 



XVll 



Arrangement of the Diseases of the Skin, altered from that by 

Dr. Willan. 



ORDER I. 
PAPULA. 

STROPHULUS - 


Page 
. 3 


VI. 
VESICULiE 

VARICELLA 


. Page 
- 257 


LICHEN 


- 9 


VACCINIA 


- 2f)6 


PRURIGO 


- 20 


HERPES 


- 276 


XL 
SQUAMJE. 




RUPIA 
MILIARIA 


- 296 

- 305 


LEPRA 


- 34 


ECZEMA 


- 305 


PSORIASIS 


- 50 


APHTHA 


- 316 


PITYRIASIS -• 


- 64 


VII. 




IIL 
EXANTHEMATA, 


TUBERCULA. 

PHYMA . . 325 


RUBEOLA 


- 72 


MOLLUSCUM 


- 326 


SCARLATINA 


- 87 


VITILIGO 


- 328 


URTICARIA 


- 106 


ACNE 


- 330 


ROSEOLA 


- 114 


SYCOSIS 


- 345 


PURPURA 


- 123 


LUPUS 


- 350 


ERYTHEMA 


- 138 


ELEPHANTIASIS 


- 352 


ERYSIPELAS 


- 145 


FRAMB(ESIA 


- 370 


IV. 
BULLAE. 

PEMPHIGUS 
POMPHOLYX 


- 163 

- 166 


ICHTHYOSIS 

VIII. 
MACULE. 
EPHELIS 


-377 
- 386 


V. 

PUSTULJE. 




NJEVUS, SPILU8, &C. 389 

IX. 


IMPETIGO 
PORRIGO 


- 174 

- 202 


DERM AT, EXCRES- 
CENCES. 


ECTHYMA 


- 219 


VERRUC A 


sm 


VARIOLA 


- 230 


CLAVUS 


■ 397 


SCABIES 


. 240 


CALLUS 


- 398 



a 



Recently nsoere published by Longman^ Reesy Orme^ 4* C(9. 

1. DELINEATIONS of the CUTANEOUS DISEASES comprfecd 
in the Classification of the late Dr. Willan ; including the greater part 
of the Engravings of that Author, in an improved State, and completing 
the Series as intended to have been finished by him. . 

By the late T. BATEMAN, M.D. F.L.S., &c. 
In one volume, 4to, with upwards of 70 coloured plates, 

price 12/. 12*. boards. 
The Series of New Engravings, representing those Diseases which 
should have been figured in the subsequent Parts of Dr. Willan's un- 
finished Work, may be had by the possessors of that Work, separate, 
price 7/. boards. 

Also, 

2. An ATLAS of DELINEATIONS of CUTANEOUS ERUP- 
TIONS ; illustrative of the Descriptions in Dr. Bateman's " Practical 
Synopsis of Cutaneous Diseases." By A. Todd Thomson, M.D. and 
F.L.S. Professor of Materia Medica and Therapeutics in the University 
of London, &c. Royal 8vo. 29 coloured Plates, 3/. 



EXPLANATION OF THE PLATE. 



The eight compartments of the plate exhibit the eight forms of 
cutaneous eruptions. 

Fig. 1. represents five varieties of Fapulce, as they are seen in (a) 
Strophulus confertus, (b) Lichen simplex, (c) Lichen pilaris, (d) Lichen 
lividus, and (e) Prurigo mitis. 

Fig. 2. shows the Scales and circular patches of Lepra yulgaris. 

Fig. 5, exhibits two forms of Exanthemata or Rashes, viz. (f) the 
Measles, and (g) the febrile Nettle-rash. 

Fig. 4. shows the Btdlcd of Pompholyx diutinus, in different stages of 
their progress. 

Fig 5. illustrates the four forms of Pustules^ namely, the Phlyzacia, 
as they appear in (h) Ecthyma vulgare, and in (i) Scabies purulenta 
upon the hands ; — the Psi/dracia, as they arise in (k) Impetigo, and 
afterwards form a scab ; — the Achores (1) of Porrigo scutulata, on the 
scalp ; — and the Favi (m) as they appear on the sca^ and other parts. 

Fig. 6. contains three genera of Vesicles; namely, patches of (n) 
Herpes zoster, and (o) Herpes phlyctaenodes ; (p) Miliary vesicles; 
and (q) the Vaccine vesicle. 

Fig. 7. exhibits different forms of Tubercles; as in (r) Acne punctata, 
and (s) Acne indurata; in (t) Sycosis; and (v) Molluscum. 

• 
Fig. 8. contains specimens of Macula; viz. (w) a Naevus compared 

to the stain of red wine ; (x) a spider Nsevus; and (y) a mole. 






PRACTICAL SYNOPSIS 



OT 



CUTANEOUS DISEASES. 



i«WI 



Order I. 

PAPULA 

SyN. 'Eligfwa ( (7.) : Exormia ( Good) : Papula 
(Sauv. Lin.) : Bouton, Elevure, Papule (-F.) 2 die 
Finne, Knoten ( Oer.) : Sheri (Arab.) : Pimples. 

Def. Papula ( Pimple) : a small and acumi- 
nated ELEVATION OF THE CUTICLE, WITH AN IN- 
FLAMED BASE, VEEY SELDOM CONTAINING A FLUID, 
OR SUPPURATING, AND COMMONLY TERMINATING 
IN SCURF,* 

Papula, or Pimples, are generally supposed to 
originate in an inflammation of the papilla of the 

* The term Papula has been used in various acceptations by the 
older writers, but the nosolc^ts hare neariy agreed in restricting it to 
the sense here adopted. Sauvages defines it, " Phyma parvulum, 
desquamari solitum. (NosoL Meth. class i. Synops. ord. iL 6.) The 
definition of Linnaeus is " Tuberculum hretum, coloratum^ inflam- 
matuniy vix suppurandum» ' (Linnaei Gen. Morbor. class xi. ord. 4.) In 
this sense also Celsus seems to have understood the term^ although he 
uses it generdly : for when he calls it a disease, in which ** the skin is 
made rmtgh and red by very minute pnstules," he means obviously dry 
papulae ; as by the word pustula he understands every elevoHon of the 
skin, even wheals. (De Med., lib. v. cap. 28. §^ 15. and 18. 

Dr. Mason Crood derives the term Papulae from irairiro^, the sprouting 
of down or buds ; and regards the radical sense to be '* production, or 
putting forth." He derives the terminating diminutive from the Greek 
iaXfi^ ** materia, materies,'* thus. Papulae, ** of the matter or nature of 
Pappus." (Nosology, p. 4«o.) T. 



i 



2 . papula: * 

skin, by which these are enlarged, elevated, and in- 
durated, and made to assume more or less of a red 
colour. It is, however, equally probable that the 
minute elevation which constitutes k pimple, is the 
consequence of inflammation in a capillary vessel ; 
and, as Mr. Plumbe has suggested, " a minute 
escapement of lymph " from it. * We even perceive, 
sometimes, thdt a slight effiision of lymph has taken 
place, which gives a vesicular appearance to several 
of the papulae ; but the fluid is re-absorbed without 
breaking the cuticle ; and papulae terminate for the 
most part in scurf. 

" Papular diseases are generally more or less of 
long continuance, one crop of pimples succeeding 
another for months, and even years, if allowed to 
run their course. They are not always attended 
by constitutional disturbance, nor are they dangerous 
diseases, although some of them resist eveiy plan of 
treatment, and render the life of the patients truly 
wretched.'* 

<* The whole cuticular surface is liable to be 
affected by papulae ; but they appear usually more 
on the extremities and the posterior part of the 
trunk, than on the face. These are preceded by a 
sensation of itching ; and then display themselves as 
small prominent points, not always to be detected by 
the eye, but generally palpable to the finger : their 
common termination is resolution, but occasionally 
ulceration supervenes, which alters the character of 
the disease ; but even when this does not occur, the 
parts of the skin occupied by the papulae are stained 
(if a brownish colour, which remains for a long time, 
sometimes for yeai-s.'* 

** The causes of papular diseases are not very 
evident ; a few of them seem to depend on a low 
state of vitality connected with age, privations, and 
the neglect of personal cleanliness." 

* Prac. Treatise on Diseases of the Skin, lit ed. p. 187. 



STROPHULUS. 3 

'^Tliey may be confounded with some pustular 
aoid vesicular diseases ; as, for example, some forms 
of ecthyma, scabies, and eczema, in their early 
stages ; but as these diseases proceed they are readily 
distinguished, and in general the diagnosis of the 
papulae is not difficult." 

The varieties of papulous eruptions are comnre- 
heanded in this arrangement under three genera ; 
namely, 

1. Strophulus, 

2. Lichen*, 

3. Prueigo. 



Genus I. STROPHULUS- 

Syn. Licheniasis Strophulus ( Young) : Exanthema 
Strophulus {Parr) : Lichen Strophulus (Biett) : Bou- 
ton, Efflorescence cutanee, Ebulhtion, Feux de Dents, 
Strophulus (F.) : Carpang ( Tamool) : Gvm Rash. 

Def. An eruption of pimples in early infancy, 

CHIEFLY ON THE FACE, NECK, ARMS, AND LOINS ; 
GENERALLY IN CLUSTERS, SURROUNDED WITH A 
REDDISH HALO. 

This genus comprises several papular affections, 
peculiar to infants, which ai*e known by the common 
appellations of red gurriy tooth eruption^ &c. They 
arise, in consequence of the extreme vascularity and 
irritability of the skin at that period of life, when 
the constitution is accidentally disturbed by irrita- 
tions, either in the alimentary canal or other parts 
of the habit ^ or in the gums* Much of the 
irritation in the alimentary canal is connected with 

* Raver regards Strophulus merely as a modification of Lichen in 
youo^ mfants; and there is much probabilky in his remark. See 
Trmti Thiorique et Pratique des Maladies de la Peau, 8vo. Paris, 1826. 
vol. i. p. 567. Biett has altogether rejected Strophulus as a generic term, 
and classes the five species of this synopsis under one species of Lichen, 
which he has named Lichen Stropkulus, See Abree4 Pratique des 
Maladies de la Peau^ &c. pour A. Cazanave, et H. E. Schledel, 8vo. 
Hurts, 1898, p. 970. T. 



4 PAPUL:E : 

irregularities in the diet of the mother ; and from 
overfeeding the infant, even when it is nourished 
entirely upon the breast; ^*and seem to be critical when 
they appear, as the functional disorder ceases. Their 
duration varies as the influence of the <jauses that 
produce them are transitory, intermittent, or per- 
manent." As these eruptions are not, however, 
very important ofbjects of medical practice, but in- 
teresting only from their occasional resemblance to 
some of the exanthemata, I shall not dwell upon 
them at any laigth. " It is necessary, however, to 
guard the infant from sudden exposure to cold 
during the continuance of these eruptions ; for, 
when repelled, the system generally suflFers, and 
sometimes convulsions supervene/' 

** Strophulus can only be confounded with Lichen, 
but the age of the patient may usually determine the 
point ; the latter sddom occurring in young infants.** 

There are five species of Strophulus : 

1. S. intertinctits. 4. S. volaticus^ 

2. S. albidus. 5. S. candidus. 

3. S. confertus. 

Specjes 1. Strophulus inter tinctusy Red Gum 
or Gown. 

Syn. Tadhes de Lait, Efflorescence benigne {F.) : 
Rothe ( Oer.) : Cheng Carapang (Tamooi) : Kurpan 
(Duk.): Carapanie ( TeL): Rooshitum (Sans.)i lied 
Gum. 

This species of Strophulus (Plate I. of Bateman ; 
PL 1. of Thomson's Atlas,) is characterized by 
papulae of a vivid red colour, situated most commonly 
on the cheeks, fore-arms, and back of the hands, but 
sometimes universally diftused. They are usually 
distinct from one another ; but are intermixed with 
red dots, or stigmata, and often with large red erythe- 
matic patches, which have no elevation. Occasionally 
a few small vesicles appear on the hands and feet ; 
but these soon desiccate, without breaking. ". It 



STROPHULUS. 5 

continues from three to four weeks, and generally 
terminates in scurf/* 

This eruption is often obviously connected in young 
infants with a weak, irritable state of the aUmentary 
canal, and consequent indigestion*; whence it is 
frequently preceded by sickness of stomach, and some- 
times by diarrhoea. But in its ordinary mild form it 
is not inconsistent with good health, and requires 
little medical treatment. Daily ablutions with tepid 
water, which remove sordes, and promote an equal 
perspiration, are beneficial ; and a proper attention 
should be enforced both to the kind and quantity of 
the aliment, and to the regularity of exercise affonled 
to the child. The cold bath, or even exposure to a 
stream of cold air, should be avoided dunng the oc- 
currence of this eruption ; and if, in consequence of 
want of caution in this respect, the eruption shall 
have disappeared, and sickness, purging, or any other 
internal disorder have ensued, a warm bath affords 
the most speedy relief: — " mild aperients, as Rhu- 
barb and Magnesia, combined with a few drops of 
the Spiritus Ammoniac compositus internally, or some 
other slight cordial, and the stimulus of a blister ex- 
ternally, have been found beneficial under these cir- 
cumstances.*' t 

Species 2. Strophulus cdbiduSj White Gum. 

This species (Plate II. of Batemak ; PL 1. of 
Thomson's Atlas,) is rather a variety of the pre- 
ceding than a distinct species ; and is occasionally 
intermixed with it ; the papulae consisting of minute, 

* Dt, Underwood, with much truth, remarks that eferj species of 
Strophulus is the effect of a predominant acid. Treat, on the Diseases 
of Children, Sto. 8th edition, p. 167. T. 

J See Underwood on the Diseases of Children, voLi. p. 79. 5th edit., 
Armstrong on the same subject, p. 84. These alternations of internal 
and super^ial <lisorder, though not so frequentl)^ seen under modern 
managemeft as under that of the older physicians, take place occasionally 
in Strophulus, as well as in the measles, and some other exanthemata. 
In such cases, diarrhoea, tormina, sickness, and sometimes a tendency to 
syncope or convulsions, ensue. 

B 3 



hard, wfaidsh specks, a Btde elevated, and stNuetimei 
surrounded by a slight redness, and a^earing chiefly 
on the face, neck, and breast. 

Speclbs 3. Strophulus con^irtuSf Rank Heh 
Gum, the Tooth-Rash. 

Strophulus confirtus (Plate III. fig. 1. of Bate* 
MAN ; PI. 1. of Thomson's Atlas,) is distinguished 
principally by the more extensive crop of ** confluent" 
papulae which appears, <' and the degree of feverish 
excitement with whidi it is generally attended.'* 
The patches of papulae are chiefly seated on the 
cheeks and forehead, when they occur about the 
fourth or fifth month, and are smaller, more crowded, 
and less vivid in their colour, than in the first species. 
But in children seven or eight months old, they ap- 

Cr in large irregular patches, on the outside of the 
ids, arms, shoulders, and loins, and are hard and 
close set, so as to give to the whole sur&ce a high red 
colour. In about a fortnight they b^in to fade and 
exfoliate, and gradually d£appear. 

Sometimes, though rarely, a varkty of the S. con- 
fertjm appears on the legs, spreading upwards even 
to the loins and navel, producing a general redness 
of the cuticle (not unlike Intertrigo*), which cracks 
and separates in large pieces, occasioning much dis- 
tress to the child. " The patches on the lower ex- 
tremities are always accompanied with trouUesome 
itching.*' This form of the disease is liable to recur 
at short intervals, ioft the i^>ace of two or three 
months. 

The S. confertus requires no specific medical treat- 
ment, as it appears to be one of the numerous symp- 
toms of irritation arising from dentition, and recedes 
soon after the cutting of the first teeth, t It can 

* In Intertrigo the surface is free from papulae ; is sbinii^ and uni- 
formly red ; and is generally confined to the nates and thighs. T. 

f Dr. Bisset, a physician of the old school, but a man of observation^ 
notices a circumstance respecting children affected with these eruptions, 
which I think I have seen confirmed in a few cases. After stating that 



STROPHULUS. 7 

only he alleviated '' by dcarifying the gums, so as to 
assist the protrusion of the teeth ; by the adminis- 
tration of mild aperients* such as Hydrargyrus cum 
creta ; ** and by the general treatment proper for the 
state of teething, with great attention to cleanhness, 
and frequent tepid ablution with milk and water. In 
India, the native physicians touch the excoriated parts 
with a little pure castor oil. ** The application of 
vinegar largely diluted with water generally allays the 
itching.** 

Sf£cies 4f. Strwhulus volaiicu$. Wildfire 

Syn. Erythema volaticum {Sauv.)". Feu volage 
(JF.) : Collie Carpang ( Tamool). 

This species (Plate III. fig. 2. of Bateman; PL 1. 
of Thokson's Atlas,) is not a frequent complaint. 
It is characterized by small circular patches, or clus- 
ters of papulae, grouped together, arising and ex- 
^^liatmg successively on different parts of the body, 
of a high red cdour, and sometimes attended with 
slight feverishness. Each patch turns brown in 
about four days, and begins to exfoliate ; and the 
whole series terminates in three or four weeks. 

This eruption is usually connected with a dis- 
oi*dered state of the stomach and bowels, and is 
alleviated by gentle laxatives; after which the de- 
coction of Cinchona, " or infusion <rf Calumba with 
Subcarbonate of Soda,*' or a slight chalybeate *, 

*' some cbUdren arie vmxh or less afiected with it till they have got all 
their first teeth, in spite of every endeavour to repress it, and after that 
period it recedes spontaneously ;'* he adds, " but in that case they are 
apt to have carious teeth after the eruption disappears.** See his Med. 
Essays and Obs. § xix. p. 274. 

• I shall take this opportunity of recommending to the attention of 
practitioners a chalybeate medicine, particularly adapted, from its taste- 
less quality, to the palates of children, and possessed of more efficacy 
than the vinum ferri ; I mean a watery solution of the tartrite of iron, 
lately introduced by an able and intelligent chemist, Mr. R. Phillips. 
See his Experimental Examination of the Pharm. Londinensis, 1811. 
Its (jualities have been weli stated by Dr. Birkb«ck> in the London 
Medical Review, No. xix. July, 1812. 

B 4 



8 • PAPULiE : 

namely, from five to ten minims of the solution of 
Hydriodate of Iron * prove serviceable. No external 
{^plication is necessary, ** unless the itching is dis- 
tressing to the infant; in which case, the patches 
may be sponged with vinegar diluted with two parts 
of water j or they may be touched with saliva.** 

Species 5. Strophulus candidv^y Pallid Gum 
Rash. 

This species (Plate III. fig. 3. of Bateman; PL 1. 
of Thomson's Atlas,) is distinguished by papulas 
of a larger size than those of the foregoing species, 
having no inflammation round their base, and a 
smooth and shining surface ; whence they appear to 
be of a lighter colour than the adjoining cuticle. 
They are most frequently seen on the loins, shoul- 
ders, and upper part of the arms ; but I have ob- 
served them also on the face and neck, when the S. 
confertus occupied the fore-arms: after continuing 
hard and elevated for about a week, they gradually 
disappear. This variety of Strophulus commonly 
succeeds some o( the acute diseases, to which infants 
about a year old are liable. It has occurred also on 
the arms, when the fece was occupied with Porrigo 
larvalis ; and, in one case, it appeared on the arms, 
thighs, and neck, at the age of three years and a 
half, during the cutting of the double teeth. It re- 
quires no particular treatment, except to regulate the 
bowels vdth some mild aperient 

Works which may be consulted on this genus xif PtxpuUe : •— 

Bisset's Medical Essays and Observations, Bvo. 1766. 

Plumbe On Diseases of the Skin, 8vo. 2d edit. 1827. 

Rayer, Trait^ des Maladies de la PeaU| SVow 1826. 

Abr^^ Pratique des Maladies de la PbfiiJ^ar A. Cazenave et H. C. 
Schedel. 8vo. 1828. 

WiLLAN On Cutaneous Diseases, 4to. 1808. 

Underwood On the Diseases of Children, edited by Dr. Merriman, 
8VO. 1827. 



* This solution contains gr. iij. of the solid salt in fjj. of the fluid. 



LICUEK. 



Genus II. LICHEN. 

Syn. Au^^riv (O.): Exormia lichen (Good): 
Lichen, Dartre farineuse, pouss^e, Dartre pustu- 
leuse miliaire, Papules (F.) : der Zitterich, Ilechte 
( German) : Licherurus Rash. 

Def. A DIFFUSE ERUPTION OF RED PAPULiE, 
SOMETIMES DISTINCT, SOMETIMES IN CLUSTERS ; 
ACCOMPANIED WITH A TROUBLESOME SENSATION OF 
TINGLING OR PRICKING, AND USUALLY TERMINATING 
IN SCURF, OCCASIONALLY IN EXCORIATIONS; RECUR^ 
RENT, NOT CONTAGIOUS, • 

The original acceptation of the term Lichen is 
not distinctly ascertained from the writings of Hip- 
pocrates, and therefore it has been variously inter- 
preted by succeeding writers,! The majority have 
deemed it synonymous with the Impetigo of the 
Latins: but, as Foes, De Gorter, and other able 
commentators hav6 remarked, the Impetigo de^ribed 
by the highest Roman authority, Celsus, is a very 
different disease ; while the Papula of the same author 
seems to accord more accurately with the Lichen 
of Hippocrates, t Whence Dr. Willan decided on 
affixing the appellation to a papular affection. 

* I have ventured to alter the definition of Dr. Willan, for the same 
reason which induced Dr. Good to take a similar step. In Willan's 
definition, which was adopted by Dr. Bateman, in the former editions 
of this work, the expressions " affecting adults," and ** connected with 
internal disorder," are at variance with some of the species of the 
genus. T. 

f Hippocrates classes the Ktvxi\viq with Prurigo, Psora, Lepra, and 
Alphos, without particularizing their characteristic forms. See his 
npoppt^rucoi;, lib. ii. and his booK IIcpi Ila^wi/, where he considers them as 
blemishes rather than diseases. It would seem, indeed, that the Greek 
writers after him looked upon the Prurigo, Lichen, Psora, and Lepra, 
as progressive degrees of the same aiTection ; the ^rst beins a simple 
itching, — the second, itching combined with roughness of the skin — 
the third, itching with branny exfoliations, — and the last, itching with 
actual scales. 

X See Foes. CEconom. Hippocr. — De Gorter, Medicina Hippocrat. 
aph. XX. lib.iii. The latter observes, respecting this aphorism, ** In hoc 
loco, Hippocr. per Leichenas intelligit tal^m cutis faedationem, in qua 
summa cutis pustulis siccis admodum prurientibus exasperatur— -sed 



10 PAPUUB : • 

<< It is sometimes an acute, but more commonly 
a chronic affection : and it is developed, occasionally, 
on all parts of the surface, although, most frequently, 
the hands, the fore-anns, the neck or the face are 
the places affected. The eruption appears in suc- 
cessive crops, some shewing themselves, whilst others 
are on the decline, and consequently it runs no de- 
terminate course. These attacks are not necessarily 
preceded by fever. 

*^ The chief existing causes of Lichen are, 1. the 
applitetion of sudden excessive heat, either natural 
or artificial, to the surface ; 2. improper diet, either 
in quantity or quality ; and the abuse of dcoholic 
fluids* 

*' The Prognosis in Lichen may be always favour- 
able, except in respect to duration and difficulty of 
removal. In the severer forms, it sometimes resists 
every form of treatment.** 

There are seven species of this eruption : 

1. L. simplex. 5. L. Uvidus. 

2. L. pilaris. 6. L. tropicus. 
S. L. cifrcumscriptus. 7* L. urticatus. 
4. L. agrius. 

Species 1. Lichen simplex^ Simple Lichen. 

This species ^Plate IV. fig. 1. of Bateman; PI. 2. 
of Thomson*s Atlas,) is an eruption of red inflamed 
opaque papulae, containing no fluid, first appearing 
on the face or on the arms, and extending, in the 
course of three or four days, to the trunk and lower 
limbs. It is sometimes preceded for a few days by 



quia humor totus fere volatilis eet, non relinquit squamas ut Lepra ne- 
que furfures ut Psora, sed siccam et asperam pustulosam cutim." . It is 
to be recollected that pusiula, among the ancients, signified any eleva- 
tion of the cuticle ; and therefore pustulte siccae are papulse* If the 
Lichen, then, be viewed in its concluding stage, when it exhibits a slight 
furfuraceous roughness, it may be said to have some affinity with the 
scaly diseases mentioned above ; and, in fact, it sometimes terminates in 
Psoriasis. See Aetius, tetrab. ii. serm. iv. cap. 16. — Actuar. lib. ii. 
cap. 1 1. «- ' Celsus de Me<ticina, lib. v. cap. ss. 



LICHEN. 1 1 

sH^ ifebrik irritation, which coimnoiily ceases when 
the eruptkm appears : << but this does not always 
happen, and the disease occasionally occurs after great 
exercise in the best state of health," The eruptioii 
is accompanied with an unpleasant sensation of ting- 
lingy espec^ly in the night, or when the habit is 
heated by exercise: it continues nearly stationary 
about a week, when its colour begins to fade, and the 
skin soon exhibits numenms scurfy exfoliations, which 
remain longest about the flexures of the joints. The 
duration of the complaint raries considerably, how- 
ever, from ten days to three weeks. 

The disorder is " either acute or chronic. In the 
^ciUe form the papulse appear mostly on the £fice 
and tnmk, are red, heated, and itch considerably: 
tl^, however, disappear in a furfuraceous scurf in a 
£ew days, and are succeeded by others; and, after 
five or six successive eruptions, the attadc generally 
subsides. In the Chronic form the papulae appear 
on the limbs, and are less inflamed and itchy than in 
the acute : sometimes they display no redness, and 
require to be discovered by the touch ; but the same 
furfuraceous scurf is firm as in the acute form. This 
form is apt to recur in changes of weather, or on the 
least irregularity of diet." It is subject to variety 
also in other respects. The papulae on the face, for 
instance, are large and rounded, and some of them 
form into small tubercles, resembling those of Acne : 
on the breast and extremities they are more aoumi- 
jiated; and on the hands they are sometimes ob- 
scurely vesicular. In some cases of the acute form, 
the eruption is partial, affecting the face, neck, or 
arms only; in some, it appears and disappears re- 
peatedly, without leaving any scurf : in others, it is 
general; and successive eruptions and exfoliations 
prolong the complaint for two or three months, and 
even longer. 

The L. simplex is liable to return every spring or 
summer in some individuals of irritable constitution. 



12 PAPlJLiE : 

It appears occasionally in those who are subject to 
severe head-ach, and pains in the stomach, as a sort 
of crisis to these complaints, which are immediately 
relieved. It is also, sometimes, a sequela of acute 
fevers. * 

This species of Lichen is often mistaken for 
Measles, Scarlatina, and other exanthemata. But a 
strict attention to the Definitions, and to the course 
of the symptoms, will enable the observer to avoid 
such errors. It is sometimes also mistaken for 
Scabies (itch), " Eczema,*' and Prurigo, from which 
it is not always so easily distinguished, t " The 
vesicular or pustular forms of Scabies, and its loca- 
lity between the fingers, on the wrists, and flexures 
of the joints, independent of its contagious nature, 
are obvious points of distinction between Lichen and 
that disease. In Prurigo the papulae are not accu- 
minated, and rarely abraded; they are also paler, 
larger, and more distinct, and infinitely more itchy 
than those of Lichen. The diagnosis is more diffi- 
cult with respect to Eczema, especially when the 
simple Lichen is accompanied with vesicles, which 
occasionally occur, and form soft crusts : but the 
primary papular form of the eruption marks its dis- 
tinction from that of Eczema. From syphilitic Lichen 
it is distinguished by displaying no copper colour, 
and the papulae being less indolent in their nature.'* 

Species 2. Lichen pilaris^ Hair Lichen. 

This form of Lichen (Plate V. fig. 1. of Bate- 
man ; PI. 2. of Thomson*s Atlas,) is rather a mo- 
dification ^f the preceding than a distinct species, 

* See Lorry de Morbis Cutaneis, cap.iii. p. 215. 

f See Scabies. — Prof. Lorry has stated the principal points of diag- 
nosis with accuracy. Sfieaking of Lichen, under the appellation of 
^' Papulae," he says, ^* Primo a bcabie difTerunt, quod papulae illae vqlgo 
mads confertae sint et elatiores ; 2do, quod rubicundae magis et minus 
ariose sint; 5tio, quod; aepe sanatis febribus superveniant ; 4to, quod 
latiores sint, et saepius recidivam patiantur quam vera et legitima Sca- 
bies ; 5to, quod in furfur abeant notabile ; 6to, demum quod remediis 
sanentur a Scatuei curatione alienis."— -Loc. cit. 



LICHEN. , 13 

the papulae appearing only at the roots of the hairs 
of the skin. Like the former, it often alternates 
with complaints of the head or stomach, in irritable 
habits. It is not imfrequently connected with that 
derangement of these organs, which is induced by 
intemperance in the use of spirits. The great irri- 
tability of the skin is manifest, from the facility with 
which the papulae are enlarged into temporary wheals 
by strong friction, which the itching and tingling 
compel the patient to resort to. It often assumes a 
chronic character, and continues for years. 

" The treatment of the foregoing species and this 
variety is simple, and consists in keeping the bowels 
lax; in confining the diet to the lightest kinds of 
fresh animal food, limited as to quantity, vegetables, 
and ripe ascescent fruits, and table beer for drink, 
instead of wine, or spirituous liquors ; to the taking 
moderate exercise in the open air, but not in the 
sun ; and to an occasional use of the tepid bath. 
Infusion of Cinchona Bark, acidulated with any of 
the mineral acids; or the solution of Sulphate of 
Quinia in the infusion of Conserve of Roses, largely 
acidulated with diluted Sulphuric Acid, prove useftil 
when the habit is languid. As a local application 
for allaying itching, the Bitter Almond emulsion, 
with a grain of Corrosive Sublimate in six fluid 
ounces, answers every purpose. I have scarcely ever 
seen a necessity for general bloodletting, when the 
bowels are freely opened. In obstinate chronic cases, 
much benefit has resulted from an alterative course 
of biniodide of Mercuiy, in doses of one eighth of a 
grain at bed-time, and the Decoction of Cetraria 
Islandica with diluted Nitric Acid, administered twice 
or three times a day." 

Species 3. Lichen circumscriptuSy Clustered 
Lichen. 

This species (Plate V. fig. 8. of Bateman ; PI. 2. 
of Thomson*s Atlas,) is characterized by clusters 



14 papula: 

or patches of papula? which hare a well defined 
*<red" margin, and are of an irregularly circular 
form.* Some of them are stationary for a week or 
two, and disappear ; but others extend gradually, by 
new papulated << inflamed '^ borders, into large figured 
formsy which coalesce. As the borders extend^ the 
central areae become even, but continue slightly red 
and scurfy. << The patches seldom exceed an inch in 
circumference.*' Sometimes, before the scurf is re- 
moved, a new crop of papul® arises, terminating like 
the former in exfoKations ; and by these new enqi- 
tions the complaint is prolonged for several weeks. 
It ** is most common in boyhood ; *' and may be ex- 
cited either by internal or external causes of irri- 
tation.t In adults it is occasionally produced by 
vaccination, and may be deemed a proof of the full 
afifection of the constitution by the virus. 

" This form of the disease is readily distinguished 
from Lepra vulgaris^ with which it has been con- 
founded, by its distinct papular form, and the nature 
of the scurf in areas of the patches, that in Lepra 
being composed of accumulated dry scales ; and from 
Psoriasis guttaiay by the sraallness of the patches of 
this species of Psoriasis, and the flattened form of the 
pimples." 

Little medicinal treatment is necessary for this 
species of Lichen. It is sufficient that patients avoid 
heating themselves by much exercise or by stimu- 
lants, and take a light diet, ^^ avoiding all spices, 

* This Tariety of Lichen was not noticed in the first edition of the 
Order of Papulae, published by Dr. Willan. It is the first of the two 
species of Papulse described by Celsus: — " medium habet pauxillum 
levius: tarde serpit; idc^ue vitium maxime rotundum incipit, eaque 
ratione in orbem procedit." De Medicina, lib. v. cap. 28. See also 
Ingrassias de Tumor, praet. Naturam, tract. 1. cap. 1. 

f Dr. Good, in his ** Study of Medicine," under Pratica Spasmodica, 
remarks, " Opium could not be had recourse to ; for in every propor- 
tion, whether large or small, it threw out a lichenous rash over the 
surface of the body, but more especially over the extremities, possessing 
a heat, itching, and pricking, more intolerable than the prickiy heat of 
the West Indies, and which was almost suf&cient to produce madness. 
Vol. i. p. 555. — Was this Lichen or Eczema ? T. 



LICHEK. 15 

wine, and alcoholic Jiquors;'' and adhering to diluent 
drinks, regulating the bowels with gentle laxatives. 
^* Reasoning from a knowledge of the great irri- 
tability of the skin which attends this disease, we 
would be led to conclude, what experience has proved 
to be true, that all diaphoretics and medicines de- 
termining the blood to the surface are injurious in 
Lichen/' The diluted Sulphuric Acid is a grateful 
tonic to the stomach during the period of exfoliation ; 
or a light chalybeate may be taken wHh advantage at 
the same period. All strong external applications 
are improper, especially preparations of Mercury and 
of Sulphur, which produce severe irritation. The 
ancients recommended that the parts should be be- 
smeared every morning with saliva: as a substitute 
for this uncleanly expedient, a lotion prepared with 
the white of egg, or the emulsion of Bitter Almonds, 
" with a small addition of Liquor Potassae,'* will re- 
lieve the painful sensations of the patient. Lotions 
of lime water, or of liquor Ammonise Acetatis, much 
diluted, occasionally also afford relief. <^ The sudden 
repulsion of this form of Lichen from the surface, by 
imprudent exposure to cold, even in the milder forms 
of the disease, is productive of febrile excitement, 
head-ach, and other symptoms of constitutional dis- 
oi*der. In this case, the use of the warm bath is 
useful ; but, occasionally, the fever subsides without 
the re-appearance of the eruption." 

Species 4. Lichen tzgriuSj Wild Lichen. 

S^n. dypoig (O.): Papula agria ( Celsus) : Lichen 
ferm (Good). 

This severe form of Lichen (Plate IV. fig. 2. of 
Bateman; pi. 2. of Thomson*s Atlas,) is ushered 
in by febrile symptoms, which are commonly relieved 
on the appearance of the papulous eruption. The 
papulae occur in large patches, are of a high red 
colour, and have a degree of inflammation diffused 
around them to a considerable extent. They are ac- 



16 pafulje: 

companied by itching, heat, and, a painful tingling, 
which are augmented to a sensation of smarting and 
scalding by the heat of the bed, washing with soap, 
drinking wine, or using violent exercise. The symp- 
toms undergo a daily increase and remission j for 
they are all greatly diminished in the morning, and 
recur after dinner. Some small vesicles, filled with 
a straw-coloured fluid, are occasionally inter^nixed 
with the papulae ; but they are not permanent. 

The duration of the L. agrius is various : some- 
times it continues for several weeks ; and in most 
instances, the eruption appears and disappears re- 
peatedly before the disease is removed. In both 
these cases, the cuticle of the parts affected becomes 
harsh, thickened, chappy, and exquisitely painful on 
being rubbed or handled. After repeated attacks, 
indeed, it is liable to terminate* in a chronic pustular 
disease, the Impetigo.* This tendency, and the 
diffuse redness connecting the papulae, distinguish 
the L. agrius from the preceding species, which oc- 
casionally pass into Psoriasis, as observed by the 
ancients. 

The L. agrius is sometimes repelled by exposure 
to cold, upon which an acute febrile disorder ensues, 
with vomiting, head-ach, and pains in the bowels, and 
continues for several days. Women are more liable 
to this species of Lichen than men, particularly after 
suffering long-continued fatigue, with watching and 
anxiety : it sometimes occurs in spirit-drinkers. 

The treatment of this form of Lichen consists in 
administering, at first, moderate laxatives, mercurial 
or saline, and afterwards, for some time, the diluted 

* Celsus describes his second species of Papula under the appellation 
of aypia ovfera ; and has also pointed out its tendency to pass into Im- 
petigo :-— " Difficilius sanescit ; nisi sublata est, in Impetiginem vertitur." 
(ioc. cit.) His successors, the Greek writers, have also applied the same 
epithet to the severe form of Lichen. Galen speaks of Lichen simplex 
et ferus, a'KksQ km ayptoQ : (Isagoge, cap. 15. See also Paul. iElgin. de 
Re Med. lib. iv. cap. 3.; and Oribas. ad Eunap. lib. iii. c. 57.) and 
Aetius of rough and of inflamed Lichens, rprix^ig km (pXeyfiaivovreg, 
(tetrab. iv. serm. i. cap, 134.) which appear to express the same varieties. 



LICHEN. 17 

Sulphuric acid, three times a day, in the infusion of 
Roses, " containing in solution a few grains of sul- 
phate of Quinia,'* or combined with decoction of 
Cinchona, " which seems to exert a specific influence 
in this disease ; allaying the tingling and itching, 
and diminishing the tendency to vesication. If 
there be any febrile excitement or headach, a few 
ounces of blood should be taken ; and this is ne- 
cessary in plethoric patients when no fever is pre- 
sent. The bleeding should be followed by a course 
of saline purgatives. In obstinately-protracted cases, 
after all excitement is removed, I have seen much 
benefit result from the solution of Arsenic.'* A 
simple cooling unguent, as the rose pomatum, or 
litharge plaster softened with oil of almonds*, allays 
the troublesome heat or itching. " Lotions with the 
chloride of Soda, often answer better than any other 
topical application. In obstinate cases, an ointment 
formed with a scruple of the protioduret of Mercury 
and an ounce of lard has been found serviceable.'* 
All stimulating applications are, still more than in 
the preceding species, both painftil and injurious : 
" and sulphureous baths, which are undoubtedly use- 
ful in several cutaneous affections, invariably increase 
this form of Lichen ; unless the disease have become 
chronic, and is disposed to pass into Impetigo. I 
am aware that this is contrary to the opinion of Mr. 
Plumbe, who remarks, that after * the bowels have 
been some time kept open,* and the habit reduced, 
*the itching and tingling during the operation of 
the sulphur bath is rather severe, but it is followed 
by a much more tranquil state of the circulation in 
the cutaneous vessels, and the cure is altogether ex- 
pedited by it.* ** t Dr. Green says, that the hot air 
and sulphur fume baths are always better borne, and 

* Mr. Pearson recommended the- following mild ointment in these 
cases : — Jt. Emplast. Plumbi Jij, Cerae flavae Jss, Olei Amy^dal. dulc. Jiss. 
Emplastro cum cera liquefacto adde oleum, dein agita misturam donee 
penttus refrixerit. 

f Practical Treatise on Diseases of the Skin, p. 196. 

C 



18 FAPULiBi 

IKToduce fiiore decidedly b^o^eial e£feets, when the 
parts affected are ei^eoriated and moist from dis- 
chai^* 

SpECisa 5. LiCHXN lividWf Livii> Lichen. 

ITiis species (Pkte Y. fig. 2. of Batsman ; PI. 2. 
of Thomson's Atlas,) is distinguished by the dark^ 
red or livid hue of its papulse, which appear chiefly 
on the extremities, and without any aecampmying 
symptoms of iever. The ps^ula^ are more perm»- 
nei^, however, than in the foregoing speeiea ; and, 
after their deioiecation, the disorder is liable to be 
prolonged for mmy week* by a fresh eruption. 

The affinity of this speaes with Purpura ia evxneed 
by the intearmixture of peteehiae with the p^puls^ ; 
aad by the similarity of the origin and requisite treat-* 
ment of the two diseases, t The nature of this species 
pomts out» that the tre^ment must necessarily he 
Umic and cordial. 

Spbcies 6, Lichen tropicm, " Pricki^y Hsat.*' 
Sjfn. Eczesma {Auct Or^Bc) : Sudamina {Aia^m 
Lat) : Essera (Plouqttefy : Chaleur piquante (F.) : 
Root vout {Bdg.): Fiacherothe flecke {Ger.)i 
Eshera (Arab.) : Priekly Heaty^ — Summer Mash* 

This is a hot and painful form of Lichen peculiar 
to tropical climates, and has been described at great 
length by most of the writ^^s on the diseases of those 
regioBus ; to whose publications I shall therefore re£ef 
the reader, t " Dr. James Johnson, who suffei^ 
from this eruption in India^ says^ < prickly heat, being 
merely a s3rmptom, not a cause of good healtl^ its 
disappearance has been erroi^ously accused of prO'* 

* Greca't Pfactkal CSompeiidium of Diaeaseft ef the Skin. 8to. 

1835. p. 181. 

+ See. below. Order iiL Gen. 5. 

:| See Hillary on the Climate and Diseases of Barbadoes, p. 3., In- 
trod.; Mosdey on the Diseases of Tropical Climates, p. 20.; Cleghom 
on the Diseases of Minorca, chap. 4.; Clark on the Diseases of Seamen 
in Long Voyages, vol. L p. 34,; Bontiut de MedidaA Indorum, c^p. 18. 



LICHEN* 19 

ducing much mischief/ He ridicules the idea of its 
repulsion proying injurious, and remarks, 'It certainly 
disappears suddenly sometimes on the acoession o£ 
other diseases, but I never had any reason to suppose 
that its disappearance occasioned them/ No ex- 
ternal applicati(»is are useful ; but some alleviation is 
afforded by light clothing, temperance, open bowek, 
and avoiding exercise in the heat of the day until 
the habit become assimilated to the climate/' 

Sfecies 7- Lichen mrticatiiSf Nettle Lichen. 

Syn. Lichen urticosus ( Good). 

The first appearance of this spedes is in irregular, 
inflamed whesds, so closely resembling the spots 
excited by the bites of bugs or gnats, as almost to 
deceive the observer. The inflammation, however, 
subsides in a day or two, leaving small, elevated, 
itching papulae, " which are spread over the upper 
part of the trunk of the body, and the extremities/' 
While the first wheals are thus terminating, new ones 
continue to appear in succession, until the whole 
body and limbs are spotted with papules, which be- 
come here and there confluent, m rnxaH patches; 
" and increase both in elevation and in irritation the 
moment any stimulant food or exercise is taken. It 
often subsides for a few days, and then rea{^ars 
more violent than ever/* This eruption is peculiar 
to children : it commences, in some cases, soon after 
birth, and sometimes later, and continues with great 
obstinacy for many months. It occurs during denti- 
tion also, " recurring,*' says Underwood, " uniformly 
a little before a tooth has been cut/** Both the 
wheals and the papulae are accompanied with intense 
itching, pricking, and tingling, which are exceed- 
ingly severe in the night, occasioning an almost total 
interruption of sleep, and considerable loss of flesh. 

Frequent tepid bathing, particularly sea-bathing, 
light covering, especially in bed, with the use of small 

* Diseases of Children, 8th edit. p. 175. 

c 2 



20 PAPULiE : 

doses of sulphur, or the hydrargyrus sulphuratus 
niger, internally, appear to relieve the symptoms. 
** Dr. Good says, that opium increases the irrita- 
bility, and no other narcotic is of avail.* No benefit 
results from the use of sarsaparilla, nor of elm bark ; 
nor any of the mercurial preparations.'* The skin 
will not bear stimulation, and is irritated even by a 
bath of too high temperature. When it has occurred 
in feeble and emaciated children, I have seen it 
eflPectually relieved by chalybeate medicines, as the 
vinum ferri, or the solution of the tartrate before 
mentioned. This combination of inflamed papulse 
with intense itching, unites the characters of the 
Lichen and Prurigo j an union, which, it must be 
allowed, is likewise not unfrequent in young adult 
persons. 

Works which Tnay he constdted on Lichen. 

BoNTius de Medicini Indorum, 8vo. cap. 18. 

Cazenaye and Schedel, Abr^^ Pratique des Maladies de la Peau, 
8vo, 1828. 

Clabk on the Diseases of Seamen, vol. i. p. 34. 

Cleghobn on the Diseases of Minorca, chap. 4. 8vo. 

Cyclopaedia of Practical Medicine, art. Lichen. 

Good, Study of Medicine, vol. iv. p. 530. 8vo. 1822. 

Green's Practical Compendium, p. 17 J. 8vo. 1835. 

HiLLAAY on the Climate and Dbeases of Barbadoes, 8vo. 
^Johnson on the Influence of Tropical Climates, 2d edit. 8vo. 1818. 

Lobby, Tractatus de Morbis Cutaneis, 4to. 1777. 

Plumbe on Diseases of the Skin, 8vo. 2d edit. 1827. 

Rayeb, Trmt^ Th^orique et Pratique des Maladies de la Peau, 8vo. 
1826. 

WiLLAN on Cutaneous Diseases, 4to. 1808. T. 



Genus III. PRURIGO. 



S^/n. xprjo-fM^os (G.) Pruritu (Mercurialis) : Scabies 
papuliformis (^Aicct. Fet): Intertrigo (Lorry) : 
Exormia prurigo (<yoorf): Prurit (F.) : Das juckten 
( Oer.) : Kejik ( Turc.) : Pruriginous rash. 



* Study of Med. vol. iv. p. 559. 



PRURIOO. 21 

Def. Severe itching, increased by sudden 

EXPOSURE TO HEAT, AFFECTING EITHER THE WHOLE 
SURFACE OF THE SKIN, OR A PART ONLY : IN SOBfE 
INSTANCES WITHOUT ANY APPARENT ERUPTION ; 
IN OTHERS ACCOMPANIED WITH AN ERUPTION OF 
PAPULA NEARLY OF THE SAME COLOUR WITH THE 
ADJOINING CUTICLE. 

" Prurigo is uninfectious, and generally a chronic 
disease : it is both general and local. The constant 
itching which it produces, has sometimes an injuri- 
ous effect on the genend health, depressing the 
spirits, and, in a few instances, has produced a de- 
gree of fatuity.* 

" The only disease with which Prurigo is likely to 
be confovmded, is Lichen ; but, independent of the 
extreme itching, the former is readily distinguished 
by the papulae being broader, and their colour not 
differing from that of the skin.'* 

There are four species of Prurigo : — 

1. Y.mitis. 3. P. senilis. 

2. V.formicans. 4. P. sine papulis.f 

Species 1. Prurigo mitiSf Mild Prurigo. 

This form of Prurigo (Plate VI. fi^. 1. of Bate- 
MAN ; PL 3. of Thomson's Atlas,) is accompanied 
by soft and smooth papulae, somewhat larger and less 
acuminated than those of Lichen, and seldom ap- 
pearing red or inflamed, except from violent friction. 
Hence an inattentive observer may overlook the 

* Dr. Elliotson mentions two cases of this kind that bad come under 
his notice. See Med. Gaz. vol. ix. p. 34. T. 

f In the former editions of this work, three species only of Prurigo 
are enumerated, and those which I have thrown together to form the 
fourth species, are described by Dr. Bateman under the term " local 
pruriginous affections.'* If we were to regard the eruption ofpapulse 
as the chief symptom of Prurigo, these local pruriginous affections 
should be separated from the genus ; but, as the chief characterbtic is 
evidently the itching, these, in truth, may be regarded as constituting 
the only real species of Prurigo, whilst the three former species mighty 
with much propriety, be transferred to Lichen. T. 

c 3 



29 PAPULiE : 

p^uhe altogether * : more es^ecidly as a number of 
smalli thin, black scabs are here and there conspicu^ 
miS) and arrest his attention. These originate from 
die amcretion of a little watery humour, mixed with 
blood, which ooses out when the tops of the papules 
are removed by the violent rubbing or scratching 
which the severe itching demands. This constant 
friction sometimes also produces inflamed pustules, 
which are merely incidental, however, when they 
occur at an early period of the complaint. ** They 
s^pear chiefly upon the shoulders, the breast, the 
loins, and the thighs.'' The itching is much aggra- 
vated both by sudden exposure to the air, by violent 
exercise, and by heat j whence it is particularly dis- 
tressing when the j^ient undresses himself, and 
often prevents sleep for several hours after he gets 
into bed. 

This eruption mostly affects young persons, " usu- 
ally in a good state of general health ;** and it com- 
monly occurs in the spring or the beginning of 
summer. It is relieved after a little time by a steady 
perseverance in the use of the tepid bath, or of 
regular ablution with warm water and mild soap, 
although at first this stimulus slightly aggravates the 
eruption.! " Or, what is more decidedly and rapidly 
useful, the daily use of the artificial Barr^e bath.'' t 
The internal use of Sulphur, alone, or combined with 
Soda or a little Nitre, continued for a short time, 
" after bleeding and active purgation," contributes 
to lessen the cutaneous irritation, and may be fol- 
lowed by the exhibition of the mineral acids : " fully 
more benefit, however, is derived from a course of 

* Pruritus enormes non semper densse confertseque papulae afierunt; 

Eaucae vix aspectu notandae occurrunt, quas hominem conyellant. — 
lOrry de Morb. Cutan. cap. iii. art. i. par. 3. 
f After recommending a bath of moderate temperature, Lorry ob- 
serves, ^ Nee mirandum, si inter balneorum usum plures papulas pro- 
deant. Etenim laxatis vasis, ad cutem omnia deferri aequum est. Sed 
nulla inde ratio est, cur minus balneis fidamus." — Loc. cit. 

:{: This bath is made by dissolving a pound of sulphuret of potassa in 
thirty gallons of water. Green, 



\ 
I 
i 



PRURIGO. 38 

coding pui^atives, particularly in young and other- 
wise healthy people. Our own experience has taught 
us to place much confidence in the following for* 
mula: ^^ 

19^. Magnesiae Sulphatis ^^j* 

Infusi Gonfectionis Ross f^xij, 
Acidi Salphurici dlluti triix; 
Mi«c6 ut fiat haustus bis die tumendus." 

A restricted diet is an essential part of the treat- 
ment. 

Under these remedies, the disorder gradually dis« 
appears ; but if the washing be neglected, and a 
system of uncleanliness in the apparel be pursued, it 
will continue during several months, and may ulti- 
mately terminate in the contagious Scabies.* 

Species 2. Frvbiqo Jbrmicans, Formicative 
Prurigo. 

This affection (Plate VI. fig. 2. of Bateman, 
PI. 3. of Thomson's Atlas,) differs materially from 
the preceding, in the obstinacy and severity of its 
symptoms, although its appearances are not very dis- 
similar. The itching accompanying it is incessant, 
and is combined with various other painful sen- 
sations; as of ants or other insects creeping over 
and stinging the skin, or of hot needles piercing 
it. On undressing, or standing before a fire, but, 
above all, on becoming warm in bed, these sensations 
are greatly aggravated: and friction not only pro- 
duces redness, but raises large wheals, which, how- 
ever, presently subside. The little black scabs which 
form upon the abraded papulae are seen spotting the 
whole surface, while the colourless papulae are often 
so minute as to nearly to escape observation. 

This Prurigo occurs in adults, and is not peculiar 
to any season. It affects the whole of the trunk 

* It it probable that the cases which hare thus termiaated were not 
genuine Prurigo. T. 

C 4 



24 PAPUL-ffi : 

and limbSy except the feet and palms of the hands ; 
but is most copious in those parts over which the 
dress is tightest. Its duration is generally consider- 
able, " seldom terminating sooner than two or three 
months j'* sometimes, ** when it attacks old and de- 
bilitated people,'* extending, with short intermissions, 
to two years or more. " In such subjects, when the 
disease is severe, the feet and ankles swell and be- 
come oedematous ; whilst the skin is thickened, and 
even, in some instances, has been hypertrophied to a 
considerable extent/* It is never, however, con- 
verted, like the preceding species, into the itch, for 
which, however, it may be readily mistaken, nor 
does it become contagious j but it occasionally ends 
in Impetigo. 

The causes of the P. formicans are not always 
obvious. In some instances the disease is distinctly 
connected with disorder in the stomach, being pre- 
ceded by sickness, gastrodynia, and headach ; " and 
these are again produced, in an augmented degree, 
by the sudden suppression of the eruption.** In 
other instances, P. formicans appears to be the result 
of particular modes of diet, especially of the use of 
shell-fish and much stimulant animal food, in hot 
weather, with a free potation of wine, spirits, and 
fermented liquors, and excess in the use of con- 
diments, pickles, and vinegar. * On the other hand, 
it is often observed in persons of lean habit, and 
sallow complexion, and in those who are affected 
with visceral obstructions, or reduced in strength by 
fatigue, watching, and low diet. 

* I have known several instances of the immediate influence of the 
acetous acid upon the skin, especially in summer, exciting heat and 
tingling very soon after it was swallowed ; andj in persons of peculiar 
cutaneous irritability, leaving more permanent effects. Dr. Withering 
asks, " Who has not observed the full scarlet flush upon the face after 
eating herrings or vinegar, after drinking acetous beer or cider ? " — 
Treatise on Scarlet Fever, p. 62. The universal recommendation of 
vegetable acids and crude herbs, indeed, in these states of cutaneous 
irritation, in consequence of a misapplication of the term scorbutic, is 
in opposition to the dictates of sound observation. 



- > ' 



PRURIGO. 35 

The treatment of P. formieans must necessarily be 
varied according to the circumstances just stated; 
but it is not readily alleviated either by internal or 
external medicines. Where it appears to be con- 
nected with a state of general debUity, or with some 
disorder of the abdominal viscera, the first object will 
be to remove these conditions by proper diet and 
exercise, together with medicines adapted to the 
nature of the case. Where the stomach is obviously 
disordered, the regulation of the diet is of material 
importance, especially as to the omission of those 
prejudicial articles above mentioned, and the sub- 
stitution of a light digestible food, and of whey, 
milk, ass's milk, butter-milk, &c. as beverage. Tins 
regulation of the diet, indeed, is in all cases of the 
disease to be recommended, though there may be no 
apparent internal complaint from which it originates.- 
For, in these cases, medicine alone is often extremely 
inert. " The use of the lancet is rarely required, 
but occasionally the influence of other remedies is 
little felt until the vascular system has been re- 
lieved." 

Combined with proper diet, the use of washed 
Sulphur with the carbonate of Soda, internally, has 
much alleviated the painful state of sensation^ and 
shortened the duration of the disorder : and where 
the habit was enfeebled, the decoctions of Sarsa- 
parilla. Cinchona, Serpentaria, and other tonic vege- 
tables, have proved essentially serviceable. I have 
seen considerable benefit derived from the internal 
use of the Oxygenated (Nitro-) Muriatic acid, in this 
and the former species of Prurigo, both the eruption 
and the itching yielding during its exhibition. It 
may be taken in doses of a fluid drachm, and in- 
creased gradually to three times this quantity, in 
water or any agreeable vehicle. Strong purgatives, 
or a course of purgation, appear to be injurious ; 
" nevertheless, much benefit is often derived from 
the employment of Colchicum as a purgative : '' anti- 



36 papuub: 

monials and mertnirials are useless; and active su- 
dorifics aggravate the com^daint. 

In respect to external remedies, frequent abluticm 
Mrith warm water, by removing the irritation of 
sordes, and softening the skin, contributes most ma- 
terially to the patient's relief. A partial bath of the 
native or artificial sulphureous waters* is still more 
efficacious in reEeving the itching : << the hot air and 
sulphur fume bath has proved hi^y useful, espe- 
. ciaUy when the patient has been previously bled, 
and has used the vapour bath for a few days. It is 
sometimes necessary to repeat the bleeding; and 
to intermit the use of the bath for a couple of 
days : ** sea-bathii^ has also occasionally removed the 
disorder. In general, the application of ointments, 
or of lotions, containing Sulphur, Hellebore, Mer- 
cury, Zinc, Lime-water, &c is productive of little 
benefit : I have sometimes, however, found a speedy 
alleviation produced by a diluted wash of the Liquor 
ammonice acetatis, or of spirit, or by a combination 
of these, varied in strength according to the irri- 
tability of the skin. " Lotions of Calomel and Lime^ 
wofter are also frequently ben^cial; and I have 
seen much relief obtdned from the use of the follow- 
ing lotion : -— 

B. Hydrargyri Oxymuriatis gr. iij, 
Acidi Hydrocyanici f^j, 
Mil tur« Amygdalae ainarffi f^viij. M« 

" Dr. EUiotson recommends a lotion with chlo- 
ride of Soda. 

" Comfort IS also sometimes procured from lotions 
of cold spring water. Much benefit is also said to 
result from touching the prominent pajpulae, pre- 
viously rubbed till they bleed, with undiluted Aro- 
matic Vinegar j and afterwards applying the following 

1 * This viay be prepared in the foUowing manner :— I^esolve two 
I drachms of siuphate ot Magnesia, ten grains of supertartrate of Potassa, 
] and half a drachm of sulphuret of Potassa in twenty-four fluid ounces i>f 
warm water. It shouldbeusedat 95°of Fdbrenbeit. T. 



ointment liberally to the whole ernption^ gil^iiig^ at 
the same time, four or fiTe grains of Plmnmer'i pill 
ey^ night, and five drops of the Aiienical Swu^ 
tion three times a day : *-^ 

^., Sulph. Sublimati^ 
Picis Liquidi, 
Adipis, &• a. Ibss* 
Crete 5!^, 

Hydrosulpb. Anunoois 5U« ^* 
ut fiat unguentum.'* 

Species 8. Prurigo senilis, Inveterate Pru- 
rigo. 

The frequent occurrence of this species of Pru- 
rigo (Plate VI. fig. 3, of Bateman ; PL 8. of Thom- 
son's Atlas,) in old age, and the difficulty of 
curing it, have been the subject of universal observ- 
ation.* The sensation of itching, in the Prurigo 
of that period of life, is as intolerable and more 
permanent than in the P. formicans; and the ap-^ 
pearances which it exhibits are very similar, except 
that the papulae are for the most part larger. Tne 
comfort of the remainder of life is sometimes entirely 
destroyed by the occurrence of this disease. 

A warm bath affords the most effectual aUeviation 
of the patient's distress, but its influence is tem- 
porary. " The itching is said to be relieved by 
the sulphureous fumigating bath, v^en used at a 
temperature so low as wiU merely disengage the 
sulphurous gas." The disorder seems to be coii* 
nected with a languid state of the constitution in 
general, and of the cutaneous circulation in parti- 
cular : hence the sulphureous waters of Harrowgate^ 
employed both internally and externally at the same 

* See Hippoc Apb. lib.iii. $iii. ?l. where, among other diseaset of 
old age, he mentions ^vafia rov ffu)ftaTOQ ^Xov.— Its obstmacy has been 
particularly noticed by the later Greeks. ** Pruritum in senectute oon* 
tingentem perfecte sanare non datur, verum subtcriptk mitigare potes.'* 
Paul. .£gin. de Re Med. lib. iv. cap. 4w Acinar. Meth. Med. lib. IL 
eap. 11.—- See also Sennert. Pract. Hb. v. p. iiL § i. cap. 8. «— Mercurialis 
de Morb. corand. cap. s. Heberden, Comment, cap. 7^. 



^ PAPULJE : 

time, a£Pord on the whole the most decided benefit. 
A wann sea-water bath has also been found service- 
able. Sometimes stimulant lotions, containing the 
oxymuriate of mercury, or the liquor ammonias ace- 
tatis, or alcohol, " chloride of Soda,*' are productive 
of great relief, and occasionally render the condition 
of the patient comparatively comfortable, or even 
remove the disease. • When the surface is not much 
abraded, the oxymuriate will be borne to the extent 
of two grains to the ounce of an aqueous or weak 
spirituous vehicle; but it is generally necessary to 
begin with a much smaUer proportion. 

This mineral salt is likewise useful in destroying 
the pediculi, which are not unfrequently genemte^ 
when the Prurigo senilis runs into a state of ulcer- 
ation.t Where the skin is not abraded by scratch- 
ing, the oil of turpentine, much diluted with oil of 
almonds, may be applied with more decided e£Pect, 
for the destruction of these insects. 1^ " Biett recom- 

* Dr. Heberden lays it down as an axiom, that stimulants are com- 
monly beneficial in diseases of the skin accompanied by itching.— 
" Quod attinet ad remedia extrinsecus admovenda, illud sedulo tenen- 
dum est, acriora plerumque convenire, ubi pruritus est; sin dolor fuent, 
lenia esse adhibenda," &c. (Comment, cap. 25.) This is true, per- 
ha[^s, as far as it regards the unbroken or papulated skin : but itching 
often accompanies chops, and rhagades, vesicular and even pustular 
diseases in a state of excoriation, and the irritable state of the surface 
left by the exfoliations of some of the scaly eruptions ; under all which 
circumstances, this is an erroneous rule of practice, as I have had many 
opportunities of witnessing. 

-|* The same languid state of skin, which is a predisposing cause of 
this species of Prurigo, is also favourable to the generation of pediculi; 
fi>r, as Alibert justly remarks, ^' la ff^n6*ation de ces d^oiitans animal- 
cules tient k une foiblesse radicale et constitutionnelle de la peau, 
comme le d^veloppement des vers, dans le conduit intestinal, tient 
^galement k un difaut dMnergie dans les propri^t^s vitales de cet or- 
gane." JDescript. des Mai. de la Peau, Discours pr^mnaire, p. xi. T. 

"^ The pertinacitjr with which these loathsome insects often continue 
to infest the skin, m spite of every application that is resorted to, is 
surprising : but, as Dr. Willan has justly observed, the marvellous his- 
tones of fatality occasioned by lice, in the persons of Pherecydes, An- 
tiochus, Herod, &c., are probably ascribable to mistsJ^e ; the writers 
having confounded other insects, or their larvae, with pediculi. Nu- 
merous instances are recorded of the generation of maggots, t. e. the 
larvae of different species of fly (Musca), and even of other winged in- 
sects, not only in toe internal cavities of the human body, but in ex- 



PRURIGO. 29 

mends fumigations with Cinnabar in preference to 
any other topical application, as acting rapidly and 
commodiously in destroying them/' 

Species 4. Prurigo sine Paptdisj Local Pru- 
rigo. 

The local pruriginous affections are accurately 
described in the first part of the general definition : 
they have scarcely any affinity with the species of 
Prurigo already described, except in the itching 
which accompanies them, not being in general pa- 
pular diseases ; a character in which all the varieties 
agree. 

J^ar. a. P. prceputii is occasioned by an altered 
or augmented secretion about the corona glandis, and 
is cured by frequent simple ablution of the parts with 
hot water, or with a weak saturnine lotion. 

Par. b. P. pubis arises solely from the presence of 
morpiones, or pediculi pubis, which are readily de- 
stroyed by the white precipitated Mercury in powder, 
or by mercurial ointment rubbed into the parts af- 
fected.* 

teraal sores and excoriations. (For several examples of this kind I beff 
leave to refer to a paper of my own in the Edin. Med. and Sure. Journal 
for Jan. 1811, p. 41., and in the new Cyclopaedia of Dr. Kees, Art. 
Insects.) In warm climates, indeed, these msects are so. abundant 
about the persons of the sick, that the utmost care is requisite to pre- 
vent the generation of larvae from the ova, which they deposit, not only 
in superficial wounds, but in the nostrils, mouth, eums, &c. Dr. Lem- 
priere has recorded the case of an officer's lady, wno had eone through 
an acute fever, but in whom these maggots were producea, which bur- 
rowed and found their way by the nose through the os cribriforme^ into 
the cavi^ of the cranium, and afterwards into the brain itself^ to which 
she owed her death. (Obs. on the Diseases of the Army in Jamaica, 
voLii. p. 182.) The worms which were generated in the patches of 
Lepra, observed by Prof. Murray, proved to be larvae of the common 
house-fly. '' Incredibile fere est," he says, '' quanta muscarum domes- 
ticarum copia continuo ad lectum advolarent, segrumque suctu suo 
torquerent, ut in clamorem usque nonnunquam erumperet." (De 
Vermibus in Lepra obviis Obs. Auct. J. A. Murray, Gott. 1769. p. 25.) 
In all such cases, the disease appears to have afforded only a nidus for 
the ova of these domestic insects, and to have been in no other way 
connected with their existence, either as cause or efiect. See Scabies. 
* Mr. Plumbe recommends the following ointment for this purpose : 

9>. Unguent! Hydrargyri, 

■ Sulphuris, &. a, partes sequales. M. 



90 FAPULJB : 

Var. c. V. ureihrtdis is commenly sjnxipathetie of 
some <&aa8e about the neck of the bladder, or of 
calculi in that organ y in women, howevar, it some* 
times occurs without any manifest cause, and is re- 
movable by the uge of bougies, as recommended by 
Dr. Hunter. 

The three neict forms of local Prurigo, namely, 
P. podidSf and padendi mtUiebris, are more fi4- 
({UMitly the objects of medical treatment. 

Vhr. €LV.podici&. Independently of ascarides, 
or hemorrhoids, which sometimes occasion a trouble- 
some itching about the sphincter ani, the P. podum 
occurs in sedentary persons, and those of advanced 
age, m connection with an altered, highly irritating 
secretion from the part, and sometin^s with consti- 
tutional ddiility. This complaint, especially in old 
men, is apt to extend to the scrotum, which becomes 
of a brown colour, and sometimes thick and scaly. 
The itching, in dnese cases, is extremely severe, ei^- 
c«dly at nig^, and often deprives the patient of a 
considerable portion of his sleep. 

Par. e. P. scroti. This variety of local Prurigo 
is occasionally produced by friction, from violent 
exercise in hot weather, and sometimes it originates 
from the irritation of ascarides in the rectum. 

Lotions, whether warm or cold, with preparations 
of Lead, Zinc» Lime-water^ &c., have httle efficacy 
m these afiections. Those made with Vinegar, or 
the acetate of Ammonia, are productive of a tem- 
porary retiaf ; but the most useful are those made 
with a scruple of Calomel, or twelve grains of oxy- 
muriate of Mercury, and six fluid ounces of Lime- 
water, and used without being filtered. ** Much 
of the advantage of any lotion depends on the mode 
of using it ; even cold water applied with a soft rag to 
the part, and the whole covered with a piece of oiled 
silk, affords great comfort : but the relief is more 
permanent if the water be mixed with hydrocyanic 
acid, in the proportion of fsij to f^viij of the water.'* 



PEvmiGO. 91 

The mereuriid omtmentay etpeoslly the Ui^ncntum 
Hydjnurgyri Nitratis^ diluted, are often successM ap- 
pliCAti0oa.'«*-IntaniaUy miaQ doses of Calomel^ with 
fm antiniomaly 9saek as the Pihik Hydiargyri Sub- 
mujriatiiit of the LcmdcHi FbannaoopcQia, seem to be 
advantageous iu correcting the morbid KcretioD: 
and the regetable or mineral tooncs sfaouU be ad^ 
minikrtered in enfeebled habits* In P. podicis, much 
b^Giefit is derived from the application of leeches to 
the verge of the anus ; and in this variety, evim num 
than in the others^ great temperance should be loeul- 
culated, sanee stimulant diet invariably aggrai/mtes 
the eomplaittt. 

Var.J'. P. pudendi fmdwbns is somewhat anala* 
gout to tl&e preceding, but is occasionally a much 
more severe complaint. It is sometimes connected 
with ascarides in the rectum, and sometanes with 
leucorrhoea ; but is most violent when it occurs soon 
after the cessation c^ the catamenia. The itching 
about the labia and os vi^ms^ k constant and ahnost 
intolerable, demanding incessantly the relief of 
friction and of cooling ^plications, so as to compel 
the patients to shim society ; and even sometimes to 
excite at the same time a degree of nymphomania. * 
This condition is generally accompanied by some 
fulness and redness of the parts. 

^< While inflammatum is present, nothing ia so ser- 
viceable as the appKeation of leeches to the affected 
parts. The itching is moderated by the abstractiou of 
the blood, and the other remedies act more effica- 
ciously after the bleeding.'' Saturnine and sa&ie 
lotions. Lime-water, Lime-water with Calomel, 
Vinegar and oily liniments prepared with Soda or 
Fotassa, are ben^ial, espeeimly in the milder cases : 
but the most active remedy is a solution of the 

* M. Biett mentions a case of it in a woman of sixty yean of age. 
He examined the parts, but could discover nothing. This woman had 
83mcope whenever she saw a young man. Ahrdgi Pratique des ilfo- 
iadies de la PeaUy p. 255. T. 



32 PAPULJE. 

Oxymuriate of Mercury in Lime-water, in the pro- 
portion of two grains, or a Kttle more, to the ounce. 
" I have seen much relief procured by a lotion com- 
posed of equal parts of the Chloro-sodaic Solution of 
Labaraque and water. As in the cases before men- 
tioned, however, the presence of rhagades or ex- 
coriations will require palliation before it can be 
employed. I have also observed great benefit to 
follow the use of a lotion composed of two fluid 
drachms of liquor Potassas, one fluid drachm of 
Hydrocyanic acid, and eight fluid ounces of emul- 
sion of Bitter Almonds. M. Rayer * details a severe 
case of a disease of this description, which was cured 
by Gelatino-sulphureous * Douches, recommended by 
M. Dupuytren. It is of importance to avoid wine, 
spirits, tea, coffee, pepper, and all aromatics, when 
tne disease is severe." 

Books which may be consulted on Prurigo. 

Cazenave et SqHEDEL, Abr^^ Pratique des Maladies de la Peau> 
8yo. 1828. 

De Ch^mberet, Dissert, sur le Prurigo, 4to. 1808. 

IHctionnaire des Sciences M^dicales, Art. Prubigo. 

Obeen's T^ractical Compendium, 8vo. 1835. 

Haffenbeffeb, Nosodoch. l2mo. 1660. « 

'^pESfiflEE, De Pruritu Senilis, 8vo. 1726. 

LoBY, De Morbis Cutaneis, 4to. 1777. 

Medical Gazette, vol. xi. pp. 34, 55. 

lyiouBONVAL. Recherches et Obs. sur le Prurigo, 4to. 1823. 

Plumbe, on Diseases of the Skin, 2d edit. 1827. 

Rayer, Trait^ des Maladies de la Peau, 8vo. 1820. 

Reil. De Pruritu Senili, 8vo. 1803. 

SqmiC£&9 De Afiectibus Pruriginosis Senum, 8vo. 1727; 

A, T. Thomson, Cyc]s^paedia of Practical Medicine, voLiv. p. 627. 
-— WiLLAN, on Cutaneous Diseases, 4to. 1798. 

Wilkinson, Remarks on Cutaneous Diseases, 8vo. 1822. 



* Tndt^ des Maladies de la Peau^ tome i. p. 620. 



33 



Order 11. 

SQUAMiE. 

SCALY DISEASES. 

JSYN. >,sTog(G.): luepidosis (Young. Good): In- 
flammations Squameuses \Rayer) : Squammes (Siett) : 
Kuba or Kouba (Arab.) : Perjun (Persic) : Scaly 
eruptions. 
Def. An eruption of scales, consisting of 

LAMINiE OF MORBID CUTICLE, HARD, THICKENED, 
WHITISH, AND OPAQUE, DETACHING ITSELF FROM 

THE SKIN. Scales, when they increase into 

IRREGULAR LAYERS, ARE DENOMINATED CRUSTS. 

Those opaque " whitish, glistening, friable,** and 
thickened laminae of the cuticle, which are called 
Scales, commonly "proceed from an altered action 
of the vessels that secrete the cuticle, approaching to 
subacute inflammation ; '* but the degree of inflam- 
mation may be such as to affect the true skin, over 
which they are formed, and prove destructive to it : 
in the slighter forms, as for example Pityriasis, the 
cuticle alone, or with the rete mucosum, appears to 
be in a morbid condition. " These eruptions gene- 
rally display themselves in minute red points, that 
enlarge and form circular patches that nm into one 
another, and at the same time are covered with 
scsJes. When the scales fall off, they leave either a 
healthy surface, or a red, smooth, and glistening 
state of the skin, which does not soon regain its 
natural appearance.** If the definition be carefully 
attended to, scales will not be confounded with the 
scabs succeeding confluent pustules and vesicles, and 
superficial ulcerations. 

** A peculiar predisposition of habit is necessary 
for the appearance of scaly eruptions^ and this ia 

D 



34 SQUAMJE : 

many instances appears to be hereditary. Women in 
general are more liable to them than men, adults 
than children. The scales appear in patches, are 
accompanied by slight itching or tingling ; and 
owing to the diminished perspiration which they 
induce, the pulmonary exhalation and the secretion 
of urine are augmented. Scaly diseases are not 
contagious, but they are always chronic : they are 
accompanied or preceded by little constitutional 
disease ; thence are devoid of danger. They occur in 
all ranks of life, and at all seasons, but they are more 
frequent in spring and autumn than in summer or 
winter.'* 

" The distinct nature of the scales renders the 
diagnosis of this class of eruptive diseases very clear : 
the flakes succeeding Eczema^ and the scurf of 
Lichen have no affinity to them.** 

The three genera of scaly diseases are, 

1. Lepra. 

2. Psoriasis. 

3. Pityriasis.* 



Genus I. LEPRA, f 

S YN. XsTpa (G.): Vitiligo ( Celsus) : Lepra Grae- 
corum {Auct. var.) : Leprosis, Lepriasis ( Good) : 
L^pre, L^proisie (/^): der Aussatz (Ger.): Berat 
(Hebrew) : Beresa (Arab.) : Kush*tu (Hindos.) : 
VuUay Koostum (Tam.)\ Telia Koostum (Tel.)i 
Sweta Koostum (Sans.)'. Suffaid khere (Duk.)i 
Velussu (Malay die) : Lepra. 

Def. Circular patches of smooth, lami- 
nated SCALES, SURROUNDED BY A REDDISH AND 

^ It is evident that Ichthyosis was improperly placed among the 
SquanuB by Willan and Bateman ; I have therefore ventured to remove 
it to a new order, under the title Cuticulares. 

f Graece \eirpa dicitur, cujus formatio aTrw ruiv XeirlSiav (a squamis) 
unde rb XeirpweffSrai, quod significat scabrum fieri et simul albescere, 
originem trahit. /. Gorrcetu, Schol. in Nicand. Theriac. p. 77 — 82. 



LEPRA* 95 

PROMINENT CIRCLE. ThE PATCHES ARE OP DIF- 
FERENT SIZES, AND DEPRESSED IN THE CENTRE. 

The tenn Lepra is here appropriated solely to 
the Leprosy of the Greeks^ as described bj the 
more accurate of those writers. It is characteriied, 
as stated in the definition, bj <' scaly patdies, of 
different sizes, but having always nearly a dhrculair 
form, and raised in the circumfereDce : several of 
these, however, may run together and form patches 
of a very irregular figure.'** The parts wnich it 
chiefly attacks are below the patella, over the tibia, 
the elbows, the fore arms, and the surface in par- 
ticular of the ulna. <* Lepra is rarely dangerous, 
although extremely obstinate and difficult to cure : 
but, instances have occurred in whidi it has ran 
on to a fatal termination: the symptoms are thus 
described by Richter. * The local . disease having 
reached its acm^, a remarkable constitutional change 
displays itself. The patient becomes languid ; asth- 
matic, especially in the night ; fits of suffocation seize 
him ; he coughs violently and spasmodically ; is wake- 
ful and falls into excessive, colliquative, clammy 

* The confusion which has every where prevailed in the use of the 
terms Lepra and Leprosy^ seems to have originated principatly with the 
translators of the Arabian writers after the revival of leamingw Th« 
Greeks agreed in appropriating the appellation otXur^a to a scaly erup- 
tion (as its etymology dictated^ ; most of them deemed it the highest 
degree of scaHnesSf exceeding m this respect the Lichenes, Psora, and 
Alphos ; and those, who were most minute in their de9eription» stated 
that " it affects the skin deeply, in circular patches, at the same time 
throwing off scales like those of large fishes." (See Paul. ^gin. de Re 
Med. lib.iv. cap. 2.;— 'and Actuarius de Meth. Med.lib.it cap. II.; 
— also Aetius, tetrab. iv. serm. i. cap. 1 J4. ; aiui Galen Isagoge.) This 
was sufficiently clear ; but those who translated the works of the 
Arabians into Latin, fell into the extraordinary mistake of applying the 
Greek term to a tubercular disease, which had been actually dCescribed 
bv the Greeks under the appellation of Elephantiasis; and they applied 
the barbarous term Morplusa, together with Scabies and Impetigo, to 
the scaly diseases of the Greeks above enumerated. Whence their 
followers, who detected the error, spoke of the Lepra Arabum as well 
as the Lepra Graecorum ; while the less accurate confounded ever)' foul 
cutaneous disease under the term Leprosy. The Arabians themselves 
do not employ the word Lepra ; but have described these diierent dis- 
eases under appropriate appellations. See Elephantiasis below. 

D 2 



36 SQUAMJE : 

sweats, that exhale an intolerably foetid odour; his 
voice becomes weaker and hoarser ; the appetite for 
food and drink is pretematurally increased ; and the 
temper becomes gloomy. At length, various nervous 
symptoms supervene, faintings, convulsions, partial 
paralysis, and at length exhaustion that terminates 
in death/ '' ♦ 

There are three species of Lepra : 

1. L. vulgaris. 

2. L. alphoides. 

3. L. nigricans. 

Species 1. Lepra vulgaris^ Common Lepra. 

Syn. Herpes furfuraceus circinatus (Alibert) : 
Dartre fuifurac6e arrondie — Lfepre (-F.): Weisse 
aussatz ( O.) : Berat lebena (Hebrew) : Beras bejas 
(Arab.) 

This species of the disease, (Plate VII. of Bate- 
man ; PL 4. of Thomson's Atlas,) the most ordi- 
nary in this country, commences with small, round, 
reddish, and shining elevations of the skin, at first 
smooth, but within a day or two exhibiting thin 
white scales on their tops. These scaly patches 
gradually, sometimes rapidly, dilate to the size of 
half-a-crown, " are depressed in the centre,** but still 
retain their oval or circular form, and are covered 
with shining scales, " not unlike mica or asbestos, 
but more opaque,'* and encircled by a dry, red, and 
slightly elevated border. " They always extend by 
the coalescing of distinct points of inflammation. The 
scales at first are thin, somewhat resembling those of 
a carp, but by degrees they become laminated and 
denser ; they fall and are renewed many successive 
times ; ** and in some cases accumulate, so as to form 
thick prominent crusts. " In mild cases of the dis- 
ease, it is probable that the morbid action is confined 

* Richter, Specialle Therapie, vol. ii. p. 440., quoted by Dr. Hough- 
ton. Encycl. of Prac. Med. iiL p. 30. 



LEPRA. 87 

to the scarf skin; but when the disease is severe, 
the cutis vera is involved/* If the scales or crusts 
are removed, the skin appears i'ed and shining, being 
very smooth, and free from the cuticular lines in the 
beginning, but marked, in the advanced stages, with 
long deep lines and reticulations, not always coin- 
ciding with those of the adjoining surface, " but 
with the under surface of the desquamated layers* 
If the first scale which forms be forcibly detached, a 
small speck of blood is found in the little hollow of 
the scale and of the slight elevation on the skin 
which occupied it/' 

The Lepra most commonly commences on the 
extremities, where the bones fie nearest to the sur- 
face ; especially below the elbow and the knee, and 
usually on both arms, or both legs, at the same time. 
From these points it gradually extends, by the form- 
ation of new and distinct patches, along the arms or 
thighs, to the breast and shoulders, and to the loins 
and sides of the abdomen. In several cases, I have 
observed the eruption most copious and most per- 
manent round the whole lower belly. The hands 
also become affected, and the roots of the nails ; and 
in many cases the hairy scalp suffers ; but the face 
is seldom the seat of large patches, although some 
scaliness occasionally appears about the outer angles 
of the eyes, and on the forehead and temples, ex- 
tending from the roots of the hair. In the more 
severe cases, the nails of the fingers and toes are 
often much thickened, and become opaque and of a 
dirty yellowish hue, and are incurvated at the ex- 
tremities ; their surface is also irregular, from deep 
longitudinal furrows, or elevated ridges. 

When the eruption of Lepra is moderate in degree 
and extent, it is not attended with any uneasy sen- 
sations, except a slight degree of itching after a full 
or an indigestible meal, or when the patient is heated 
by exercise, or becomes warm in bed ; and a little 
occasional tingling in certain states of the atmo- 

D 3 



98 SQUAMi£ : 

^here. * ^^ JVJj** Plumbe has remaribed that a sen.* 
sataon of pricing always accompanies the separation 
of the first scales, before they hare attained the size 
of spangles. This he attributes ^ to the raising up 
of the edge of the scale, produced by the t^mefac* 
tioQ and devation of the inflamed margin, and fresh 
growth of the scale detaching the centre forcibly 
from the cutis :' but is more likely to depend on the 
altered condition of the cuticular secretion affecting 
the sensitive extremities of the nerves.** t When the 
patches are generally diflSised, however, and there is 
a considerable degree of inflammation in the skin, 
the disease is acc^ompanied with extreme soreness, 
pain, and stiffiiess ; which I have sometimes seen so 
great as to render the motions of the joints im- 
practicable, and to ecmfine the patient to bed. Yet 
ev^i uiuler these circumstances, there is little con- 
stitutional dii^urbance ; and if no medicine be em- 
ployed, the xiisease of the skin may continue for 
months, or even years, without any material derange- 
ment of the system. 

^^ Lepra is easily distinguished from most other 
eruptions : from I^oriasis by the regular circular 
form of the patches, which, in the latter disease, are 
always insular ; and in which, also, the borders are 
neither elevated nor inflamed. With one species, 
however, of Psoriaids, the guttata^ Lepra may be 
readily confounded: but the patches are generally 
smaller and less regular in their figure than those of 
Lepra. There are no rhagades and ulcerations in 
Lepra. It has beai said that Lqpra, when it attacks 
the scalp, may be confounded with what has been 
named Porrigo scutulata ; but, independent of the 
latter disease being contagious, in the former the 
scab of Lepra is readily distinguished from the 
laminar scab of this Porrigo. From those syphilitic 

* Hippocrates remarks that some LeprcB itch before rain : lib. Ile/oi 
f Fiumfoe on Diseases of the Skin, 2d edit. 1827. 



LEPRA. 39 

eruptions that assume its form, Lepra is distinguished 
by the absence of the dark coppery hue which cha^- 
racterizes all true venereal eruptions. 

It is not easy to point out the causes of this dis- 
ease, which appear, indeed, to be very various ; for 
it is one of the most common affections of the skin, 
at least in this metropolis, and occurs at all periods^ 
and under every circumstance of life.* It is im- 
doubtedly an inflammatory disease : it is as certainly 
not communicable by contagion ; nor does it appear 
to originate from confinement to certain kinds of 
diet, such as fish, dried or salted meats, &c. since it 
is not endemic in districts where these are habitually 
used, and occurs frequently where they are almost 
unknown. But, like some other cutaneous affections 
of a more transient character, it is certainly produced 
occasionally by the influence of particular articles of 
food and arink, which operate through the idiosyn- 
crasy of individuals.! I have met with one gentle- 
man, in whom spices or alcohol speedily produce it. 
The original attack in him occurred after eating 
some hot soup, containing spice, the first spoonful of 
which excited a violent tingling over the whole head, 
followed by the leprous eruption, which soon extended 
to the limbs. In another case, in a young gentle* 
man of nineteen, the disease commenced after taking 
copious draughts of cream. Vinegar, oatmeal, and 
other species of food, to which it has been ascribed, 

* It is difficult, therefore, to account for the oiiHuion expressed by 
the late Dr. Heberden, respecting the extreme rarit}' of Lepra in this 
country. « De vero scorbuto et Lepra, nihil habeo quod dicaro, cum 
alter rarissimus est in urbibus, altera in Anglia pene ignota; unde 
factum est ut hos morbos nunquam curaverim." (Comment, cap. S5.) 
And still more difficult to explain the statement of Dr. Cullen, whose 
definition of Lepra will include both the dry and humid tetters (Pso- 
riasis and Impetigo) with the proper scaly Lepra; but who nevertheless 
affirms that ne had never seen the disease. Nosol. Meth. class iii. 
gen. 88. note, 

f Larrey ascribes the attacks of Lepra, which the French suffered in 
Egypt, to die unwholesome character of the pork in that country ; for 
all those who lived upon pork for some time were attacked by a leprous 
eruption. Relation Chirurgieale de I* Ai'm^ d* Orient, 8vo. Pans, 1804. T. 

D 4 



40 sauAMiE : 

have probably given rise to it occasionally : but these 
are all anomalies, and are only referable to peculiar 
idiosyncrasy.* In some cases it has commenced after 
violent and continued exercise, by which the body 
had been much heated and fatigued: ^^ and occasion* 
ally it has followed violent mental emotions, namely, 
anger, sudden grief, or fright/' 

Dr. Willan has imputed the origin of Lepra to 
cold and moisture t, and to certain dry sordes on the 
skin. It has seldom occurred to me, however, to 
witness the disease in bakers, laboratory-men, and 
others who work among dry powdery substances; 
while I have observed a considerable number of cases 
ii^ young ladies, and in persons of both sexes in re- 
spectable ranks of life, by whom every attention to 
cleanliness was scrupulously paid. Where cold and 
moisture have excited the eruption of Lepra, the 
predisposition to it must have been peculiarly great. 
" Dr. DuflBin has remarked, that the greater number 
of persons afflicted with Lepra are of a ruddy, fair 
complexion. The following is his opinion of the 
proximate cause of the disease : * I imagine that the 
primary evil lies in the secretions of the true skin, 
which, becoming vitiated by their local irritation, in- 
duce chronic or subacute inflammation of the vessels, 
that either nourish or produce the cuticle ; and that 
they produce a superabundant supply of morbid 
cuticle.' t This theory is ingenious, but not alto- 
gether free from objection ; '* and, on the whole, it 
must still be admitted, that the causes of this dis- 

* Some poisonous substances taken into the stomach have produced 
an eruption of Lepra. The poison of copper is stated to have speedily 
excited it in several persons at the same time, in one of whom it con- 
tinued for a month, but disappeared in the others in about ten days. 
See Med. Facts and Obs. vol. iii, p. 61. 

f The effects of cold and moisture on some quadrupeds tend, in some 
degree, to confirm this opinion. Thus Dr. Baron, having kept rabbits 
in a cold damp place, ana fed them on green food, perceived that they 
became low in flesh ; the abdomen became tumid, and the whole skin 
scaly and unhealthy. Vide Delineations of the Origin and Progress of 
the Changes of Structure in Man, 8vo. 1 8S8. 

:|: Edin. Med. and Surg. Joum. Jan. 1826. 



^ LEPRA. 41 

ease are involved in much obscurity. There is ob- 
viously an hereditary predisposition to it in some 
individuals. 

. Species 2. Lepra alphoides*, White Lepra. 

St/n. *Ax<po^, (Aii€. Or.) : Alphos ( Celsits) : Le- 
priasis albida ( Good) : L^pre Alphoide (-F.) : der 
Weisgeflecke aussatz ( German) : Boak (JSeb.) : 
Albohak (Arab.) 

This is a less severe form of the disease (Plate 
VIII. fig. 1. of B axeman ; PL 4. of Thomson's 
Atlas,) than the preceding, for it is merely a 
variety of it. It diners chiefly in the small size of 
the patches, which seldom extend beyond the dia- 
meter of a few lines, or become confluent, — in the 
minuteness and greater whiteness of the scales, — 
and in its limitation to the extremities. << It gives 
the parts affected a speckled appearance, formed of 
red patches and silvery scales irregularly dispersed." 

* The Greeks have described the Alphos as a milder difeaie, being 
more superficial, and less rough, than tne Lepra (see Galen, de Svmpt. 
Caus. lib. iii. — Aet* tetrab. iv. senn.i. cap. 154.): and the description 
pf it given by Celsus accords with the appearances of the L. alphoidet 
above stated. " AX^oc vocatur, ubi color albus est, fere subasper, et 
non continuus, ut quaedam quasi guttas dispersse videantur. Interdum 
etiam latins, et cum quibusdam intermissionibus, serpit.'* (De Medicina, 
lib. V. cap. 18.) Celsus nowhere employs the term Lepra. 

This scaly Alphos, which was deemed by Hippocrates a blemish, rather 
than a disease (IIcpi IlaOwv, sect. 15.), was mstinguished from another 
white affection of the skin, the Leuce, which was not scaly, but consisted 
of smooth, shining patches, on which the hairs turned white and silky, 
and the skin itself, and even the muscular flesh underneath, lost its sen- 
sibility, The Leuce was a disease of an incurable nature. (Hipp. Upoppifru:. 
lib. ii.) Celsus, although pointing out this distinction, includes the Leuce 
and the Alphos under the same generic title, Vitiligo, (loc. cit.) 

It may be remarked, that the Arabians distinguished these two ailec- 
tions by different generic appellations; calling the Alphos, Albohak, and 
the Leuce, Albaras^ with the epithet white. Their translators have 
called the former Morphisa, and included the Leuce and Elephantiasis 
under the appellation of Lepra, By retaining these distinctions in re- 
collection, the accounts of the older writers may be read, while the con- 
fusion arising from their misapplication of names may be avoided. 

It appears probable that the Leiice was the Leprosy of the Jews, de- 
scribed in Leviticus, chap. xiii. See Greg. Horssii Obs. Med. lib. vii. 
S. 330, — Leon. Fuchsii Paradox, lib. ii. cap. 16. — Th. CampaneUae Ord. 
fedic. lib.yi. cap. 23: — Hensler, Von Abendlandischen Aussatz, p. 541. 



42 SQUAMA : 

This variety of Lq>ra is most common in children, 
*> and girls under the age of fourteen, or old per- 
sons, or those of debilitated habits. When it affects 
adults, the site of the scaly patches is considerably 
redder than the surrounding parts ; and the exfoli- 
ating scales leave a smooth, red, glistening surface; 
which, in old cases, is intersected with fissures." It 
is tedious and difficult of cure, like the former, and 
requires similar treatment. 

Species 3. Lepra nigricans^ Black Lepra. 

St/n. [jLsXag (G.): Melas ( Cels.) : Swarze Aussatz 
( Oer.) : Berat cecha (Heb.) : Beras asved (^^rab.): 
Black Lepra* 

This species (Plate VIII. fig. 2. of Bateman ; 
PI. 4. of Thomson's Atlas,) is a more rare form 
of the disease, differing externally from the L. vul- 
garis chiefly in the dark and livid hues of its patches, 
which is most obvious in the margin, but even ap- 
pears through the thin scales in the area of each 
patch.* The scales are thinner and more easily 
detached in this form of Lepra, and the surface 
remains longer tender, and is often excoriated, dis- 
charging bloody serum, till a new, hard, and irregular 
incrustation is formed. There is much probability 
in Dr. Duffin's opinion, that this form of the disease 
is merely the vulgaris in a cachectic habit. " M. 
Biett regards it as invariably of syphilitic origin.*' 

It occurs chiefly in persons whose occupations ex- 
pose them to the vicissitudes of the weather, and to 
a precarious diet, with fatigue and watching. It is 
cured by nutritive food, with moderate exercise, 

* The Melas of the ancients was deemed a superficial afiection, 
resembling the Alphos, except in its colour. ^^ McXac colore ab hoc 
differt, quia niger est, et umbrae similis : cestera eadem sunt." (Celsus 
loc. cit.) Possibly it included the Pityriasis versicolor. See below. 
Genus iii. of this Order, Spec. iii. 

** I cannot understand the reference to Pityriasis in this note ; for, if 
Celsus is to be followed, it is evident, from the expression * caetera 
eadem sunt,' that he intends to describe the Melas as a species of the 
same genus as the Alphosy that is, as a Lepra." T. 



LEPRA. 49 

£^lbwed by the use of the Cinchona bark, muieral 
acids, and sea-b^hing; and, as a local application, 
the Unguentum Hydrargyri NitnUis^ diluted with 
two parts of lard. 

It would be superfluous to enumerate the cata- 
logue of useless medicines, which have been recom^ 
mended from ancient times for the cure of Lepra; 
I shall, therefore, confine my attention to those, of 
the beneficial agency of which I can speak from 
experience. It is necessary to premise, however, 
that there is no one remedy, nor any invariable plan 
of treatment, which will succeed in Lepra, under all 
the circumstances of its appearance in different in- 
stances ; and that great errors are committed by 
prescribing for the name of the disease. The cir- 
cumst^ices to which I allude more particularly, are 
the diflferent degrees of cutaneous excitement, or 
inflammatory action, which accompany the disease in 
different habits ; and which, if carefully attended to, 
afford an important guide to the most successful ap- 
plication of remedies. 

" There are few cases of any of the varieties (for 
they can scarcely be regarded as species) of Lepra 
in which more than one moderate bleeding is not 
requisite, even where a tonic plan is indicated. The 
circumstances usually regarded as indicating blood- 
letting, are an active irritable state of the patches, 
with feverishness : but, even when these symptoms 
are not present, it aids the action of other remedies 
in a remarkable degree. In general our practice has 
been too exclusively depleting or stimulant." 

In the less irritable conditions of the leprous erup- 
tion, in which no inflammatory tendency appears, 
such as the L. alphoides frequently, and the L. vul- 
garis occasionally, exhibit, " after the abstraction of 
eight or ten ounces of blood,** a gently stimulant 
mode of treatment, at least externally, is requisite ; 
though in all cases of Lepra, the diet should be light 
and moderate, and heating liquors should be avoided. 



44 SQUAMA : 

especially malt liquors and spirits : for every indulg- 
ence in these points will be felt in the aggravation 
of the symptoms. " When the eruption is limited 
in extent, has existed for some time, and is un- 
attended with much itching, pain, or irritation, little 
more than local remedies are required/' A frequent 
use of the wann bath, at 89"* to 95** Faht., with 
which a moderate degree of friction may be com- 
bined, contributes to remove the scales, and to soften 
the skin. " If the scales be forcibly removed before 
the exfoliating process is complete, the skin will 
bleed, which is not the case when the exfoliation is 
complete.*' If the eruption be confined to the ex- 
tremities, local ablution may be sufficient, ^' and this 
is best performed by immersing the part in warm 
artificial Harrowgate water, as recommended by Dr. 
Duffin.* The following is the method of preparing 
this water : Dissolve jij of Sulphate of Magnesia, 
gr. X. of Bitartrate of Potassa, and jss of Sal Poly- 
chrest in f ^xxiv of hot water. The temperature of 
the solution when used should be 95° Fahrenheit : it 
should be used daily for 10 or 15 minutes each 
time.'* These cases are benefited by the use, both 
internally and externally, of the sulphur waters of 
Harrowgate, Lucan Spa, Leamington, Crofton, Mof- 
fat, and other well-known springs " in this country ; 
and those of Barnes, de Cauterets, de Bagnferes, de 
Bagnoles, St. Gervaise, and d'Enghien on the Con- 
tinent,'* and by the warm sea-water bath. In fact, 
these gently-stimulant ablutions are often sufficient, 
if persevered in during several weeks, to remove the 
modifications of Lepra of which I am now speaking. 
" The sulphureous vapour baths are still more useful, 
particularly when combined with moderate friction.*' 
— " All of these baths operate more beneficially when 
they are aided by moderate friction with the flesh- 
brush.** 

* Edin. Med. and Surg. Journ. Jan. 1826, p. 23. 



LEPRA. i5 

But if the scales adhere teDaciously, or are accu- 
mulated into thick crusts, then some more active 
lotion must be conjoined with the warm ablution, or 
with the application of steam, in order to clear the 
surface. Lotions of diluted Alcohol, of sulphurated 
FotaiSsa, or the. decoction of Dulcamara, will aid the 
exfoliation; and the thick crusts may be softened 
and loosened by lotions containing a portion of the 
liquor Potassae, or of the Muriatic acid. " Blisters 
have been advantageously employed for this pur- 
pose.'* When these are removed, the cuticle may 
be restored gradually to its healthy condition, by the 
Unguentum Picis, or the Unguentum Hydrargyri 
Nitratis diluted with Saturnine Cerate, or simple 
ointment, " or, which is better than any other, an 
ointment composed of equal parts of Unguentum 
Hydrargyri Nitratis and Unguentum Picis:" or 
lotions containing a small proportion of Oxymuriate 
of Mercury may be substituted. " M. Biett re- 
commends an ointment composed of from twelve to 
fifteen grains of loduret of Sulphur * and an ounc^ 
of Lard.*' The ointments should be applied at night, 
and washed off in the morning with warm water, or 
a slight saponaceous lotion, *^ composed of f3iij of 
Liquor Potassae in f ^ vj of water ; after which the parts 
are to be brushed over with a solution of Oxymurias 
Hydrargyri gr. ij : Spiritus Vini f ^j. Dr. Duffin f 
ascribes much of the benefit derived from the alka- 
line solution to its being a perfect ablution to the 
part, and requiring the aid of considerable friction, 
two circumstances of great importance in Lepra.*' 
In a few cases, the continued application of the tar 
ointment has effectually cleared the skin of the 
patches, and restored its texture, even when internal 
remedies had little influence ; but this advantage has 
not been permanent. 

* loduret of Sulphur is readilv prepared by melting together, in a 
flask, equal parts of Iodine and Sulphur. T. 
f Loco citato. 



45 SQUAMiE : 

The same inert cases will be accelerated in their 
progress towards a cure, by the use of those internal 
remedies which tend to support the strength and to 
simulate the cutaneous vessels. Purging is injurious, 
but the bowels should be kept easy by a mild pilL 
The Arsenical Solution*, recommended by Dr. 
Fowler is the best tonic, and proves often extremely 
beneficial, in doses of four or five drops, which may 
be slowly increased to eighteen, and persevered in 
for a month or more.t ** It may be given in the 
Decoction of Dulcamara, or of Sarsaparilla : and its 
eflScacy is much augmented by employing for common 
beverage, water moderately acidulated with Nitric 
Acid, and sweetened. The sensible eflFects of the 
Arsenical Solution are quickening of the pulse, and 
an uneasy sense of stiflBiess in the eye-lids : but when 
these are accompanied with griping pains, a white 
tongue, with its tip and edges of a florid red, anxiety 
in the praecordia, and frequent sighing, the remedy 
should be discontinued ; and when it causes pains 
of the chest from the first, it should not be given 
at all. I have generally employed the Solution of 
Hydriodate of Iron, in doses of a fluid drachm, in a 
glass of water, three times a day, during the in- 
tervals between the bleedings. The Tincture of 
Cantharides, brought into notice by Dr. Mead, has 
been given in doses of tixv to tixviij, in a basin of 
milk or barley water, three times a day, with evident 
benefit.'* Pitch, " in doses of from six to twelve 
grains, and Turpentine, in doses of from ten to 
thirty grams,'* administered in the form of pills, are 

* Preparations of this mineral have a direct tendency to stimulate 
the cutaneous circulation, and to inflame the skin ; and are, therefore, 
altogether inadmissible in the irritative forms of Lepra. 

f This active medicine being now not only sanctioned by the pro- 
fession in general, but by the Pharmacopoeia of the College, it will be 
enough to state, that in these smaller doses, which experience has 
proved to be sufficient, it may be taken without any inconvenience. 
Another preparation, introduced by the late Dr. De Valangin, is kept at 
Apothecaries' Hall, under the name of Solutio Solventis Mineralis, and 
is equally efficacious. 



LEPRA. %J 

prodiictiTe of a similar good efl^, whene the cutanea 
ous circulation is very inert; but these medicines 
are liable to aggravate the eruption, where it is con- 
nected with much irritability of the skin. The 
Solution of Oxymuriate of Mercury in Alcohol, or in 
doses of ono'fourth of a grain in a fluid drachm of 
the Tincture of Cinchona, has appeared to have some 
efficacy in these inert states ; and thin and delicate 
girls, of relaxed habit, a£Pected with the Lepra 
alphoides, have taken the Vinum Ferri, or the 
tartrite before mentioned, with much advantage.* 
** Decoctions of Mezereon, Guaiacum, the Compound 
Decoction of Sarsaparilla, have, in many instances, 
proved useful." 

One of the most effectual remedies for Lepra, 
however, under all its varieties, is the decoction of 
the twigs of the Solanum Dulcamara^ Bitter-sweet, 
which was introduced to the notice of British practi. 
tioners by Doctor, now Sir Alexander, Crichton.t 
This medicine is at first administered in doses of two 
or three ounces thrice every day, which are gradually 
augmented, until a pint is at length consumed daUy. 
When there is a degree of torpor in the superficial 
vessels, the same decoction, made with a larger pro-* 
portion of the shrub, is advantageously employed as 
a lotion ; but if there is any inflammatory dispositicm, 
this and every other external stimulus must be pro- 
hibited. " In a case described by Turner, after the 
patient, a maiden, had been salivated without efl^, 
a cure was effected by a gentle alterative containing 
Ethiops Mineral, washed down with a decoction ci 
Rumex Acutus^ Sarsaparilla, and some inert roots ; 

* If in any case the Tinct.Lyttae prove useful in Lepra, it would pro- 
bably be in these more inert instances. But it is to be observed, that 
Dr. Mead, who originally recommended thk medicine, wafl probably 
spediing, not of the scaly Lepra, but of the Leuce, or of the Elephan- 
tiasis. See his Medicina Sacra, cap. ii. 

f See his communication to Dr. Willan. (Treatise on Cutaneous 
Diseases, p. 145.) His formula has been adopted by the London Col- 
lege, and inserted into its Pharmacopoeia. 



48 SQUAMA : 

with an ointment of the Hydrargyri Praecipitatus 
AlbuSy the bowels having been occasionally well 
purged. In all the cases I have seen, the inild alter> 
ative plan has proved the most effectual. The de- 
coction of Dulcamara, with minute doses, i. e. tV of 
a grain of Oxymuriate of Mercury, or from gr. v 
to gr. X of Hydrargyrum c. Creta, night and morn- 
ing, have seldom disappointed me : but it is difficult 
to say what share the Dulcamara has in the cure. 
Among other vegetable infusions, that of the Ledum 
Palicstrej Marsh Rosemary, in the proportion of ^iv 
to Oij of boiling water, has a high popular reputation 
in the north of Europe. It is taken to the extent 
of a pint daily.* Dr. Duffin is of opinion, that both 
the Arsenical Solution and the Alcoholic Solution of 
Corrosive Sublimate produce some specific alteration 
on the secretions of the skin, which does not result 
from the employment of other stimulants ; and 
thence their superiority in Lepra.** 

Where an irritable state of the disease exists, in- - 
deed, (and it is the most frequent) nothing more 
stimulating than tepid water, or thin gruel, or an 
infusion of Digitalis, made with ^j of the leaves to a 
quart of boiling water, can be used for the purposesr 
of ablution ; and the Arseniates, Pitch, &;c. above 
mentioned, must be excluded. The disease, under 
this condition, will be certainly aggravated by sea- 
bathing, by fnction, by the external use of the strong 
sulphureous waters, or of any irritant, as I have fre- 
quently observed ; but it will be alleviated by blood- 
letting, either general or local, " which requires to be 
repeated at short intervals ; '' and followed by the use 
of the simple "tepid** or the vapour bath ; and by the 
internal employment of Sulphur, with Soda or Nitre, 
or the Hydrargyrus Sulphuratus Niger with an anti- 
monial, especially when conjoined with the Decoction 
of Dulcamara or of the 'Ledum Palmtre. The Caustic 

* Linnaeus, Dissert, de Ledo Palustre. Upsal. 1775. 



LEPRA. 49 

Fotassa, or Liquor Potassae of the London Pharma- 
copoeia, in the dose of twenty or thirty drops, alone, 
or in combination with the Precipitated Sulphur, is 
likewise beneficial : and the Tinctura Veratri, given 
in such doses as not to disorder the bowels, has oc- 
casionally removed this state of the disease. " When 
the eruption has repeatedly returned, the Sulphur 
fume baths may be used in conjunction with the 
use of the Arsenical Solution, in moderate doses; 
and in using these it should be recollected that they 
are apt to excite an itching of the skin, which must 
not be confounded with that of the disease. When 
it is severe, the baths should be omitted for a few 
days, and then resumed.'* 

When the skin is highly inflamed, thickened, and 
stiflP, of a vivid red colour, intermixed with a yel- 
lowish hue (where the cuticle is separating in large 
flakes), the heat, pain, and itching are often ex- 
tremely troublesome, and the motion of the limbs is 
almost impracticable. ** In this state of the habit, 
the irritability of the skin must be diminished by an- 
timonial emetics, and mercurial purgatives ; and if 
the excitement be considerable, general bleeding 
should be resorted to before either Arsenic or any of 
the remedies already mentioned can be employed. If 
the local irritability be great, nauseating doses of 
Antimonials should be persisted in for a few days, 
with the use of the tepid bath." The most effectusJ 
relief is obtained, in these cases, by gently besmear- 
ing the parts with cream, or a little fresh and well- 
washed lard or butter, or cold drawn castor oil, while 
the itching is relieved by a lotion of Prussic Acid in 
Rose-water. *' The progress of the cure, in all the 
species, is marked by the scales detaching themselves 
in the centre of the patches, and their edges be- 
coming dry; and the skin gradually ceasing to be 
scaly; but, in every instance, this occurs first in 
the centre of the patch, and extends to the circum- 
ference." 

£ 



50 SQUAMA : 

j^qoks which iMfy be cqnsuUei on Lepr^, 

Aeqcbq. Aca4* vp^ viii. p. 285. 

PoNORpEy^ Diss* de Lepra Squsunosa, 8v6. Halse. 1795. 
CAZ£NAy£ et ScHEOSL, k\>T€gi Protique des Maladies de hi Faau, 
8Y0-, ^828. 
Cyclopaedia of Practical, Medicine, vol. iii. p. 25. 
DictionnaiFe de M^dedne, art, L^pre. Paris. 
Dpffin, on Sqi^mous Disorders. Edinburgh Med.. an4 Su^. jpura« 

No. 86. 

Good's Study of Medicine, vol. iv. p. 574. 

Q]|een's Practical Compesidiuni, 8vo. 1855. 
'^irOEY, de Morbia Cutan?is, p^365. 4to. Paris. 1777. 

Meckel, Diss, de L^pra Squamosa, 8vo, Halae. 1795. 

Flumbe, on Diseases of the Skin, 8vo. 2d edit. 1827. 

Kayeb, Traits des Maladi^ de la PeaM, tome i. p« I . ^vo. Par% 1827. 

WiLLAN, on Cutaneous Disjeases, 4to. London, 1811. 



Genus II. PSORIASIS. 

Syn. Impetigo ( Sexmerty Plenck, et alia) : Scabie& 
sicca (EtmulL Hoffm. Plater)^ Hasef (^/rvicenna)^ 
Lepidosis Psoriasis (Good^ Young): Kleinaussatz 
((?.): Dartre squammeuse sfeche (F.) : Saphat 
{Hebrew) : Sahafati (^Arabic) : Dry Scall. 

Def. Patches of dry, amorphous scales ; 

CONTINUOUS, OR OF INTERMEDIATE OUTLINE J SKIN 
OFTEN CHAPPY. 

The Psoriasis, or &caly tetter *, occurs under a 
considerable variety of forms, exhibiting, in commoiL 
with Lepra, more or less roughness and scaHness of 
the cuticle, with a redness underneath. It differs, 
however, from Lepra, in several respects. Some^ 
times the eruption is diffiise and continuous, and 
sometimes in separate patches, of various sizes ; 1>ut 
these are of an irregular figure t, without the cle^ 

* The scaly tet;ter was denominated Fsora by |he Greeks, or some? 
times rough and leprous Psora. (See Aetius, tetr. iv. 1. cap. ISO, &c.) 
But the same generic term, with the epithet ulcerating^ os pustular y "irutpa 
ihciadrig, was applied to the humid tetter (Impetigo), and perhaps also 
to Scabies. As the appellation Psora has been appropriated to Scabies 
by many of the modern writers. Dr. Willan adopted the term Psoriasis 
(which was chiefly used to denote a scaly afiection of the eyelids apd of 
the scrotum by the ancients) for the name of the genus. 

f Paul of ^gina, who treats of Lepra and Psoriasis together, points 
out the irregular figure of the latter as a principal distinction, that oC 



PSORIASIS. 51 

vated border, the inflamed mai^in, and the oval or 
circular outline of the leprous patches : the surface 
under the scales is likewise much more tender and 
irritable in general than in Lepra ; and the skin is 
often divided by rhagades or deep fissures. It is 
generally a chronic auction, and is accompanied by 
some constitutional disorder, and is liable to cease 
and return at certain seasons.* In Psoriasis the 
scales are less firmly attached than in Lepra, and do 
not accumulate over one another as in that disease : 
on the contrary, " when the second set of scales 
form, the first fall off :" they separate with facility, 
leaving, as has been already mentioned, a more tender 
surface than in Lepra. 

The causes of Psoriasis are nearly as obscure as 
those of Lepra. *< In almost all the cases which I 
have seen, except those of a purely local nature^ the 
digestive organs have been in iault; and great aci- 
dity of stomach has prevailed. It is not improbable 
that the arthritic diathesis, mental anxiety, and the 
other exciting causes mentioned in the latter part 
of this paragraph) always produce this state of 
stomach previous to the appearance of Psoriasis : and 
it is probable that the irritable state of the stomachy 
which gives rise to the imperfectly-formed gastric 
juice in these cases, is accompanied by a correspcmd- 
ing irritable condition of the skin, which, inducing 
sub-acute inflammation of the superficial capillaries, 
causes the cuticle to be secreted in the diseased state, 
which characterises this eruption/' — " Instances, 



the former being orbicular. " ABvpa per profundi tatem corporem cutem 
depascitup orbiculaiiore modo, et squamus piscium squamis similes dimit- 
tit : "ircjpa autem magis in superficie haeret, et varie Jigurata est," &c. 
lib. iv. cap, 2. " De Lepra et Psora." 

* Celsus seems to have had this tetter in view, when describing his 
second species of Impetigo, and comparing it with Lichen. *' Alterum 
genus est pejus, et simile Papulae fere, sed asperius rubicundiusque, 
figuras varias habens: squamulse ex cute decidunt: rosio major est; 
celerius ac latius procedit, certioribusque, quam prior, temporibus, et 
fit, et desinit : Rubra cognoiainatur/^ (lib. v. cap. 38.) 

E 2 



52 SQUAMA : 

however, have occurred in which it has disappeared 
at times when the digestive organs display the greatest 
irritability, namely, during pregnancy/' * The dis- 
ease is not contagious ; with the exception, perhaps, 
of the first species, which Dr. Willan had observed 
to occur among children in the same school or 
family, at the same time ; a circumstance, however, 
which I never witnessed. An hereditary predis- 
position to it is manifest in some individuals. Dr. 
Falconer has frequently traced it to sudden chills, 
from drinking cold water after being violently heated 
by exercise, — a cause to which Lepra and other 
eruptive diseases are occasionally to be imputed.! 
Women, and especially those of a sanguineo-melan- 
cholic temperament, with a dry skin and languid 
circulation, are most liable to it: it aflFects them 
more particularly after lying-in, or during a state of 
chlorosis. And in children, it is not unfrequently 
produced by dentition and the many sources of irri- 
tation to which they are exposed. It is also some- 
times observed, in both sexes, connected with 
jttthritic complaints ; and we have seen it occur 
under states of great mental anxiety, grief, or appre- 
hension. In those who are predisposed to this erup- 
tion, slight occasional causes appear to excite it: 
such as, being overheated by exercise ; the unseason- 
able employment of the cold bath ; a copious use of 
acid fruits, vinegar, or crude vegetables ; and some 
peculiar mixtures of food. The first two species of 
the eruption are sometimes the sequel of Lichen. 

Dr. willan has given names to eleven kinds of 
Psoriasis; " but as several of them are local, and may 
be regarded as varieties of one species, a£Pecting 

* Encyclopaedia of Prac. Med. vol.iii, p. 545. 

f See Memoirs of the Med. Society of London, vol. iii. — In fact. 
Dr. Falconer, and even the nosologists down to our own time, include 
the Lepra, Scaly Tetter, and Pustular Impetigo, in their description of 
Lepra. See Voeel, de Cogn, et Curand. Homin. Affect, class viii. § 699. 
— Sauvages, Nosol. M^th. class, x. ord. 5. — Linn. Gen. Morbor. 
class. X. ord. 4. — Cullen, Nosol. class, iii. ord. j. gen. 88. 



PSORIASIS. 53 

different parts of the body *, it is more correct to 
regard the genus as comprehending five species 
only:'* viz. — 

1. P. guttata. 4. P. inveterata. 

2. P. diffusa. 5. P. localis. 

3. P. gyrata. 

Species 1. Psoriasis guttata : Minute dry 

SCALL. 

St/n. Dartre squammeuse humide et orbiculaire: 
Herpes squammosus madidans et orbicularis (Alt" 
heri). 

This species (Plate IX. fig. 1. of Bateman, PI. 5. 
of Thomson's Ati.as,) is a sort of connecting link 
between the genus of Psoriasis and Lepra, the little 
patches being distinct, and small (seldom exceeding 
two or three lines in diameter), but with an irregular 
circumference, and the other peculiar characters just 
described. They " first appear in the form of small, 
solid, red elevations, resembling flat pimples, which 
are soon covered with small dry scales : '* this occurs 
on almost every part of the body, and even on the 
face : but in the latter situation they exhibit only 
a redness and roughness, without scales. " The 
patches increase in size, but seldom exceed half an 
inch in diameter ; and these, in the decline of the 
disease, first become healthy in the centre, and on 
this account often assume the appearance of circles, 
or segments of circles." The patches frequently 
coalesce. This eruption is most common in the 
spring and autumn, at which season it is liable to 
recur for several years. It is preceded by general 
pains and slight feverishness ; and in the night is 
often accompanied with itching. In children it often 
spreads rapidly over the body in two or three days ; 
but in adults its progress is gradual and slow. 

* In this arrangement we have followed Dr. Good : see Study cf 
Medicine, vol. iv. p. 593. T. 

E 3 



54 SQUAMJE : 

Species 2. Psoriasis diffusa : Spreading dry 

SCALL. * 

Syn. Dartre squammeuse humide, — • Dartre 
squammeuse orbieulaire (Alibert). 

This species (Plate IX. fig. 2. ; X. 1. and 2. ; 
XI. XIIL 1. of Bateman ; PI. 6. of Thomson's 
Atlas) presents a considerable variety of appear- 
ances. In most cases it " commences like Psoriasis 
guttata, but soon coalesces " into large patches, which 
are irregularly circumscribed, and exhibit a rough, 
red, and chappy superficies, with very slight scaliness 
interspersed. This surface is exceedingly tender and 
irritable, and is aflFected with a sensation of burning 
and intense itching, both of which are much aug- 
mented on approaching a fire, on becoming warm in 
bed, or even on exposure to the direct rays of the 
sun ; " and in some cases which have come under 
my care, a humid state of the atmosphere has always 
augmented the imtation and itching ; *' but they are 
relieved by the impression of cool air. Sometimes 
these extensive eruptions appear at once ; but, in 
other instances, they are the result of numerous 
minute elevations of the cuticle, upon which small 
distinct scales, adhering by a central point, are soon 
formed, and which become gradually united by the 
inflammation of the intervening cuticle. As the dis- 
order proceeds, the redness increases, and the skin 
appears thickened and elevated, with deep intersect- 
ing lines or furrows, which contain a powdery sub- 
stance, or very minute scurf. The heat and painful 
sensations are much aggravated by the least friction, 
which also produces excoriation, and multiplies the 
sore and painful rhagades. — This form of the disease 
is most frequent about the face and ears, and the 
back of the hands ; the fingers are sometimes nearly 

* Correct representations of this affection are given in Alibert's 13th 
and 14th plates; the former exhibiting it on the neck and ear (" Dartre 
squammeuse humide"), — the latter in a patch on the cheek ("Dartre 
squammeuse orbieulaire.") Liv. iii. 



PSORIASIS. 55 

surrounded With a loose scaly incrUistation, aiid the 
Mits crack and exfoliate : but it occasionally occurs 
on other parts of the body, either at the same time, 
Oi" in succession. " Rayer remarks, that it is not 
uncommon to see P. guttata in the trunk of the 
body, whilst the limbs are affected with the species 
under consideration/** It commonly begins with 
som^ general indisposition ; and a degree of erethism, 
with occasional Ishdrp pains in the stomach, is some- 
times kept up, during several weeks, by the constant 
irritation which it excites^ Its duration is from one 
to four months, and sometimes much longer ^ and it 
ii*i liable to tequila, in successive years, in the spring 
oi" autumn, and sometimes in both seasons. 

" This species of Psoriasis occasionally occurs in a 
severe degree in children from two months to two 
years of age. It commences like the P. guttata ; 
but the inflammation gradually extends around the 
patches, and these rapidly coalesce, resepabling in 
some degree the Impetiginous Eczettia^ which is, 
hoWerer, a Vesicular disease. The scdes are rather 
whiter, and approach neai*er to the character of Lepra 
than those of the common form of P. diff^a (see 
Ttt0MS0N*s Atlas, Plate 6.). I cannot agree with 
Willan in regarding it as a distinct species* Dr. Un- 
derwood Jremarks, that he had * seen it chiefly during 
a cold season/ . It is certainly connected with den- 
tition, often subsiding as this is perfected, or after the 
gums are lanced. * When it accompanies this infantile 
statCj it is Usually conjoined with an affection of the 
mucous membrane of the nostrils.* Its appearance in 
infants is described in the following manner by Dr. 
Underwood : — * It appears in some parts in Very small 
eruptions, like the points of pins, with watery heads ; 
and in other parts ais large as peas, and sometimes in 
foul blotches, which, aflter breaking, form sores, and 
broad ugly scabs* These die away, and the like ap- 

* Traite Thdorique et Pratique des Mai. de la Peau, tome ii. p. 51. 

E 4 



56 SQUAMJE : 

pear successively, in other parts, sometimes for two 
or three months, leaving the skin of a dirty adust 
hue/ He considers that it is contagious. The prac- 
tice he recommends is to wajsh the parts with a lotion 
composed of f3ij of Liquor Potassae in a pint of water ; 
and, at the same time, to administer Hydrargyrum 
cum Creta, or Hydrargyrum c. Sulphure and the juice 
of Sium nodiflorum. He says, * an ointment consist- 
ing of the Unguentum Sulphuris and Unguentum Hy-- 
drargyri Nitratis, with a greater or less proportion 
of the latter, has hitherto never failed/ " * 

In other cases, the P. diffusa commences in separate 
patches, of an uncertain size and form, \vhich become 
confluent until they nearly cover the whole limb. 
Local instances apparently of this species also occur ; 
but as they arise from local irritations, they will be 
described under P. localis. 

Species 3. Psoriasis gyrataj Gyrated or Ser- 
pentine* dry SCALL. 

In this species (Plate XII. of Bateman ; PL 5. of 
Thomson's Atlas,) the patches are in stripes of a 
tortuous or serpentine form, resembling worms or 
leeches, or sometimes bending into rings, " which 
usually appear on the back or breast ; these tortuous 
stripes are of a red colour ; but this is partly ob- 
scured by light branny scales/* It is apt to be con- 
founded with the vesicular and pustular ring-worm 
(Herpes and Impetigo). " Its perfect freedom, 
however, from vesicles, distinguishes it from Herpes j 
and to freedom from pustules, prevents it from being 
confounded with Impetigo. It is most intense in 
spring and autumn." 

Species 4. Psoriasis imwteratay Inveterate 

DRY ScALL. 

St/n. Psoriasis agria (^Auct. Fet.) : Dartre squam- 

* Treatise on Diseases of Children^ 8th edit. p. 184. 



PSORIASIS. 57 

meuse licheuoide : Herpes squammosus lichenoides 
{Alibert). 

This species (Plate XIII. fig. 2. of Bateman ; 
PI. 5. of Thomson's Atlas,) is the most severe 
modification of the complaint, beginning in separate 
irregular patches, which extend and become confluent 
until at length they cover the whole surface of the 
body, except a part of the face, or sometimes the 
palms of the hands and soles of the feet, with an 
universal scaliness, interspersed with deep transverse 
furrows, and a harsh, stiff, and thickened state of the 
;skin. The production of scales is so rapid, that large 
quantities are found every morning in the patient's 
bed.* The nails become convex, thickened, and 
opaque, and are frequently renewed ; and, at an ad- 
vanced period, especially in old people, extensive ex- 
coriations sometimes occur, frequently caused by the 
attrition of the clothes, chiefly on the thighs, nates, 
and scrotum ; and these are followed by a discharge 
of lymph, followed by a hard dry cuticle, which 
separates in large pieces. Sometimes small suppurat- 
ing patches are interspersed, which occasionally are 
crowded in patches, intersected with deep fissures 
and excoriations. In this extreme degree, it ap- 
proaches very closely to the inveterate cases of 
Lepra vulgaris in all respects; the only difference 
being in the form of the patches before they coalesce. 
It is sometimes the ultimate state of the Psoriasis 
diffusa ; and occasionally a sequel of the Prurigo 
senilis. As the disease declines, the new cuticle is 
at first red, harsh, and sometimes shrivelled, and does 
not acquire its natural texture for several weeks. 

Species 5. Psoriasis localis : Local dry Scall. 

This species comprehends several varieties, which 

exhibit appearances closely resembling some of the 

* In a case detailed by Turner (Treatise on Diseases of the Skin)» 
this was one of the symptoms ; yet many of the other symptoms of that 
case leads to the supposition that the disease was Ichthyosis simplex. T. 



5S SQUAMA : 

foregoing species^ but which dre seldom ^wmpdXdtd 
with constitutional aflFections. 

f^ar. u. P, labialis. Scall o^ TttE Lips* This 
affects the prolabium, especially of the under lip, the 
tender cuticle of which is thickened, eracks and e5c- 
fbliates, sometimes for a long period of time: the 
scales usually adhere more firmly than oh other parts, 
and are only detached when the new cuticle under 
them is completed, which in its turn cracks and is 
thrown off in the same manner ; and this occurs suc^ 
cessively whilst the disease remains^ 

J^ar. b. F. lotorum. Washerwomen's * Scall* 
This variety (Plate X. fig. 2. of Bateman ; PL 6. 
of Thomson's Atlas,) appears on the wrists and 
forearms of washerwomen, from the irritation of soap. 
The inflammation is considerable, and the cuticle, 
which becomes brittle, separates in large irregular 
plates in rapid succession. 

Far. c. P. palmaria.* ScalL op the Palm. 

S;i/n. Dartre squammeuse centrifuge : Herpes 
squammosus centrifugus (Aliberty 

This variety (Plate XIV. of BAtEMAN ; PL 6. of 
Thomson's Atlas,) is an obstinate tetter, confined 
to the palm of the hand and inside of the wrist^ 
which are rough, hot> and itchy^ of a dirty hue, and 
clefl by deep fUrrows, that bleed when the fingers 
are stretched. " The nails, in protracted cases, be- 
come thickened and opaque, and unnaturally brittle.'* 
A variety of P. diffusa closely resenjbles P* palmaHa > 
but it is not a local affection, and the disease in the 
commencement is accompanied with pustules or favi \ 
and may be readily mistaken for Eczema. The itch- 
ing is intolerable whenever the hands are exposed to 
heat ; the palm is harsh and dry, and rhagades 
rapidly form. The soles of the feet are often the 
seat of this local Psoriasis : " but the disease is less 

♦ Well represented in M. Alibert's 15th plate, under the title of 
'* Dartre s^uammeuse centrifuge/' 



PSORIASIS. 59 

severe^ owing to the parts being more protected, 
and seldom exposed to the air whUe moist." 

Var. d. P. ophthahnica. Ophthalmic Scall. In 
this the sealiness occurs chiefly about the angles of 
the eyes, producing an itching, inflammation, and 
thickening of the eyelids, with a watery discharge. • 
In children this variety is often productive of the 
loss of the eyelids. 

/^«r. e. P. pistoriay Baker*s Scall or Itch. 
This variety (Plate XI. of Bateman ; PL 6. of ' 
Thomson's Atlas,) chiefly attacks the back of the 
hands of bakers, and those who work with dry 
powder, " and also cooks/* The hands tumefy, and 
are covered with rough, scaly patches, interspersed 
with rhagades. The nails sometimes thicken, be- 
come curved, and are cast off ; but those which re- 
place them are genemlly attacked by the disease, and 
run the same course. 

Var.f. P. prcpputii^ Scall op the Prepuce. 

This variety often accompanies the P. palmaria, is 
characterised by painful fissures and thickening of 
the part, and is usually attended with phymosis. 

Far. g. P. scrotalisy Scall of the Scrotum. 
In this variety the sealiness, heat, itching, and red- 
ness are followed by a hard, brittle texture of the 
skin, and by painful chaps and excoriations. 

The same general plan of treatment is applicable 
to the different modifications of Psoriasis ; the period 
of its duration, and the degree of irritability, being 
carefully attended to. The popular practice, which 
hinges upon the old humoral hypothesis, consists 
chiefly in attempts to expel imaginary humours by 
evacuations, or to correct them by what are called 
antiscorbutics. But bleeding and repeated purging 

* Galen distinguished the Psoriasis from the Psorophthalmia. 
*' Psoriasis autem exterius est ; Psorophthalmia internam palpebram^ 
superiorem praecipue aificit." Galen de Oculo, cap. 7. 



60 SQUAMA : 

^re injurious ; and the vegetable juices, which an 
absurd notion of the scorbutic nature of Psoriasis 
suggested, appear to be totally inefficacious. " Not- 
withstanding this objection of Dr. Bateman to bleed- 
ing, the Editor has had much experience of its salu- 
tary influence, even when repeated at short intervals, 
provided the quantity abstracted at one time be 
moderate." A more recent empiricism, which re- 
sorts to mercury in all aflFections of a chronic nature 
• and of some obscurity, is not more successful : in 
fact, all these varieties of scaly tetter are ultimately 
aggravated by perseverance in a course of mercurials. 
" In Psoriasis diffusa^ however, benefit is derived 
from Plummer*s pill, in doses of five grains every 
night ; whilst Cinchona and Soda, as we shall have to 
notice afterwards, are given during the day. We 
have, also, seen considerable benefit derived from 
Hydrargyrum cum Creta in Psoriasis guttata^ carried 
to the point of slightly touching the gums.** 

In the commencement of the eruption, when it 
appears suddenly, and the constitution is obviously 
disordered, a moderate antiphlogistic treatment must 
be pursued. A " small bleeding,** followed by a 
gentle purgative, and the diet made light, by ab- 
stracting every thing stimulant. This regimen, in- 
deed, is requisite throughout the course of the disease, 
which is immediately aggravated in sympathy with 
irritation of the stomach, whether by spices, fer- 
mented liquors, pickles, or vegetable acids ; whence 
the disuse of these articles contributes materially to 
its cure. 

But if the constitutional disturbance has subsided, 
the use of the fixed alkali, combined with Sulphur 
Lotum, " or the Sulphuret of Potassa, is useful : the 
Sulphuret, however, is apt to nauseate, and therefore 
is seldoip continued long by the patients of private 
practitioners. The waters of Harrowgate, Bareges, 
&c. are beneficial when the skin is inert, but hurtful 



PSORIASIS. 61 

in irritable states of the nervous system.** These, in 
conjunction with an infusion of Cinchona, together 
with tepid washing with simple water, or milk and 
water, will gradually remove the complaint. If the 
scaly patches have extended over a considerable part 
of the body, and have assumed a more inert and 
chronic character, it must be viewed in a similar light 
with the Lepra, and the remedies recommended for 
the first and second species of that disease must be 
resorted to. " Alibert mentions that an inveterate 
case of Psoriasis diffusa, chiefly affecting the thighs, 
was much benefited by the use of a strong infusion of 
Saponaria officinalis^ during the use of which he says, 
* que les symptomes diminuaient d*intensit6, que le 
prurit sur-tout s'6teignait entiferement.* ** • 

** In Psoriasis inveterata^ the use of the Arsenical 
Solution has, in many instances, been found highly 
beneficial when the dose has been gradually carried 
to an extent, which would be dangerous in other 
states of the habit. Thus in a case successfully 
treated by Mr. Gaskoyne t, the dose was gradually 
increased to thirty-eight drops twice a day ; and it 
was not until the desired change occurred in the 
eruption, that the colicky pains and other symptoms 
of an overdose of Arsenic presented themselves. 
Candour obliges me to acknowledge that, notwith- 
standing the powerful influence of Arsenic in Pso- 
riasis inveterataj I have met with cases which resisted 
it, even when administered in the largest doses. In 
some instances Erysipelas has accompanied the use of 
the Arsenical Solution ; in which case the admini- 
stration of the remedy should be suspended until the 
Erysipelas be removed, and afterwards renewed in 
smaller doses. " In one form, however, I have lately 
seen it prove highly serviceable ; namely, in that of 
the Prot'iodide administered in doses of gr. one tenth, 

* Mai. de la Peau, p. 95. 

f Plumbe's Practical Treatise, 2d edit. p. 170. 



62 SQUAMi^: : 

in combination with gr.iij. of Extract of Coniunj,* 
every night at bed-time; whilst, at the same time, 
the sulphur fume bath is used every third day.** 

^* From my own experience, I cim confidently 
assert, that the medicine on which the greatest con- 
fidence may be placed, in Psoriasis diffusa^ and in the 
milder cases of P, inveterata^ is the Liquor Potassa^. 
I usually commence with thirty drops of the solution 
in two fluid ounces of the Bitter Almond Emulsion, 
twice a day ; and gradually increase the dose of the 
solution to eighty or even one hundred and twenty 
drops. If the patient be delicate, the infusion of 
Yellow Ciuchow Bark or of Cascarilla may be sub- 
stituted for the Almond Emulsiion ; * or, what is 
preferable to either, the Solution of the Hydriodate 
of Iron may be given alternately with the Solution 
of Potassae, twice or thrice a day/ I have fre- 
quently found the Hydrargyrum cum Creta, in doses 
of six or eight grains, given at bed^timei m useful 
ac^unct to the Solution of Potassa/* 

The shooting and burning pain and itching, in the 
early and more inflammatory stages of Psoriasis, in- 
duce the patient to seek anxiously for relief from 
local external applications; but he is mortified to 
find that even the mildest substances prove irritants, 
and aggravate his distress^ A decoction of bran, a 
little cream, or oil of almonds, sometimes produce 
ease ; but any admixture, even of the Oxide of Zinc, 
or preparations of Lead, with these liniments, is com- 
monly detrimental. ^* Dr. Morrison treated several 
cases of Psoriasis successfully by friction, at the same 
time excluding the atmospheric air. His plan is to 
dip a sponge in tepid water, and after squeezing it 
hard, to cover it with oatmeal. With this the affected 
parts are briskly rubbed for a considerable time, re- 
newing the oatmeal on the sponge ; and after this 
operation, when the parts have been well washed and 
dried, applying neatsfoot oil over them with a var- 



PSORIASIS. 63 

niching brusb* This operation is to be repeated 
twice or thrice a day, according to the urgency of 
the case/** " Much depends on the exclusion of 
the air ; and I have seen more comfort derived by 
applying a piece of lint moistened with cold water, 
and covered with a piece of oiled silk, than from any 
other local application. When the skin is less irrit- 
able, the solution of Subaqetate of Lead,, largely di* 
luted, may be used in the same manner/' ^^ CautioQ» 
however, is requisite in the use of external remedies^ 
Alibert mentions the case of a lady afi^ted with 
Psori^is i^veterata all over the abdomen \ and who, 
to absprb the discharge, covered the eruption with 
hot flour. The eruption disappeared after eight days ; 
but left behiud it great irritability of stomach, avd 
an uuquenchahte thirst \ ^ $a salive est devenue ^isse, 
fetide, et qomme platrcuse^ Pour comble d*infortune, 
ses yeux swt totalement perdus/ ** t 

" Much benefit often results from the use of the 
tepid bath \ but in general it is not used long enough 
each time of employing it. Alibert mentions a case 
of Psoriasis diffusa cured by tepid baths alone, * pris 
tons les jours, et pendant Pespace de deux heures/**$ 

But the more local, and less inflammatory, erup- 
tions of Psoriasis are considerably alleviated by local 
expedients. " A bath, with the Sulphuret of Potassa, 
twice a week, has been found useful. In chronic 
cases the sulphur fume bath is extremely beneficial.** 
The P. palmaria is deprived of its dryness and itch- 
ing by exposure to the vapour of hot water, and 
by the application of the Unguentum Hydrargyri 
Nitratis, diluted with the Unguentum Cetacei or 
Cerae, according to the degree of irritation in the 
skin \ ^^ or an ointment made with a scruple of the 
Iodide of Sulphur and one of Lard.'* " It has 
yielded to blisters after resting both internal and 

* Edinburgh Med. and Surg. Journ. ?ol. xvi. p. 525. 
+ Mai. de la Peau, p. 84,. 
\ Ibid. p. 97. 



64 SQUAMA : 

external remedies for upwards of a year.* The 
following ointment, recommended by M. Chevalier, 
has been found useful : — 

Chloruret of Lime, 3 gros 
Turbith Mineral, 2 gros 
Oil of Almonds, 6 gros 
Lard, 2 ounces. Mix. f 

Sea-bathing, continued for many weeks, has been 
found an effectual remedy. The P. scrotalis and 
P. ophthalmica are also relieved by the same appli- 
cation, or the Unguentum Hydrargyri Praecipitati 
albi : but great care is requisite, in the former case, 
to keep the parts clean by frequent ablution, and to 
prevent attrition. In the Psoriasis of the lips, nothing 
acrid can be borne ; and much of the cure depends 
upon securing the parts from irritation, even from 
heat and cold, by a constant covering of some mild 
ointment or plaster. In all these cases some of the 
internal remedies above mentioned must be at the 
same time employed, according to the period and 
oth^r circumstances of the disease. 

Boohs which may be consulted on Psoriasis. 

Alibert, Maladies de la Peau, fol. 

BiETT, Cazenave, and Scuedel^ Abr^g^ Pratique des Maladies de 
la Peau, 8vo. p. 308. 1828. 

PnFf tN, on Squamous Disorders, Edin. Med. & Surg. Journ. No. 86. 

Edinburgh Med. and Surg. Journ. vol. xvi. p. 526. 

Goon's Study of Medicine, vol. iv. 2d edit. 1822. 
^Plumbe's Practical Treatise on Diseases of the Skin, 2d edit. 1827. 

Rayer, Trait^ Th^orique et Pratique des Mai. de la Peau, t. 2, p. 51. 

Will AN on Cutaneous Diseases, 4to. 1808. 



Genus III. PITYRIASIS. 

Syn. wiTD^iarng ( O. etAuct. Vet) : Lepidosis Pi- 
tyriasis ( Youngs Good) : Schuppen ( Ger.) : Dan- 
driff. 

Def. Irregular patches of thin bran-like 

SCALES, WHICH REPEATEDLY EXFOLIATE AND RECUR, 

* Med. Repos. vol. iii. New Series, p. 58. 
f Journ. de Chimie M^d. Mars, 1826. 



PITYRIASIS. 65 

BUT WHICH NIVER FORM CRUSTS, NOR ARE ACCOM- 
PANIED WITH EXCORIATIONS. It IS NOT CONTA- 
GIOUS.* 

There are four species of Pityriasis : — 

1. P. capitis. 8. P. versicolor^ 

2. P.. rubra. 4. P. nigra. 

Species 1. Pityriasis capitis^ Dandriff of the 
Head. 

Syn. Dartre furfuracee volante. — Herpes furfu- 
raceus volitans {Alibert) : Shoondoo ( Tarn.) : BuSk 
(Duk.) : Tsoondoo ( Tel.) : Crusta capitis numato- 
rum (Plenck): der Kneis, Haufstschappen (Oer.) 

This afiPeetion (Plate XV. fig. 1. of Bateman), 
which in infants is called simply dandriffy appears 
in a sJight whitish scurf along the top of the fore- 
head and temples, but in larger, flat, separate, semi- 
transparent scales on the occiput. A. similar affec- 
tion occurs on the scalp of aged persons, t 

It is only necessary to enforce a regular ablution 
of the scalp with tepid soap and water, or with an 
alkaline or weak spirituous lotion ; for which purpose 
the hair must be removed, if it be not thin. If this 
be neglected, the affection may ultimately degenerate 
into Porrigo, 



* These negative characters distinguish this eruption, especially when 
it affects the scalp, from the furfuraceous Porrigo; a distinction which 
the last-mentioned circumstance rendered important and necessary. The 
ablest of the later Greek writers, Alexander and Paul, have described the 
disorder as consisting of " slight, scaly, and branny exfoliations, without 
ulceration." (See Alex. Trail, lib. i. cap. 4. — Paul, -ffigin. lib.iii. cap. 3.) 
Yet all the translators have rendered Uitvpuktiq by the word Porrigo; 
which, according to Celsus, comprehended the ulcerating pustules, or 
achores, of the Greeks (de Med. lib. vi. cap. 2.\ The use of the term 
Pityriasis, therefore, to designate a dry and furfuraceous eruption, as 
distinct from the ulcerating Porrigo, is sanctioned by authority, as well 
as by etymology, and pathological observation. 

f A good representation of Pityriasis on the occiput of an adult is 
given by Alibert, pi. 11., which he calls " Dartre furfuracee volante,' 



a 



66 SQUAHs : 

Species 2. The Pityriasis ruhra^ Red Daw- 

DBIFF. 

This species occurs most frequently in advanced 
life, and is the result of a slight inflammation of the 
portions of the skin affected, somewhat resembling in 
this respect the Psoriasis diffusa. The cuticle is at 
first only red and rough, but soon becomes mealy or 
scurfy, and exfoliates, leaving a similar red cuticle 
underneath, which undergoes the like process; the 
scaliness becoming greater, as the exfoliation is re- 
peated. This complaint is attended with a dry and 
unperspiring surface, a troublesome itching*, and a 
feeling of stiffiiess. 

There is also a general languor and restlessness. 
When the redness and scales disappear, the patches 
are left of a yellowish or sallow hue. But the whole 
process is liable to be repeated at short intervals, 
and the disease to be thus greatly prolonged. 

The P. rubra is removed by a combination of anti- 
monials with the decoction of woods, and the warm 
sea-water bath. I have also seen it materially re- 
lieved by small doses of the Tinctura Veratri. "The 
bowels should be kept lax with mild purgatives ; a 
combination of Epsom Salts and Magnesia answers 
every indication.'* Where the irritability of the 
skin is not very great, a gentle restringent lotion or 
ointment, containing a portion of Borax or Alum, 
and Acetate of Lead, " to which a moderate quantity 
of Hydrocyanic Acid is added,** may be applied to 
the parts affected with advantage. 

Species 3. The Pityriasis versicolory Varie- 
gated Dandriff. 

This species (Plate XV. fig. 2. of Bateman) is 
most remarkable for the chequered and variegated 

* Alibert, nevertheless, remarks, ** dans les Dartres furfurac^es, le 
pnirit est presaae nul, parceque les papilles de la peau y sont tris-peu 
int^ress^es." Vide Mai. de la Peau, p. 81. T. 



discblordtion of the ciitide which it i^xhibits; It 
appears mostly about the breast and epigastrium^ 
and sometimes on the arms and shoulders, m brown 
patches of different shades, variously branching and 
coalescing, and interspersed with portions of the 
natural hue^ *- In a few instances, it has extended 
over the Whole back and abdomen, even to the 
thighs^ and slightly affected the face. There is 
generally a dight scurfy roughness on the discoloured 
parts ; biit this is in some cases Scarcely perceptible, 
aiid thene is no elevation or distinct border to the 
pitches. Dr. Willan states, that the P. versicolor 
** is hot merely a cilticular disease ; for, when the 
cuticle is abraded from any of the patches, the sallow 
colour remains as befoit, in the i^kin, or rete muco- 
tom.** This, howeVet, is not universted : for I have 
lieeri setferal instances of the eruption, in which the 
diseoloUfed cuticle peekd off at intervals, in a 
thickened state^ and a tiew Cuticle was found under- 
neath, of a red hue, as is Usual under large exfoH* 
ationsi ** Mr. Plumbe metitions a variety of ildi 
species ih Which no sensible elevation is perceptible 
to the flttger When it is rubbed Over the discoloratioti ; 
but when the part is forcibly rubbed with a dry cloth j 
large films of thin delicate cuticle are detached, and 
the cutis which is bated remains tender^ and becomes 
mote inflamed.** t Dt. Cumins, with the view of 
decidiilg the question of the seat of the eruption, 
blistered the coloured surface, and foundj on re- 
moving the blister, that the mottling still remained ; 
tod the patches, instead of being taWny, Werd changed 
to a deeper red than the rest df the excoriated surface. 

* These patches scarcely ever appear, like EpheHdes and freckles; 
on the face and hands^ but chiefly on covered parts, as is remarked by 
Sennertus, who has given an accurate description of this eruption, under 
the appellation of ^' Maculae hepaticse,*' latinising the popular German 
term, Leberflechte, He Connders it as the Mdiui at dark variety of 
Vitiligo. I^e his Pract. Med. lib. v. partiii. jj 1. cap. 7. 

f Plumbe's Practical Treatise, 2d edit. p. 202. 

F 2 



68 SQUAMA : 

The conclusion is, that the seat of the colour is in 
the true skin/^* 

The P. versicolor is usually of little moment ; foi: 
it is rarely accompanied by internal disorder, or by 
any troublesome sensations, if we except a slight 
itching on growing warm in bed, after strong 
exercise, or drinking warm or strong liquors. In 
those instances, however, where the eruption is very 
extensive, the itching and irritation connected with 
it are sometimes extremely distressing, depriving the 
patients of their natural rest. In these cases the 
digestive organs are also commonly disordered. But 
even when the eruption is not troublesome, great 
uneasiness is often occasioned by its appearance; 
since its brown and almost coppery hue frequently 
suggests, even to medical practitioners, the idea of a 
syphilitic origin. But a little experience will soon 
enable the observer to recognise the eruption, inde- 
pendently of the total absence of any tendency to 
ulceration, however long its duration may be, and 
of every other concomitant symptom of syphilis. 

The causes of this Pityriasis are not well ascer- 
tained. It occurs most frequently in those who 
have resided in hot climates, especially in its trouble 
some form. In one young gentleman it began after 
a year's residence in the Greek islands : it is also not 
uncommon in military and seafaring people- The 
most extensive eruption that I have seen, occurred 
in a custom-house officer, after drinking spirits freely 
during a day of fasting in a boat on the Thames, 
Fruit, mushrooms, sudden alternations of heat and 
cold, violent exercise with flannel next to the skin, 
have been mentioned as probable causes of this 
eruption. 

Intemal medicines have not appeared to have 
much influence on this eruption, as Dr. Willan has 
stated. The Oxygenated Muriatic Acid, however, 

* Cydopsedia of Practical Medicine^ vol.iii. p. 351. 



PITYRIASIS. 6g( 

I think, is possessed of some efficacy ; " or, what is 
much better, a lotion of Chloride of Soda ; '* and if 
the affection were of sufficient importance to induce 
the patient to persevere in swallowing medicine, the 
Pitch pills would probably be serviceable. By 
active external stimulants the disorder is often re- 
moved ; as by lotions of strong spirit, containing the 
Muriatic Acid, or the Caustic Potassa : one drachm 
of the former, or two or three of the Liquor Potassas, 
may be added to half a pint of distilled water. Sea- 
bathing is likewise beneficial, both as a remedy and 
as a preventive of its recurrence. The more exten- 
sive and irritable eruptions of Pityriasis approximate 
somewhat in their character to the Psoriasis, and are 
alleviated by the same treatment. 

Species 4. Pityriasis nigra. Black Dandriff. 

Subsequent to the period of his publication. Dr. 
Willan had observed a variety of Pityriasis in children 
bom in India, and brought to this country, which 
commenced in a partially papulated state of the skin, 
and terminated in a black discoloration, with slight 
furfuraceous exfoliations. It sometimes affected half 
a limb, as the arm or leg ; sometimes the fingers and 
toes.* 

" The disease termed Pint a, or Blv£ stain^ which 
prevails in Mexico, appears to be a variety oif Pity- 
riasis nigra. It commences with slight febrile symp- 
toms, which last a few days only ; and, on subsiding, 
leave the face, breast, and limbs covered with yel- 
lowish maculae, which change to a blue, and, in 
advanced stages, to a black colour. The skin assumes 
a rough and scaly appearance, and exhales a very 
offensive perspiration : but the general health is not 

* M. Alibert has figured an eruption on the hand, which seems re- 
ferable to this species, and whi^h he denominates a " scorbutic Ephelis," 
(See his plate 27, bis>) It appears to be the result of a degree ot misery 
and filth, as little known in this country as the disease. 

F 3 



70 sauAM*. 

afl^ted. It is said %o be infectious. Xt is reli^ve^ 
by light cathartics and active d^phore^ics." * 

Books which may be conttdted on Pitt/riasit* 
Alibert, Pr6ck Tli^rique et {^ratique sur lea MaL de la Peau, s tonnes 

6Vp. 1822. 

JBiDoux, Reflex. Pratiques sur les Mai. de la Peau> 8vo. 18^6. 'Cy- 
clopaedia of Practical Medicine, vol. liL p. 350. 

iGooD, Study of Medicine, vol.iv, 
/HPlumbe, On Diseases of the Skin, 2d. edit. 1827. 

Raye^, Trait^ des Maladies de la Peau. 

SsNNEBTus, Pract. Med. lib. v. partiii. 8vo. 

WiLLAN, On Cutaneous Diseases, 4to. 1805. 



# American Med. ReyieWji vol. ii 



71 



Order III. 

EXANTHEMATA. 

o YN. fi|avd7jjttara( O.)'. Exantheinatica( Oood) : Ex- 
anthfemes, Exanth^mateux (-F.) : Inflammations ex- 
anth^mateuses (^Rayer) : Rashes. 

Def. Superficial red patches, variously fi- 
gured, AND DIFFUSED IRREGULARLY OVER THE 
BODY, LEAVING INTERSTICES OF A NATURAL COLOUR, 
AND TERMINATING IN CUTICULAR EXFOLIATIONS. 

The term Exanthemata, efflorescence^ appears 
to have been used by the Greek writers in a very 
general sense, equivalent to that of our word erup- 
Hon * ; and it has been employed, in this accept- 
ation, by many modern authors. The nosologists, 
however, have limited it to those eruptions which 
are accompanied with fever t, and which have their 
regular periods of efflorescence and decline. In this 
arrangement, it is appropriated solely to those ap- 
pearances which are usually called Rashes ; namely, 
to patches of superficial redness of the skin, of various 
extent and intensity, occasioned by an unusual deter- 
mination of blood into the cutaneous vessels, some- 
times with partial extravasation. It has no refer- 
ence, therefore, to the existence of fever or contagion, 

* Hippocrates applies the term to numerous eruptions, which b« 
oflen Classes together, as to Lichdn, Lepra, Leuce (Frasdict. Hb. ii. ad 
finem]; to miliary vesicles, and wheals (Epid. i. in the.case of Silenus, 
some of which were prominent, like van); and to eruptions resemblhig 
burns, flea-bites, bug-bites, &c. (Coac. Prsenot. 441. 39. ed. Foes.— Epi- 
dem. lib. vii. p. 959. 28. &c.) : he speaks also of ra afAux^tet (^avOurfuira, 
or excoriations (Coac. Prsenot. 444.); and applies the verb even to 
ulcers; — c^avOcct iXxta ig rtiv fcc0aX9v(de Morbo Sacro, $iii. p. 88.) 
He has likewise c^av&ijffitc eXjcw^cec (aph. 20. lib. iii.). 

-{* CuHen confines the term to comprehend those eruptions only 
which arise from the application of a specific contagion, ^ which first 
produces fever, and afterwards an eruption upon the surfkce of tb« 
body." First Lines, § dlxxxv. T. 

F 4 



72 BXANTHEMATA : 

or to the duration and progress of the complaint. 
" In general, every part of the body is liable to the 
eruption, and this appears to be seated chiefly in the 
most superficial dermal layer; but occasionally the 
true skin is affected through its entire thickness. 
The redness is sometimes circumscribed, at other 
times diflFused:** the heat and tumefaction of the 
aflFected parts vary, and pain is not always present ; 
but instead of it there is itching. The genera are 
acute diseases, which run their course within a 
certain space of time; "each is distinguished by 
symptoms peculiar to itself; but in all, fever is the 
precursor of the eruption : '* sometimes the accom- 
panying fever assumes the intermittent character ; at 
other times, the typhoid. The first and second and 
the last genus only of this order are contagious ; and 
these, in general, occur once only in a lifetime. 

The order comprehends seven genera : — 

1. Rubeola, 5. Purpura*, 

2. Scarlatina, 6. Erythema, 

3. Urticaria, 7* Erysipelas, t 

4. Roseola, 



Genus L RUBEOLA. % 

Syn. Morbilli; Blactias (Auct. varies): Febris 
morbillosa {Hoffman) : Phoenicismus (Plotiqicet) : 
Typhus morbillosus ( Crichton) : Enantnesis rubeola 
(Jjood)'. Fi^vre morbilleuse, Rougeole,Roseole(i<'.): 
die Kindsfecken ( German) : Hasbet (Arab.) : 

* Purpura is here misplaced by Bateman. T. 

f I have ventured to remove Erysipelas from the Bullae, and to place 
it here, for reasons which shall be afterwards stated. T» 

% The Continental writers in general have designated this disease by 
the term Morbilli, the minor plague ; an appellation borrowed from the 
Italians, among whom il Morbo (the disease) signified the Plague (see 
Sennert. Med. Pract. lib.iv. cap. 12.) The terms Rubeola, Rubeoli, 
Roseola, Rossalia, Rossania, &c. had been applied, with little discrimi- 
nation, to Measles, Scarlet Fever, Eczema, &c. until Sauvages fixed the 
acceptation of the first of them. 



RUBEOLA. 73 

Kyzamak ( Tv/rkish) : Serukje {Persian) : Chin 
ummay ( Tarn.) : Chin umma ( TeL)i Gobrie (Duk.) : 
Khrusvamasoorikale {Sans.)\ Chumpak {Malay) i 
Measles. 

Def. An eruption of crimson stigmata, or 

DOTS, GROUPED IN IRREGULAR CIRCLES OR CRES- 
CENTS, CONTINUING FOR FOUR DAYS, AND TERMI- 
NATING IN MINUTE FURFURACEOUS SCALES; PRE- 
CEDED BY FEVER, SNEEZING, HOARSENESS, AND A 
SEROUS DISCHARGE FROM THE EYES AND NOSTRILS. 

" Measles is a contagious disease, rarely appearing 
more than once during life. It is infectious before 
the eruption appears ; which is sometimes from five 
to ten days after the infection has been taken. It 
affects at the same time the skin and the gastro-pul- 
monary mucous membrane, and is preceded by ca- 
tarrhal fever,** during which a rash appears usually 
on the fourth, but sometimes on the third, fifth, or 
sixth day, and, after a continuance of four days, gra- 
dually declines with the fever. The disease com- 
mences from ten to fourteen days after the contagion 
has been received. " It attacks chiefly children and 
young people ; but no period of life is exempt * ; and 
it is seen in all climates. It is frequently epidemic, 
appearing in spring and autumn. It rarely attacks 
more tlum once in a lifetime : nevertheless instances 
have occurred in which the disease has returned t; but 
we must not regard as such those eruptions, without 
the catarrhal symptoms, that not unfrequently occur 
in children that have had measles, when the disease 
prevails as an epidemic, although both Heberden and 
Willan hold a different opinion.** This genus com- 
prehends three species X : 

^ Instances have occurred of children having the disease before 
birth, in conjunction with the mothers. Guirsent (Diet, de Med. 
t. xviii. p. 513.) mentions having seen an infant born with the eruption 
on it. T. 

f Trans, of a Society for Improving Med. and Chirurg. Knowledge, 
vol. vii. pp. 258. 265. Diet, de Med. t. xviii. p. 512. T. 

% These are rather to be regarded as varieties than spedes. T. 



74 EXANTHEMATA : 

1. R. vulgaris. 

2. R. sine catcmrho^ seu spuria. 

3. R. nigra. 

Species 1. 'SLvbeoJuK vulgaris. Common Measles. 

Syn. Morbilliregulares(>S^flfew.): Rougeolevul- 
gaire (jP.) : Measles. 

The precursory fever of the measles " is often ex- 
tremely slight ; but sometimes it is severe ;** it is ac- 
companied, especially on the third and fourth days, 
with a tenderness and some inflammation of the eyes, 
and a slight turgescence of the eyelids, " sufiused 
eyes, with an intolerance of light,** together with a 
serous discharge both from the eyes and nostrils, 
whiph excites frequent sneezing. There is likewise 
a teasing dry cough, with some degree of hoarseness 
and difficulty of breathing, " for some days before the 
eruption appears, sometimes seven or even fourteen,** 
and oft^n accompanied with sighing and a roughness 
or slight soreness of the throat. " There is occa- 
siim^lly great pain of the chest, the back, and some- 
times of the epigastrium ; with somnolency, although 
when the patient sleeps he is soon aroused by a start, 
as if he were alarmed. The pulse is quick and sharp.** 
These symptoms are generally more severe in chil- 
dren than in adults, and are sometimes accompanied 
with slight delirium in the night : " and the more 
severe the preceding symptoms are, the worse is the 
disease. The surface of the tongue at this time is 
^nerally white, with the edges of a vivid red.** 

The rash (Plate XIX. of Bateman ; PI. 8. of 
Thomson's Atlas), on the fourth day, begins to 
appear like the bites of fleas, gradually clustering into 
irregular crescent-shaped patches about the forehead, 
at the roots of the hair, and below the chin, then on 
the i^ose and over the rest of the face ; and on the 
following morning it is visible on the neck and breast, 
spreading towards evening over the trunk of the body, 
and lastly over the extremities. ** If the finger pe 



BUBiK>LA* 7^ 

pmf^ oyer the eruption^ it ^ felt to be sUglitly pro- 
minept ;, especiaUy on the face and the arma. At 
tlw time 9pQts. appear on the palate and velum pa* 
l^tiy of 9t deep rfid hiAe ; and hoarseness supervenes. 
The eruption is seldom vivid on the arms until the 
second or third day after its appearance ; and it is not 
fuUy out until the third on the legs and feet.^ 
J>uring the second day the fever is generally increased, 
sLSi is also the restlessness ; but the eyes are less im- 
patient of light : the efflorescence in the face is most 
vivid : ^< on the feUowijo^ day (the fifth), the erup- 
tion is feding on the face, but increasing on the neck 
and chest : '' on the sixth day it begins to &de and 
subside on the neck, while the patches on the body 
are highly red. The eruption is accompanied with 
itching and heat of the skin. The patches on the 
body and the extremities begin to fade on the seventh 
day ; and the patches on the back of the hand, which 
usually apfiear last (sometimes on the sixth or even 
the seventh day of tne fever), do not always decline till 
the eighth*. On the ninth day, slight discolorations 
only remain^ which vanish before the end of the tenth, 
leaving a slight pulverulent or brown desquamation. 

*^ Although tne progress of the disease is such as 
has been just detailed, yet occasionally deviations occur. 
The eruption may appear soon, or be delayed con- 
siderably beyond the ordinary time of its appearance* 
It has been known not to appear until the twenty- 
first day of the fever. Now and then vomiting 
ushers in the eruption ; and Dr. Elliotson mentions 
that he has seen free salivation take place * : sometimes 
it is preceded by convulsions. The eruption has oc- 
casionally appeared first on the trunk of the body ; 
and, in some instances, it has never appeared on the 
arms during the whole course of the disease. Some- 
times, but very rarely, it has reappeared, immediately 
after its disappearance at the usual period.^'t 

* Medical Gazette. f Frank, torn. ii. p. 37 7. 



76 EXANTHEMATA : 

It is important, with a view to diagnosis, to attend 
accurately to the form of the rash, that it may not be 
confounded with Scarlatina and Roseola. It first 
shows itself in distinct, red, and nearly circular spots, 
somewhat less than the ordinary areolae of flea-bites.* 
As these increase in number, they coalesce, forming 
small patches, of an irregular figure, but approaching 
nearest to that of semicircles or crescents.t These 
patches, which give no sensation of roughness to the 
finger, are intermixed with the single circular dots, 
and with interstices of the natural colour of the skin : 
on the face, although they are slightly raised, so as 
to give the sensation of inequality of surface to the 
finger passed over the cuticle ; yet no suppuration 
occurs. The whole face, indeed, is often sensibly 
swelled, at the height of the eruption ; and occasion- 
ally the tumefaction of the eyelids is so great as to 
close the eyes for a day or two, as in the small-pox t : 
but on the other parts of the body the patches are 
not sensibly elevated. In many persons, however, as 
Dr. Willan has remarked, miliary vesicles appear (see 
Thomson's Atlas, PI. 8.) during the height of the 
efflorescence, on the neck, breast, and arms; and 
papulae often occur on the wrists, hands, and fingers. 
The decline of the eruption is accompanied with 
more troublesome itching than is experienced during 
its rise. 

Measles, before the eruption appears, may be mis- 
taken for severe catarrh ; but it is of little moment, 
as the treatment is the same. The catarrhal symp- 
toms, and even the fever, are somewhat augmented 
on the appearance of the eruption; the latter lisu- 

* See the excellent history of measles detailed by Sydenham, Obs. 
Med. sect. iv. cap. 5. 

f This observation, which is peculiar to Dr. Willan, is important ; 
for, though entirely overlooked by ordinary observers, it is commonly 
veiT manifest, and therefore a valuable diagnostic guide. 

if See Macbride, Introd. to Med. part ii. chap. 14. — Heberden, 
Med. Trans, of the Coll. of Phys. vol. iii. art. xxvi., and Comment, de 
Morb. cap. 63, 



RUBEOLA. 77 

ally ceases when the eruption declines, which is 
generally on the fourth or fifth day ; but, a day or 
two days before, the vivid redness changes to a brown- 
ish red. At this period a diarrhoea commonly super- 
venes, if it have not occurred earlier, and affords re- 
lief to the other symptoms. This, however, is the 
period when the danger, which is a consequence 
rather than a concomitant of measles, commences : 
for now the catarrh is occasionally aggravated to acute 
inflammation of the lungs, of more obstinacy than 
ordinary pneumonia, on which hectic sometimes su- 
pervenes, and ultimately hydrothorax, spitting of 
blood, or, in scrophulous habits, confirmed consump- 
tion. 

Other inflammatory affections, indicative of a ca- 
chectic condition of the system, are liable to occur at 
the close of the disease, and prove tedious and trou- 
blesome. In some, severe attacks of ear-ache, with 
deafness ; in others, inflammation of the eyes and 
eyelids of a more unmanageable character than the 
common ophthalmia ; and in others, swellings of the 
lymphatic glands take place. Sometimes the mesen- 
teric glands become diseased, and marasmus ensues : 
and sometimes chronic eruptions on the skin, espe- 
cially Ecthymata, Rupia, Herpes, and porriginous 
pustules with tumid lip, discharges l^ehind the ears, and 
tedious suppurations, are the sequelae of the disease. 
** Measles frequently occurs as an epidemic, some- 
times benign, at other times proving very fatal. The 
disease, however, is seldom severe, unless in children 
at a very early age ; or during dentition. In adults 
predisposed to pulmonary aSections, it is to be 
dreaded ; and it is is also frequently severe in preg- 
nant women. The intensity of the pulmonary inflam- 
mation, and symptoms of meningitis accompanying 
the eruption, always authorise a doubtful prognosis. 
The season of the year when measles is most com- 
monly epidemic is early in springw*' The eruptive 
stage of measles in general is seldom attended with 



78 EXAStfiEMAl-A : 

danger, and, therefore, requires littte medicinal treat- 
ment. It is chiefly necessary to open the boWels, to 
confine the patient to a light vegetaWe diet, with cold, 
sub-acid, aqueous drinks, and to maintain a cool re- 
gular temperature of the room, which should be 
moderately obscured. I have seen fatal effects t^sult 
from t&e exposure of the patient to cold air during 
the eruption. An emetic is sometimes useful at the 
commencement of the disease. The usual diiphore- 
tics and emulsions have little influence over the fever 
or catarrh ; and the inhalation of steam, or the use 
of the pediluvium, is not more efficient * : but a 
steady refrigerant regimen, while it is grateful to the 
feelings of the patient, contributes to repress present 
fever, restlessness, and delirium, and to diminish the 
inflammatory tendency of the disease in the cerebral 
membranes, the lungs, eyes, &c. on the decline of the 
eruption, t 

Almost all practitioners have concurred in the 
recommendation of blood-letting in measles j some 
employing it at the height of the eruption, which 

* Dr. Macbride (loc* cit.) and Dr. Willan have recommended thb 
two last as palliatives. 

f I am indebted to Mr. Magrath of Plymouth, through the medium 
of mjT friend Dr. Lockyer, of the same place, for some important in- 
struction, respecting the safety and efficacy of the cold effunon during 
the fever and eruption of measles. Mr. Magrath favoured me with a 
perusal of the official reports of the treatment of a great number of 

Eatients in the hospital of the Mill prison, in which the practice was 
ighly successful. He affirms that he has never witnessed any of the 
untoward circumstances which are usually apprehended from cold, 
such as the retrocession of the eruption, increase of the catarrhal symp- 
toms, &c.; but, on the contrary, he is persuaded that the inflammatory 
affections of the chest, which are apt to supervene, on the decline ojf 
the rash, are prevented by the suppression ot the early excitement, to 
the violence of which they are chiefly to be attributed. This accords 
strictly with well-established experience of the operation of cold in 
scarlet fever and small-pox. See an interesting^ case in illustration of 
the safety and advantages of this practice in measles, communicated to 
me by Mr. Magrath, in the Edin. Med. and Surg. Journal, for April, 
1814, p. 258. 

'* I nave seen the most marked benefit result from the cold effusion 
in Scarlatina; but I should be extremely cautions of ordering it in 
measles, on account of the pneumonic symptoms. I have had occasion 
to witness a fatal result in a case of measles, from the imprudent ex* 
posure of the body to cold air." T. 



BUBEOX.A. 79 

they deem the most inflammatory period, smd some 
at the close of it^ when pneumonic inflammation more 
commonly supervenes ; while others consider it as safe 
and beneficial ak any period in or after the diswae. 
where the symptoms are very distressmg. * Dr. 
Heberden, indeed, contends that ^^Ueeding, toge- 
ther with suc^ medicines as the occasional symptoms 
would require in any other fever, is the whole of the 
medical care requisite in the measles : " and he con- 
siders that this cannot be dispensed with even during 
the flow of the menses ; be should have adde^ 
provided the cough is hard, and the breert;hing much 
oppressed. Dr. WiUan has placed this matter in the 
most judicious point of view. The mere (^ipression 
of the respiration, with a labouring pulse, on the first 
or second day of the eruption, is common to other 
eruptive fevers^ and usually disappears in the course 
of twenty-four hours. When, therefore, it is not 
accompanied by a hard coi^h, and pains in the chest, 
h mayi even in adults, be safely left; to the natural 
termination : *' indeed, it is seldom requisite in any 
edse during the continuance of the eruption.'' C^ 
the other hand, when the erupti(m has disappeared, 
and these symptoms, together with difficulty of breath- 
ing, have become severe^ bleeding, either from the 
arm or by leeches, and cupping, may be repeatedly 
necessary, aided by blisters, ^d demulcents, with 
anodynes. * * In applying leeches on very young and on 
delicate children, they should be placed on parts only 
which will admit of the application of pressure, should 
the bleeding not readily stop ; for example^ behind 
the ears, or on the back of the foot, or on the wrists:'* 
much danger has often resulted from placing them 
on soft parts. " When blistering is indicated, it is 
of importance to recollect that, in children labouring 
under measles, vesication is often followed by severe 
sloughing sores ; and, therefore, counter-irritation by 

* See Morton de Morbillk. — Sydenham, loc. ck. — Heberden, loc. 
cit. 



80 EXANTHEMATA : 

stimulant liniments is preferable to blistering/' When 
the eruption retrocedes suddenly, and the pneumonic 
symptoms increase, the tepid bath must be employed ; 
with sinapisms to the chest afiber bleeding, Opiates, 
although recommended by several authors*, do not 
allay the the violence of the cough during the erup- 
tive fever ; and tend to aufimaent the heat and rest- 
lessness." 

A diarrhcea frequently occurs at the close of the 
measles, which appears to alleviate the pneumonic 
symptoms, and to prevent some of the troublesome 
sequelae of the disease before noticed. Hence this 
evacuation should not be interrupted, at least for a 
few days ; and laxatives should be administered, 
where it does not take place, as the most advan- 
tageous mode of allaying and preventing inflammatory 
symptoms. If the usual diarrhoea should be pro- 
tracted, however, the patient will require the support 
of light but nutritious diet, and cordials, t ** When 
the severity of the symptoms has required that the 
depleting plan be carried to a great extent, the 
patient is often left in such a state of debility as to 
require bark with a nourishing diet, and even the use 
of wine, provided there be no reason to dread a return 
of the inflammatory symptoms.'* 

Species 2. Rubeola sine catarrho, seu spuria vel 
Incocta. Imperfect Measles. 

This is a peculiarity, scarcely amounting to a 
species, observed by Dr. Willan, in a few rare in- 
stances, during an epidemic Rubeola, which is only 
important as it leaves the susceptibility of receiving 
the febrile measles after its occurrence, t The course 

• Riverius, Obs. Cent. U. n.45. Sydenham Opusc. p. 247. Young 
on Opium, sect. 36. 

f Dr. F. Home attempted to communicate measles by inoculating with 
the blood of the parts on which the eruption appeared ; but the results 
of his experiments were unsatis&ctory. Vide Med, Facts and Experi- 
ments. Lond. 1758. * 

"^ Rayer denies its existence, and regards it as Roseola : but both 
Willan and Heberden regard the disease as measles. T. 



RUBEOLA. 91 

and appearance of the eruption (Plate XX* of Bate- 
man ; PL 8, of Thomson's Atlas,) are nearly the 
same as in the R. vulgaris ; hut no catarrh, ophthal- 
mia, or fever accompanies it. An interval of many 
months, even two years, has been observed betweto 
this variety and the subsequent febrile Rubeola : but 
the latter more frequently takes place about three or 
four days after the non-febrile eruption. * 

Species S. Rubeola mg-ra. Black Measles. 

Dr. Willan applied this epithet to an unusual ap- 
pearance of the measles about the seventh or eighth 
day, when the rash becomes suddenly livid, with a 
mixture of yellow (Plate XXI. of Bateman; PI. 8. 
of Thomson's Atlas,) ** accompanied with languor 
and quickness of pulse. It is, in truth, a mere variety 
of common measles, occurring in persons of debili- 
tated habits.** It is generally devoid of inconve- 
nience or danger, and is removed in a week or ten 
days by a light infusion of Cinchona bark with the 
mineral acids. " The symptoms, nevertheless,, some- 
times present the most alarming aspect : for example, 

* The correctness of all the statements of writers before the close of 
the last century, in regard to the recun'ence of febrile measles, is very 
questionable; since the eruption had been confounded with that of 
Scarlatina down to this period. — Tozzetti, a physician of Florence ; — 
Schacht, (Inst. Med. lib. i. cap. 12.); — Meza, (Compend. Med. fascic. u 
cap. 20.), — and de Haen (de Divis. Febrium, cap. vi. § vi. p. 106.) 
affirm that they have seen the measles more than once in the same 
individual ; while Rosenstein (on the Dis. of Children, chap, xiv.) 
affirms, that during forty years he had never seen such a recurrence, 
and Morton, that, in the same period of practice, he had witnessed it 
but once. But Morton himself deemed Scarlatina and Measles only 
varieties of the same disease ! (De Morbillis et Scarlatina, cap. 4.^ 

It cannot now be doubted, however, that exceptions occasionally 
occur in respect to measles, as well as to small-pox and other contagious 
diseases which in general affect individuals hut once during life. Since 
my first edition was printed, I have met with two papers by Dr. Baillie, 
in the 3d vol. of the Trans, of a Society for the Improv. of Med. and 
Chir. Knowledge (p. 258.), which prove decisively that measles may 
occur a second time in the same individual, accompanied by their 
peculiar febrile and catarrhal symptoms. His authority will not be 
questioned." The Editor has, witnin this month. May 1835, seen a 
case, in consultation with Mr. Squib, of Orchard Street, in which the 
second attack occurred six weeks after the first. T. 



82 EXANTHEMATA : 

in a case which came under the care of the Editor in 
1804, the relaxation was so great, that the cuticle 
rubbed off, like a moist cobweb, when the wrist was 
compressed in feeling the pulse. The Cinchona, 
with the diluted Sulphuric Acid, wine and cordials, 
were freely administered; and' the patient, a child 
eight years of age, recovered, has since enjoy^ good 
health, and is now (1828) alive/' 

** The sequelae of measles are often of great im- 
portance, in patients of a strenuous or phthisical 
diathesis ; chronic diarrhoea, discharge from the ear, 
ophthalmia, anasarca occasionally, and various other 
diseases harass and exhaust the patient. In such 
cases medicine is of little value, and every thing must 
be trusted to country air, sea-bathing, and, in adults, 
to travelling.*' 

Works which may be consulted on Measles, 

Cazenaye and SchedsLi Abregd Pratique des Maladies de la Peau, 
8vo. 1828. 

De B aches ^ de Morbillis. 1790. 

Fabbi cius. Diss, de Variolis et Morbillis. 1628. 

Fbank, Historia de Cur. Horn. Morb. 1. iii. p. 245. 

Good's Study of Medicine, vol. ii. 

Hebeeden, Uom. in Morb. Hist, et Cur. 

Home's Facts and Experiments. 
/liEB, de Rubeola, 1779. 

IjObby, in M^m. de la Soci^t^ de M^decine, 1776. 

MoBTON, de Morbillis et Scarlatina. 

Med. Trans, of the Col. of Physicians, vol. iii. 

Pebcival's Essays. 

Rayeb, Traits des Maladies de la Peau, vol. i. 

Rqb^bi^ iebe^ Recherches sur la Rougeole. 1776. 

Royx, Traiti sur la Rougeole. 1807. 

ftuBH, Medical Inquiries^ vol. ii. N. S. 

SiMs's Observations. 

§£N2i£aXAS> Diss. xiii. de Variolis, Morbillis, &c. 1628, 

Sydenham, Opera Univ. 3d edit. 

Trans, of a Society for the Improv. of Med. and Chirurg. Knowledge, 
vol. iii. 

Watson, Med. Obs. and Inquiries, vol. iv. n. 22. 

\ViL§Qj!j_on Febrile Diseases, vol. ii. 

Willan on Cutaneous Diseases. 

Young on Opium, sect. Z6, 

Underwood, on the Diseases of Children. 



The limits of this Synopsis will not allow me to 
enter fully into the interesting inquiry, respecting 



RUBEOLA. 83 

the existence of the contagious eruptive fevers in 
the time of the Gredc and Roman physicians. The 
general inference in favour of the negative has arisen 
from the defect of such unequivocal descriptions of 
these formidable maladies, as might have been ex- 
pected in the writings of those who have accuratelv 
delineated many other diseases of less moment, with 
which we are now familiar. But it appears to me, on 
the other hand, that this defect is perfectly explicable 
upon the ground of their absolute devotion to the 
humoral pathology, and of their systematic adopticm 
of the dogmata of their predecessors ; and, on the 
other, that there is a sufficient, though scattered, 
evidence in their works to sanction th^ opposite 
conclusion. I shall here therefore briefly state the 
reasons of my belief in the affirmative of this 
question. 

It is almost superfluous to remark, that, from Galen, 
who adopted and extended the doctripe of the four 
humours mentioned by Hippocrates, through the 
whole series of Greek writers, down tp Actuarias, 
the same opinions were received with the utmost 
servility. They supposed that they had reached the 
perfection of * medical observation, when they had 
named the hypothetical humours which were be- 
lieved to be in fault. They contented themselves, 
therefore, with classing together all the eruptive 
fevers as pestilential, and with referring the various 
eruptions, that accompanied them, to diflferent com- 
binations of the humours. Such eruptions were 
frequently mentioned by Hippocrates and Galen, 
under the appellation of erysipelata, herpetes, phlvQ- 
ta^ae, phlyzacia, ecthymata, erythemata, exanthe- 
mata, &c. as the concomitants of malignant and 
epidemic fevers. Hippocrates has generalized some 
of these observations, and has deduced especially the 
following prognostic, respecting the eruptions of in- 
flamed pustules (phlyzacia), which seems referable 
only to the small-pox. " Quibus per fehres conti- 

G 2 



84 EXANTHEMATA I 

nuas ^Tio^axia toto corpore nascuntur, lethale est 
nisi superveniat apostema, quod fiat praecipue circa 
aures/'* 

But omitting, for the sake of brevity, the de- 
tached passages relating to this subject, it will be 
suflScient, I think, to refer to a remarkable chapter 
of Herodotus, "On the treatment of eruptions 
(^e^avQrjfjLOLTo) occurring in fevers," which has been 
preserved by Aetius. t This Herodotus was an 
eminent physician of the pneumatic sect at Rome, in 
the reign of Trajan, more than half a century before 
Galen settled in that city. He describes first the 
herpetic eruptions " which appear about the mouth 
at the crisis of simple fevers,** and subsequently the 
wheals of the febrile Urticaria, the miliary vesicles, 
and, I conceive, with considerable precision, the 
rashes of measles and scarlatina, and the pustules of 
smallpox. After mentioning the labial Herpes, 
which occurs at the termination of catarrhal and 
other slight fevers, he says, " But in the early stages 
of fevers, which are not simple^ but the result of 
vicious humours, there arise over the whole body 
patches like flea-bites ; and, in the rjialignant and 
pestilential fevers, these ulcerate^ and some of them 
liave an aflSnity with carbuncles : all these eruptions 
are signs of the redundancy of corrupt and corrosive 
humours in the habit ; but those which appear on 
the fojce are the most malignant of all.'* He then 
proceeds to describe the prognostics to be derived 
from the diflferent appearances of these eruptions, 
almost in the same terms which the Arabian writers 
on the smallpox and measles subsequently used ; and 
he was obviously acquainted with the danger of the 
highly confluent, and red or livid forms of these 
eruptions. ** They are worse if numerous, than if 
few,'* &c. — " Moreover," he remarks, ** those which 
are extremely red are of the worst kind ; but those 

* See his Coac. Praenot. n. 1 14. ed. Foes. See also Epidem. lib. iii. 
f See his Tetrabib. ii. serin, i. cap. 129. 



RUBEOLA. 6S 

which are livid, black, and tumid, like flesh that has 
been stained, are still more fatal ^ and these are copi- 
ous on the face and breast, abdomen, sides, and 
back." He considers these cases as so desperate^ 
that he advises the practitioner not to hazard his re- 
putation by any active interference, lest the blame of 
their fatality should be imputed to his attempts. 
** For those eruptions,'* he asks, " which arise from 
beneath, in a mortifying state, to the surface, what 
can they denote but that the life is passing from 
within?'' 

Now it seems unquestionable, that these, and much 
more ample details, delivered in the language of ex- 
perience, are applicable exclusively to the contagious 
eruptive fevers ; i. e. to smallpox, measles, and scar- 
latina. For we are not acquainted with any other 
continited fevers^ that are malignant and pestilential^ 
in the early stages of which eruptions appear all over 
the body, beginning like flea-bites ^ and sometimes uU 
ceratingi i. e. suppurating, specially on the Jace, 
except the diseases just mentioned. 

But the diflSculty and rarity of original observ- 
ation, even under more favourable circumstances, will 
be suflBciently manifest, if we trace the history of 
medical opinions upon the subject of the same diseases 
in later times. 

It might be supposed that, after the existence of 
these eruptive fevers had been so clearly pointed out 
by the Arabians, their distinctive characters would 
have been speedily ascertained, even by ordinary 
observers. But the fact was directly the reverse. 
Almost a thousand years elapsed, during which the 
smallpox, measles, and scarlet fever continued to 
commit their ravages, and physicians continued to 
record them ; while the individuals, who were spared 
by one of these maladies, were seen to su£Per succes- 
sively from attacks of the others : nevertheless, they 
were still viewed through the eyes of the Arabians, 
and were universally deemed varieties of one and 

G 3 



86 EXANTHEMATA I 

thfe ^the disease, until near the beginning of the 
eighteenth cehtiity : and it was not till towards the 
close of that age of enlightened observation, that the 
distinct character and independent origin of these 
three cbntagioiis disorders were universally perceived 
and acknowledged. 

We not only find the able and learned Sennertus, 
in the middle of the seventeenth century, discussing 
the question, " Why the disease in some constitu- 
iions assumes the form of smallpox, and in others 
that of measles ? " * but in the posthumous work of 
Diemerbroeck, an intelligent Dutch professor, pub- 
lished in 1687, it is affirmed that smallpox and 
measles difer only in degree. **Differunt (scil. 
mprbilli) a variolis accidentaliter, vel quoad magis et 
minus." t And still later, the same assertion was 
made by J. Christ. Lange, a learned professor at 
Leipsic. " Praeterea tam morbilli quam variolae sunt 
eruptiones in eo duntaxat discrepantes, quod vel 
miiius vel magis appareant,** &c.i But we must 
descend still nearer our own times, before we discover 
the complete unravelling of the subject, in the sepa- 
i^tion of scarlatina and measles, as distinct genera ; 
although, as varieties, they had been pointed out even 
by Haly Abbas. § Our countryman Morton main- 
tained the identity of these two exanthemata, and 
0on§id^red their relative connexion the same as that 
jof the distinct and confluent smallpox. || And so 
late as the year 1769, Sir William Watson did not 
distinguish the measles from the scarlet fever. % The 
publication of Dr. Withering*s Essay on Scarlet Fever, 
in 1778, or rather of the second edition of that work 
in 1793, may be considered perhaps as the date of the 
correct diagiaosis of this disease. So difficidt is the 

* Medidn. Pract. lib. iv. cap. 12. 

Tractat. de Variolis et Morbiliis, cap. 14, 

Miscell. Med. Curios. § xxxiv. 

Theorice, lib. viii. cap. 14. 
11 De Morbiliis et Scarlatina, exercit.iii. 
i See his paper in the Med, Obs. and Inquiries, vol.iv, p. 132, 



SCARLATINA. 87 

task of observation, — so tardy the development of 
truth.* 

Surely, then, the imperfection of the knowledge 
of the ancients, respecting the nature of these erup- 
tive fevers, affords no just inference against their ex- 
istence : while, on the contrary, the brief but re- 
peated notices, which they have transmitted to us, 
of eruptions resembling nothing that we are now ac- 
quainted with, except the contagious maladies in 
question, lead to the fair and legitimate conclusion, 
that the diseases of mankind, like their physical and 
moral constitution, have not undergone any great and 
unaccountable change ; imd that the eruptive fevers 
have prevailed from the earliest ages* 



Genus II. SCARLATINA- f 

S^n. 'Purpura (SchulZfJunck): Rossalia (Jkgrass 
et auct Neap.) : Rosalia {Aiict. Htsp.) : Febris 
Scarlatina {Syden. Morton^ et aicct. Ang.) : Mai de 
la Rosa ( Thiery) : Febris rubra (Heberd.) : Typhus 
Scarlatinus ( Oricht.) : Enathesis Rosalia ( Oood) : 
Fifevre rouge, scarlatine (jP.) : der Scharlachauf- 
schlag ( Oer.) : Scarlet Fever. 

Def. A CONTAGIOUS FEVER, ACCOMPANIED WITH 
A SCARLET RASH, APPEARING THE SECOND DAY ON 
THE FACE AND NECK ; SPREADING PROGRESSIVELY 

* It is not the least curious circumstance in the history of medical 
discoveries, that the vulgar have, in many instances, led toe w%y; ffid 
have actually given distinctive appellations to many varieties pC disease, 
before medical philoeophers had learned to distinguish them.. This is 
strongly exemplified in the history of chidcen-pox (see the 24 note on 
Varicella below) ; and also in Scabies, cow-pox, &c. 

f This barbarous term, which appears to have been of British origin, 
having found admission into all the systems of nosology. Dr. Willan did 
not deem it expedient to reject it. 

With regard to the origin of the term Scarlatina, Dr. Good savs that 
Dr. Willan is mistidcen, ** for the term itself is Italian, and was long in 
use as a vernacular name, on the shores of the Levant, before it was. 
imported into our own country."— Study of Medicine, vol. ii. T« 

6 4 



88 EXANTHEMATA : 

OVER THE BOi)Y; AND TERMINATING ABOUT THE 
SEVENTH DAY, AFTER WHICH THE CUTICLE EXFO- 
LIATES, 

The scarlet fever is characterized by a close and 
diffuse efflorescence, of a high scarlet colour, which 
appears on the surface of the body, or within the 
mouth and fauces, usually on the second day of fever, 
and terminates in about five days. 

Scarlatina sometimes appears as an epidemic ; but» 
in general, it is propagated, like the smallpox, measles, 
and chicken-pox, by a specific contagion ; and, like 
them, it aflFects individuals but once during life. * But 
it commences after a shorter interval from exposure 
to the contagion than the disorders just mentioned ^ 
namely, " sometimes in a few hours," sometimes on 
the third, fourth, or fiifth day. t Adults, however, 

* This fact is now fully ascertained. Dr. Withering, when he pub- 
lished the first edition of his tract, was of opinion, that the ulcerated 
sore-throat might occur in those who had undergone the Scarlatina 
anginosa: but, in the subsequent edition, he expresses his conviction 
that he wad In error. Among two thousand cases, Dr.Willan never 
saw the recurrence of the disease, under any of its forms. (See also 
Rosenstein on the Dis. of Child, cap. xvi.) Dr. Binns, indeed, mentions 
two instances of such recurrence at distant periods : but, at all events, 
these can only be looked upon as exceptions to the general fact, such 
as occur both in small-pox and measles. 

That sudi cases occur is undoubted. In the autumn of 1826, 1 at- 
tended a gentleman who was labouring under Scarlatina anginosa ; and. 
who informed me that this was the third time he had been attacked b^ 
the disease. Expressing some doubt regarding the correctness of his 
information, he gave me an accurate history of each attack, and stated 
tha^t in both the prior cases he had suffered severely from the ulceration 
of the throat, and that in both there was extensive desquamation of the 
cuticle. The second attack was at the distance of three years after 
the first ; the third five years after the second. T. 

A ftirther -analogy is also observable between these diseases and Scar- 
latina; f^iE. the poison may operate locally, and even excite some 
secondary constitutional indisposition, in persons who have previously 
gone through the fever. Thus such persons, if much exposed to the 
contagion of Scarlatina, are liable to severe affections of the throat 
unaccompanied by the rash on the skin. 

iSee Withering on the Scarlet Fever and Sore-throat, p. 61.— 
erden. Comment, de Morb. cap. 7. De Angina et Febre rubra, 
p. 20. — Dr. Blackburn e states the interval to be "from four to six 
days." (On Scarlet Fever, p. 34.) In one family Dr. Maton says the 
intervals varied from seventeen to twenty-six days ; but Dr. Good cor- 
rectly refers this to idiosyncrasy. 



SCARLATINA. 89 

are not so susceptible of the contagion as children, and, 
in them, the disease does not always appear so soon : 
women also are less susceptible than men.* Many 
medical practitioners, who have attended great num- 
bers of patients affected with every species of scarla- 
tina, have never experienced any of its effects. 
There are three species of Scarlatina : 

1. S. simplex y 

2. S. anginosay 

3. S. maligna.^ 

Species 1. The Scarlatina simplex^ Simple 
Scarlet Fever. 

Syn. Scarlatina febris ( Sydenham) : Scarlatina 
maligna (ilfocfcr.): Rosalia simplex (Oood): Ro- 
seole (F.). 

This species (Plate XXII. of Bateman ; PL 9* of 
Thomson's Atlas,) consists merely of the rash, with 
a moderate degree of fever. The day after the slight 
febrile symptoms have appeared, the efflorescence 
begins to shew itself about the neck and face, in in- 
numerable red points, which, within the space of 
twenty-four hours, are seen over the whole surface 
of the body. These, as they multiply, coalesce into 
small patches, but on the following day (the third) 
form a diffuse and continuous efflorescence over the 
limbs, especially round the fingers. On the trunk, 
however, the rash is seldom universal, but is distri- 
buted in diffuse irregular patches, the scarlet hue 
being most vivid about the flexures of the joints and 

* Some practitioners maintain the directly opposite opinion : in a 
table kept in the London Fever Hospital, of two hundred cases, one 
hundred and thirty-eight are females. See Cyclopaedia of Pract. Med. 
vol. iii. p. 627. T. 

f Many authors regard Cynanche maligna as a species of Scarlatina, 
although no rash appears on the skin ; and with this opinion Dr. Bate- 
man, in the former editions of this work, accords ; observing that the 
rash, which characterizes the three species above named, appears ** in 
the fourth only in the mouth and throat, to which, therefore, the ap- 
pellation of Scarlatina has never been applied." T. 



90 EXANTHEMATA : 

the loins. On the breast and extremities, in conse- 
quence of the great determination of blood to the 
miliary glands and papillae of the skin, the surface is 
somewhat rough, like the cutis anserina : several 
papulae are scattered on these parts : " occasionally 
minute vesicles are visible, sometimes apparently 
filled with a pellucid serum, at other times empty*:'* 
and, when these desquamate, a peculiar scaly state of 
skin remains. On the followmg (the fourth) day 
the eruption remains at its acm^ ; and on the fifth it 
begins to decline, disappearing by interstices, and 
leaving the small patches as at first, t On the sixth 
day it is indistinct, and is wholly gone before the 
end of the seventh. Between the fifth, eighth, and 
twelfth days a scurfy desquamation of the cuticle 
takes place. 

The efflorescence spreads over the surface of the 
mouth and fauces, and even into the nostrils, and is 
occasionally visible over the tunica albuginea of the 
eye : the papillae of the tongue, too, which are con- 
siderably elongated, extend their scarlet points through 
the white fur which covers it. The face is often con- 
siderably swelled. There is usually great restlessness, 
and sometimes slight delirium, which appear to be 
much connected with the great Keat of the surface, 
and continue in various degrees of severity, together 
with the fever, from three to seven days. A few 
patients escape with very little fever, almost without 
indisposition. 

^ Sauvage considers this circumstance sufficient to constitute a dis- 
tinct species, under the name Scarlatina variolodes. T. 

-(< At this period, and on the evening of the second day, some atten- 
tion is requisite to distinguish the scarlet rash from Rubeola : the ob- 
servation of the crescent-like form of the patches of the latter, and the 
more diffuse and irregular shape of the former, will be a material guide. 
This re-appearance of the rash in patches is noticed by Sennertus. ** In 
statu vero, universum corpus rubrum et quasi ignitum apparet, ac si 
universali erysipelate laboraret. In dedinatione, rubor ille imminuit, et 
maculae rubrae lata, ut in principioy apparent," &c. (De Febribus, lib. iv. 
cap. xii.) See also Etmuller. Opera, torn. ii. p. 416. where this circum-* 
stance is accurately stated. 



SCARLATINA. 91 

" The disease with which Scarlatina is most likely 
to be confounded, is the Roseola : but it is readily 
detected by noticing the manner in which the eruption 
appears. In Scarlatina it first attacks the face, and 
then extends to the trunk of the body, passing off by 
the extremities, whereas in Roseola the extremities 
are first affected.*' 

" It has also been confounded with measles ; but 
it may be readily distinguished : 1st, by the earlier 
appearance of the eruption after the commencement 
of the fever, generally on the second day, whereas 
in measles it does not shew itself until the -fourth, 
at soonest : 2d, by the inflamed eyes, sneezing, and 
other catarrhal symptoms that precede measles, not 
appearing; 8d, by the eruption not assuming the 
horse-shoe or semilunar form which it displays in 
measles ; and 4th, by the greater affection of the 
throat at the peculiar aspect of the tongue.** 

It is scarcely necessary to speak of the treatment of 
a disease which has been pronounced, by great medi- 
cal authority, fatal only "through the officiousness of 
the doctor.** * The principal business of the practi- 
tioner, therefore, is to prevent the useless and perni- 
cious expedients of nurses ; but, above all, to insist 
upon the coolness of the patient*s apartment, and the 
lightness of his bed-clothes ; and to restrict him to 
the use of cool drinks and of light diet, without 
animal food. Moderate laxatives are also to be re- 
commended. 

<* It is, nevertheless, requisite to watch every case 
of Scarlatina, however mild it may be in the com- 
mencement ; and, should the febrile symptoms in- 
crease, and the temperature of the surface rise, to 
sponge the body with cold or tepid water, and to 
open the bowels more actively than otherwise would 
be necessary. An emetic sometimes immediately 
subdues these threatening symptoms.** 

* " Mger non rar6 nulla alia de causd, quam nimi^ medici diKgentiA 
ad plures migrat," (Sydenham, § vi. cap. 2.) 



92 EXANTHEMATA : 

Species 2. Scarlatin a anginosa^ Scarlet Fever 
WITH Sore Throat. 

S^n. Scarlatina cynanchica ( Cullen) : Rosalia 
paristhmitica ( Good). 

In this variety of Scarlatina (Plate XXIII. fig. 2. 
of Bateman; PL 9* of Thomson's Atlas,) the 
precursory febrile symptoms are more violent, and an 
inflammation of the fauces appears, together with the 
cutaneous efflorescence, and goes through its progress 
of increase and decline with it. Occasionally, how- 
ever, the affection of the throat commences with the 
fever, and sometimes not until the eruption is at its 
height. 

With the first febrile symptoms, a sensation of 
stiflBiess and a dull pain on moving are felt in the 
muscles of the neck ; and on the second day the thrpat 
. is rough and straitened, the voice thick, and degluti- 
tion painful. On this and the two following days, 
the symptoms of fever are often severe ; the breathing 
is oppressed ; the heat of the skin is more intense 
than in any other fever of this climate, rising to 106% 
108°, or even 112° of Fahrenheit's thermometer * ; 
there is sickness, with headach, great restlessness, and 
delirium ; and the pulse is frequent, but feeble : there 
is also an extreme languor, faintness, "and general 
prostration of strength." The tongue, as well as the 
palate and the whole interior of the mouth and fauces, 
is of a high red colour, especially at the sides and 
extremity, and the papillae protrude their elongated 
and inflamed points over its whole surface. (Plate 
XXIII. fig. 1. of Bateman; PI. 9. of Thomson's 
Atlas.) 

The rash does not always appear on the second 
day, as in Scarlatina simplex, but not unfrequently on 
the third ; nor does it so constantly extend over the 
whole surface, but comes out in scattered patches, 
which seldom fail to appear about the elbows " and 

♦ See Dr. Currie's "Reports on the Effects of Water," &c. vol.ii. 
p. 428. Sennert observes, " Calor ferventissimus." Loc. cit. 



SCARLATINA, 93 

the wrists/' " On the third and fourth day, symptoms 
of Coryza frequently show themselves : but the mat- 
ter is less acrid and foetid than that discharged in 
Scarlatina maligna/' Sometimes too the eruption 
vanishes the day after its appearance, and re-appears 
partially at uncertain times, but without any corre- 
sponding changes in the general disorder : the whole 
duration of the complaint is thus lengthened, and the 
desquamation is less regular. When the rash is slight, 
indeed, or speedily disappears, no obvious desquam- 
ation often ensues ; while, in other instances, exfo- 
liations continue to separate to the end of the third 
week, or even later, and large pieces of the entire 
cuticle fall off, especially from the palms off the hands 
and the soles of the feet. 

The tumour and inflammation of the throat often 
disappear, with the declining efflorescence of the skin, 
on the fifth and sixth day of the fever, without having 
exhibited any tendency to ulceration. Slight super- 
ficial ulcerations, however, not unfrequently form on 
the tonsils, velum pendulum, or at the back of the 
pharynx, sometimes early, and sometimes late ; " but 
it has been observed that they never extend to the 
larynx or trachea.'* Little whitish sloughs are seen, 
intermixed with the mottled redness ; and when they 
are numerous, the throat is much clogged up with a 
tough viscid phlegm, which is secreted among them. 
When these are removed, after the decline of the fever, 
some excoriations remain, which soon heal. 

The S. anginosa is not unfrequently followed by 
a state of great debility, under which children are 
affected with various troublesome disorders, similar 
to those which more commonly supervene after the 
cessation of Rubeola. * ** These are often of a gastro- 
enteritic character ; displaying a clean, red-glazed 
tongue, and occasionally attended by harassing nausea 
and diarrhoea.'' There is one affection, also, peculiar 

* See Heberden, Comment, cap. vii. p. 20. 



94 EXANTHEMATA : 

to the decline of Scarlatina, which occurs especially 
when the eruption has been extensive ; namely, 
anasarca of the face and extremities. This dropsical 
effusion is commonly confined to these parts, and, 
therefore, unattended with danger : it usually ap- 
pears in the second week after the declension of the 
rash, and continues for a fortnight or longer. But 
in a small number of cases, when the anasarca had 
become pretty general, a sudden effusion has taken 
place into the cavity of the chest, or into the ven- 
tricles of the brain, and occasioned the death of the 
patient in a few hours, of which I have witnessed two 
instances. * " One sequel of the disease is a fcetid 
purulent discharge from the ears, which is scarcely 
ever cured, and frequently terminates in permanent 
deafness. Keeping the meatus clean, by syringing it 
with warm water containing a small proportion of the 
Chloro-sodiac solution of Labaraque, and dropping 
into it a few drops of the following mixture, is the 
best mode of correcting the foetor and lessening the 
discharge : 

5t. Bals. Peruv. f 511. 

Fellis Bovinse fji. Misce.** 

The principles, by which the treatment of Scar- 
latina anginosa should be regulated, have been 
satisfactorily established within the last few years; 
especially since the influence of diminished tempera- 
ture, in febrile diseases, was demonstrated by the late 
Dr. Currie of Liverpool, and the effects of purgative 
medicines have been better understood. For we have 

* There is some difference of opinion as to the dangerous tendency 
of the dropsical state, which succeeds the scarlet fever. Dr. Willan 
never saw any considerable efiiision take place into the internal cavi- 
ties; and several other writers look upon this dropsy as altogether 
harmless. (See Cullen, First Lines, § 664. — Dr. Jas. Sims on Scarlatina 
ang. in Mem. of the Med. Soc. vol. i.) Other practitioners, however, 
have mentioned the occurrence of these effusions as of dangerous 
tendency, and not un frequently fatal. (See Plenciz, Tract, de Scar- 
latina ; Frank de curand. Horn. Morbis, p. iii. § 295. ; Vogel. de cognosce 
et curand. Aff. § 154.) 



SCARLATINA, 95 

thus acquired two instruments, which are singly <^ 
the utmost value in the management of fever, and 
when combined are greatly auxiliary to each other. 

As a general rule, the Scarlatina anginosa must be 
submitted, from its commencement, to a strict anti- 
phlogistic treatment. The extraordinary heat, the 
great restlessness, anxiety, and distress, and the other 
symptoms of high excitement, which accompany the 
efflorescence, do not, indeed, require blood-letting, as 
was formerly supposed ; on the contrary, that evacu- 
ation would, in most cases, occasion a hurtful waste 
of strength. But ** it is impossible to lay down any 
general rule with regard to the use of the lancet in 
Scarlatina ; ** on the other hand, in respect to the 
moderate but free evacuation of the bowels, the use 
of cold drinks, and of external cold, and the inter- 
diction of all stimulant and cordial ingesta, under this 
state of excitement, experience has clearly decided. 

The best writers on this disease agree in recom- 
mending the exhibition of an emetic in the beginning 
of the fever ; which some have deemed it advisable 
to repeat, at intervals of forty-eight or twenty-four 
hours, or even at shorter periods, according to the 
urgency of the symptoms. * An emetic is, doubtless, 
a safe, and perhaps an useful medicine, at the very 
onset of the diserse : but this active employment of 
emetics seems to be supported neither by experience 
nor by principle, t Some practitioners, indeed, com- 
bined the emetic with Calomel, and ascribed a con- 
siderable portion of the advantage to the laxative 
operation, t Dr. Hamilton more lately has affirmed, 
that moderate purgatives of Calomel, with Rhubarb 

* See Dr. "Withering's Treatise before quoted. 

+ There appears to be a considerable inconsistency in Dr. Wither- 
ing s recommendation of " larger doses'* and " powerful vomits," in 
order " to secure a certain violekce of action upon the system," and in 
the apprehension of the danger of their acting as purgatives, which he 
at the same time expresses, and principally from hypothetical consider- 
ations. (Loc. cit. p. 78—81.) 
• X Dr-Rush. 



96 EXANTHEMATA : 

or Jalap, are not only extremely beneficial, in the early 
stages of Scarlatina ; but that they may supersede 
the use of emetics. * My own observation accords 
with this view of the subject. I have never witnessed 
any injurious eflPect from trusting to moderate purg- 
ing, and have frequently seen the disease proceed 
with uniform security, where the affection of the 
throat was very considerable, under the use of laxa- 
tives alone, with the cool treatment to be mentioned 
immediately. 

The value of moderate purgation, indeed, has been 
admitted by several cautious physicians. Dr. Willan, 
although stating that "purgatives have nearly the 
same debilitating effects as blood-letting,'' observes, 
nevertheless, that " the occasional stimulus of a small 
dose, as two or three grains, of Calomel, is very use- 
ful ; *' and in the beginning of the disease he combined 
with it an equal portion of antimonial powder. The 
same combination, he informs us, was freely adminis- 
tered by a physician at Ipswich, in 1772, in larger 
doses ; and of three hundred patients, thus treated, 
none died. (P. 357, note.) Dr. Binns t candidly 
acknowledges his obligations to a medical acquaint- 
ance, " for his removal of a prejudice against laxatives 
in the early stage of the disease, imbibed from various 
authors, and confirmed by the dreadful consequences 
he had seen, when a diarrhoea came on in this fever.*' 
But, so far from producing injury, he was afterwards 
satisfied, that the laxatives actually tended to prevent 
the diarrhoea which he dreaded, t " When the stomach 

* See his Treatise on Purgative Med. 

•|- See his able account of the management of Scarlatina, when it 
prevailed in the large school at Ackworth, in Dr. Willan's treatise, 
p. 357. 

X It can scarcely be matter of surprise, that purgatives should have 
been deemed highly injurious in fevers, by those practitioners who were 
unacquainted with the cool treatment. For the extreme degree of 
depression and exhaustion which the hot regimen occasioned, was a 
sufficient cause for a just apprehension of the ill effects of purgation. 
Mr. White informs us, when speaking of the miliary fevers ofpuerperal 
women (which occurred under the depressing influence of that regii- 
naen), that '* a few loose stools, in some cases spontaneous, in others 



SCARLATINA, 97 

is very irritable, Calomel, in doses of from five to 
seven grains, uncombined with either antimonial or 
purgative, sooner allays this morbid irritability than 
any other medicine, whilst at the same time it stimu- 
lates the peristaltic motion of the bowels.'* 

Many practitioners recommend the use of anti- 
monials, and of saline and camphorated diaphoretics, 
in order to excite perspiration, during the first days 
of this fever ; and some have advised the exhibition 
of opium in small doses, to alleviate the great inquie- 
tude and wakefulness that accompany it. But a little 
observation will prove, that sucn medicines fail alto- 
gether to produce either diaphoresis or rest, under the 
hot and scarlet condition of the skin ; and that, on 
the contrary, they aggravate the heat and dryness of 
the surface, and increase the thirst, the restlessness, 
the quickness of pulse, and every other distressing 
symptom.* In truth, the temperature is considerably 
too high to admit of a diaphoresis ; and the only 
"safe** or effectual "method** of producing it ^ which 

was a desideratum with Dr. Withering) consists in 

^ 

produced by art, have sunk patients beyond recovery." (Treatise on 
the Management of Pregnant and Lying-in Women, chap. 8.) 

We may remark, on ihe other hand, that the same artificial ex- 
haustion created a necessity for the copious use of wine and other 
stimulants, in these fevers, to prevent the patients from sinking irre- 
coverably. And hence a great two-fold mistake, in the treatment of 
fevers, was propagated ; viz., the fear of purgatives, and the excessive 
administration of stimulants. See Miliaria, infrh, 

♦ See Huxham on the malignant ulcerous Sore-throat ; Fothergill ; 
Grant; Plenciz, &c. — Dr. Huxham, however, acknowledges the great 
difficulty of producing sweating by any means. Dr. Withering writes 
** Sudorifics, Cordials, Alexipharmics, The medicines generally signified 
by these denominations have but little to do in the cure of Scarlatina. 
The patients are not disposed to sweat, when the scarlet rash prevails 
upon the skin ; nor do I know of any safe method by which we could 
attempt to excite a diaphoresis, even if we should expect it to be ad- 
vantageous," p. 81. Dr. Willan (p. 359.) and Dr. Blackburne (Facts 
and Obs., &c. on Scarlatina, p. 27.) make the same observation in 
stronger terms. 

With respect to opium. Dr. Withering observes, " I never saw it 
effect the purpose for which it was given ; on the contrary, it visibly 
increased the distress of the patient," p. 91. Dr. Cotton has a similar 
remark. (See his '* Obs. on a particular Kind of Scarlet Fever, that 
prevailed at St. Alban's," 1749. p. 16.) 

H 



98 EXANTHEMATA : 

reducing the heaty by the application of external cold, 
upon the principles established by Dr. Currie, 

We are possessed of no physical agent, as far as my 
experience has taught me (not excepting even the 
use of blood-letting in acute inflammation), by which 
the functions of the animal oeconomy are controlled 
with so much certainty, safety, and promptitude, as 
by the application of cold water to the skin, under the 
augmented heat of Scarlatina, and of some other 
fevers. " The patient is to be taken out of bed, 
stripped naked, and placed in an empty tub : a bucket 
or two of cold water is then to be suddenly emptied 
over the head ; and, the body being quickly dried, he 
is to be again placed in bed. If the sensation of 
chilliness remain, a little warm wine and water is to 
be administered.'' This expedient combines in itself 
all the medicinal properties which are indicated in this 
state of disease, and which we should scarcely ^ 
priori expect it to possess : for it is not only the 
most dBfectual febrifuge (the "febrifugum magnum,'* 
as a reverend author long ago called it *), but at is, 
in fact, the only sudorific and anodyne^ which will 
not disappoint the expectation of the practitioner 
under these circumstances. I have had the satisfaction, 
in numerous instances, of witnessing the immediate 
improvement of the symptoms, and the rapid change 
in the countenance of the patient, produced by wash- 
ing the skin. Invariably, in the course of a few 
minutes, the pulse has been diminished in frequency, 
the thirst has abated, the tongue has become moist, a 
general free perspiration has broken forth, the skin 
has become soft and cool, and the eyes have bright- 
ened; and these indications of relief have been speedily 
followed by a calm and refreshing sleep. In au these 
respects, the condition of the patient presented a 

* Dr. Hancocke, rector of St. Margaret's, Lothbury, published a 
pamphlet in 1722, entitled ** Fehrifugum Magnum; or, Common Water 
the best Cure for all Fevers," &c., whicli contains many sound observ- 
ations and valuable facts, detailed in the quaint language of tl^ time. 



SCARLATINA. 99 

complete contrast to that which preceded the cold 
washing ; and his languor was exchanged for a con- 
siderable share of vigour. The morbid heat, it is 
true, when thus removed, is liable to return, and 
with it the distressing symptoms; but a repetition 
of the remedy is followed by the same beneficial effects 
as at first.* 

Partly from the difficulty of managing the cold 
affusion, and partly from its formidable character in 
the estimation of mothers and nurses, imbued with 
the old prejudices, I have generally contented myself 
with recommending the washing of the skin with cold 
water^ or water and vinegar, more or less frequently 
and extensively, according to the urgency of the heat« 
In the beginning of the disease, the affiision of a 
vessel of cold water over the naked body is, doubtless, 
the most efficacious : but, by a little management, all 
the benefits of a reduction of the morbid temperature 
that can be expected at a subsequent period, may be 
obtained by the simple washing. In less violent cases, 
washing the hands and arms, or the face and neck, is 
of material advantage.t 

* After the extensive evidence, which a period of more than twenty 
years has furnished, in proof of the uniform efficacy and security of the 
external use of cold water in Scarlatina, and in other febrile dtseases 
connected with high morbid heat of the skin, it is to be lamented that 
some practitioners still look upon the practice as an experiment^ and 
repeat the remnants of exploded hypotheses, about repelling morbid 
matter, stopping pores, &c., as reasons for resisting the testimony of some 
of the greatest ornaments of the medical profession. For my own part, 
I have been in the constant habit of resorting to the practice at every 
opportunity in Scarlatina (and also in typhoid fevers, during my super- 
intendence of the Fever Institution for the last ten years), attending to 
the simple rules laid down by Dr. Currie, and I have never witneMed 
any inconvenience, much less any injury, from it; but an uniformity in 
Its beneficial operation, of which no other physical expedient, witk 
which I am acaumnted, affords an example. 

•)• For the direction of those who may not be acquainted with the 
principles of this practice, if any such remain in the profession, it may 
be stated, in the words of Dr. Currie, that the cold washins is inva- 
riably safe and beneficial, ** when the heat of the body is steadily above 
the natural temperature— when there is no sense of chilliness present, 
— and no general or profuse perspiration." But I have found the f<^ 
lowing direction to the nurses amply sufficient ; viz., to apply it ** when^ 
ever the skin is hot and </ry." Dr. Stanger, in treating Scarlatina among 

H 2 



JOO EXANTHEMATA : 

It is, of course, necessary to enjoin the cool regimen^ 
lus directed for the Scarlatina simplex ; to attend to 
the ventilation and moderate temperature of the apart- 
ment ; and to administer the drink cold.* Acidu-^ 
lated drinks are grateful, and, by coagulating the mucus 
gecreted in the fauces, are beneficial to those parts. 
Dr. Willan and Dr. Stanger have recommended the 
oxygenated muriatic acid, in doses of half a drachm 
for adults, and ten or twelve drops for children^ 
diluted in water, as an agreeable refrigerant. 

When there is a considerable degree of inflamma- 
tion and tumefaction of the tonsils, rendering the act 
of deglutition difficult, the application of a blister to 
the external fauces has proved extremely beneficial.^ 
Acidulated gargles, "containing a moderate proportion 
of the Tincture of Capsicum,*' likewise afford a ma- 
terial relief, and probably contribute to obviate the 
diarrhoea, by preventing the acrid mucus from being 
swallowed. 

Wine, Cinchona, and other cordials and tonics, are 
not only useless, but injurious, until after the efflor- 
escence has declined, together with the febrile symp- 
toms. During the hot feverish state, the cold washing 
is, in fact, the best cordial ; for, by allaying the ex- 
cessive febrile action, it removes the cause of the 
extreme languor and depression, and thus prevents 
the tendency to those symptoms of malignancy and 
putrescency, to obviate which the bark and wine have 



the children of the Foundling Hospital, found no other precaution 
necessary. *' Its effects in cooling the skin, diminishing the frequency 
of the.pulse, abating thirst, and disposing to bleep, were very remarkable. 
Finding this application so highly beneficial," he adds, " I employed it 
at every period of the fever, provided the skin were hot and dry." See 
a note in Dr, V^illan's Treatise, p. 360. 

^ Cold drink is, like the washing, always salutary in the same hot 
and dry state of the skin, and tends, like it, to promote perspiration. 

f Drs. Willan, Heberden, Rush, Clark, and Sims have concurred in 
the same observation. But Dr. Withering was of opinion that blisters 
were injurious, when the brain was affected ; and that they were less 
Advantageous when the inflammation was confined to the fauces than 
in other quinsies. 



SCARLATINA. 101 

been supposed to be particularly required. The con- 
valescence, likewise, is more rapid, and the tendency 
to dropsical efiusions is less, when the violence of the 
febrile symptoms has been restrained by this expedient. 
It is advisable, however, with a view to accelerate the 
convalescence, and to prevent anasarca, to resort to 
the Cinchona, with mineral acids, and a little wine, as 
soon as the fever and rash have entirely disappeared. 
The same medicines, combined with diuretics, and 
small purgative doses of Calomel, are generally effica- 
cious remedies for the dropsy, when it supervenes. 

Species 3. Scarlatina maligna^ Malignant 
Scarlet Fever. 

Syn. Cynanche maligna ( Cullen) : Angina ma- 
ligna seu gangrsenosa (^Auct. var.) : Empresma 
paristhmitis ( Good) : Angine maligne (I^») 

This form of Scarlatina (Plate XXIII. fig. 8. of 
Bateman ; PI. 9. of Thomson's Atlas), although 
it commences like the preceding, shows in a day or 
two symptoms of its peculiar severity. The efflor- 
escence is usually faint, excepting in a few irregular 
patches, and the whole of it soon assumes a dark or 
livid red colour. It appears late, and is very uncer- 
tain in its duration ; in some instances, it suddenly 
disappears a few hours after it is seen, and comes out 
again at the end of a week, continuing two or three 
days. The skin is of a less steady and intense heat : 
the pulse is small, feeble, and irregular : the functions 
of the sensorium are much disordered ; sometimes there 
is early delirium, and sometimes coma, alternating 
with fretfulness and violence. The eyes are dull and 
suflused with redness, the cheeks exhibit a dark red 
flush, the mouth is incrusted with a blackish or brown 
fur, and there is a black streak in the centre of 
the tongue. "The tonsils are not much swelled; 
but, with the rest of the fauces, appear of a dark red 
hue.*' The ulcers in the throat are covered with dark 
sloughs, and surrounded by a livid base ; and a large 

H 3 



102 EXANTHEMATA : 

quantity of viscid phlegm clogs up the fauces^ im- 
peding the respiration, and occasioning a rattling 
noise, as well as increasing the diflSculty and pain of 
deglutition. An acrid, often foetid discharge also 
distils from the nostrils, producing soreness, chops, 
and even blisters of the upper lip. " The cervical 
glands also enlarge, and abscesses sometimes form in 
Qiem.*' These symptoms are often accompanied by 
severe diarrhoea, and by petechiae and vibices on the 
skin, with hsemorrhagy from the mouth, throat, 
bowels, or other parts, which, of course, but too 
often lead to a fatal termination. This generally 
takes place in the second or third week ; but, in a 
few instances, the patients have suddenly sunk as early 
as the second, third, or fourth day, probably from the 
occurrence of gangrene in the fauces, oesophagus, or 
other portions of the alimentary canal * : and some- 
times, at a later period of the disease, when the 
symptoms had been previously moderate, the malig- 
nant changes have suddenly commenced, and proved 
rapidly fatal. Even those who escape through these 
dangers, have often to struggle against many dis- 
tressing symptoms for a considerable length of time ; 
such as ulcerations spreading from the throat to the 
contiguous parts, suppuration of the glands, tedious 
cough and dyspnoea, excoriations about the nates, 
&c., with hectic fever. 

" The most distressing sequel of every variety of 
Scarlatina is Dropsy, especially when the disease attacks 
children. It generally makes its appearance ten or 
twelve days after the disquamation ; sometimes, how- 
ever, it does not display itself for several weeks after 
that event. It is preceded by great languor and las- 
situde ; the appetite fails, the bowels become costive, 
the urine scanty and coagulable, and the pulse quick 
and irregular. The fluid is sometimes deposited in 

* " Haec gangrena (Bsophagura> asperamque, arteriam, sfiepe ante oc- 
cupat, qukm illam percipere, iliique medeii queamus." Navier, in Com. 
de Reb. p.i. Tol.iv. 338. 



SCARLATINA, lOS 

the cellular membrane, at other times in the serous 
cavities, or in the head. It seems to depend on in- 
flammation ; and in fatal cases this is demonstrated 
in the lungs, or pleura, or kidneys, or other internal 
organs.'* 

The treatment of Scarlatina maligna must ne- 
cessarily be diflPerent from that prescribed for the 
preceding species, and is unfortunately much less 
efficient. " In the commencement, the use of the 
lancet may be necessary to subdue excitement with a 
full and firm pulse ; but the quantity of blood taken 
should be moderate.'* The active remedies, which 
operate so favourably in the S. anginosa, especially 
the cold washing, are altogether out of place here : 
even the effect of a cathartic is admitted by the un- 
prejudiced to be often deleterious, by rapidly sinking 
the powers of the constitution} **but, nevertheless, 
much advantage is obtained from Calomel, given to 
the extent of eight or ten grains for a dose, and per- 
mitting it to pass off without the aid of a cathartic : ^ 
blisters, also, are not always applied with impunity. 
On the whole, the practice of administering gentle 
emetics appears to be beneficial, especially at the very 
onset of the disease. It is of great importance to 
remove frequently, but in a gentle way, the viscid 
offensive matter that encumbers the fauces, and which, 
if swallowed, produces considerable irritation in the 
stomach and bowels. For this purpose, warm re- 
stringent gargles are useful : such as the decoction of 
Contrayerva, with Oxymel of Squills, or Muriatic 
Acid : an infusion of Capsicum, or an acidulated de- 
coction of Cinchona. ** No gargle is more useful 
than the following : — 

131. Solutionis Confect. Rosae fjvj, 
Tinct. Capsici f5ij, 
' Acidi Muriatici diluti f5ss, 
M. et cola ut ft. Gargarisma, saepe utendum. 

The Chloro-sodaic solution of Labarraque, in the 
proportion of f3xij of the solution to f5vss of water, 

H 4 



104 EXANTHEMATA I 

and siv of honey, forms,, also, an excellent gargle. 
The same solution, in the proportion of f^vj to f ^v 
of water, without the addition of honey, if frequently 
thrown into the nostrils by means of a gum elastic 
bottle mounted with a tube, soon removes the Coryza ; 
after which the malignant character of the disease 
vanishes, and the case is reduced to one of Scarlatina 
a/nginosa.^' Tincture of Myrrh, camphorated spirit, 
and other stimulant liquids, may be likewise em- 
ployed with advantage. Fumigations, by means of 
the vapour of Myrrh and Vinegar, but particularly 
by the Nitrous Acid Gas (separated from powdered 
Nitre by the strong Sulphuric Acid), contribute ma- 
terially to cleanse the fauces. The latter vapours, or 
the Nitro-muriatic Acid Gas (chlorine) (separated 
from a mixture of equal parts of powdered Nitre and 
of Sea Salt by the strong Sulphuric Acid), often 
supersede the necessity of gargles. 

" A high eulogium on the powers of Ammonia 
in malignant Scarlatina has been paid by Dr. Peart, 
who regards it almost in the light of a specific. He 
recommends it to be administered in doses of gr. iij, 
dissolved in two or three tea-spoonfuls of water, every 
second or third hour, according to circumstances." 

As the disease advances, and the symptoms of 
malignancy or extreme debility increase, it becomes 
necessary to support the patient by moderate cordials, 
Wine, Opium, and the mineral acids, with light 
nourishment. In this, as in other violent fevers ac- 
companied with much sinking of the vital powers, it 
was formerly the custom to prescribe the Cinchona 
copiously. But while the tongue is loaded, the face 
flushed, and the skin parched, I believe this drug to 
be always prejudicial. Much of this malignancy, 
indeed, may be often counteracted by proper venti- 
lation ; and where the cutaneous heat is great, and 
the surface dry, gentle tepid washings, especially in 
the early stages of the disease, contribute much to 
prevent the future depression. Subsequently, where 



SCARLATINA. 105 

there is great languor of the circulation in the skin, 
warm bathing or fomenting, or even the application 
of the warm vinegar and spirits, has been attended 
with benefit. 

Similar treatment, both local and general, will be 
required in that variety of the disease, in which the 
throat is ulcerated, without any efflorescence on the 
skin, according to the degree of its virulence. 

" The Dropsy that supervenes is best managed by 
blood-letting and purging, or, when the debility of 
the patient prevents the use of the lancet, by brisk 
purging alone. Diuretics are of no use ; and the 
only tonic that is likely to prove useful after the ex- 
citement is reduced and the fluid removed, is the 
Tincture of Muriate of Iron. Country air, gentle 
i^xercise, and attention to diet and to the state of the 
bowels, form, however, still better modes of strengthen- 
ing the powers of the habit." 

The Scarlatina rapidly infects children, whenever 
it is introduced among those who have not already 
undergone its influence in some one of its forms; 
insomuch that the most rigid separation of tke dis- 
eased from the healthy, in schools or large families, 
has not always prevented its propagation. It is not 
accurately ascertained, at what period a convalescent 
ceases to be capable of communicating the infection : 
in some cases, the infectious power certainly remained 
above a fortnight after the decline of the efflorescence ; 
and there seems to be little doubt that, so long as the 
least desquamation of the cuticle continues, the con- 
tagion may be propagated.* 

^ Dr. Hahnemann, and several continental physicians, recommend the 
administration of Extract of Belladonna in mmute doses, during the 
prevalence of Scarlatina, to prevent the infection from being received. 
Two grains of the extract are dissolved in fjj of Cinnamon Water; 
and V\ ij of this solution are given night and morning to a child under 
one year of age ; and in larger doses, according to the age of the 
children ! It requires more faith than we possess to credit the asser- 
tions which have been given to the public on this subject. But we 
have no doubt that, by carrying the dose of Belladonna so far as to 
produce a scarlet efflorescence on the skin, the contagion might be 
warded off. T. 



106 EXANTHEMATA 



Works which may he eoruuUed on Scarlatina , 

Archives G^n^rales de M^d. torn. v. 8vo. Paris. 
Armsx&on^ Practical Illustrations of Scarlet Fever, 1818. 
Beoooes, Contributions to Med. and Phys. Knowledge, 1799. 
Blackburne, Facts and Observations, &c. 1803. 
Bremseb^ Diss, de Scarlatina anginosa, 1800. 
QoTTON, Observ. on a particular Kind of Scarlet Fever, 1749. 
Cjo yENTRY . And. de Scarlatina Cynanch. 1785. 
Edinburgh Med. and Surg. Joum. vols. iii. xiv^ xvi. xvii. xviii. 
HAHNE^ fANw (S.), Heilung und Verhiitang des Scharlach Fiebers, 
8V0. 1801. 

, Haken (T.X De Febre Scarlatina, 1781. 
^^HuFFELAND, Joum. de Pract. Hulkunde, passim. 
"^M^sMiCBASI^ New View of Scarlet Fever. 
Plekciz, de Scarlatina Tractatus. 
Sims, Memoirs of the Med. Society, vol. i. 
Sydenham, Opera Universa, § vi. cap. 2. 
Wi Lsoy on Febrile Diseases. 
WiLi^Atfj A Treatise of Scarlatina, 1815. 
Wixofi&uifi's Account of Scarlet Fever and Sore Throat, 1703. 
YywnBttierTv^ de I'Anasarque k la Suite de la Scarlatine. 
Zimmerman , De Scarlatina, &c. 



Genus III. URTICARIA. 

. Si/n» Uredo (Lin.) : Purpura urticata (Junck) : 
Scarlatina urticata ( Sauv.) : Febris urticata ( Fogei) : 
Essera, Aspritudo (AucL Far.) : Der Brennessel- 
ausschlag ( German) : Fi^vre ortiee, Porcelaine (JP.) : 
Essera Benat allil {Arab.)^ Nettle-rash. 
Def. Itching, nettle-sting wheals appearing 

ABOUT THE SECOND DAY AFTER A SLIGHT FEBRILE 
ATTACK ; FADING AND REVIVING, AND WANDERING 
FROM PART TO PART. 

The nettle-rash is distinguished by those elevations 
of the cuticle, which are usually denominated wheals, 
produced by the sting of the urtica dioica^ stinging 
nettle* (Def. 9.) They have a white top, often 
surrounded by diffiise redness. The complaint is 
not contagious, **and the accompanying fever is gene- 
rally of the remittent type ; occasionally it has proved 
intermittent.'* * It maybe confounded with Erythema 

* Bricheteau mentions a case of this kind ; see Joum. Comp. des 
Scien. M^d. t. xxxvii. p. 266. 



URTICARIA. 107 

nodosum ; but this does not disappear and again re- 
appear, nor has the elevated part the aspect of the 
sting of the nettle* It more closely resembles 
Roseola ; but this never rises into wheals^ Dr. Willan 
particularly noticed six species of Urticaria : — 

(1. V.fi^l^ 4- U. confetia. -'^ ^J:^ 

2. tJ. evanida*-- S. U. suhcutanea. , 

3. TJ . perstans. 6. U. tuberosa. CXiA<rw^t . 

A^ Species 1 . Urtic aria^JW/w • ; Febrile Nettle- 
Rash. 

Si/n. Purpura urticata (Juncker) : Febris erysi- 
pelatosa (S^/denh.): Exanthemata urticata {Bur- 
seriics) : Scarlatina urticata ( Sauv.) 

The rash, in this variety of Urticaria (Plate XXIV. 
fig. 2. of Bateman ; PI. 10. of Thomson's Atlas), 
is preceded for two days or more by feverish symp- 
toms, with cramps of the limbs, headach, pain and 
sickness of the stomach, and considerable languor, 
anxiety, and drowsiness, and sometimes even by syn- 
cope. The "appearance of the eruption mitigates 
these symptoms.*' The wheals appear in the midst 
of irregular patches of a vivid red efflorescence, some- 
times nearly of a^ crimson colour, on different, even 
very distant parts of the body, and accompanied by 
an extreme degree of itching and tingling, especially 
during the night, or on exposing the parts affected by 
undressing.t 

The eruption appears and disappears irregularly ou 

* This form of the disorder has been accurately described by Juncker 
and others under the name of " Purpura Urticata." (See his Conspect. 
Med. Pract. tab. 64.; also Lochner, Eph. Nat. Cur. cent. 6. obft.96.; 
and Schacht, Inst. Med. Pract. cap. ix. §vi.) Sydenham has likewise 
described it, under the title of " Febris Erysipetalosa;" (Obs. Med. § v. 
cap. 6.) and Sauvages, as a variety of Scarlitana, spec. 2. S. urticata. 
But Vogel pointed out its distinction from Purpura, Erysipelas^ and 
Scarlatina. (De cogn. et curand. Morb. § 158. " de Febre UrtixAta.") 
See also Burserius '' de Exanthemata Urticato," torn. ii. cap. 5.; and 
Frank, " de curand. Hom. Morb." lib. iii. § 106. 

f *^ Illud enim singulare habent, quod in frigido magis emergant, et 
in calido evanescant." Vogel. See also Burserius^ §96.; and Frank, 

§309. 



108 EXANTHEMATA : 

most, parts of the body ; " some days it appears on 
the anns, in others on the legs, or the trunk, or the 
face : ** but it may be excited on any part of the skin 
by strong friction or scratching.* The surrounding 
efflorescence fades during the day, and the wheals 
subside ; but both return in the evening, with slight 
fever. The patches are often elevated, with a hard 
border ; so that, when they are numerous, the face, or 
the limb chiefly aflFected, appears tense and enlarged. 

The febrile nettle-rash continues about a week t, 
with considerable distress to the patient, in conse- 
quence, of the heat, itching, and restlessness with 
which it is accompanied : the disorder of the stomach, 
however, is relieved by the appearance of the erup- 
tion ; but it returns if the eruption disappears. A 
slight exfoliation of the cuticle generally succeeds. 

This eruption occurs chiefly in summer; it affects 
persons of all ages, but most commonly the young : *' 
it is often connected with teething or disordered 
bowels in children, in whom, however, it is attended 
with less fever than in adults, and often disappears in 
a few hours ; and among adults, affects persons of 
ftiU habit, who indulge in the gratifications of the 
table, or suffer from domestic afflictions and other 
causes of anxiety. It sometimes occurs as a symp- 
tom of other diseases, cancer uteri, for instance, as 
mentioned by Sir C. M. Clarke.t 

Modifications of the febrile nettle-rash, indeed, are 
produced by certain articles of food, which, in par- 
ticular constitutions, are offensive to the stomach ; 
especially by shell-fish, such as lobsters, crabs, and 
shrimps, but above all by mussels. § In a few indivi- 

* See Sydenham ; and Frank, § 307. 

+ " Febris primo septenario inter sudores decedit." Vogel. 

4: Observ. on Diseases of Females, which are attended with dis- 
charges. By C. M. Clarke, 8vo. London, 1814. 

§ On some parts of the coast of Yorkshire, where mussels are abun- 
dant, a belief is prevalent among the people, that they are poisonous, 
and they are consequently never eaten. This opinion is most probably 
the result of traditional observation, in regard to the frequent occur- 
rence of Urticaria, after they were swallowed. A case, indeed, is 



URTICARIA. 109 

duals, in consequence of a peculiar idiosyncrasy, other 
substances, when eaten, are followed by the same imme- 
diate affection of the skin ; such as white of eggy mush- 
rooms, honey, oatmeal, almonds, and the kernels of 
stone-fruit, raspberries, strawberries, green cucumber 
with the skin upon it *, &c. In some persons, the in- 
ternal use of Valerian has produced the nettle-rash, t 
The operation of these substances is sometimes almost 
instantaneous t, and the symptoms are extremely vio- 
lent for several hours ; but they generally cease alto- 
gether in a day or two. Not unfrequently, in delicate 
and irritable females, febrile nettle-rash arises from 
overloading the stomach. The eruption, however, 
is not always accompanied with wheals, but sometimes 
is a mere efflorescence, not unlike that of Scarlatina. 
It is generally attended by great disorder of the 
stomach, with violent pains in the epigastrium, and 
other parts of the body, sickness, languors, fainting, 
with great heat, itching, stif&ess, and often much 
swelling of the skin. In a few instances, it is said to 
have been fatal. § 

An emetic of Ipecacuanha, if there be suspicion 
that the disease arises from any thing which has been 
taken into the stomach ; but, if the offending cause be 
putrid fish, the Sulphate of Zinc, or that of Copper, 
is to be preferred as an emetic, on account of the 



mentioned by Ammans and Valentinus, in which a man died so sud- 
denly after eating mussels, that suspicion of having administered poison 
fell upon his wife. (See Behrens, " Diss, de Afiectionibus a comestis 
Mytilis.") 

* Dr. Winterbottom, who is subject to this affbction after eating 
sweet almonds, observes that he takes them with impunity, when they 
are blanched. See Med. Facts and Obs.vol. v. where the symptoms are 
minutely described. 

+ Dr. Heberden, Med. Transact. voLii. p. 176. — Frank, §310. 

4: See Moehring de Mytilorum Veneno. aegrot.iii. in Haller's Disput. 
tomJii. p. 191. 

§ ** Licet etiam ea symptomata, quamcunque gravia, intra unum 
alterumque diem, sine vitse periculo deflagrare, aut extingui soleant ; 
tamen non desunt exempla rariora, nobis quidem non visa, ubi mortem 
arcessiverunt." Werlhofl^ Pref. to the Diss, of Dr. Behrens, subjoined 
to his treatise " De Variolis et Anthracibus," Hanov. 1 755 ; also Van 
Swieten, Comment, ad aph. 723, 



110 EXANTHEMATA : 

quickness of its operation. This, followed by a gentle 
cathartic, or, in ordinary cases, by a gentle laxative, 
with light and cooling diet (with total abstinence from 
fermented liquors, ^id from sudorific medicines), 
'< and confinement to bed," constitute the sole treat- 
ment which appears to be requisite for the safe conduct 
of these disorders to their period of decline ; at which 
time the Cinchona, with diluted Sulphuric Acid, is 
beneficial. " I have generally found it beneficial to 
combine Sulphate of Magnesia with the Infusion of 
Cinchona ; or to give it in the Infusion of the Con- 
fection of Roses, with Sulphate of Quinia, acidulated 
with the diluted Sulphuric acid.** In children, when 
the disease does not soon spontaneously disappear, 
it is best managed by the Compound Powder of Con- 
trayerva, or any other absorbent powder ; at the same 
time keeping the bowels in a lax state. As local 
applications to allay the sensation of stinging and 
tingling, which accompanies the wheals, a lotion con- 
sisting of one part of Alcohol with three of water, or 
of two parts of vinegar, and three of water, will be 
found beneficial. 

Species 2. The Urticaria eoaniddj Evanescent 
Nettle-Rash. 

This species (Plate XXIV. fig. 1. of Bateman; 
PI. 10. of Thomson's Atlas) is a chronic affection, 
in which the wheals are not stationary, but appear and 
disappear frequently, according to the temperature of 
the air, or the exposure of the patient, and vary with 
the exercise which he uses, &c. It is not accompanied 
by fever, and seldom by any other derangement of 
health. The wheals are sometimes round ; and some- 
times longitudinal, like thosQ which are produced by 
the stroke of a whip ; they may be excited on any 
part of the body, in a few seconds, by friction or 
scratching ; but these presently subside again. • They 

* I knew a young la<ly, enjoying good health, who could at any time 
instantaneously excite long, white, and elevated wheals on her skin, by 



URTICARIA. Ill 

are sometimes slightly red at the base; but never 
surrounded by an extensive blush. A violent itching, 
with a sensation of tingling, or stinging, accompanies 
the eruption ; which, as in the febrfle species, is most 
troublesome on undressing, and getting into bed. 
The disorder is extremely various in its duration. 
' The eruptions, as Dr. Heberden remarks, last only 
I a few days in some persons ; while in others they 
continue^ with veiy short intervals, for many months, 
and even for several years. * Persons affected with 
it are liable to suffer headach, languor, flying pains, 
and disorders of the stomach. Xt attacks people of 
all ages and both sexes ; but more especially those of 
sanguine temperament, and females more frequently 
than males. 

As it is often obviously connected with irritability 
of the stomach, or some peculiar idiosyncrasy ; so, 
when it continues long. Dr. Willan justly su^ests 
the probability, that it originates from some article 
of diet, which disturbs digestion. Hence, he says, 
" I have desired several persons, afiected with chronic 
Urticaria, to omit first one, and then another article 
of food or drink, and have thus been frequently able 
to trace the cause of the symptoms. This iq)peared 
to be different in different persons. In some it was 
malt-liquor; in others, spirit, or spirit and water; 
in some, white wine ; in others, vinegar ; in some, 
fruit ; in others, sugar ; in some, fi^ ; in others, 
unprepared vegetables.** He acknowledges, however, 
that, in some cases, a total alteration of diet did not 
produce the least alleviation of the complaint. In 
such cases^ occasional laxatives, and the mineral acids« 
have been found the most advantageous remedies. 
Sometimes, where the indigestion was considerable, I 



drawing the nails along it with some degree of pressure : but the wheals 
soon subsided, and she was not subject to them from any odier cautew 
The same cutaneous irritability coexists occasionally with Impetigo, and 
other chronic affections of the skin, which have no relation to Urticaria. 
* Med. Trans, p. 1*75. See also his Coflomentar. cap. 56. De Essera. 



11^ EXANTHEMATA : 

have found Soda or the Caustic Potass, combined 
with Aromatic bitters, such as Cascarilla, afford relief. 
Dr. Underwood recommends the following : — 

]^. Hydrarg. Sulph. Rubri 5s8, 

Radicis Serpentarise, in pulvere, 9 j, 
Syrupi q. s. ut Bat bolus, 
Bis die sumendus; superbibendo haust: Infusi florum 

Sambuci. 

The complaint is generally too extensive to be 
completely alleviated by lotions of Spirit, Vinegar, 
or Lemon juice, &c., which afford loc^ relief. But 
the warm bath is beneficial ; and a persevering course 
of sea-bathing, for a considerable time, has generally 
been found an effectual remedy. 

Species 3. Urticaria perstans^ Stationary 
Nettle- Rash. 

This differs from the preceding species, principally 
in the stationary condition of the wheals, which re- 
main afler the redness, at first surrounding them, has 
disappeared. They continue hard and elevated, with 
occasional itching, when the patient is heated, for two 
or three weeks, and gradually subside, leaving a red- 
dish spot for some days. The treatment directed for 
the foregoing species is here beneficial. 

Species 4. Urticaria conferta^ Confluent 
Nettle-Rash. 

In this species the wheals are more numerous, and 
in many places coalesce, so as to appear of vei^ irre- 
gular forms : they are also sometimes considerably 
inflamed at the base ; and the itching is incessant. 
This variety of the complaint differs from febrilis in 
the absence of fever ; and by its chronic character : 
it chiefly affects persons above forty years of age, who 
have a dry and swarthy skin ; and seems to originate 
from violent exercise, or from indulgence in rich food 
and spirituous liquors. Hence the patients find little 



URTICARIA. ' 118 

relief from medicine, unless they use at the same 
time a light cooling diet, and abstain from malt-liquor, 
white wines, and spirits. Alterative medicines, or 
tonics, are sometimes useful, if this plan of diet be 
conjoined with them ; and warm bathing affords a 
temporary relief. The eruption often continues many 
/ weeks. 

Species 5. Urticaria subcutaneaj Subcuta- 
neous Nettle-Rash. 

This is a sort of lurking nettle-rash, which is 
marked by a violent and almost constant tingling in 
the skin, and which, from sudden changes of tempe- 
rature, mental emotions, &c., is often increased to 
severe stinging pains, as if needles or sharp instru- 
ments were penetrating the surface. These sensations 
are at first limited to one spot on the leg or arm; 
but afterwards extend to other parts. It is only at 
distant intervals that an actual eruption of wheals 
takes place, which continue two or three days, without 
producing any change in the other distressing symp- 
toms. In persons so affected, the stomach is fre- 
quently attacked with pain, and the muscles of the 
legs are subject to cramps. It is relieved by repeated 
warm-bathing in sea- water, and gentle Jriction. 

Species 6. Urticaria tuherosa^ Tumid Nettle- 
Rash. 

This species, which was named by Dr. Frank, is 
marked by a rapid increase of some of the wheals to a 
large size*, ** sometimes the breadth of the hand; they 
are accompanied with intense itching, *' and form hard 
tuberosities, which seem to extend deeply, and occasion 
inability of motion and deep-seated pain. They ap- 
pear chiefly on the limbs and loins, and are very hot 

* " Tamores vero, palmae latitudinem habentes, et colore rubro sed 
obscuro instruct!, cum pruritu ad animi deliquium usque intolerabili, 
universam corporis, sed femorum imprimis, superficiem occupare cer- 
nuntur." Frank, loc. cit. § 399. torn. iii. p. 108. 

I 



114 exanthemata: 

and painful for some hours: they usually occur at 
night, and wholly subside before morning *, leaving 
the patient weak, languid, and sore, as if he had been 
bruised or much fatigued. It seems to be excited 
by excesses in diet, over-heating by exerdse, and the 
two free use of spirits ; and is often tedious and ob- 
stinate. A regular light, diet and a course, of warm- 
bathing are to be recommended, with occasional gentle 
laxatives, where the organs of digestion appear to be 
deranged, t 

Bookt which may be comulted on Urticaria. 

Burrows, London Med. Repository, vol. iii. p. 445. 

BiETT, (^Cazenave and Schedel) Abr^^ Pratique des Mai. de la Peaii. 
Paris. I8fi8. 

Cbames^ Diss, de Purpurae Urticatae et Scarlat, Febris discrimine, 
Hal. 1759. 

Frank, de Curand. Horn. Morbis, lib. iii. 

Grauer. Progr. de F^bre Urticata, &c. 1774. 

Heberden, IVled. Trans, vol. i. 

Journal de M^decine, Annies 1759 et 1763. 
^ ^ocKf Progr. de F^bre Urticata, Lips. 1792. - 

MoERiNG, Epist. de Mytilprum Ven^no, 4to. 1747. 

Plumbe, on Diseases of the Skin, 2d. edit. 1 827. 

Rayer, Traits des Maladies de la Peau, 1826. 

T2ii>MAs, on the Nature and Ciu'e of Essera, 8vo. 1774. 

WiLLAN, on Cutaneous Diseases, 1818. 

WiNTERBOTTOM, Med. Facts and Obsenr. vol. v. No. 6. 



Genus IV. ROSEOLA. 

Syn. Rubeola Rossalia, Rosania {AuLct. vet.) : 
Exanthesis Roseola ( Good) : Exanthisma Roseoue 
( Young) ; Roseole, Fausse rougeole, Eruption ano- 
male rosace (i^.), lied-rash. Rose-rash. 

Def. A ROSE-COLOURED EFFLORESCENCE, VA- 
RIOUSLY FIGURED, MOSTLY CIRCULAR AND OVAL, 
WITHOUT WHEALS OR PAPUL-E, OCCASIONALLY 
FADING AND REVIVING : NOT CONTAGIOUS. 

* Some writers have hence considered this eruption as the Epinyctis 
of the ancients : but Sennertus corrects this mistake. The epinyctides 
contained a bloody sanies, according to Gralen, Aetius^ and raui : and 
Celsus says, ** reperitur inter exulceratio mucosa." 

f Frank, loc, cit. § 312. 



ROSEOLA. 115 

The efflorescence, to which Dr. Willan appro- 
propriated the title of Roseola, is of little importance 
in a practical view * ; for it is mostly symptomatic, 
occurring in connection with dentition, dyspepsia, 
and different febrile complaints, and requiring no 
deviation from the treatment respectively adapted 
to them. It is necessary, however, that practitioners 
should be acquainted with its appearances, in order 
to avoid the error of confounding it with the idio- 
pathic exanthemata. It has been occasionally mis-, 
taken both for measles, erythema, urticaria, and 
scarlet fever ; and, from this want of discrimination, 
probably, the supposition that scariatina was not 
limited, like the other eruptive fevers, to one attack 
during life, has been maintained by many persons up 
to the present time.t There is no difficulty in dis- 
tinguishing it from erjrthema and urticaria; from 
measles it is known by the absence of the catarrhal 
symptoms ; and from scarlatina by the course of the 
rash, which, contrary to what occurs in scarlatina, 
begins at the extremities and terminates upon the 
face and trunk of the body. It is not contagious. 

There are seven species of Roseola : 

1. R. cestiva. 5. R. variolosa. 

2. R. autumnalis. 6. R. vaccina. 

3. R. annulata. 7» R- vniliaris. 

4. Rx infantilis. 

Species 1. Roseola cBstiva^ Summer Rose- 
Rash. 

This species (Plate XXV. fig. 1. of Bateman; 

* Fuller (in his Exanthematologia, p. 1 28.) ^peal^s of this sort of rose-, 
rash, as a flushing all over the body, like fine crimson, which is void 
of danger, and ** rather a ludicrous spectacle, than an ill symptom." 
The appellation of Roseola is to be found in the works of some of the 
early modern writers ; but it was applied somewhat indiscriminately to 
scarlet fever, measles, &c. (See above, p. 58. note.) 

1 Instances have occurred in which undoubted Scarlatina has at- 
ed the same individual more than once. I witnessed a severe 
instance which was the third attack of the disease in the same indi- 
vidual. T. 

I 2 



116 EXANTHEMATA : 

PL 11. of Thomson's Atlas,) is sometimes pre- 
ceded for a few days by slight febrile indisposition. 
It appears first on the arms, face, and neck, and, in 
the course of a day or two, is distributed over the 
rest of the body, producing a considerable degree 
of itching and tingling. The mode of distribution 
is into separate small patches, of various figure, not 
crescent-shaped, but larger and of more irregular 
forms, and paler than in the measles, with numerous 
interstices of the natural skin. It is at first red, but 
soon assumes the deep roseate hue peculiar to it. 
The fauces are tinged with the same colour, and a 
slight roughness of the tonsils is felt ill swallowing. 
The rash continues vivid through the second day, 
after which it declines in brightness ; slight specks 
only, of a dark red hue, remaining on the fourth day, 
which, together with the constitutional affection, 
wholly disappear on the fifth. 

Not unfrequently, however, the efflorescence is 
partial, extending only over portions of the face, 
neck, and upper part of the breast and shoulders, 
in patches, very slightly elevated, and itching con- 
siderably, but without the tingling which accom- 
panies nettle-rash* In this form the complaint 
continues a week or longer, the rash appearing and 
disappearing several times ; sometimes without any 
apparent cause, and sometimes from sudden mental 
emotions, or from taking wine, spices, or warm 
liquors. The retrocession is usually accompanied 
with disorder of the stomach, headach, and faintness ; 
which are immediately relieved on its appearance. 

This variety of Roseola commonly occurs in sum- 
mer, in females of irritable constitution; and is 
ascribed to sudden alternations of heat and cold, 
especially to drinking cold liquors after violent exer- 
cise. It is sometimes connected with the bowel- 
complaints of the season. 

Light diet, and acidulated drinks, with occasional 
laxatives, alleviate the symptoms. The complaint is 



ROSEOLA. 117 

liable to retrocession, it is affirmed, from the influence 
of very chill air, or the application of cold water, 
which ocQasions considerable disorder of the head and 
alimentary canal ; but I have not Seen any instance 
of this kind. 

Species 2. Roseola autumnalis^ Autumnal 
Rose-Rash. 

This species (Plate XXV. fig. 2. of B axeman ; 
PI. 11. of Thomson's Atlas,) occurs in children, 
in the autumn, in distinct circular or oval patches, 
which gradually increase to about the size of a shil- 
ling, and are of a dark damask-rose hue. They 
appear chiefly on the arms, and continue about 
a week, sometimes terminating by desquamation. 
There is little itching, tingling, or constitutional 
aflPection, connected with this efflorescence ; and its 
decline seems to be expedited by the use of Sulphuric 
Acid internally, exhibited in the infusion of Con- 
serve of Roses, or the infusion of Gentian, in com- 
bination with small doses of Sulphate of Magnesia.* 

* The following cases are certainly severe instances of this species of 
Roseola, although Dr. Bateman, who details them, regarded them as dif- 
ferent from any of the species described by D r.Willan. I have quoted 
them to show the height to which the Febrile symptoms may extend: — 

" The two cases, set down under the head of Roseola, were febrile 
diseases, and one of them was of considerable severity and duration. 
In both these instances the rash appeared on the second day of fever, 
and continued beyond the ninth day, the fever then declining with it. 
In the more severe case, the rash bore a considerable resemblance to 
that of rubeola, consisting of numerous small, slightly-elevated spots, of 
a pale red colour, not acuminated, covering the face, extremities, and 
trunk; but, although here and there confluent, not forming into 
crescents, like the measles, nor approaching to the raspberry hue. The 
patient complained during the whole period of great general distress; 
the skin was exceedingly hot, although the perspirations were con- 
siderable, and there was even a tendency to delirium. On the ninth day 
the eruption began to disappear, and the fever to diminish j but she was 
left in a state of great debility and languor, and recovered slowly. 
Purgatives, diaphoretics^ and acids were principally employed; but it is 
probable that a cooler bed and apartment, than the parents of the girl 
chose to maintain, would have materially alleviated the complaint. 
The second patient, a younger girl, only eleven years of age, exhibited 
on the second day of a moderate fever, accompanied by sickness, a 
diffuse rose-red rash on the legs, of an erythematous form, slightly 

I 3 



118 EXANTHEMATA I 

l^PEciEs 3. The Roseola annulatay Annulae 
Rose-Rash. 

This species (Plate XXVI. fig. 1. of J^ateman ; 
PL 11. of Thomson's Atlas,) appears on almost 
every part of the body, in rose-coloured rings, with 
central areas of the usual colour of the skin ; some- 
times accompanied with feverish symptoms, in which 
case its duration is short ; at other times, without 
any constitutional disorder, when it continues for a 
considerable and uncertain period. The rings at 



elevated, but of an uneven surface, the most elevated parts being 
reddest : on the fourth and fifth days (the fever, with slight headacb, 
continuing), a similar rash appeared on the arms; and t>n the sixth day, 
when the eruption i>n; the legs began to fade, a large circular patch of 
the same bdght Ted rash showed itself upon each cheek. These 
patches were extremely vivid, when the patient was first seen on the 
seventh day, at which tune the eruption on the arms was less bright, and 
that on the legs was much faded, the elevated parts only remaining red, 
and giving a mottled appeareance to the skin. Some remains of the 
rash continued on the face on the eleventh day, when she visited the 
Dispensary, free from fever ; and a slight roughness, from imperfect 
desquamation, was found on the arms. She had taken some laxative 
before she applied to the charity, and was treated with Infusum Rosae 
and Magnesias Sulphas, followed by the decoction of Cinchona and 
Sulpliuric Acid. 

** These febrile rashes, of which there is a considerable variety*, are not 
often either dangerous or severe, and chiefly deserve to be noticed with 
a view to the diagnosis from the contagious eruptive fevers, scarlatina 
and measles. I lately attended a case, resembling the former of these in 
appearance, although not in the severity of the concomitant fever, 
which excited a great alarm in the family, ft'om the belief that it was 
scarlet-fever ; a supposition which was strengthened by the occurrence 
of a slight sore throat. But a careful attention to the form, dis« 
tribution, and progress of the eruption, as well as to the concomitant 
circumstances, will generally enable an observer, accustomed to analyse 
those appearances, to decide promptly as to their diflerence from the 
contagious fevers just mentioned. The causes of them are by no means 
easily traced ; in the latter of the two cases above described, the dis- 
order was supposed to have been occasioned by having been excessively 
heated, by working at a mangle, a week before the symptoms appeared.^ 
Vide Edin. Med. and Surg. Journ. vol. viii. p. 224. 



n 



* Neither of these cases accorded accurately with the species of Roseola 
described by Dr. Willan, as having most frequently occurred to his observ- 
ation. But it Were not easy to follow these rashes through all their varieties. 
They agreed with his general definition : ^' a roie-coloured efflorescence, 
variously figured, without wheals or papulae, and not contagious.'*— ^-Ord. III. 
Genus VI. 



ROSEOLA. 119 

jBrst are from a line to two lines in diameter; but 
they gradually dilate, leaving a larger central space, 
sometimes to the diameter of half an inch. The 
efflorescence is less vivid (and, in the chronic form, 
usually fades) in the morning, but increases in the 
evening, or night, and produces a heat and itching, 
or prickling in the skin. If it disappears or becomes 
very faint in colour for several days, the stomach 
is ^sprdered, and languor, giddiness, and pain of the 
Umbs ensue,— symptoms which are relieved by the 
warm bath. 

Sea-bathing and the mineral acids afford much 
relief in the chronic form of this rash. 

Species 4. The Roseola infantilis. Infantile 
Rose-Rash. 

This form of Rose-rash (Plate XXVI. fig. 2. of 
Bateman; pi. 11. of Thomson's Atlas,) is closer, 
leaving smaller interstices than the R. cestiva above 
described, and occurring in infants during the irrita- 
tation of dentition, of disordered bowels, and in 
fevers. It is very irregular in its appearances^ some- 
times continuing only for a night ; sometimes appear- 
ing and disappearing for several successive days, with 
violent disorder; and sometimes arising in single 
patches, in different parts of the body successively. 

Where the rash is pretty generally diffiised, it is 
often mistaken, as Dr. Underwood has remarked,* 
for measles and scarlatina: whence it is necessary 
that practitioners should be acquainted with it; 
although it requires no specific treatment, but is 
" alleviated by testaceous powders, or the Pulvis 
Contrayervae Compositus and Nitre," and other re- 
medies adapted to bowel-complaints, painful denti- 
tion, and various febrile affections, with which it is 
connected. 

* On the Diseases of Children, vol.i. p. 87. 

I 4 



120 EXANTHEMATA : 

Species 5. Roseola variolosa. Variolous Rose- 
rash. 

This rash (Plate XXVII. fig. 1, 2. of Bateman ; 
PI. 11. of Thomson's Atlas,) occurs previous to 
the eruption both of the natural and inoculated 
small-pox, but not often before the former. . It 
appears in about one case in fifteen, in the inoculated 
disease, on the second day of the eruptive fever, 
which is generally the ninth or tenth after inocula- 
tion. It is fii:st seen on the arms, breast, and face ; 
and on the following day it extends over the trunk 
of the body and the extremities. " In general, like 
rash in R. aestiva and autumnalis, it appears first 
on the extremities, and gradually advances to the 
trunk and face, taking the opposite course of scar- 
latina, which generally terminates on the extre- 
mities." * Its distribution is various : sometimes in 
oblong irregular patches, sometimes difiused with 
numerous interstices (see PI. 10. of Thomson^s 
Atlas) J and, in a few cases, it forms an almost 
continuous redness over the body, being in some 
parts slightly elevated. It continues about three 
days, on the second or last of which the variolous 
pustules may be distinguished, in the general redness, 
by their rounded elevation, by their hardness, and by 
the whiteness of their tops : and, as soon as these ap- 
pear, the rose-rash declines. 

* This course of the eruption is well exemplified in the following 
instance, which occurred previous to the eruption in a case of small- 
pox after vaccination. " On the 30th of June 1826, 1 was called to see 

Miss , who was supposed to be labouring under scarlatina. The 

hands, the forearms, the feet, the legs half way up, and the mammse 
around the nipples, are covered with the rose eruption ; but there 
are scarcely any patches on the thorax, and none on the face nor on 
the trunk of the body. The fever is moderate, the pulse soft, and the 
tongue moist : there is a slight blush over the &uces, and a pustule on 
the left tonsil. 1st July: The rash is nearly gone from the legs and 
arms, and beginning to appear on the face and neck and trunk; the va- 
riolous pustules which have appeared, are few and distinct ; the pulse is 
soft ; there is no feeling of sore-throat 2d July : The rash is entirely 
gone, and the pustules are advancing." T. 



ROSEOLA. 121 

This rash is generally deemed, by inoculators, a 
certain prognostic of a small and favourable eruption 
of the smallpox ; but such does not always follow. * 
It is not easily repelled by cold air or cold drinks, 
against which the old inpculators enforced many pro- 
hibitions and cautions. 

These roseolous eflBiorescences, antecedent to the 
eruption of smallpox, were observed by the first 
writers on the disease ; and, both by them and sub- 
sequent authors, were deemed measles, which were 
said to be converted into smallpox. 

Species 6. Roseola vaccina ; Vaccine Rose- 
Rash. 

An eflBiorescence (Plate XX VII. fig. 3. of Bate- 
man; pi. 10. of Thomson's Atlas,) which appears 
generally in a congeries of dots and small patches, but 
sometimes diffuse, like the variolous Roseola, takes 
place in some children on the ninth and tenth day of 
vaccination, at the place of inoculation, and at the 
same time with the areola that is formed round the 
vesicle ; and thence it spreads irregularly over the 
whole surface of the body. But this does not occur 
nearly so often as after variolous inoculation. It is 
usually attended with, a very quick pulse, white 
tongue, and great restlessness. 



* Dr. R. Walker, indeed, speaking of the natural smallpox, says, ** In 
every bad kind of smallpox, the eruption is ushered in by a scarlet rash, 
which appears -first upon the face, neck, and breast, and sometimes 
spreads over the whole body ; it is observed some part of the second 
clay, and within twelve hours, sooner or later, the pimples emerge from 
these inflamed parts of the skin.." See his " Inquiry into the Smallpox, 
Medical and Political," chap. viii. Edin. 1790. — But Dr. Willan re- 
marks, that it is an universal efflorescence, of a dark red colour, with 
violent fever, that indicates a confluent eruption and a fatal disease. See 
also Morton de Variol. et Morb. p. 186. — Rayer, speaking of the usual 
prognostic of a mild disease, when Variola is preceded by Roseola, re- 
marks, ^^ Mes observations, du moins, me conduisent k penser pr^cis^- 
ment le contraire.'' Traits Thiorique et Pratique des Maladies de la 
Peau, torn. i. p. 47. 



122 EXANTHEMATA : 

Species 7- Roseola rmliariSy Miliary Rose- 
Rash. 

This rash often accompanies an eruption of miliaiy 
vesicles, with fever. 

In simple continued fevers *, whether the bilious 
fever of summer, in this climate, or the typhus or 
contagious fever, an efflorescence resembling * the 
Roseola {estiva occasionally takes place, pf a hue, 
however, more approaching to that of measles. I 
have seen this efflorescence in three cases of mild 
fever, in the House of Recovery,- at a late period of 
its course ; in two of which it was slight, and remained 
from two to three days. In the third case, it appeared 
on the ninth day of fever, in a young woman, after a 
sound sleep and a moderate perspiration, in patches of 
a bright rose-pink colour, of an irregular oval form, 
somewhat elevated, and smooth on the surface, afiect- 
ing the arms and breast, but most copious on the 
inside of the humerus. It was unaccompanied by 
any itching or other uneasy sensation. All the febrile 
symptoms were alleviated on that day, and she did 
not keep her bed afterwards. On the following day 
the efflorescence had extended, the patches having 
become larger and confluent ; but the colour, espe- 
cially in the areas of the patches, had declined, and 
acquired a purplish hue in some parts, while the 
margins continued red and slightly elevated. The 
whole colour on the third day had a livid tendency ; 
and on the fourth there were scarcely any perceptible 
remains of it, or of the febrile symptoms.^ 

A roseolous efflorescence is sometimes connected 
with attacks of gout, and of the febrile rheumatism. 
I lately attended a gentleman of gouty habit, in 
whom a Roseola, accompanied with considerable fever, 
and with extreme languor and depression of spirits, 
total loss of appetite, and torpid bowels, subsisted a 

* These roseolous spots are also sometimes connected with inter- 
mittents. See Pechlin, Obs. Phys. Med. lib. ii. 18* 



PUKFURA. 128 

week upon the lower extremities, and also upon the 
fordiead and vertex of the scalp. On the seventh 
day, the latter terminated by desquamation, and at 
midnight his knuckles and right foot were attacked 
with arthritic inflammation. 

Books which may he coruulied on Roseola, 

Baumann. Diss, de Roseolis saltantibus, Altd. 1700. 

BiETT, (Cazenave and Schedel) Abr^^ Pratique des Maladies de la 
Peau, 8V0, Paris, 1828. 

Edinburgh Med. and Surg. Journ. vol. yiii. p. 245. 

Heim, Journ. de Med. de Huffland, 1812. 
^ pRLOYa Programma de Rubeolarum et^orbil. discrimine, 4to. 1785. 

Plumbib, On Diseases of the Skin, 2d. edit. 1827. 

Rayer, Trait^ Th^rique et Pratique des Maladies de la Peau, 8to. 
Paris. 

Seileb, Diss, de Morbilles inter et Rubeolas differentia veH^ 4to, 1805. 

WiLLAN, Description and Treatment of Cutaneous Diseases, 4to. 
London. 



Genus V. PURPURA. 

Syn. TIop(p6poL ( G,) : Scorbutus, Petechiae sine febre 
{Auct var.) : Purpura (^Sduv. T^og. Sag. Riverus 
iVillan) : Haemorrhoea petechialis (^Adair) : Profu- 
sio subcutanea ( Young) : HoDraa-celinose (Pterquin) : 
Porphyra ( Good) : (Rayer) : Scurvy, Purple 
Spots. 

Def. An eruption of small, distinct, purple 

SPECKS AND PATCHES, ATTENDED WITH LANGUOR, 
GENERAL DEBILITY, AND PAINS IN THE LIMBS. 

The specks and patches, mentioned in this defini- 
tion, are petechi4B and ecchymomatay or vibiceSy occa- 
sioned, not, as in the preceding exanthemata, by an 
increased determination of blood into the cutaneous 
vessels, but by an extravasation, from the extremities 
of these vessels, under the cuticle. * Purpura t, in 

* Rayer objects, with justice, to Purpura being placed among the 
Exanthemata. — Traits Th^orique et Pratique des Maladies de la Peau^ 
Introduction, p. xii. T. 

f The term Purpura was applied to petechial spots only by Riverius. 
Diemerbroeck, Sauvages, Cusson, and some others. But it has been 
employed by different writers in so many other acceptations, that some 
ambiguity would, perhaps, have been avoided by discarding it altogether ; 



124 EXANTHEMATA : 

this arrangement, is therefore intended to include 
every variety of petechial eruption, and of sponta- 
neous ecchymosis ; not only the chronic form of it, 
which is unaccompanied by fever, and which has re- 
ceived various denominations (such as Haemorrhoea 
petechialis, Petechiae sine febre*, land-scurvy, &c.), 
but also that which accompanies typhoid and other 
malignant fevers. 

The chronic Purpura appears under three or four 
varieties of form ; the first and second of which, 
however, seem to differ chiefly in the degree of seve- 
rity of their symptoms. 

There are five species of Purpura : — 

1. P. nmplex. 4. P. senilis. 

2. P. hcemorrhagica. 5. P. contagiosa. 

3. P. urticans. 

Species 1. Purpura simplex^ Petechial Scurvy. 

Syn. Petechiae sine febre (^Aibct. var.) : Phae- 

nigmus petechialis (Sauv.) : Profusio subcutanea 

for some authors have used it as an appellation for measles, others for 
scarlet fever, for Miliaria, Strophulus, Lichen, Nettle-rash, and the pe- 
techise of malignant fevers. The title of Hcsmorrheea petechicUis, which 
was given to the chronic form of the eruption by Dr. Adair, in his 
inaugural thesis in 1789, and which I adopted in my own dissertation 
upon the same subject in 1801, would perhaps have been more unex- 
ceptionable. But, m deference to Dr. Willan, I retain this term. 

* This appellation is generally ascribed to Dr. Graaf (see his Diss. 
Inaug.D<? Petech,sine FebrCjGott.ms); but it was employed half a 
century before his time by Rombergius (see Ephem. Nat. Cur. decad. 
iii. ann. 9 & 10, obs. 108 ; and Acta Phys. Med. Acad. Nat. Curios, vol. 
ix.obs. 21. p, 95). The term was adopted by many writers as expres- 
sive of the most remarkable feature of the disease ; fc^ petechias had 
been generally deemed symptomatic of fevers only. Whence also J. A. 
Raymann, who has given a good history of the disease, called the spots 
"petechiae mendacesy* in contradistinction from the febrile petechiae, 
which he denominated "sincer<B*' (See the Acta Phys. Med. for 1751, 
just quoted, p. 87. — See also Duncan's Med. Cases and Obs. p. 90; 
Med. Comment, vol. xv. and xx. and Annals of Med. vol. ii. — Dr.Ferris's 
case, Med. Facts and Obs. vol. ii. 1791. — Dr. Zetterstroem*s Diss. Inaug. 
Upsal, 1797). Amatus Lusitanus had also marked the absence of fever, 
about the year 1550, when he described the disease under the similar 
title of *' Morbus pulicaris sinefbre*^ (Curat. Med. cent. iii. obs. 70) ; as 
had Cusson, who called it " Purpura apyretay — Pezoldus (obs. 6) and 
Zwingerus (Paedoiatreia Pract. p. 622) treated of it under the appellation 
of ** maculae nigrae nnefehre^^ 



PURPURA. 125 

(Young) : Porphyra simplex, var^ piUicosa ( Good) : 
Blaueflecken Rothe punkt ( Ger.): Pourpre P^t^chies 
sans fi^vre (F.) : Petechial Scvrvy. 
• In this species ( Plate XXVIII. fig. 1 . of Bateman ; 
PI. 12. of Thomson's Atlas,) there is an appear- 
ance of petechise, without much disorder of the con- 
stitution, except languor, and loss of the muscular 
strength, with a pale or sallow complexion, and often 
with pain in the limbs. " The tongue is covered 
with a yellow fur, the bowels are constipated, the 
aj)petite is diminished, and not unfrequently there is 
nausea and head-ach.*' The petechia are most nu- 
merous on the breast, and on the inside of the arms 
and legs, and are of various sizes, from the most 
minute point to that of a fleabite, and commonly cir- 
cular. They may be distinguished from recent flea- 
bites, partly by their more livid or purple colour, and 
partly because, in the latter, there is a distinct cen- 
tral puncture (PL 12. of Thomson's Atlas), the 
redness around which disappears on pressure : whereas 
the spots in Purpura simplex bear the strongest 
pressure without any change of hue. There is no 
itching, nor other sensation attending the petechiae. 

" The eruption varies in duration from two to 
three and four weeks. The spots are at first of a 
lively red, and this is more remarkable the- younger 
the patient : after a few days the vividness is obscured, 
they gradually become yellow, and gradually dis- 
appear. The eruption appears in the most opposite 
states of ^e habit, occasionally shewing itself in 
strong and plethoric individuals ; but most commonly 
it occurs in women, and in delicate children, with 
white, thin skins. It is seen more frequently in 
summer than in any other season.*' 

" The treatment of this species of Purpura depends 
on the habit of the individual affected. In the ple- 
thoric and robust, bleeding must be resorted to, with 
cold bathing, and a spare diet : on the other hand, in 



126 EXANTHEMATA : 

weak and broken-down systems, the opposite plan 
should be adopted : namely, preparations of iron, 
bitters, and a generous diet* M. Biett recommends 
an alcoholic vapour bath, at a temperature of 120® 
Fahrenheit.'* 

Species 2. Purpura HcBmorrhagica* ^ Land 
Scurvy* 

5y;^. 'IXeo^ aHiMJOLTirr^g (Uippoc.) : Haemorrhagia 
universalis ( Wolf.) : Stomacace universalis (Sauv.) : 
Porphyra haemorrhagica ( Oood) : Morbus Maculosus 
haBmorrhagicus(^iFJ?r/Ao/^): Il6macelinose(jRayer): 
Pourpre, H^morrhagie p6t^hiale {F.) i Lcmd 
Scurvy. 

This>species (Plate XXVIII. fig. 2. of Bateman ; 
PI. 12. of Thomson's Atlas,) is considerably more 
severe than the fonner ; the p/techi^ are often of a 
larger size, and are interspersed with vibices and ecchy- 
moses, or livid stripes and patches, resembling the 
marks left by the strokes of a whip or by violent 
bruises. They commonly appear first on the legs, 
and, at uncertain periods afterwards, on the thighs, 
arms, and trunk of the body ; the hands being more 
rarely spotted with them, and the face generally free. 
They are usually of a bright red colour when they 
first appear, but soon become purple or livid ; and, 
when about to disappear, they change to a brown or 
yellowish hue : so that, as new eruptions arise, and 
the absorption of the old ones slowly proceeds, this 
variety of colour is commonly seen in the diflferent 
spots at the same time. The cuticle over' them ap- 
pears smooth and shining^ but is not sensibly elevated : 

* This term is not very correctly employed in this place; since it 
implies that these more extensive eruptions, or rather extravasations 
of Purpura, are always accompanied by hsemorrhages ; which is not 
the fact. 

By a sort of solecism, Sauvages has described this form of the disease 
under the title of Stomacace universalis, class ix. gen. 7. The Purpura 
simplex he terms Phoenigmus petechialis, class x. gen. 32. 



PURPURA. 127 

in a few cases, however, the cuticle has been seen 
raised into a sort of vesicles, containing black blood. * 
This more frequently happens in the spots which 
appear on the tongue, gums, palate, and inside of the 
cheeks and lips, where the cuticle is extremely thin, 
and breaks from the slightest force, discharging the 
effiised blood. The gentlest pressure on the skin, 
even such as is applied in feeling the pulse, will often 
produce a purple blotch, like that which is left after 
a severe bruise* ■ 

The same state of the habit which gives rise to 
these effiisions under the cuticle t, produces likewise 
copious discharges of blood, especially from the in^ 
temal parts, which are defended by more delicate 
coverings. These hemorrhages are often very pro- 
fuse, and not easily restrained, and therefore some- 
times prove suddenly fatal. But in other cases they 
are lei copious ; Jmetnaes returning every day a^ 
stated periods, and sometimes less frequently and at 
irregular intervals; and sometimes there is a slow 
and almost incessant oozing of blood. The bleeding 
occurs from the gums, nostrils, throat, inside of the 
cheeks, tongue, and lips, and sometimes from the 
lining membrane of the eyelids, the urethra, and the 
external ear ; and also from the internal cavities of 
the lungs, stomach, bowels, uterus, kidneys, and 
bladder. There is the utmost variety, however, in 
different instances, as to the period of the. disease in 
which the haemorrhages commence and cease, and as 
to the proportion which they bear to the cutaneous 
efflorescence. 

This singular disease is often preceded for some 

* See Reil, Memorab. Clinic, vol.l. — Comment, in Reb. Med. &c. 
gestis, Leipsic.vol.vi. — Dr. Willan's Reports on^ the Dis. of London, 
p. 167. — Wolff, in Act. Nat. Cur. (before quoted), vol. vii. obs. 131. and 
Ro&ert, in Act. Reg. See. Med. Hauniensis, vol. i. p. 185. 

+ It has been a question whether the vessels are dilated or ruptured : 
•—It is certain that in haemorrhage from the gums, and from some in- 
ternal organs, as, for instance, the bladder, the blood comes from the 
whole sunace, not from any organic lesion in one or more points. T. 



128 EXANTHEltfAtA : 

weeks by great lassitude, faintness, and pains in the 
limbs, which render the patients incapable of any 
exertion; but, not unfrequently, it appears suddenly, 
in the midst of apparent good health.* It is always 
accompanied with extreme debility and depression 
of spirits: the pulse is commonly small and feeble, 
and sometimes hard and quickened ; and shiverings, 
succeeded by heat, flushing, perspiration, and other 
sjnnptoms of slight febrile irritation, recurring like 
the paroxysms of hectic, occasionally attend. In 
some patients, deep-seated pains have been felt about 
the praecordia, and in the chest, loins, or abdomen ; 
and in others a considerable cough has accompanied 
the compliant, or a tumour and tension of the epi- 
gastrium and hypochondria, with tenderness on 
pressure, and ^ constipated or in-egular state of 
bowels. But in many cases no febrile appearances 
have been noticed ; and the functions of the intes- 
tines aTe often natural. In a few instances frequent 
syncope iias occurred. When the disease has con- 
tinued for some time, the patient becomes sallow, or 
of a dirty complexion ; " the conjunctiva is tinged 
with bile; there is often a foetid odour about the 
body,*' and he is much emaciated ; and some degree 
of oedema appears in the lower extremities, which 
afterwards extends to other parts. 

The disease is extremely uncertain in its duration : 
in some instances it has terminated in a few days ; 
while in others it has continued not only for many 
months, but even for years. Dr. Duncan related a 
case to me, when I was preparing my thesis on this 

* See a case related by Dolaeus, in the Ephemer. Nat. Cur. dec. ii. 
ann.iv. obs. 118, which occurred in a boy, *'cujus omne corpus, absque 
dolore, febre, aut lassitudine praegressa, subito un4 cum facie, labiis, et 
lingua, ubi mane absurgeret, numerosissimis maculis lividis et nigerriniis 
obsitum fuit," &c. — Similar cases are described by Zwingerus, in the Act. 
Nat. Cur. vol. ii. obs. 79 : by WerlhoffJ in the Commerc. Liter, Noriinberg. 
ann. 1735, hebd. 7&2: and Biett, in the Abr^g^ Pratique des Mala- 
dies de la Peau, of Cazenave and Schedel, p. 4&5. In all these in- 
stances, the eruption was discovered on rising in the morning, having 
taken place during the night. 



PURPURA. 129 

lyubject, which occurred in a boy, who was employed 
for several years by the players at golf to carry their 
sticks, and whose skin was constantly covered with 
petechiae, and exhibited vibices and purple blotches 
wherever he received the slightest blow. Yet he 
was, in other respects, in good health. At length a 
profuse haemorrhage took place from his lungs, which 
occasioned his death. When the * disease terminates 
fatally, it is commonly from the copious discharge of 
blood, either suddenly effused from some important 
organ, or more slowly from several parts at the same 
time. A young medical friend of mine was instan- 
taneously destroyed by pulmonary haemorrhage, while 
affected with Purpura, in his convalescence from a 
fever, after he had gone into Lincolnshire to ex- 
pedite his recovery * : and I have seen thi-ee in- 
stances of the latter mode of termination ; in all of 
which there was a constant oozing of blood from the 
mouth and nostrils, and at the same time consider- 
able discharges of it from the bowels, and from the 
lungs by coughing; and in one it was likewise ejected 
from the stomach by vomiting, for three or four 
days previous to death, t On the other hand, I 
lately saw a case of Purpura simplex, in which the 
petechiae were confined to the legs, in a feeble 
woman, about forty years of age, who was suddenly 
relieved from the eruption and its attendant debility, 
after a severe catamenial flooding. X 

The causes of this disease are by no means clearly 
ascertained, nor its pathology well understood. It 

* Several instances of' sudden death, in this dmease, from the occur- 
rence of profuse haemorrhage, are mentioned by respectable authors. 
See Lister, Exercit. de Scorbuto, p. 96, &c. — Greg. Horst. lib. v. obs. 17. 
Two examples (one from pulmonary, and the other from uterine haemor- 
rhage) were communicated to me by my friend Mr. James Rumsey, of 
Amersham, one of which occurred in his own family. 

•(• Two of these cases were described in my Report of the Diseases 
treated at the Dispensary, Carey Street, in the spring of 1810; See 
Edin. Med. and Surg. Journal, vol. vi. p. 374. 

J See my Report for 18 lO, ibid, p. 124. — See also a case related by 
WolflJ in the Act. Acad. Natur. Curios, vol.iii. obs. 79. 

K 



130 EXANTHEMATA : 

occurs at every period of life, and in both sexes ; 
but most frequently in women, and in boys before 
the age of puberty, particularly in those who are of 
a delicate habit, who live in close and crowded situ- 
ations, and on poor diet, or are employed in seden- 
tary occupations, and subject to grief and anxiety 
of mind, fatigue and watching.* It has likewise 
attacked those who were left in a state of debility by 
previous acute or chronic diseases. In one of the 
fatal instances above mentioned, it came on during a 
severe salivation, which had been accidentally in- 
duced by a few grains of Mercury, given, as I was 
informed, in combination with opium, for the cure 
of rheumatism. It has sometimes occurred as a 
sequela of smallpox, and of measles ; and sometimes 
in the third or fourth week of puerperal confine- 
ment, t The disease, however, appears occasionally, 
and in its severest and fatal form, where none of 
these circumstances existed : for instance, in young 
persons living in the country, and previously enjoy- 
ing good health, with all the necessaries and com- 
forts of life. " There seems, indeed, in some 
persons to be a peculiar predisposition to the disease ; 
depending upon defect of tone in the capillary sys- 
tem. Thence we can easily conceive the reason why 
it may appear in plethoric persons.'* 

Tins circumstance tends greatly to obscure the 
pathology of the disease. For it not only renders 
the operation of these alleged causes extremely 
questionable, but it seems to establish an essential 
difference in the origin and nature of the disorder, 
from that of scwrvyX^ to which the majority of 

* See Dr. Willan's Reports on Dis. in London, p. 90. 

f See Joerdens, in Act. Acad. N. Cur. vol. vii. obs. 1 10. — This is the 
Purpura Symptomatica of Sauvages, class iii. gen. vi. spec. 3. 

X I mean the true scurvy, or rather sea scurvy, formerly prevalent 
among seamen in long voyages, and among people in other situations, 
when living upon putrid, salted, dried, or otherwise indigestible food, 
yielding imperfect nutriment. See Lind, Trotter, &c. on the Scurvy, 
and Vander Mye, de Morbis Bredanis. The symptoms are concisely de- 
tailed by Boerhaave in his 1151st aphorism. 



PURPURA. 131 

writers have contented themselves with referring it. 
In scurvy, the tenderness of the superficial vessels 
appears to originate from deficiency of nutriment ; 
and the disease is removed by resorting to whole- 
some and nutritious food, especially to fresh vege- 
tables and to acids : while in many cases of Purpura, 
the same 'diet and medicine have been taken abun- 
dantly, without the smallest alleviation of the com- 
plaint. In the instance of the boy mentioned by 
Dr. Duncan, the remedies and regimen which would 
have infallibly cured the * scorbutus, were liberally 
administered, without affording any relief; and in 
other cases, above alluded to, where a residence in 
the country, and the circumstances of the patients, 
necessarily placed them above all privation in these 
respects,^ the disease appeared in its severest degree. 

On the other hand, the rapidity of the attack, the 
acuteness of the pains in the internal cavities, the 
actual inflammatory symptoms that sometimes su- 
pervene, the occasional removal of the disease by 
spontaneous haemorrhage, the frequent relief derived 
from artificial discharges of blood*, and from purg- 
ing, all tend to excite a suspicion that some local 
visceral congestion or obstruction is the cause of the 
symptoms in different instances. This point can only 
be ascertained by a careful examination of the viscera, 
after death, in persons who have died with these 
symptoms. The ancient physicians directly referred 
some of them, especially the haemorrhages from the 
nose, gums, and other parts, to morbid enlargement 
of the spleen, t In one case, in which an opportunity 
of dissection was afforded at the Public Dispensary, 

* See two cases of Purpura, related by an able and distinguished 
physician. Dr. Parry of Bath, which were speedily cured by two bleed- 
ings from the arm. In both these cases, which occurred in a lady and an 
officer, the latter accustomed to free living, some degree of feverishness 
accompanied the symptoms of Purpura ; and the blood drawn exhibited 
a tenacious, contracted coagulum, covered with a thick coat of lymph. 
See Edin. Med. and Surg. Journal, vol. v. p. 7, for Jan. 1809. 

f See Celsus de Med. lib. ii. cap. 7. 

K 2 



132 EXANTHEMATA : 

and which occurred in a boy under the inspection of 

my friend and colleague Dr. Laird, the spleen, which 

[ had been distinctly felt during life protruding itself 

! downwards and forwards to near the spine of the ilium, 

was found enormously large. In another instance, 

which occurred under my own care, in a boy thirteen 

, years old, the abdominal viscera were found to be 

sound ; but a large morbid growth, consisting of a 

\ fleshy tumour, with a hard cartilagii^us nucleus, 

; weighing about half a pound, was found in the situ- 

i ation of the thymus gland, ^rmly attached to the 

sternum, clavicle, pericardium, and surrounding 

Earts. * Cases not unfrequently occur, in which 
epatic obstruction is connected with Purpura. A 
man, habituated to spirit-drinking, died in about a 
fortnight from the commencement of an eruption of 
petechiaB, which was soon followed by profuse and 
unceasing haemorrhage from the mouth and nostrils ; 
but I had no opportunity of examining the body. 
The jaundiced hue of the skin and eyes, however, 
with the pain in his side, diy cough, and quick wiry 
pulse, left no doubt of the existence of considerable 
hepatic congestion. And, lastly, I attended a young 
woman, about the same time, labouring under the 
third speciiBS of the disease (P. urticans)^ with a sal- 
low complexion, a considerable pain in the abdomen, 
and constipation, without fever. While she was 
taking acids and purgatives, which had scarcely acted 
upon the bowels, the pain on a sudden became ex- 
tremely acute, the pulse frequent and hard, and the 
skin hot, with other symptoms denoting inflammation 
in the bowels, which were immediately relieved by a 
copious bleeding from the arm, followed by purga- 
tives ; after which the sallowness of the skin was gone, 
and the pui-ple spots soon disappeared. 

* This boy, though delicate, had enjoyed a moderate share of health, 
until ten or twelve days previous to his death, notwithstanding the 
diminution of the cavity of the thorax, occasioned by this tumour. See 
the Edin. Journal, vol. vi. just referred to. 



PURPURA. 138 

" Purpura hcemorrhagica may be confounded with 
some secondary syphilitic eruptions, which are accom- 
panied with large ecchymosed spots ; but the other 
symptoms of these eruptions and their progress point 
out the distinction/* ** This species of Purpura is 
always a threatening disease, but it is seldom fatal if 
properly treated.'* 

These facts are not sufficient to a£Pord any general 
infCTence, respecting the nature or requisite treat- 
ment of Purpura haemorrhagica ; on the contrary, 
they tend to prove, that the general conclusions 
which are usually deduced, and the simple indica- 
tions* which are commonly laid down, have been 
too hastily adopted, and that no rule of practice can 
be universally applicable in all cases of the disease. 

In the slighter degrees of the Purpura, occurring 
in children who are ill fed and nursed, and who re- 
side in close places, where they are little exercised, 
or in women shut up in similar situations, and de- 
bilitated by want of proper food, and by fatigue, 
watching and anxiety, the use of tonics, with the 
mineral acids and wine, will doubtless be adequate to 
the cure of the disease, especially where exercise in 
the open air can be employed at the same time, t 
But when it occurs in adults, especially in those 
already enjoying the benefits of exercise in the air of 
the country, and who have suffered no privation in 
respect to diet ; or when it appears in persons pre- 
viously stout or even plethoric j when it is accom- 

* I am sorry to be under the necessity of differing from my respected 
friend and preceptor, on this subject ; who would, perhaps, subsequently, 
have deemed the following statement, respecting the method of cure m 
the hsemorrhagie Purpura, too general. ** The mode of treatment for 
this disease is simple, and may be comprised in a very few words« It is 
proper to recommend a generous diet, the use of wine, Peruvian Bark, 
and acids, along with moderate exercise in the open air, and whatever 
may tend to produce cheerfulness and serenity of mind.** See Reports 
on the Dis. of London, p. 95, for May 1797. 

f In enumerating the remedies, mentioned in the preceding note, 
Dr. Willan lays the most particular stress upon this point, and adds, that 
" without air, exercise, and an easy state of mind, the effect of medicines 
is very uncertain," On Cutan. Dis. p. 461. 

K 3 



134 EXANTHEMATA : 

panied with a white and loaded tongue, a quick and 
somewhat sharp, though small, pulse, occasional chills 
and heats, and other symptoms of feverishness, how- 
ever moderate; and if at the same time there are 
fixed internal pains, a dry cough, and an irregular 
state of the bowels ; — symptoms which may be pre- 
sumed to indicate the existence of some local con- 
gestion; — then the administration of tonic medicines, 
particularly of wine. Cinchona, and other warmer 
tonics, will be found inefficacious, if not decidedly 
injurious. In such cases, free and repeated evacu- 
ations of the bowels, by medicines containing some 
portion of the Submuriate of Mercury, will be found 
most beneficial. The continuance or repetition of 
these evacuants must, of course, be regulated by 
their effects on the symptoms of the complaint, or on 
the general constitution, and by the appearance of 
the excretions from the intestines. * " Indeed, the 
cases in which tonics are admissible in the commence- 
ment of the disease are rare ; even when symptoms of 
debility are obvious, purgatives combined with Ca- 
lomel are the means chiefly to be depended upon. In 
making this remark, however, it is essentially to dis- 
tinguish between that debility which is dependent on 
poor, crude, indigestible diet, and a residence in 
confined, bad air, and that which is indirect and the 
result of febrile congestions.'* If the pains are severe 
and fixed, and if the marks of febrile irritation are 

* While these sheets were in the press, I received a valuable commu- 
nication from ray friend Dr. Harty, of Dublin, detailing the result of his 
experience in this obscure disease ; and it afforded me great satisfaction 
to learn, that, after having witnessed the death ef a patient, who waa 
treated in the ordinary way, with nutritive diet and tonic medicines, he 
has been uniformly successful in the management of upwards of a dozen 
cases, since he relied solely upon the liberal administration of purgatives. 
He prescribed Calomel with Jalap, in active doses, daily, which appeared 
to be equally beneficial in the hsemorrhagic, as in the simple Purpura ; 
the haemorrhage ceased, and the purple extravasations disappeared, after 
a few doses had been taken. 

. This document being, in my estimation, too valuable to be lost, I 
transmitted it to Edinburgh, and it was published in the Medical and 
Surgical Journal, for April 1813. 



PURPURA. 135 

considerable, and the spontaneous haemorrhage not 
profuse, local or general blood-lettmg may, doubtless^ 
be employed with great benefit, especially in robust 
adults ; ** but, even in such habits, much caution is 
requisite not to carry it too far/' When the disease 
arises from congestion, and languor of the absorbents, 
blood-letting may be useful by taking off the load 
which obstructs the action both of the blood-vessels 
and the absorbents. It is a well-known fact, that 
blood-letting promotes absorption ; and if Purpura be 
blood effiised into the substance of the cutis, the 
bleeding, both by promoting absorption and relieving 
a congestion which implicates the venous capillaries, 
must be useful in Purpura. But it must be employed 
with cautious reference to the state of strength of the 
patient, separated from the temporary debUity occa- 
sioned by the disease. 

*' In the majority of cases, in which blood-letting 
has been requisite, the blood has exhibited the 
bu% coat: in general there is little or no serum 
separated* 

" When no congestion exists, and the disease ap- 
pears to be referrible to want of tone in the extreme 
vessels, Dr. Whitlock Nicol has proposed the use of 
Oil of Turpentine, and has detailed two cases in 
which it proved successful.* It has also been sue* 
cessfuUy given by Dr. Magee of Dublin, in doses of 
f 3ss mixed with f ^ss of Castor Oil, and some Cin*- 
namon or Peppermint Water.^* 

When the urgency of the haemorrhagic tendency 
has been diminished by these means, the constitution 
rallies, though not rapidly, with the assistance of the 
mineral acids, " especially the nitric acid,** and the 
Decoction of Cinchona, or of Cascarilla ; or with the 
aid of some preparation of Iron, together with mo- 
derate exercise and nutritious diet. 

* London Med. Repository, July 1811. 

K 4 



1 36 EXANTHEMATA : 

Species 3. Purpura urticans. Nettle Rash 
Scurvy, 

Syn. Porphyra simplex ; S. urticans ( Oood). 

This species (Plate XXIX. of Bateman ; PI. 12. 
of Thomson's Atlas,) is distinguished by this pe- 
culiarity, that it commences in the form of rounded 
and reddish elevations of the cuticle, resembling 
wheals, but which are not accompanied, like the 
wheals of Urticaria, by any sensation of tingling or 
itching. These little tumours gradually dilate, but, 
within one or two days, they subside to the level of 
the surrounding cuticle, and at the same thne their 
hue becomes darker, and at length livid. As these 
spots are not permanent, but appear in succession in 
:£flFer>ent places, they are commonly seen of different 
liues ; the fresh and elevated ones being of a brighter 
red, while the level spots exhibit different degrees of 
lividity, and become brown as they disappear. They 
are most common on the legs, where they are fre- 
quently mixed with petechiae; but they sometimes 
appear also on the arms, thighs, breast, &c. 

The duration of the complaint is various, from 
three to five weeks. It usually occurs in summer 
and autumn ; and attacks those who are liable to 
iatigue, and live on poor diet : or, on the xjontrary, 
delicate young women, who live luxuriously, and take 
little exercise. Some oedema of the extremities 
usually accompanies it, and it is occasionally pre- 
ceded by a stiffness and weight of the limbs. 

" Bleeding and purging are more decidely useful 
in this than in the preceding species ; but in general 
the same rules of treatment are applicable to ail 
of them.** 

Species 4. Purpura senilis. Scurvy of^ Old 
Age. 

I give this appellation to a variety of the complaint 
(Plate XXX. of Bateman ; PI. 12. of Thomson's 



PURPURA. 1 37 

Atlas,) of which I have seen a few cases, occurring 
only in elderly women. It appears principally along 
the outside of the fore-arm, in successive dark purple 
blotches, of an irregular form and various magnitude. 
Each of these continues from a week to ten or twelve 
days, when the extravasated blood is absorbed. A 
constant series of these ecchymoses had appeared in 
one case during ten years, and in others for a shorter 
period ; but in all, the skin of the arm was left of a 
brown colour. The health did not appear to suffer ; 
nor did purgatives, blood-letting (which was tried in 
one case, in consequence of the extraordinary hard- 
ness of the puke), tonics, or any other expedient, 
appear to exert any influence over the eruption. 

Species 5. Purpura contagiosa. Contagious 
Scurvy. 

S^n. Purpura maligna (5'awv.). 

This species is introduced for the purpose of 
noticing the eruption of petechiae, which occasionally 
accompanies typhoid fevers, where they occur in close 
situations : but, as these are merely symptomatic, it 
would be surperfluous to dilate upon the subject here. 
1 may observe, in addition to the facts which I 
formerly communicated to Dr ^ Willan, respecting the 
occurrence of petechiae in patients admitted into the 
Fever-House*, that such an efflorescence is very 
rarely seen in that establishment. 

Works which may be consulted on Purpura , 

Ada^b. Diss, inaug. de Haemorrhaea Petechial!, 1781. 
BATEBiAli* Th. Dissert, inaug. Hsemorrheea Petechiali, Edin. 8vo. 
BiETT, Abr^^ Pratique des Mai. de la Peati, 8vo. 1828. 
— Blackall (J.) on Dropsies, chap. viii. 3d edit. 1800. 1810. 
Bkee (R.), Med. aod Phys. Journ., Lond. 1809. 
• Co»p E (J. S.), Cases, Edin. Journ., vol. xvii. 1821. 
IJarwall (J,), Edin, Journ., vol. xxiii. 1825. 
Duncan (A.), Jun., Edin. Journ., vol. xviii. 1822* 
EiMNBURGH Med. and Surg. Journal. 



*. See hb Treatise on Cutan. Dis., p. 468 and 469, note. 



138 EXANTHEMATA : 

EvsEia Db. de Febre purpuratS^ 1702. 

Fairbairn (P.), Edin. Med. Chir. Trans, vol. ii. 1826. 

Gairdner (E.), Edin. Med. Chir. Trans., vol.i. 1821. 

GoLDiE, Cyclopsdia of Pract. Med., toI. iii. 

HaRty (E.), on Purgatives in Purpura (Edin. Journ. vol. ix.), 1815. 
< ^OHNSTQ N (G.), Cases, Edin. Journ., vol. xviii. 1822. 

London Med. Repository. 

Massib (Steph.) de Purpurd, 8vo. 1762. 

Mentzl»r . ae Venaesect. in Purpura abusu, &c. 1744. 

NicH0L(Wh.), Edin. Journ., vol. xviii. 1822. 

Neucramtz. de Purpura liber singularis, 1660. 

Parry (Ch.), Edin. Med. and Surg. Journ., vol. v. 1 809. 

Plumbe on Diseases of the Skin, 2d edit. 1827. 

Rayer, Traits des Maladies de la Peau, 1827. 

Stoker's Pathological Observations, Parti. Dub. 1825. 

Tattersal (W.) Cases of Petechia; sine febre, Edin. Med. Com., 
▼ol. XX. 8vo. 1795. 

Yeats (G. D.), Med. Transactions, vol. v. 1815. 



Genus VI. ERYTHEMA, Inflammatory Blush. 

Syn. E^udrifjiM (O.): Erysipelas ( Celsics, Galen) : 
Hieropyr (P^og.): Erythema (Sauv.): Phlogosis 
erythema ( Cullen): Caumor erythematicum ( Young): 
Dartre erythemoide, Herpes erythemo'ides (^Alibert) : 
Efflorescence cutanee, {F.) : Roadvouk (Dutch) : 
Rodskalla (5'2^erf.) : Risculdamenlo (/i5a/.): Fuego 
(Spanish) : die Hautrothe (Germ.): Injlammatory 
Blush. 

Def. A RED SMOOTH FULNESS OF THE INTEGU- 
MENTS : ACCOMPANIED WITH BURNING PAIN ; TER- 
MINATING GENERALLY IN SCALES ; OCCASIONALLY, 
BUT RARELY, IN GANGRENE I NOT CONTAGIOUS. 

Erythema, like Roseola, is commonly sympto- 
matic, and occurs with much variety in its form ; 
yet sometimes, like the same efflorescence, it is the 
most prominent symptom, and is, therefore, in like 
manner, liable to be mistaken for the idiopathic 
eruptive fevers. This term is often erroneously ap- 

Elied to eruptions, which, together with redness, ex- 
ibit distinct papular and vesicular elevations * \ as, 

* The word spvOrtjia^ as used every where by Hippocrates, signifies 
simply redness; and is therefore correctly appropriatea to this affection^ 
which differs from Erysipelas, inasmuch as it is a mere rash or efflores- 



ERYTHEMA. 139 

for example, to the Eczema produced by the irritation 
of mercury. 

" Every part of the body may be attacked by 
ErjTthema ; and, when it commences in one part,' it 
is liable to extend to others. It runs its course 
generdly in six or eight days ; as^ in some of the 
varieties, namely, Ttodomm and tubercutatv/nij it is 
occasionally accompanied with intermittent fever. 
This eruption is often locals and referrible to local 
irritations when the skin is delicate ; when general^ to 
gastric and intestinal irritation : it is more frequently 
observed in women than in men, and in delicate 
children. In no instance is it a fatal disease ; for in 
all cases in which death has occurred when erythema 
has existed, the fatality is to be referred to the febrile 
affection, to which the erythematic eruption is merely 
secondary.'* 

Dr. Willan has described six species of Erythema, 
which include all the ordinary forms of the efflor- 
escence ; but there are, properly speaking, seven 
species : 

1. Yi.fagdx. 5. E. tuberculatum. 

2. E. l<Bve. 6. E. nodosum. 

3. E. marginatum. 7- E. intertrigo. 

4. E. papulatum. 



cence, and is not accompanied by any swelling, yesication, or regular 
fever. — Modem authors have not agreed in their distinctions between 
these two terms^ Dr. CuUen applies the word Erythema to a slight 
affection of the skin, appearing without fever, or attended by a secondary 
fever of irritation ; and Erysjpeku^ to an affection of the skin, when it 
is the result, or is symptomatic of fever; making no distinction a,s to the 
termination in bullae, &c. See his Nosol. Metn. gen. vii. spec. Q, ; and 
/ First Lines, } 274. — Prof. Callisen deems Erythema only a lesser degree 
•^--^ of Erysipelas. See his Systema Chirurg. Hodiem. J 485. 

Mr. Travers considers Erythema and Erysipelas ** modes of inflam* 
mation with inadequate power to carry them on to a termination. Thus 
they are deficient in the adhesive state ; they are incapable of a healthy 
suppuration ; and their imperfect effusion or suppuration is at the ex- 
pense of the life of the part." See his vol. on Constitutional Irritations, 
p. 220. However we might in part admit this reasoning in some of the 
species of Erysipelas, it certfunly does not apply in Erythema. T. 



140 EXANTHEMATA : 

In some of these, as appears from their titles, the 
surface is more or less elevated during the course 
of the disease, approximating to the papular or 
tubercular tumours; but these elevations are ob- 
scurely formed, and soon subside, leaving the redness 
undiminished. 

Species 1. Erythema fugax. Fugacious In- 
flammatory Blush. 

Syn. L*Eryth^me symptomatique {Rayer). 

This species consists of red patches, of an irregular 
form, and short duration, resembling the redness 
produced from pressure. These patches appear suc- 
cessively on the arms, neck, breast, and face, in 
various febrile diseases, and in bilious diarrhoea, 
generally denoting, as Hippocrates and the ancients 
have observed, a tedious and dangerous disease. 
They sometimes occur in chronic affections, especially 
** bilious diarrhoea, and other affections ** in which 
the primae viae are deranged ; as in dyspepsia, hysteria, 
hemicrania, &c. 

Species 2. Erythema Icevej Smooth Inflam- 
matory Blush. 

Syn. Erythema oedematosum (Oood) : L'Ery- 
theme idiopathique {Ilayer) : CEaematous inflam- 
mation {J. Hunter\ 

This species exhibits an uniformly smooth, shining 
surface, and chiefly appears on the lower extremities, 
in confluent patches, and is generally accompanied by 
anasarca. It affects young persons, who are sedentary, 
with slight fever, and terminates gradually, after an 
uncertain period, in extensive desquamation, as soon 
as the anasarca has disappeared. Exercise, with 
diuretics and corroborants, contributes to shorten its 
duration in this class of patients. It occurs also in 
elderly persons, labouring under Anasarca (especially 
in those accustomed to excessive drinking), and is 
liable to terminate in gangrenous ulcers. Indeed, 



ERYTHEMA. 14t 

under whatever cirumstances Anasarca occurs, so as 
to stretch the skin greatly, this Erjrthema is liable to 
be produced : it is often chequered with patches and 
streaks of a dark red or purple hue. Relief is aflPorded 
by the horizontal posture of the limbs, by the in- 
ternal use of diuretics and bark, and also by weak 
spirituous lotions, or those formed with Solution of 
Acetate of Ammonia and C^unphor Mixture, or of 
diluted Acetate of Lead, applied to the surface. 

This species of Erythema sometimes occurs, with- 
out oedema, when the bowels- have been much dis- 
ordered ; and, occasionally, in women, at the men- 
strual periods. 

Species 3. Erythema marginatvm^ Maroi- 
NATED Inflammatory Blush. 

(Plate XXXII. fig. 2. of Bateman ; PI. 13. of 
Thomson's Atlas.) The eruption in this species 
occurs in patches, which are bounded on one side by 
a hard, elevated, tortuous, red border, in some places 
obscurely papulated ; but the redness has no regular 
boundary on the open side. The patches appear on 
the extremities and loins in old people, and remain 
for an uncertain time, without producing any irri- 
tation in the skin. They are connected with some 
internal disorder, a small quick pulse, anorexia, pain 
of the limbs, and great depression ; and their occur- 
rence is to be deemed unfavourable. Diaphoretics, 
gentle purgatives, followed by the mineral acids and 
light diet, constitute the treatment. 

Species 4. Erythema papulatum, Papulated 
Inflammatory Blush. 

(Plate XXXI. fig. 1. of Bateman ; PI. 13. of 
Thomson's Atlas.) This rash occurs chiefly on 
the arms, neck, and breast, in extensive irregular 
patches, " frequently slightly elevated above the un- 
affected skin,'* of a bright red hue, presenting not 
an inelegant painted appearance. For a day or 



142 EXANTHEMATA : 

two, before the colour becomes vivid, the Surface is 
rough or imperfectly papulated. The redness after- 
wards continues for about a fortnight ; and, as the 
eruption declines, it assumes a blueish or pale purple 
hue, especially in the central parts of the patches. 
"It is generally attended, during the height of the 
eruption, with a sensation of tingling, which is much 
increased at night; and is sometimes followed, as 
the patches change in colour, by a sensation of sore- 
ness/* I have seen this eruption attended with 
great disorder of the constitution, similar to that of 
the former species ; especially with a frequent small 
pulse, anorexia, watchfulness, and extreme depres- 
sion of strength and spirits, and with acute pains 
and great tenderness of the limbs : but the general 
disorder is often trifling,* Light diet, with dia- 
phoretics, and the mineral acids, and an attention to 
the state of the bowels, comprise all that is neces- 
sary iij the treatment of this disorder. ** To allay 
the uneasy tingling, and secure rest at night, com- 
binations of Tartar emetic, or of James's Powder and 
Opium, will be found useful/* 

Species 5. Erythema tuberculatum. Tuber- 
GULATED Inflammatory Blush. 

(Plate XXXI. fig. 2. of Bateman ; PL 13. of 
Thomson's Atlas.) This species resembles the 
last in the large irregular patches of red efflorescence 
which it exhibits ; but they are small, slightly-ele- 
vated tumours interspersed through the patches, 
subsiding in about a week and leaving the Erythema, 
which becomes livid and disappears in about a week 
more. It commences with fever, and is accompanied 
with great languor, irritability, and restlessness, and 
succeeded by hectic. In the only three cases of this 
Erythema which had occurred to Dr. Willan, the 
medicines employed did not appear to alleviate the 

♦ See Report of the Public Dispensary, Edin. Med. and Surg. Journ. 
for Jan. 1812. 



ERYTHEMA. 143 

symptoms, or to prevent the subsequent hectic. I 
have not seen any instance of it. 

Species 6. Erythema nodosum. Nodose In- 
flammatory Blush. 

(Plate XXXII. fig. 1. of Bateman ; PI. 13. of 
Thomson's Atlas.) This species is a more com- 
mon and milder complaint : it seems to affect females 
chiefly : " but Dr. Merriman says, that he has * fre- 
quently witnessed it in children of both sexes * :* 
and Mr. Plumbe has also seen it in children, t I 
have seen it several times in girls under ten years of 
age, and once only in a boy :" it occurs on the fore 
part of the legs. It is preceded by slight febrile 
symptoms for a week or more, which generally abate 
when the Erythema appears. It shows itself in 
large oval patches, the long diameter of which is 
parallel with the tibia, and which slowly rise into 
hard and painful protuberances, and as regularly 
soften and subside, in the course of nine or ten days ; 
the red colour turning blueish on the eighth or ninth 
day, as if the leg had been bruised. It has always 
gone through its course mildly, under the use of 
small doses of Calomel and mild laxatives, followed 
by the mineral acids, Decoction of Cinchona Bark, 
and other tonics. When the pain is severe, an 
opiate, combined with James's Powder and Calomel, 
is necessary. The best local application is a lotion 
compounded of f3X of Alcohol, and f^v of Rose 
Water. 

Species 7* Erythema intertrigo. Fret or Ero- 
sion OF the Skin. 

S^n. Erythema intertrigo (Sauv.) : Intertrigo 
(Linn. V^og.) : Erythema ab acri inquilino ( Cull^ : 
Macular volaticae (Aiict. var.) : Kerch (j^rai.) : 

* Underwood on the Diseases of Children, 8th edit. p. 176. 
f Plumbe on Diseases of the Skin, 2d edit. p. 44 9. 



144* EXANTHEMATA : 

Erat (Oerman): Ecorchure, Rougeurs desrnouveau 
n6s (F.) Fret. 

Undier the head of Erythema, Dr. Willan has 
made mention of that form of Intertrigo which is 
produced in some persons, especially those of san- 
guine temperament and corpulent habit, by the 
attrition of contiguous surfaces.* It most frequetitly 
occurs beneath the breasts, round the axillse, in the 
groin, and at the upper part of the thighs. " This 
species of Intertrigo is very common in fat children, 
occurring in all the folds of the skin, and causing an 
acrimonious discharge, which excoriates the Isurface 
beyond the afiected parts, if attention to cleanliness 
be neglected.'* Sometimes it is accompanied by a 
glairy foetid secretion ; and sometimes the surface is 
dry, and the redness terminates in a scurfy or scaly 
exfoliation. An erythematous appearance, analogous 
to the Intertrigo, is occasioned by acrimonious dis* 
charges, as by those of fluor albus, dysentery, gonor- 
rhoea, &c. and by the irritation of the urine and 
alvine discharges, in infants, when a sufficient atten- 
tion is not paid to the proper changes of their linen. 

The heat and uneasiness attendant on this com- 
plaint are allayed by frequent tepid ablution, which 
removes the acrid secretion, where it occurs, and 
tends to prevent excoriation. If this take place, 
any simple ointment, or, which is preferable, some 
mild absorbent powder, such as that of Calamine or 
of Cerussa, will be applied with relief.^ " When the 
discharge is foetid, the odour is almost immediately 
destroyed, and the inflammation rapidly allayed, by 
frequently bathing the affected parts with a lotion 
composed of six fluid drachms or a fluid ounce -of 
the Chloro-sodaic solution and five fluid ounces of 



* Sauvages includes this variety of Intertrigo^ and the chafing and 
inflammation produced by riding on horseback, tight shoes, the use of 
tools, and even that of bedridden persons, under Erythema, denomi- 
nating the former Erythema intertrigo (spec. 5), and the latter E. para- 
trimma (spec. 6.) 



ERYSIPELAS. 145 

Water/* When there is much irritability, a lotion 
composed of ten grains of Oxymuriate of Mercury, 
and six fluid ounces of Lime Water, will be found 
serviceable. 






Books which may be corutUted on Erythema, 

Alibert, sur les Maladies de la Peau. 

3iETT, Abr^^ IVatique des Mai. de la Peau, 8vo. 1825. 

Joy, Cyclopaedia of Prac. Med., vol. ii. Bvo. 1832. 

Leco prt-Chantilly. sur PEryth^m^ et I'Erysip^le^ 4to. 1854. 

Plumbe on Diseases of the Skin, 2d edit. 1827. 

Rayer, Traitddes Maladies de la Peau, 1826. 



Genus VII. ERYSIPELAS.* 

Si/n. Ignis sacer ( Celsus) : Febris erysipelatosa 
{Sydenham)-. Febris erysipelacea {Hoffm. Vog.)i 
Emphlysis Erysipelas ( Oood) : Erysipelas (u4uct 
var.) : Rosa, Ignis Sancti Antonii {Auct. var.) : 
Er6sipfele, la Rose (i^.) : Rose, Rothlauf ( Oerm.) : 
Roos, St. Anthoni*s vuur, (Dutch) : Rosen (Dan. 
Swed.): Roza (Polon,): Risipola, Fuoco di S. 
Antonio (Ital.) : Erisipela, Ros (Span.) Hemnet 
(Arab.): Akki (Tarn. Tel.): Shirjah (Duk.): 
Pitta vicharchika (Sans^: Soorkh (Pers.): Kas- 
zalapani (Malayalie) : •The Rose^ St. Anthony's 
Fire. 

Def. A FEBRILE DISEASE, IN WHICH SOME PART 
OF THE BODY IS AFFECTED EXTERNALLY WITH HEAT, 
REDNESS, SWELLING, AND SOMETIMES VESICATIONS. 

The tumour in this affection is soft, difiuse, and 
irregularly circumscribed, and not accompanied by 

* In the former editions of this work, Erysipelas is ranked among 
Bullae. It may> in my opinion, with more propriety be regarded as one 
of the Exanthemata; I have therefore removed it to this place. Vesi« 
cations certainly occur in severe. and aggravated cases of^ the disease ; 
but, in the great majority of instances, this symptom is absent : and 
unless it be an invariable attendant of the disease, there is more pro- 
priety in placing Erysipelas in its present situation, than where it formerly 
stood in this work. T. 



146 EXANTHEMATA : 

throbbing or acute pain, nor terminating in trufj 
suppuration. 

The last-mentioned circumstances distinguish the 
tumour of Erysipelas from that of Phlegmon * ; and 
the presence of tumour, together with vesication, 
distinguishes the disease from Erythema. The dis- 
appearing of the redness on pressure, and its imme- 
diate return when the pressure is removed, are com- 
monly mentioned among the characteristics of Erysi- 
pelas, by medical writers, from Galen downwards, t 
This phaenomenon, however, belongs to Erysipelas in 
common with several of the Exanthemata ; as with 
the efflorescence in Scarlatina, in some varieties of 
Roseola, and in Erythema. " From Phlegmon it is 
distinguished by the sloughing of the cellular tissue 
in its advanced stage, in severe cases which only are 
likely to be confounded with Phlegmon.** Erysipelas 
is often a contagious disease. It more frequently 
attacks women than men. 

" Mr. Lawrence, in a paper on Erysipelas t, con- 
ceives that this disease in every instance is a modifi- 
cation of inflammation, and that its various forms 
depend upon accidental circumstances. This doc- 
trine appears to be evidently erroneous. It is indeed 
highly probable that Erysipelas arising from wounds 
or other injuries is simple m^ammation, modified by 
the structure which it has attacked ; but that there 
is a distinct febrile affection, of which the eruption 
termed Erysipelas is a characteristic symptom, as 
much as the eruption in Scarlatina, or in any other 
of the Exanthemata. The eruption being preceded 
by the fever, the disease running a tolerably regular 

* See Galen. Meth. Med. cap. xiv.and Comment, in aph. 20. lib. iv.; 
also Aetius, tetrab. iv. serm. ii. cap. 59. 

f Galen speaks of Erysipelas phlegmonodes and oedenudodes, in which 
he has been followed by Forest, Obs. Chirurg. lib. ii. 1. 3. & 4.; by 
Plater, De Superfic. Corp. Dolore, cap. 17.; and Frank, De Ctirand. 
Horn. Morbis, lib. iii. — Mr. Pearson divides Erysipelas into three species, 
adding the gangrenous to the two just mentionea. See bis Principles <^ 
Surgery, chap. x. 

J Med. Chirurg. Trans, vol. xiv. 



ERYSIPELAS. 147 

course, its being occasionally contagibus, and never 
by any treatment being cut short, are very strong 
evidences in favour of this opinion." 

There are four species of Erysipelas : 

1. E. phlegmonodes. 3. E. gangrcenosum. 

2. E. cBdemaiodes. 4. E. erraticvm. 

Species 1. Erysipelas phlegmonodes^ Phleg- 
monous Erysipelas.* 

It is scarcely necessary to enter into a minute de- 
scription of the well-known appearance of acute Ery- 
sipelas, t This form of it most frequently occurs in 
the face, the head, the neck, and sometimes the chest, 
affecting usually one side of it only; sometimes, 
" indeed most frequently,** it seizes one of the ex- 
tremities i and in both cases it is ushered in by a 
smart feverish attack, " with great irritability of the 
stomachy often with delirium, and a tendency to coma. 
The colour of the eruption is more of scarlet than of 
the tint of the rose, as in the other species ; and the 
pam and burning heat and tingling in the part are 
exceedingly distressing. The swelling geneially ap- 
pears on the second night, or the third day of tne 
fever, " and extends to the cranium from the face : 
the cutis only, however, is affected, and in the line 
of its progress is elevated, and shews a well-defined 
edge, the diseased parts appearing upon the healthy 
almost as embossed work.** The vesications, when 
they arise, appear on the fourth and fifth, and break 
or subside on the fifth or sixth day, when the redness 
changes to a yellowish hue, and the swelling and 
fever begin to diminish; — and on the eighth day 
both disappear: on the tenth, the new cuticle is 
commonly left exposed, the old one having cracked 

* Mr. Arnott (Med. & Phys. Journ. vol. Ivii. p. 210.) objects to this 
name, as being ** unnecessary, inaccurate, and applied to dissimilar mor- 
bid conditions." See Mr. Earle's paper in the same volume. 

f Dr. CuUen has given an excellent history of the disease. First 
Lines, $ 1696. 

*L 2 



148 EXANTHEMATA : 

and separated : the brownish or dark seab^ which had 
formed where the fluid of the vesications had been 
discharged, having fallen off. — The progress of the 
disease, however, is more rapid, and its duration 
shorter, in young and sanguine habits, than in those 
more advanced in life * : in the former, the tumefac- 
tion is sometimes fully formed on the second day, 
and the whole terminates on the sixth or seventh ; 
while in the latter, it may be protracted to the tenth 
or twelfth, and the desquamation may not be com- 
pleted before the fourteenth day. " As the redness 
declines, the swelling gradually subsides, and the skin 
assumes a yellow tinge : this is the visual progress of 
the attack when it ends in resolution.** The vesica- 
tions, when these appear, are often succeeded by a 
profuse discharge of acrimonious lymph for several 
days, so that scabs do not form. Suppuration very 
rarely occurs in this species of Erysipelas, especially 
when it affects the face. It rarely terminates in 
death, " It may terminate in gangrene, in which 
disorganisation of the cellular substance takes place, 
and it comes away in shreds soaked in pus ; the inte- 
guments becoming livid and losing their vitality. 
When the patient survives, an agglutination of skin, 
fascia, and muscle takes place, and the motions of the 
parts are lost, or seriously impaired. 

Species 2. Erysipelas cedematodes^ Edematose 
Erysipelas. 

In this species, which is less severe in its attack, 
the tumour is more gradual in its rise and extension, 
is of a paler red, or of a yellowish brown colour, and 
is accompanied by less heat and local distress ; its 
surface is smooth and shining j and if it be strongly 
pressed with the finger, a slight pit remains for a short 
time.t " The inflammation is subacute, and the 

* Quo vehementius malum, eo etiam gravius est, sed brevius. Lorry 
de Morb. Cutan. 4to. p. 192. 

t Mr. Pearson obsehres, that " the part afiected is almost wholly free 
from tension, and gives the sensation of an oedematote or emphysenuUose 



ERYSIPELAS. 149 

swelling pits, as in ordinary oedema.*' Vesications, 
which are smaller, less elevated, and more numerous 
than those which occasionally appear in the former 
species, rise on the third or fourth day from the 
commencement of the swelling ; and are suc- 
ceeded, in two or three days, by thin, dark-co- 
loured scabs, giving an appearance not unlike the 
confluent smallpox, from the edges of which a clear 
lymph exudes. The whole face is much enlarged, so 
that the form of the features is scarcely recognised, 
wd the appearance is not unaptly compared by Dr. 
Willan to that of a bladder distended with water. 
** This species is often accompanied with an affection 
of the throat, evidently erysipelatous. The symp- 
toms are a red blush over the velum palatum and 
uvula, slight tumefaction, and considerable pain on 
deglutition. After a few days, excoriation and super- 
ficial ulceration sometimes extend to the larynx, 
effecting speech and respiration ; sometimes to the 
pharynx and oesophagus.'' 

Edematose Erysipelas is attended with considerable 
danger when it affects the face, as above described ; 
for the disorder of the functions increases with the 
advancement of the external disease. Vomiting, 
rigors, and ddirium, followed by coma, take place 
about the height of the disorder, and often terminate 
fatally on the seventh or eighth day : " there is great 
depression of the muscular strength ; the pulse is 
feeble and quick, and the tongue dry, with a brown 
streak in the centre :" while in other . cases, the 
symptoms continue undiminished, and death occurs 
at a later period ; or a slow and tedious convales- 
cence ensues. 

This form of Erysipelas most commonly affects 



state, except that there is no crepitation." He compares the sensation, 
on pressing a part in which a considerable formation of pus has taken 
place in Erysipelas, *' to that which is excited by a quagmire or morass." 
Loc. cit. 

L 3 



150 EXANTHEMATA : 

persons of debilitated or impsured constitution, drop^ 
sical patients, and those who have long been subject 
to other chronic maladies, or live in habitual intem- 
perance. It is not attended with danger, however, 
when it aflPects one of the extremities ; miless symp- 
tomatic of a punctured wound in a bad state of the 
habit. In some un&vourable cases matter is f(»rmed, 
which is apt to make its way through the cellular 
substance, producing irregular sinuses between the 
muscles, which it often materially injures, and pro- 
longing the suflferings of the patient for many weeks. 
" In some situations, namely, on the scrotum or the 
lower extremities in dropsical patients, a cessation of 
pain sometimes suddenly takes place, the ccJour 
becomes livid, and gangrene is apt to supervene.** 

Species 3. Erysipelas gangrcenosum^ Gangre- 
nous Erysipelas. 

This species commences sometimes like the one, 
and sometimes like the other, of the foregoing q)eciesi 
and most commcmly occurs in th^ face, neck, or 
shoulders. ^* It is not improbable that it is merely 
an increased degree of the first species.** It is ac« 
companied with symptcnns of low fever, and with 
delirium, which is soon followed by coma, which 
remains through the subsequent course of the dis- 
ease. The colour of the affected part is a dark red ; 
and scafttered f^lycteenae, with a livid base, ^p^ar 
upon the surface, and frequently run into gai^enous 
ulcerations. Even when it terminates favourably, 
suppuration and gangrene of the muscles, tendons, 
and eetlular substance often take place, producing 
little caverns and sinuses, which contain an ill-con- 
ditioned pus, together with sloughs of the mortified 
parts, which are ultimately evacuated from the ulcers. 
It is always a tedious and precarious disease, and 
irregular in the period of its termination. 

A peculiar variety of gangrenous Erysipelas occa- 
sionally occurs in infants, a few days after birth. 



ERYSIPELAS. 151 

^fpeeially in lying-in hospitals*, and is often fatal. 
Sometimes, indeed, infants have been born with 
livid patches, vesications, and even gangrene already 
advanced. t " In such young patients*' it most fre- 
quently commences about the umbilicus or the geni- 
tals, and extends upwards, or downwards, affecting 
the parts which it reaches with moderate swelling, 
and slight hardness t ; the skin puts on a dark-red 
colour, and vesications with livid bases break out ter- 
minating in sphacelus, which, if the child be not 
speedily cut off, nearly destroys some of the fingers 
or toes, or even the genitals. In the milder cases, 
when the extremities alone are affected, suppurations 
take place rapidly about the joints of the hands and 
feet. The complaint, however, often terminates 
favourably in ten or twelve days. 

Species 4. Erysipelas erraticum. Wandering 
Erysipelas. 

In this species the morbid patches appear, one 
after another, on different parts of the body ; in 
some cases, those which appeared first remain till the 
whole eruption be completed; in others, the first 
patches decline as fresh ones appear. Sometimes 
the disease thus travels progressively from the face 
downwards to the extremities. § Sometimes it sud- 
denly leaves one part, and appears at another. It 

* See Underwood on the Diseases of Children, vol. i. p. 31. (5th edit.) 
— and an ample account of it by Dr. Grarthshore, in the Med. Commu- 
nications, vol. ii. art, V. (17 90) — with some references. 

+ See a case related by Dr. Bromfield, in the same vol., art. iv. 

j^ Umbilicalem regionem in infantibus frequentius infestat, ac inde 
per abdomen spargitur, cum pathematibus, funesto ut plurimum eventu. 
— Hoffl de Morb. Infantum, cap. 13. T. 

§ Mr. Pearson mentions this progression of the disease as belonging 
to the Erysipelas oedematodes ; and adds, that each renewed accession 
of the complaint was less and less severe, as it receded to a greater dis- 
tance from the part first affected^ § 308. See also Frank, lib. iii. $ 281. 

Ita k facie in genitalia saepe ruit Erysipelas, quod jam intellexerat 
Hippocrates, ab aurium postic& parte ad articulos fluxisse yidi, ab hb in 
oculos. Lorry de Morb. Cutan. 4to. p. 193. T. 

L 4 



152 EXANTHEMATA : 

commonly terminates favourably, however, in a week 
or ten days.* 

The exciting causes of Erysipelas are not always 
obvious : but it is commonly attributed to the action 
of cold or damp air, after being heated t, or to expo- 
sure to a strong heat, whether from the direct rays 
of the sun or from a fire ; to intemperance, or to 
violent emotions of the mind, especially anger and 
grief. " Some practitioners refer it, in the majority 
of cases, to a superabundant acid in the blood, arising 
from acid or acidifiable diet, such as raw vegetables, 
too much fruit, sweets, &c. ; and it has even been 
stated that the serum in the vesicles is of an acid 
nature, which can be detected by tests. " There can 
be no doubt that it is frequently symptomatic of 
gastro-enteric irritation ; and in such as are liable to 
derangements of the digestive organs, there appears 
to be a peculiar predisposition to the disease. Women 
at the period of the cessation of the menses are liable 
to attacks of it, accompanied with gastric symptoms. 
Erysipelas is more prevalent in spring and autumn 
than at the other periods of the year : it occasionally 
appears as an epidemic." Erysipelas is likewise 
symptomatic of wounds and punctures, the local 
application of poisons, the stings of insects, &c. t 
" This is particularly the case in slight injuries of 
the scalp ; and not unfrequently terminates fatally,'* 
especially when the periosteum is injured. "It is 

* * It has been reasonably suggested by Mr. Arnott, that the term 
Erysipelas is improperly implied to aponeurotic inflammation, in which 
the skin is raised and becomes puffy, and often ends in suppuration. 
Many cases of what is regarded as Erysipelas Phlegmonodes are of this 
description.' T. 

f Virum novi militarem qui nunquam aeris nvidi liumiditati exponi- 
tur per horam unam aut alteram, quin illico corripiatur erysipelate. 
Lorry de Morb. Cutan. 4to. p. 196. T. 

% An erysipelatous affection, which has even proved fatal, has occa- 
sionally come on two or three days after inoculation, both variolous and 
vaccine, in children of irritable habits. See some cases in the Med. and 
Phys. Journal for 180L 



ERYSIPELAS. 153 

nlore prevalent in spring and autumn, biit rarely ap- 
pears in winter." 

It has been the subject of some discussion, whether 
Erysipelas be not sometimes propagated by contagion 
and infection. The disease has been noticed, in 
several hospitals, to prevail in certain wards, among 
patients admitted with different complaints ; but has 
seldom been known to spread in private houses. Dr. 
Wells, indeed, has collected several examples of the 
apparent communication of Erysipelas by contagion, 
which occurred in private families * : " and instances 
recorded by Dr. Stevenson, Dr. Gibson, Mr. Law- 
rence, and others, leave no doubt on this head. Dr. 
Stevenson, in particular, met with many instances of 
it in private practice; and mentions one case in which 
a person who was attacked while attending an ery- 
sipelatous patient carried the disease home to her 
family, all the members of which were successively 
seized with it, and the mother died, t In the North 
London Hospital, in March, 1835, the disease, 
which accidentally occurred after an operation, spread 
through the ward, and even attacked a patient in an 
adjoining ward." But such cases, *^in private fa- 
milies," are, at all events, extremely rare, and perhaps 
never happen in well-ventilated and cleanly houses. 
From the Royal Infirmary, at Edinburgh, this dis- 
ease, like the puerperal fever, was banished by 
ventilation, whitewashing, and other means of purifi- 
cation ; and it has seldom occurred in any hospital 
of late years, since a better system has been adopted 
in these respects. Other diseases, not infectious in 
themselves, appear to become united with typhus, or 
contagious fever, under similar circumstances, and 
thus to be propagated in their double form ) the 
dysentery t, for example, the peritonitis of women in 

* See Transact, of a Soc. for the Improvement of Med. and Chirurg. 
Knowledge, vol. ii. art. xvii. (1800.) 

+ Trans, of Med. Chir. Soc. of Edin. vol. ii. 
j. See Dr. Harty's Observations on Dysentery. 



154 EXANTHEMATA : 

childbed, ulcerated swe4hroat, &g. * The simple 
phlegmonous Erysipelas, at all events, was never seen 
to spread like an infectious disease. ^ " Persons who 
have once had the disease me very liable to a repe- 
tition of it. What, it may be asked, is the tempera- 
ment which predisposes to it ? Is it simple increased 
irritability? The soluticm of this question would 
throw great light upon the pathology of the dis- 
ease.*^ 

The method of treatment must necessarily be 
widely different in the phlegmonous, from that 
which the other forms of the disease demand. " It 
dso requires to be varied according to the age, tem- 
perament, and habit of the patient , and, not less so, 
according to the nature of any epidemic fever pre- 
vailing at the time. Sometimes a strict depleting 
plan is requisite, whilst at other times this would not 
only be indiscreet but highly injurious." In the 
ordinary cases of this species of Erysipelas, the prin- 
cipal plan of cure consists in the administration of 
moderate purgatives, with a light vegetable diet, and 
in enjoying repose of body and mind, and a cool 
apartment. ^^ M. Reil and M. Retz strongly re- 
commend emetics in the commencement of Ery- 
sipelas. Calomel, in full doses, is always beneficial 
in the early stage of the disease. Saline and other 
diaphoretic medicines may be employed, as auxi- 
liaries of secondary importance ; as, for instance, 
the Liquor Ammonias Acetatis, Tartarised Anti- 
mony, and similar sudorifics. Colchicum has been 
advantageously used in the two first species of the 
disease.** Blood-letting, which has been much re- 
commended as the principal remedy for the acute 
Erysipelas, " even of the phlegmonous kind,** is sel- 
dom requisite, " unless the face or head be the part 

* In the case of Mr. Newly, who died of a disease closely resembling 
Erysipelas oedeniatodes, caused by a wound received in dissection, Mr. 
Travers states, that besides the nurse, who took the disease and died, 
another woman, who merely assisted in the room, was attacked, but 
recovered. Travers on Constitutional Irritation, p. 389. T. 



ERYSIPELAS. 155 

attached, in wliich case the abstraction of blood 
should be free ; and the general bleeding followed 
by cupping or leeches. In aged persons the bleeding 
should be altogether local : and even when this is 
taking place, the system should be supported by 
light cordials ; and the utmost care taken to prevent 
exhaustion of the system. When the disease super* 
venes convalescence from other diseases, the best 
mode of abstracting, blood is by punctures from the 
inflamed surface, and promoting the flow of the 
blood by poultices or fomentations.'^ Unless there is 
a considerable tendency to delirium or coma, general 
bleeding cannot be repeated with advantage, at least 
in London, and other large towns.* Local bleeding 
and blistering may be substituted in such cases. It 
is usual to forbid leeches to be appliied upon, or very 
near the diseased surface ; << but although the bites 
of leeches are, in some states of the habit, followed 
by Erysipelas, yet they do no harm when applied to 
the inflamed surface in this disease." The adminis* 
traticm of Cinchona, Sulphate of Quinia^ and Opium, 
in this form of the complaint, is certainly unnecessary, 
and appears to be of very equivocal saiety, notwith- 
standing the authority upon which it has been recom« 
mended. « In general, however, some form of tonic 
is requisite after purging : the best is a light Infusion 
of Cascarilla Bark, so combined with Carbonate of 
Soda as to be taken in a state of effervescence. When 
wine or spirits have been indulged in, they should be 
allowed, under due restraint.! Under the impression 
of a prevailing acidity, Carbonate of Ammonia has 
been extolled as a remedy in this affection. It is 
probable that the benefit which results from it, de-^ 
pends more upon its power over the nervous sys-» 
tern, than in its chemical union with the add of the 
stomach." 

* See Pearson's Principles of Surgery, § 320. — Bromfield's Chir. Oba. 
Tol.i. p. 108.; — also Prof. Callisen, Syst. Hodiera } 491. 
f See Sir A, Cooper's Surgicd Lectures, vol. i. p. 249. 



156 -JiXANTHEMATA : 

In the Erysipelas cedematodeSj and erraticimij the 
Cinchona or Quinia and Opium are highly useful, in 
accelerating the decline of the disease, and relieving 
irritation, when the active symptoms of the first three 
or four days have been subdued by purgatives and 
diaphoretics ; or, if the functions of the sensorium 
were considerably disordered, by a blister between 
the shoulders, or a topical bleeding in the same part. 
The strength should be supported, during the decline 
of the complaint, by a more cordial regimen, with a 
view to obviate the tendency to gangrene : " and in 
such cases the allowance of wine should be liberal ; 
and, indeed, solely regulated by its eflPects on the 
pulse/* 

In the Erysipelas gangrcBUOsum* ^ the Cinchona 
Bark is necessary, in considerable doses ; ^^ but Sul- 
phate of Quinia is preferable. It may be given to 
adults in two-grain doses every three hours ; and in 
Erysipelas infantum^ which is a variety of this spe- 
cies, it is the medicine chiefly to be relied upon." 
Opium also. Camphor, the mineral acids. Wine, 
Wine-whey, and the general regimen adapted to gan- 
grenous affections occurring under other circum- 
stances, must be freely employed. The formation of 
sinuses, the separation of sphacelated parts, &c. will 
require surgical attention for some time. 

With respect to external applications in the early 
stages of Erysipelas, experience seems to have de- 
cided that they are generally unnecessary, if not pre- 
judicial, t " Puncturing or scarifying the skin with 
the point or the shoulder of a lancet has been found 
highly beneficial. In E. phlegmonoides, these inci- 
sions should be about an inch in length, and carried 
completely through the cutis vera ; after which, fo- 
mentations should be applied over the incisions. This 
practice, however, is less frequently necessary than 

* '* In tenellis infantibus observatum fuit Erysipelas k causa abscon- 
dita, saepissime lethali, nisi corticis usu occurratur malo." Callisen, 
p. 493. — See also Underwood, and Garthshore, before quoted. 

f Mr. Pearson, § 531. 



ERYSIPELAS. 157 

" Mr. Copland Hutchison, who introduced the practice 
into this country, and'' some other modem surgeons 
would lead us to believe.* It is useful in that state 
of the disease in which the inflammation runs so high 
as to threaten destruction to the subcutaneous struc- 
ture. " Theemployment of incisions is rarely required, 
except in the phlegmonous form of the disease : the 
operation, especially in elderly patients, requires to 
be done with caution, as fatal haemorrhages have fol- 
lowed these incisions.** One advantage arising from 
incisions is the free exit which they afford to pus, 
when cellular suppuration occurs. The application 
of powdery substances has commonly, according to 
my own observation, augmented the heat and irritaticm 
in the commencement ; and afterwards, when the fluid 
of the vesications oozes out, such substances produce 
additional irritation, by forming, with the concreting 
fluid, hard crusts upon the tender surface. t In order 
to allay the irritation produced by the acrid discharge 
from the broken vesications, Dr. Willan recommends 
us to foment or wash the parts affected, from time to 
time, with milk, bran and water, thin gruel, or a de- 
coction of elder flowers and poppy heads. In the 
early state of the inflammation, when the local heat 
and redness are great, moderate tepid washing, or 
the application of a cool but slightly-stimulant lotion, 
such as the diluted Liquor Ammonias Acetatis, has 
appeared to me to afford considerable relief. " Com- 
presses dipped in Camphorated Spirits of Wine in 
the first stages are beneficial. The following lotion 
has generally proved usefiil : 

J:^ Plumbi Acetatis gr. xij, 
Aquae Rosae f ^v, 
Aceti Distillati f 5UJ9 
Spiritus Vini rectificati f 5v. M. 

* See Med. Chirurg. Trans, vol. xiv. 

f ^ Exteraa remediare solventia, emollientia, adstrineentia, vel calida, 
vel fngida, — uti (]|uoque pulveres varii, parum vel ninil in erysipelate 
prosunt ; nee omnis noxse suspicionem, experienti& teste, effugiunt.'* — 
Callisen. • 

•l 7 



158 EXANTHEMATA : 

Dr. Merriman reeommends fomentations made. of 
extract of Poppies^diffused in warm water, and poul- 
tices made of crumb of bread and the same fluid. * 
When gangrene supervenes. Port wine poultices or 
the Nitrous acid lotion, in the proportion of f3J of 
the acid to Oij of water, are the best applications : 
or the Chloro-Sodaic Solution of Labarraque, diluted 
with five parts of water. The best local application, 
in ordinary cases, is that recommended by Mr. Higgin- 
bottham, on his own experience,^ — the lunar caustic* 
He desires that the pssrt be well washed with warm 
soap and water, and then a long stick of caustic ap- 
plied to the inflamed surface : but not sufficiently 
strong to abrade the surface. <* It arrests almost in- 
stantly the spreading of the inflammation ; its influ- 
ence, besides, extends beyond the surface, and checks 
the tendency to cellular inflammation,^ the sjrmptom 
to be most guarded against in Erysipelas.'^ t 

** No disease is so liable to return as Erysipelas. 
Tissot recommends the following as the best prophy- 
lactic plan : The patient must carefully avoid the use 
ef milk, cream, £u] rich and viscid food, baked and 
strong meats, aromatics, strong wines, a sedentary 
life, mental irritations: and live on light, cooling 
veget^le food ; and drink water with a little weak 
wine.'* 

The zanoj zoster, or shmgles, is considered as a 
vBrietj of Erysipelas by ike nosologists, as well as by 
several practical writers : but it is invariably an erup- 
tion of vesicles, and possesses all ike other charac- 
teristics of Herpes. See ord. vi. gen. 3. 

Sauvages, under the head of Erysipelas pestUens, 
(spec. 5.) arranges the fatal epidemic disease, which 
prevailed extensively in the early and dark ages, as 
the sequel of war and famine, and which has received 
a variety of denominations ; such as ignis sacer, ignis 

* See Merriman's edit, of Underwood, sro. p. 127. 
" t Higginbotthara on the Use of Nitrate of Silver in the Cure of 
lajflammaJtion, &c. 



ERYSIPELAS. 159 

S^^ Anthonii, mal des ardens, ergot, Kriebel krank- 
heit, die Feverflecke, &c. &c. according to its various 
modifications and degrees of severity, or according to 
the supposed cause of it.* The erysipelatous red- 
ness, however, followed by the dry gangrene, which 
often destroyed the limbs joint by joint, was only one 
of the forms or stages of that disease ; as the con- 
tracted and palsied state of the limbs, to which the 
ancients gave the name of scelotyrbei^ constituted 
another. Instead of originating from eating rye 
affected with the ergotj as was supposed in France t; 
or barley with which the raphanus was mixed, as 
was imagined in Sweden § ; the disease was, doubtless, 
the result of deficient nourishment, — a severe land- 
scurvy, which was a great scourge of the ancient world, 
and often denominated 'pestilence. || — The name of 
St. Anthony seems to have been first associated with 
an epidemic disease of this kind, which prevailed in 
Dauphin6 about the end of the twelfth century. An 
abbey, dedicated to that saint, had recently been 

* Sagar has included the varieties of this disease under the genus 
NecrosUy of which he thus details the symptoms : — *^ Est partis mors 
lenta, sine prsevio tumore, mollitie, et dissolutione foetid^, cum dolore 
ardente orciinario et stupore, quae sequitur exsiccatio partis, induratio, 
nigredo, et mumia : difiert ^ gangrena in eo, quod lentius procedat, cum 
dolore rodente et stupore, et in mumiam abeat ; gangrena contra rooU 
lescat, phlyctaenas elevat, putrescat, foeteat, atque cito decurrat." Syst. 
Morbor. cl. iii. ord. vii. gen. 42. He describes five species ; and of the 
fourth, epidemical he says, "Apud Flandros regnavit haec Necrosis 
1749-50. spasmiartuum cum doloribus vagis; post 2 vel 3 septimanas 
stupor, fremitus obscurus, artus cum frigore daciali, contracturis, et 
anaesthesia ; tandem livor partis, nigredo, flavedo, phlyctaenae, et siccis- 



sima mumia*" 



+ See Plin. Nat. Hist. lib. xxv. cap. 5. 

\ See an able history of the Ergot, in the M ^m. de la Soc. Roy. de 
M^decine de Paris, tom.i. p. 260. by MM. Jussieu, Paulet, Saillant, and 
the Abb^ Tessier. — See also the Philos. Trans, vol. Iv. p. 1 18. An in- 
teresting account of the Kriebel krankheit, which was endemic in Hessia 
and Westphalia during a season of dearth in 1597, is preserved by Greg. 
Horst. in Oper. lib. viii. obs. 22. tom. ii. 

§ See Linnaeus, Amoenit. Academ. vol. v. 

II Several instances of pestilence mentioned by Livy appear to have 
been of this kind. Indeed the learned Heyne observes : — " Nobis 
manifestum videtur, ne uUam quidem inter Romanos pestilentiam me- 
morari, quae pro pestilentid propria dkld haberi possit," &c. (Opusc. 
Academ. lii. p. 113.) 



160 EXANTHEMATA : 

founded at Vienne, in that province, where his bones 
were deposited ; and it was a popular opinion, in that 
and the succeeding century, that all the patients who 
were conveyed to this abbey were cured in a space of 
seven or nine days * ; a circumstance which the ample 
supply of food in those religious houses may probably 
satisfactorily explain. It would be foreign to my 
purpose to pursue the subject here. 

Works which may be cofuulted on Ertfs%peiat» 

Aekts (Jo8. Joan.) de Erysipelate Diss. Inaug. Paris, 1782. 

61LLAR0 CyTrait^ des Maladies des Infants Nouveau-n^, 8vo. 1828. 

Bromfield-s Cases, Medical Communications, vol.ii. p. 322. 1790. 

BuiiHAli, James, on the Erysipelas, 12mo. Lond. 1777. 

xfluT TEB, Remarks on Irritative Fevers, 8vo. 1825. 
X Caillau, Essai sur TEndurcissement du Tissu Cellulaire chez lea 
En fans, 8vo. 1805. 

Carimnati, suU' Induramento Cellulare de' Neonati, 8vo. 1821. 

Closier, Dissertation sur TErysipele, 8vo. 1809; 

Dale, Dissertatio de Erysipelate, 8vo. 1781. 

£)ENrs, sur la Phlegmasie Enterocellulaire, 8vo. 1826. 

Duncan, A., Jun., Edin. Med. & Chir. Trans., vol. i. 8vo. 1824. 

Edinburgh Med. and Surg. Joum. vol. viii — xvii. 

Ellingeji, De Erysipelate, 8vo. 1 560. 

Engelbarj, Diss, de Erysipelate, 1797. 

Garthshore, Med. Communications, vol. ii. p. 526. 

Gendrin, Histoire Anatomique des Inflammations, 8vo. 1826. 

Haden, Pract. Obs. on Colcnicum Autumnalis, 8vo. 1821. 

Harmand de Montgarney, Precis des Maladies, Eruptions, &c., 4to. 
1793. 

HiGGiNBOTH AM, Essay on the Use of Nitrate of Silver, 8vo. 1826. 

Hunter, Treatise on the Blood, 8vo. 1794. 

Hutchison A. C, Med. Chir. Trans., vol. v. 1814. 

Hutchison, Surgical Observations, 8vo. 1816. 
/^Tames, Jacksonian Prize Essay for 1818, 8vo. 

KuTSCHi De Erysipelate Neonatorum, &c., 8vo. 1810. 

Eawrence, Med. Chir. Trans., vol. xiv. 8vo. 1828. 

LEcauttxdCoiiULLy, Essai sur TErytheme et PErysipele, 4to. 1804. 

London Med. Repos. vol.iv. 

Mahon, Edin. Med. Com., vol. xviii. 8vo. 1795. 

Medical and Phys. Journ. January, vol. Ivii. 

Medico- Chirubg. Trans, vol. v. and xiv. 

Paul us -^ginetus, 1. iv. c. 21. 

Pear t^ Practical Information on St. Anthony's Fire, 8vo. 1 802. 

pATisaifia, Essai sur I'Erysipele Phlegmoneux, 4to. 1815. 

Pearson, Principles of Surgeiy, 8vo. 1808. 

Plumbe on Diseases of the Skm, 2d edit. 1827. 



* Mezeray, Abr^g^ Chronologique. See the articles Ergot, and Ignis 
Sacer, in Dr. Rees's Cyclopaedia. 



ERYSIPELAS. l6l 

RAYEE,Trait^ sur les Maladies de laPeau, 1836. 

Renaup. Diss, sur I'Er^ip^le, 1802. 

Renauldin, Dissertation sur I'Erysip^e, 8to. 1802; et Diet, des 
Scien. M^d. tTxiii. 1815. 

RiCHTER, Opuscula Med. vol.i.4to. 1780. 

Saob isseai? , Dissertation sur I'ErysipMe Bilieux, 8vo. 1813. 

Schmidt, de Erysipelate Neonatorum, 8vo, 1821. 

Schroedeb. De Febribus Erjsipelatosis, 12mo. 1777. 

Sydenham, O^scp. 155. 

Terrion, Essai sur rErysip^e, Sec. 4to. 1807. 

Thomson J. on Inflammation, 8to. 181^. 

TwEEDiE, Cyc. of Pract. Med. vol. ii. 8vo. 1833. 

Walshman^ Med. Mem. vol. v. 8vo. 1799. 

Weatherhead . Diagnoas between Erysipelas, Phlegmon, &c. svo. 
1819. 

Wells, Trans. Med. and Chir. vol. ii. 8vo. 1800. 

Wilson on Febrile Diseases, vol. ii. & iii. 



M 



162 



Order IV. 

B U L L iE. 



BLEBS. 

O YN. Phlyctaenae (Aiict. vet.) : Ecphlysis ( Good) : 
Inflammations Bulleuses, Bulles (F.): Wasserblat- 
tem (Germ.). 

Def. A PORTION OF THE CUTICLE DETACHED FROM 
THE SKIN BY THE INTERPOSITION OF A TRANSPARENT 
WATERY FLUID. 

In the original sketch of his arrangement, Dr. Willan 
conjoined in one Order the three following genera, 
Erysipelas, Pemphigus, and Pompholyx, and 
those which now constitute the Order of Vesicles : 
but he was led to separate them in consequence of 
a just criticism of Prof. Tilesius, of Leipsic. * The 
large and often irregular vesications, which are termed 
BullcBy discharge a watery fluid when they break ; 
and the excoriated surface sometimes becomes covered 
with a flat, yellowish or blackish scab, which remains 
till a new cuticle is formed underneath ; and occa- 
sionally is converted into an ulcer, that does not 
readily heal. 

" These blebs sometimes are preceded by redness 
of the skin, but at other times nothing of this kind 

* This criticism was contained in a paper on herpetic eruptions, " Uber 
die flechtenartigen Ausschlage," pubhshed in a German periodical work, 
the Paradoxien of Dr. Martens, at Leipsic, 1802, ii band, i heft. Dr. 
Tilesius pointed out the improper application of Dr. Wilian's definition 
of Bulla, ^ of a large size, and irregularly circumscribed," to the small, 
regular, and clustered vesicles of Herpes ; and he mentioned aJso the 
common inflamed base, upon which the herpetic clusters are seated, the 
scabby crust which invariably forms upon them, &c., as further grounds 
of separation. See p. 18. et seq. of the Paradoxien. — The substance of 
the descriptive part of this paper was inserted by myself in the Medical 
and Physical Journal, for March 1804, vol. xi. p. 250., with an engraving 
of the Herpes zoster. 



PEMPHIGUS. 163 

appears. Their progress is rapid j the full size of the 
bleb being often attained in forty-eight hours. They 
vary in size according to the part of the body on which 
they appear ; those on the face being generally smaller 
than elsewhere.*' 

** They appear on eveiy part of the body, but most 
frequently on the lower limbs. They are seldom 
attended with danger.** 

For the reasons previously stated, Erysipelas has 
been removed from this order into that of the 
Exanthemata. 

The genera of Builse are, 

1. Pemphigus. 

2. pompholyx. 



Genus I. PEMPHIGUS.* 

Syn. Pemphigus (^wc#. «?«r.): Pemphigus major 
{Sauv.): Morta (Z<^/^.) : Febris bullosa ( ^^. Sel- 
ligevj Marten) : Hidrea {Piso) : Typhus vesicularis 
( Young) : der Blasenausschlag ( Oerman) : Blic- 
muitslag (Dutch) : Blancpher {Danish) : Bladder- 
pert ( Smed. ) : Penfigo (Ital. ) : Burbriga ( Span. ) : 
Dartre phlyct6noide, Fifevre v6siculaire ou buUeuse 
(Fr.) Vesicular Fever. 

Def. An eruption of transparent vesicles, 

ABOUT THE SIZE OF A FILBERT, WITH A BED, IN- 
FLAMED EDGE, BUT WITHOUT SURROUNDING BLUSH 
OR TUMEFACTION, CONTAINING A PELLUCID FLUID ; 
ON BREAKING DISPOSED TO ULCERATE. 

There is probably no such fever as that which 
has been described by a few continental physicians, 
under the titles of Febris vesicularis^ ampullosa, or 
bullosa, and to which Sauvages applied the term 

* Ilfft^t^, a bleb. 
M 2 



164 bullje: 

Pemphigus. * * Subsequent nosologists have given 
definitions of the disease, upon the same authority, 
as an idiopathic, contagious, and malignant fever, 
in the course of which phlycta^nae or vesications, 
of the size of a filbert, with an inflamed base, appear 
ifji succession on diflPerent parts of the surface of the 
body, and sometimes in the mouth, t But Dr. 
CuUen justly expressed his doubts as to the accuracy 
of the original writers. The case related by Seli- 

fert, on which Sauvages founds his first species, 
^emphigus major, is worthy of little attention, and 
was perhaps, as Dr. Willan suggests, a case of 
Erysipelas, with some incidental variation. The 
account of the epidemic at Prague, mentioned by 
Thierry §, which is the prototype of the Pemphigus 
castrensis (spec. 2.) of Sauvages, is not entitled to 
credit, as Dr. Cullen remarks, in some of its circum- 
stances : the bullae are supposed by Dr. Willan to 
have been symptomatic of severe typhus, or of pesti* 
lential fever, in the same manner as Dr. Hodges 
described those appearances in the plague of 1666, 
and as* they are occasionally seen, intermixed with 
petechisB and vibices, or with patches, of Erythema 
fugax in typhoid fevers. Again, as to the Pemphigus 
Helveticus (spec. 3.) of Sauvages, which is borrowed 
from the description of Dr. Langhans ||, Dr. Cullen 
is of opinion that the disease was the Cynanche 
maligna ; and Dr. Frank viewed it in the same light, 
referring it to Scarlatina anginosa. % Dr. Willan, 

* Frdtn iti^^Ci^ buUa^ phli/ci<sna. See his Nosol. Method, class iii. 
gen. S, 

f Dr. Cullen defines Pemphigus, "Typhus contagiosa; primo, se- 
cundo, vel tertio morbi die, in variis partibus vesiculae, avellanas mag- 
nitudine, per plures dies manentes, tandem ichorera tehuem fundentes.'^ 
Nosol. Meth. gen. xxxiv. — Linnaeus, who has designated the disease by 
the barbarous term Morta, characterises it as " Febris diaria^ malignis- 
sima, funestissima." Gen. Morbor. class, i. gen. 1 . 

t SeeEphem, Acad. Nat. Cur. dec. i.ann. viii. obs. 56, — Also Delius, 
Amoenit. Medicae, referred to by Sauvages. 

§ See his M^decine Exp^rimentale, p. 134. Par. 1755. 

II In the Acta Helvetica, vol. ii, p. 260. 

t *^ Quern Helveticum alii dixerunt Pe;mphigum, hie ad Scarlatin^ spe- 
ciem tdceros(B pertinere videtur.** Lib. iii. p. 263. Dr. Frank himself, 



PfiMPHIGtrS. 165 

who points out the unsatisfactory nature of the history 
given by Langhans, independently of the contradic 
tions which it contains, proposes a query, whether the 
disease was not rather endemic^ than epidemic or con« 
tagious, and referable to some local cause, like the 
Ergoty Mai des Ardens, &c. before alluded to ? 

In a word, this conclusion seems to be deducible 
from an examination of these slight and imperfect 
histories of the subject, that the notion of an idio- 
pathic contagious fever, terminating in a critical 
eruption of bullae, has been founded in error. All 
the cases of phlyctaenae, which have been related by 
authors, are therefore referable either to typhoid 
fevers, malignant dysentery, &c. in which they are 
accidental and symptomatic * ; or to the following 
genus, Pompholyx, in which they are unconnected 
with fever. " Notwithstanding the authorities which 
Dr. Bateman has brought forward to negative the 
existence of Pemphigus^ I cannot help agreeing with 
fiiett and those who take the opposite side of the 
question, having some years since been fortunate 
enough to meet with an acute case of it in a boy of 
fourteen years of age. The eruption appeared in 
successive crops, and was accompanied with fever not 
of a typhoid type. None of the vesicles exceeded 
th? size of a filbert.** 

Dr. Willan mentions a Pemphigus infantilisy of 
which he had seen a few cases in infants, generally 
soon after birth, and which he considered as analogous 



however, is the author of a singular confusion in regard to the genus 
Pemphigus. He divides it into two species ; the first of which, 1% am- 
pUoTy includes the eruptions of bullae, which he deems in all cases 
fymptomatic of gastric or nervous fevers, or of a chronic nature, witli- 
out any fever : and the second, P. variolodes, which is the chicken-pox ; 
and which he agun subdivides into vesicularis (the true chicken or 
swine-pox), and soiidescens (the acuminated, warty, dry hompock), which 
is, in fact, smallpox. 

* Such was the Pemphigus Indicus (spec. 4.) of Sauvages, taken from 
a single case mentioned by Bontius. — Tne swine-pox, however, seems to 
have been described by mistake under the title of Pemphigus, by Mr^ 
R. B. Blagden, in the Med. Facts and Observations, vol. i. p. 205^ 

M 3 



166 BULL^ : 

to the Erysipelas, which occurs at the same period^ 
and as originating from the same causes. It com- 
monly affected weak and emaciated infants, with a dry 
i^riveled skin, and proved fatal in a few days, from 
the complicated distress arising from pain, loss of 
sleep, and violent fever. The vesications, which were 
at first small and transparent, became large^ oblong, 
and of a purplish hue, and finally turbid, and were 
surrounded by a livid red border. After breaking, 
they left ulcerations, which ^read beyond their ori^ 
ginal limits, and became extremely painful. * •* Gen- 
tle purgatives, with Bark, are the remedies which have 
been found most beneficial in this affection.'^ 

Booh wkkh may be consulted on Pemphif^ ut. 

RitAPWK. Versuch (iber den Pemphigus und das Blasen fieber, 1795. 
Bu NNELy Dissertation sur le Pemphigus, 4to. Paris, 1811. 
Dickson, Trans, of the Roy. Irisn Academy, 1787. 
Gaitskell, Mem. of the Med. Society of London, vol. iv. 
GiLipERT. Monographie du Pemphigus, 8vo. Paris, 1813. 
Hall, Duncan's Annals of Medicine, 1799. 
^Rayeb, des Maladies de la Pean, Paris, 1827. 

WiCHMAWN . Boitrag zur kenntniss des Pemphigus, Erfurt, 1791. 
Wilson on Febrile Diseases, vol. ii. 8vo. 1800. 



Genus II. POMPHOLYX. 

St/n. no/t(poXw§ (Auct GhrcBC.) : Pemphigus sine 
pyrexia (Sauv.) : Pemphigus apyretus (Plemk.) : 
Dartre phlyctenoide confluente — Herpes phlycte- 
no'ides eonfluens (Alibert) : Ecphlysis Pompholyx 
( Oood) : Wassenblasen ( O.) : Ahenje (Arab.) 
Water blebs. 

Def.As ERUPTION OF BULLiE, OR BLEBS, "WITH- 
OUT ANY INFLAMMATION ROUND THEM, AND WITHOUT 

* Consistently with the opinion that all these bullae are symptomatic, 
and that the existence of a peculiar eruptive fever, characterised by such, 
vesications, is imaginary, this infantile disease should, I conceive, have 
been referred to Pompholyx, since it appears to differ from the Pom- 
pholyx benignus of infants, only in beins connected with a severe and 
fatal marasmus, instead of the irritation of dentition. 



pompholyx* 167 

fever/* breaking and healing without scale 

OR CRUST, 

Dn Willan has described three species of Pom- 
pholyx * : 

1. P. benignus. 2. P. diutinits. 

3. P. solitarius. 

Species 1 . Pompholyx hemgnu^ Mild Water 
Blebs. 

This species exhibits a succession of transparent 
bullse, about the size of a pea, or sometimes of a 
hazel-nut, which break in three or four days, dis- 
charge their lymph, and soon heal. They appear 
chiefly on the face, neck, and extremities ; and 
occur in boys in hot weather, in infants during 
dentition, and in young persons of irritable habit 
from eating acrid vegetable substances, or from 
swallowing a few grains of mercury. " This appears 
to be the disease which Dr. Underwood has described 
under the title Phlyctaenae. He says it occurs dur- 
ing dentition, and sometimes in new-bom infants, 
and always appears to be beneficial : * it consists of 
vesications or blisters, of different sizes, resembling 
little scalds or burns, and continues for several days. 
They come out in different parts, but chiefly on the 
belly, ribs, and thighs ; and contain a sharp lymph, 
which it may be prudent to let out by a pimcture.* 
No medicine is necessary but such as the particular 
state of the bowels may caU for/' 

Species 2. Pompholyx diutinuSj Lingering or 
Chronic Water Blebs. 

Syn. Le Pemphigus ctronique {Rayer). 

(Plate XXXIII. of Bateman; PI. 14. of Thom- 
son's Atlas). This is a tedious and painful disorder, 

♦ Foesius observes (OBconon. Hippoc. ad voc. wofi^i^ that Hippo- 
crates uses that word to denote wheals, or those eminences wnich 
resemble the eruption produced by nettles (lib. ii. Ile^i lla9tjv), and that' 
vofi^Xvysc are bubbles of air, which appear upon water : but that Galen 
explains the pomphu as eminences of the cuticle, containing a fluid ; in 
Exegesiy lib. li. de Mulier. — See also Gorreeus, Def. Med. 

M 4 



1^68 BULLiE : 

and is usually preceded for some weeks by languor and 
lassitude, headach, sickness, and pains in the limbs. 
Numerous, red, pimpleJike elevations of the cuticle 
appear, with a sensation of tingling. These are pre- 
sently raised into transparent vesications, that become 
as large as a pea within twenty-four hours, and, if 
not broken, afterwards attain the size of a walnut. 
If they are rubbed off prematurely, the excoriated 
surface is sore and inflamed, and does not readily 
heal. The bullse continue to arise in succession on 
different parts of the body, and even re-appear on 
the parts first affected, in some cases for several 
weeks, so that the whole number of bullae is very 
great ; and when the excoriations are thus multiplied, 
a slight febrile paroxysm occurs every night, and the 
patient suffers much from the irritation, and from 
want of sleep. 

This disease chiefly affects persons of debilitated 
habits, and is very severe in the aged. It seems to 
originate under different conditions of the body, but 
oflen after continued fatigue and anxiety, with low 
diet ; sometimes from intemperance ; and not un- 
frequently it is connected with anasarca, or general 
dropsy, scurvy. Purpura, and other states of the 
constitution, in which the powers of the cutaneous 
circulation are feeble. It has, in some instances, 
appeared after profuse sweating, during which cold 
liquors were copiously swallowed, in common with 
several other forms of chronic cutaneous disease. In 
the fevers in which it has been observed, it was ob- 
viously symptomatic ; for it has not only occurred at 
various periods, and varied much in its duration, but 
has accompanied fevers of the continued, remittent, 
and intermittent type, as well as arthritic, and other 
secondary fevers. * 

* Many cases iilustratiTe of these observations are on record ; espe^ 
daily those related, under the appellation of Pemphigus, by Mr. Grait- 
skel^and Mr. Upton, in the Memoirs of the Medical Society of London, 
vol. iv. art. i. and vol. iii. appendix ; by Mr. Christie, in the Lond. Med» 
Journal, vol. x. p. 385. (for 1789); by Dr. Stewart, in the Edin» Med. 



POMPHOLYX. 169 

«* This form of Pompholyx may be confounded 
with Ecthyma ; but, to an acjpustomed eye, this is 
not very likely to occur, as the buUe of the one 
differ from the pustules of the other, both during 
their continuance, and in the marks which they leave 
after they disappear. The bullae of Pompholyx leave 
a dusky red, isolated^ irregular stain, sometimes 
slightly scaly, like Psoriasis. From Herpes it is easily 
distinguished by the vesicles in the former appearing 
in clusters, in the centre of inflamed patches.'^ 

It is sufficiently clear, from the statements of the 
writers just referred to, that the Pompholyx is never 
communicated by contagion — "indeed, when lymph 
was taken from a vesicle, and introduced by inocula- 
tion into the system of another individual, no disease 
followed. The fluid contained in the vesicles is not 
ichorous, but a bland lymph*, resembling that which 
is poured into the ventricles of the brain in hydro- 
cephalus. In several of the persons, whose cases 
are recorded, the disease occurred more than once. 
The Pompholyx is most troublesome and obstinate in 
old persons, in whom the transparent bulls some- 
times equal the size of a turkey's egg, while others of 
a smaller size are intermixed with them, which appear 
dark and livid. When broken, they leave a Diack 
excoriated surface, which sometimes ulcerates. " The 
first-mentioned form of this disease is seldom severe, 
and never fatal, unless complicated with some internal 
inflammation : but the second, the diiUintiSy is often 
followed by severe ulcerations, which, in the aged, 
are not devoid of danger.*' 



Commentaries, vol. vi. art. 5, p. 79. ; by Dr. Hall, in the Annal^ of 
Med. vol. ill. art. ix. ; by Mr. Ring, in the Liond. Med. Joum. xi. p. 9^5. ; 
by Dr. Dickson, in the Trans, of the Royal Irish Academy for 1787, luid 
liond. Med. J. vol. ix. p. 309. ; and by Bang, in the Acta Keg. Soc. Med. 
Hauniensis, vol. i. p. 8., &c. See also Frank, de Curand. Horn. Morbis,. 
lib. iii. p. 265. Sennert. de Scorbuto, cap. v. § 59» 

* Mr. Gaitskell not only proved this by analysis; but also ascertained 
the uncontagious nature of the fluid, by inoculating himself with it with 
perfect impunity. 



170 BULL^ : 

The warm bath^ used every second day,, was con- 
sidered by Dr. Willan as the most active palliative, 
and the best remedy. I think I have seen the de- 
coction of Cinchona, with cordials and diuretics, of 
considerable advantage in these cases, specially wh^i 
the eruption was combined with anasarca. In young 
persons, in whom Pompholyx is seldom severe, these 
remedies are affirmed by Dr. Willan to be success^ 
ful within two or three weeks ; but the warm bath 
seems to increase both the tingling in the sdcin, and 
the number of the vesications, in these patients.* 
" In the benign form of the disease little is requu-ed 
from the physician: diluents, or vegetable cooling 
diet and mild pui^tives, constitute the whole of the 
treatment. When accompanied with inflammation of 
the mucous membrane, the necessary remedies to re- 
lieve this are to be prescribed without any reference 
to the cutaneous eruption. The excoriations which 
follow the rupture of the vesicles are to be dressed 
with any mild ointment, and if troublesome, to be 
touched with the nitrate of silver. In the more 
severe form of the disease, the warm bath proves often 
highly beneficial ; but it must not be too long con- 
tinued ; never to produce Minting. If there is in- 
ternal inflammation, the antiphlogistic treatment is to 
be pushed to its utmost length. Narcotics are also 
useful ; but the preparations of these ought not to 
contam either wii^ or alcohol. In old persons, and 
those of a delicate habit, acidulated decoction of 
Cinchona Bark, or the Sulphate of Quinia, if not 
forbidden by intestinal irritation, are necessary for 
maintaining the tone of the habit. Purgatives are al- 
ways injurious in the chronic form of Pompholyx." 

* The warm bath sometimes aggravates the disease, even in the aged, 
as I lately had an opportunity of witnessing in an old lady of 80. In 
this case, however, the bvlla, of which eight or ten arose daily for 
several months, were surrounded by an extensive erythematous inflam- 
mation, and there was a considerable tendency to the febrile state. A 
single immersion in the warm bath excited a vioIesMever; and Bark, 
Sarsaparilla, and other tonics, produced a similar efiect. She ultimately 
recovered, under a light and refrigerant diet and regimen. 



POMPHOLYX. 171 

Species 3. The Pompholyx solitaries is a rare 
form of the disease, which seems to affect only women. 
One large vesication usually appears in the night, after 
a sensation of tingling in the skin, and rapidly dis- 
tends itself so as to contain sometimes a tea-cupful of 
lymph, " and closely resembles the effect produced by 
a blistering plaster.** Within forty-eight hours it 
breaks, discharging its fluid, and leaving a superficial 
ulceration. Near this another bulla arises in a day or 
two, and goes through the same course; and it is 
sometimes followed, in like manner, by two or three 
others in succession ; so that the whole duration shall 
be eight or ten days. Cinchona, widi the diluted 
Sulphuric Acid, internally, and linseed poultices, 
followed by light dressings to the sores extemally> 
were employed with advantage in three cases seen 
by Dr. WiUan. 

Books which may be consulted on Pompholi/x,* 

Acta Reg. Soc. Med. Hauniensis, vol. i. 
Annals of IVf edicine, vol. iiL 
BonEl, Dissertation sur le Pemphigus, 4to. 1811. 
Edin. Med. Commentaries, vol. vi. 
Frank de Carand. Horn. Morb. lib. iii. 
^GiLiBgET, Monographie du Pemphigus, 8vo. 1815. 
Condon Med. Joum. vol. ix. x. xi. 
London Med. Repository, vol. ii.Ti. 
Mem. of the Med. Society of London, vol. iii. iv. 
Plumbe's Practical Treatise on Diseases of the Skin, 2d edit. 1827. 
Rater, Trait^ des Maladies de la Peau, 8vo. 1826. 
Tbans. of the Roy. Irish Acad. 1 787. 
WicHMANN , Boitrag zur kenntnis des Pemphigus, 1791. 
WiLLAN on Cutaneous Diseases. 



'* In most of the woi^s referred to, the disease is termed Pemphigus. 



172 



Order V. 



PUSTULiE. 



PUSTULES* 

SYN. ^Xuxraivai (Auict Chrcpc.) : Pustulas (Linn. 
Sag.): Pustules, Boutons (i^.): die Eiterblattem 
( Oerman\ 

Def. (Pustule): an elevation of the cu- 
ticle, WITH AN INFLAMED BASE CONTAINING PUS, 

There are four varieties of pustules. 

a. Phlyzacium ; a pustule commonly of a large 
^ize, raised on a hiard circular base, of a vivid red 
colour, and succeeded by a thick, hard, dark-coloured 
scab.* This variety generally accompanies acute 
diseases. 

h. Psydracium ; a small pustule, often irregularly 
circumscribed, producing but a slight elevation of 
the cuticle, and terminating in a laminated scab.t 
Many of the psydracia usually appear together, and 
become confluent ; and, after the discharge of pus, 
they pour out a thin watery humour, which fre- 
quently forms an irregular incrustation. They appear 
in chronic affections. 

* The derivation of this term, ^ avo rov ^Xvm, 0XvCa>» fiive f!\v<r<r6iif 
quod J^ervere significat, et ebtdUre^* (Gorraei Def. Med.) would render it 
sufficiently appropriate to elevated and inflamed pustules, if we had not 
possessed also the Interpretation left by Celsus : " ^Xv^okcov autem paulo 
durior pustula est, subaibtda, acuta; ex qua quod exprimitur, huroidum 
est. Ex pustulus vero nonnunquam etiam ulcuscula fiunt, aut aridiora, 
aut humidiora : et modo tantum cum prurigine, modo etiam cum in- 
flammatione aut dolore; exitque aut pus, aut sanies, aut utrumque. 
Maxim^ue id evenit in setate puerili: raro in medio corpore; ssepe in 
eminentibus partibifs." (De Medicina, lib. v. cap. 28. ^ 1 5.) 

f As the Phlffzacia were denominated from the heat of the eruption, 
so the Psydracia received their appellation from the opposite quality, 
^ quasi U^Kpa vSpaKiOy id est, frigidtB seu frigefacts guUuug,** says Gor- 
rseus. — The psvdracia are enumerated among the eruptions peculiar to 
the head by Alexander and Paul, and some other Greek writers; but 
Galen and others mention them as common to other parts of the body 
(See Alex. Trail. Op. lib. i. cap. 5. Paul. .^E^n. lib. iii. cap. 1, Actua- 
rius, lib. vi. cap. 2.) See also Impetigo, below, p. 145. 



PUSTULJE. 173 

c. Achor ; and 

d. Favus. These two pustules are considered 
by the majority of writers from the Greeks down-^ 
wards, as varieties of the same genus, differing 
chiefly in magnitude.* The Achor may be defined, 
a small acuminated pustule, containing a straw- 
coloured matter, which has the appearance and 
nearly the consistence of strained honey, and succeeded 
by a thin brown pr yellowish scab. The Favus^ or 
xTj^iov, is larger than the achor, flater, and not 
acuminated, and contains a more viscid matter; its 
base, which is often irregular, is slightly inflamed ; 
and it is succeeded by a yellow, semi-transparent, and 
sometimes cellular scab, like a honeycomb ; whence 
it has obtained its name. 

Pustules t originate from an inflammation of the 
skin, and the consequent partial effiision of puru- 
lent matter under the cuticle, by which the latter 
is elevated into small circumscribed tumours. Some^ 
times several of these elevations arise upon a common 
inflamed surface ; but most frequently the inflam*- 
mationof the base of each is distinct and circumscribed. 
The fluid contained in them desiccates, and often 
terminates in a scabby incrustation, varying in 

* See Aetius, tetrab.ii. serm.ii. cap. 68. — Alex. Trail, lib. i. cap. 8. 
& 9. — Paul. ^gin. de Re Med. lib. iii. cap. 5.— Oribas. de Loc. Affect, 
lib. iv. cap. 12. 

f Although it seems obvious, that the origin of this tenn was deduced 
from the purulent contents of the eruption (({uasi, pus iulU); yet the 
best ancient authority sanctions the common indefinite and unlimited 
use of it. For Celsus applies it to every elevation of the cuticle, includii^ 
evens wheals and papulse, " quae ex urtica, vel ex sudore nascuntur;" 
and he deems it synonymous with t^av9tifia of the Greeks, which was, 
in fact, the general term for every species of eruption. (Celsus de 
Med. lib. V. cap. 28. $ 15.) — The Greek physicians appear to have 
comprehended both pustules and vesicles under the term ^Xvicratvai, 
which their translators have rendered by the word puttuUs; and in this 
double sense the latter has also been generally used. Some discrimin- 
ating writers, however, have, correctly appropriated it to suppurating 
eruptions. ** Pustularum nimirum conditio, ' says Prof. Amemann, 
** exigit, ut in apice suppurentur vel in pus abeant," Commentar. de 
Aphtnis, Crott. 1787. § 2. See also Linn. Gen. Morb. class, xi. ord. 4, 
— ^Sagar, class i. ord. 2. 



174 pustule: 

hardness according to the various tenacity of the 
€(Hitained iluid : sotmetimes in superficial ulceration. 
<* Rayer justly remarks, that the number, form, and 
aspect of the |mstulous ulcerations, of the tubercles 
which succeed them, and even of the cicatrices, should 
be attentively studied, as they are often characteristic 
of the genera.** " Every part of the body may be 
the seat of pustules : but some are more liable to 
attack certain parts than others : thus Fbrrigo 
j generally afiects the hairy scalp, Acn^ the face and 
chin, and Impetigo the lower extremities. The 
colour of pustules varies from a dull white to a bright 
yellow; and that of the crusts that succeed them 
■ from greenish-yellow to dark brown/' 
f " Pustular eruptions are usually contagious ; but 
)they also appear spontaneously. The diagnosis is 
not difficult, and depends on the opacity of the fluid 
I contained in the pustules, at an early stage, whereas 
\ in vesicular eruptions, the sero^purulent matter of the 
' vesicles does not appear until their decline, the fluid 
in the commencement being nearly tranroarent." 
With the exception of smallpox, the prognosis in the 
pustulae is favourable : they rarely or never terminate 
/in death. The five genera of pustular diseases, 
comprehended in this order, have nothing in common 
in their character, except the appearance of pustules 
in some state of their progress ; for some are con- 
tagious, and others not ; some are acute, and others 
chronic. These genera are, 

1. Impetigo. 4. Variola. 

2. PoRRKJo. 5. Scabies. 
S. Ecthyma. 



Genus I. IMPETIGO. 



Sj/n. Lepra Squammosa, herpes, vitiligo, phlystena, 
{Aicctorum) : Ecpyesis Impetigo ( Good) : rhlysis 
In^petigo ( Young) : Herez (Arab.) : Courap 
(Hindos.): der Kleienausatz Zittermal, ring- worm 



IMPETIGO. 175 

( O.) : Schurftheid, ring-wonn(2>.) : Ringwonn (i>aw. 
and Swed.) : Impetigine {ItdU) : Compeine {Span.) : 
Dartre crustacee, Lfepre humide (i^.): Humid or 
Running jHsttery or ScalL 

Def. An eruption of yellow, itching pus* 

TULES APPEARING IN CLUSTERS } AND TERMINATING 
IN A YELLOW, THIN, SCALY CRUST. 

This eruption is diaraeterised by the abearance 
of the small pustules^ denominated Psydrada. It 
is not accompanied by fever, is not contagious, nor 
communicable by inoculation. It chiefly occurs mi 
the extremities, although sometimes on tihe &oe. It 
appears under the seven following forms * : 

1. l.Jigurata. 5. I. rodens. 

2. I. sparsa. 6. I, larvalis. 

3. I. erysipelatodes. 7* !• favosa. 

4. I. scabida. 

Although the Editor would willingly retain the ar- 
rangement of Bateman, yet he prefers a modification 
of that which he proposed in the article Impetigo^ in 
the Cyclopaedia of Practical Medicine j namely. 

Species 1. Impetigo simplex. 

Var. a. Impetigo figuratOy 
6. Impetigo sparsa^ 

c. Impetigo scabida, 

d. Impetigo rodens, 

e. Impetigo larvalis, 
f. Impetigo favosa : 

2. Impetigo erysipelaiodes. 

In the first of the above species, little or no fever 
precedes the eruption ; in the second it is always a 
preliminary. 

* Celsus has described four species of Impetigo, the first of which is 
a pustular disease, terminating in excoriation, and corresponds with the 
affection described in the text. His other varieties seem to include some 
of the more violent forms of Psoriasb, or Lepra. See the 28th chapter 
of his 5th book, §17. 

The ulcerated Psora (ij/a»pa cXkwJiic) of the Greeks was apparently the 
same affection with the Impetigo of Celsus. 



176 fustulje:: 

Species 1. Impetigo simplex. 

Var. a. Impetigo Jigurata^ Figured or Herpetic 

ScALIi. 

Syn. Ecpyesis Herpetica ( Good) : Herpes ( CW- 
len)i Phlyctaena (/^og*.). 

This species (Plate XaXIV. of Bateman ; PI. 15. 
of Thomson's Atlas,) is the most common variety of 
the moist tetter. " It generally attacks the youi^, 
and those ^ho possess what is termed a lymphatic tem- 
perament; but is rarely preceded by symptoms of 
fever, or general derangement of the habit. It is more 
commonly situated on the face, as the cheeks, the chin, 
the upper lip, the sides of the nostrils, than on other 
parts of the body : but it occasionally occurs on the 
extremities.'^ It appears in circumscribed patches, 
of various figure and magnitude, which are usually 
small and circular on the upper, and large, oval, and 
irregular on the lower extremities. The patches 
consist at first of clusters of the yellow psydracious 
pustules, set close together, and surrounded by a 
slight inflammatory border ; the whole being some- 
what raised, but the pustules not very prominent nor 
acuminated. In a few days the pustules break, and 
discharge their fluid ; the surface becomes red and 
excoriated, shining as if it were stretched, but 
exhibiting numerous minute pores, from which a 
considerable ichorous discharge is poured out, accom- 
panied with much troublesome itching, heat, and 
smarting. The discharge soon concretes partially 
into thin, semitransparent, yellowish or greenish scabs ; 
but it still continues to ooze from under the scab, 
which it forms, " and occasionally forms a thick crust, 
not unlike the exudation of gum on a cherry tree." 
In the course of three or four weeks, as the quantity 
of the discharge diminishes, the scabs dry and fall off, 
leaving the surface » of the cuticle red, rough, and 
somewhat thickened, and at the, same time extremely 
brittle, and li^^ble to crack and to be excoriated ; so 
that the ichorous discharge and scabbing are easily 
reproduced, and the disease is often thus much 



IMPETIGO. 177 

prolonged in its duration. Occasionally fresh crops 
of the psydracious pustules re-appear, as at the com- 
mencement ; and the whole course of the eruption is 
repeated. 

When the Impetigo figurata is beginning to heal, 
the patches undergo a process somewhat similar to 
that which takes place in the Lepra vulgaris. The 
amendment commences at the centre of the patch, 
which first subsides, leaving the border elevated : at 
length this also disappears; but the cuticle, which 
was the seat of the patch, remains for some weeks red, 

•shining, and tender. 

But though this is the most usual and regular, it 
is by no means the uniform progress of Impetigo. 
For this eruption, like Scabies and Eczema, varies^ 
so much in iis phaenomena, as almost to bid defiance 
to arrangement. Sometimes the patches enlarge 
by the formation of successive pustular margins ^ 
an exterior circle of pustules arising, while the 
preceding border is drying, to be followed by others 
which go through the same course, until the patch 
attains a considerable extent. The area, in the 
meantime, becomes dry and rough, with a scaly 
or scabby incrustation in its centre.* Sometimes 
the papulse of the Lichen agrius becom^ pustular, 
or are intermixed with psydracia, as before men- 
tioned^ and the disease assumes all the characters 

^ of Impetigo. 

But the aflGlnity of Impetigo with the vesicular 
diseases is manifested by a common variety of it, 
in the upper extremities, in which the psydracious 



* This impetiginous ringworm bears a considerable resemblance to 
the Herpes circinatus, which spreads by a succession of vesicular bor- 
ders. A severe form of this tetter occurs in hot climates, according to 
the testimony of physicians who have practised there. See Hilary on 
the Diseases of Barbadoes, p. 352. (2d edit.) — Towne on the same^ 
chap. 8 — Winterbottom's Account of Sierra Leone, vol* ii. chap. 9. — 
Probably it is this form of Impetigo which Bon tins mentions as a most 
distressing disease in India, where it is called by the natives Courap, 
(De Med, Indorum, cap. 17.) 

N 



178 PUSTULiE : 

pustules are intermixed with transparent vesicles, 
resembling the pustules in size and form. Where 
this intermixture occurs, the disease is much more 
troublesome, from the extreme irritation, itching, 
smarting, and heat, which accompany it ; and much 
more tedious and difficult of cure. It takes place 
chiefly on the hand, about the knuckles and sides of 
the fingers, or on the wrist ; and the space between 
the metacarpal bones of the fore-finger and thumb is 
usually the seat of one of the blotches. The vesicles 
are slower in their progress than the psydracia : they 
remain many days transparent, but not much elevated, ' 
the cuticle over them being thick in that situation. 
When they break, an acrid ichor is discharged, which 
produces inflamed points where it touches the cuticle, 
and these become vesicles or psydracia. i£ach vesicle, 
thus broken, is not disposed to heal ; but the cuticle 
round its base now becomes inflamed and raised, and 
discharges a thin ichor, when in any degree irritated. 
The vesicles appear, in slow succession, at a little 
distance from each other and from the pustules ^ and 
at length an irregular blotch is produced, of a red, 
chopped, and thickened cuticle, interspersed with the 
rising eruptions, little humid ulcers, and chops or 
fissures.* The sense of burning and intense itching, 

* This mixed form of the disease has misled the generality of writers 
to confound it with Herpes, under which term it is commonly described. 
Such is the Herpes of Dr. Cullen. '* Pblyctaense, vel ulcuscula plurima, 
gregalia, serpentia, dysepuleta." Nosol. gen. 147. And Prof. Callisen's 
brief description of Herpes, in one of its varieties, is an accurate deli- 
neation of this Impetigo. *' Herpes pustuiosia, crustotus, serpigo, quern 
constituunt papulae pejores corrosivse, quae congestae aream circularem 
constituunt, acut^ pungentem, valde pruriginosam, deind^ pars ilia te- 
gitur crusta cuti firmiter adglutinata, k transudatione humoris tenuis 
et acris h cute porosa ; ichor, si tangit alias partes, istas simili malo de- 
faedat, unde late serpere solet hoc malum, tamen absque exulceratione." 
(Chirurg. Hodiem. § 612.) See also Wiseman's Chirurg. Treatises, i. 
chap. 17. on Herpes. Turner on the Dis. of the Skin, chap, v., where 
Herpes and Tetter are used as synonymous terms. — But it is to be 
recollected, that, in this arrangement. Herpes is appropriated to a purely 
vesicular disease, which has a short and nearly uniform course often or 
twelve days, the vesicles of each natch becoming confluent, and at 
length covered with a dry crust. Ot this genus, the shingles afTord the 
most characteristic example. 



IMPETIGO. 179 

accompanying especially the first rise of the vesicles, 
is extremely distressing, and is much aggravated by 
the irritation of almost every application that is re- 
sorted to. 

Var. b. Impetigo sparsa^ Scattered Running 

So ALL. 

St/n. Ecphyesis sparsa ( Good). 

This species (Plate XXXV. of Bateman ; PI. 15. 
of Thomson's Atlas) differs from the preceding 
rather in the form^ than in the nature and progress 
of the eruption ; for, with the exception of tne inde- 
terminate distribution of the pustules, which are not 
congregated in circumscribed clusters, but dispersed 
without any regular order along the extremities, and 
sometimes about the neck and shoulders, and even on 
the face, ears, and scalp, the foregoing description is 
applicable to both species of the disorder. The Im- 
petigo sparsa more frequently occurs in the lower 
extremities than the former; and is, in that situ- 
ation, more troublesome and obstinate. It occasion- 
ally appears in one limb only, whilst every other part 
of the body is free from eruption. In elderly people, 
especially of debilitated habits, the excoriations are 
liable to pass into deep, irregular ulcers, surrounded 
by a purplish colour, and often accompanied with 
oedema. 

These two forms of Impetigo are not always traced 
to any obvious exciting cause : but they are frequently 
preceded by some derangement of the digestive 
organs, languor, and headach. A predisposition to 
the disease appeahrs to be conected with the sanguine 
temperament, with a thin soft skin, and a relaxed 
and bloated habit of body ; or with the sanguineo- 
melancholic temperament, a spare form, and a thin 
but harsh skin. Certain seasons appear to have great 
influence on the disease, in those who are predisposed 
to it. " Certain kinds of diet also, as salt, and 
especially tainted food.'* The I. sparsa, especially 

N 2 



180 pusTULiE : 

on the lower extremities, is apt to return with regu- 
larity in spring and at the latter end of autumn, and 
to harass the patient during the whole of the winter, 
but disappears in the warm weather: while the !• 
figurata, aflPecting the upper extremities, is liable to 
recur chiefly in the spring ; of both which I have 
witnessed several examples.* The accession of the 
eruption has, in other instances, been ascribed to 
violent exercise, intemperance, cold, and sudden de- 
pressing passions, especially fear and grief.t 

The I. sparsa is not unfrequent in young children, in 
whom it appears to be a sequela of the Porrigo (Impe- 
tigo) larvalis; if, indeed, it be not the same disease, as 
I have above hinted. The disease in these young sub- 
jects fixes itself particularly in the flexures of the 
large joints, and is accompanied with intense itching,^ 
which greatly disturbs the rest. It recurs frequently 
under every irritation, as from dentition, &c., some- 
times even till after the second dentition is com- 
pleted, or till near the period of puberty; after 
which the predisposition to its attack ceases. It 
occasionally supervenes to Lichen. 

Local Tetters are produced by the action of par- 
ticular iiritants on the cuticle, which soon disappear, 
when the source of irritation is withdrawn. The 

* In this and some of the preceding circumstances, the accuracy of 
the brief description of Celsus is manifest. The first form of Impetigo 
is that, * quae ^militudine scabiem repraesentat ^ nam et rubet, et du- 
rior est, et exulcerata est, et rodit. Distat autem ab ea, qua: magis ex- 
ulcerata est, et varis similes pust-ulas habet, videnturque esse in ea quasi 
buUuIse qnaedam, ex quibus interpositio tempore quasi squamuise 
solvuntur; certioribusque haec temporibus revertitur." 

•(* In two gentlemen, whom I lately had occasion to see, affected with 
Impetigo, the eruption was imputed to great alarm and agitation of 
mind. Some of the scaly eruptions also are now and then referred to 
fear and grief, as well as the tubercular Elephantiasis. Sec Dr. Tho. 
Heberden's remai4c8 on the Elephantiasis in Madeira (Med. Trans, vol.i. 
art. 2.); and those of Dr. Joannis on that of Martigues (Med. Obs. and 
Inquir. vol.i. art. 19.) Some time ago we witnessed the extraordinary 
influence of mental alarm on the cutaneous circulation, in a poor 
woman, who became a patient of the Public Dispensary. A sudden 
universal anasarca followed,- in one night, the shock occasioned by the 
loss of a small sum of money, which was all she possessed. (SeeEdinb. 
Med. and Siirg. Journal, vol. v. p. 127.) 



IMPETIGO. 181 

aflPection of the hands and fingers, in those who work 
among sugar, which is called the grocer^s itchy is of 
this nature ; and similar eruptions are produced on 
the hands of bricklayers, by the acrid stimulus of 
,lime ; and in workmen employed with some metallic 
\ powders. It is worthy of remark, that both the 
grocer's and the bricklayers itch is, in some indi- 
viduals, a pustular, and in others a vesicular eruption, 

1 referable to the Eczema ; but in neither case conta- 
gious, as the popular appellation might lead us to 
suppose. 

Local pustular patches are also the result of the 
application of theTartrate of Antimony and Potassa to 
the skin by friction, and in some cases of the application 
of blisters, and other stimulating plasters. These pus- 
tules are liable to extend considerably beyond the 
blistered or stimulated part, and sometimes continue 
to arise in succession for a fortnight or more ; and 
many of them often assume the form of Phlyzacia 
(Def 5. a), or of large protuberant pustules, with a 
hard, elevated, and inflamed base. Some of these 
even acquire the size of small boils, and suppurate 
deeply and slowly, with great pain, and considerable 
restlessness and feverish heat in the night. 

f The Impetigo figurata and sparsa are sometimes 
confounded with two contagious diseases, of the pus- 

I tular order, Porrigo and Scabies. The appellation of 

' ring-worm^ which is popularly given to the oval or 
circular patches of the first, has partly contributed to 
occasion this mistake. They diflPer, however, from 
the circles of Porrigo, inasmuch as the \. figurata 
seldom affects children, — occurs principally on the 
extremities, — and they do not continue to discharge 
a purulent and glutinous, but, after the first erup- 
tion, an ichorous humour, — nor do they form the 
thick, soft, and copious scabs of Porrigo : not to 
mention the absence of contagion. 

The prevalence of transparent vesicles in the 
patches of Impetigo, may mislead an incautious or 

N 3 



182 PUSTULJE : 

inexperienced obseiTer into a suspicion that the 
disease is Scabies : but the distribution of the erup- 
tion in patches^ — the copious exudation of ichor, — 
the rough, reddened, and fissured cuticle, — the 
magnitude and slow progress of the vesicles, and the 
heat and smarting which accompany the itching in 
ImpetigOj will serve in general to determine the 
diagnosis. In the strictly purulent form of Scabies, 
the pustules about the hands arise to a much greater 
magnitude and elevation than the psydracia; they 
are filled with a thick yellow pus, and are more con- 
siderably inflamed round their base. 

The Impetigo in its advanced stage is, however, 
more liable to be mistaken by common observers, and 
is, in fact, daily mistaken for Psoriasis or Lepra ; as 
a sufficient discrimination is not made between the 
laminated and scale-like concretions of the ichorous 
matter, and the exfoliations of morbid cuticle which 
constitute the true scab. But the scaly diseases emit 
no fluid and the very existence of a discharge, how- 
ever slight, is sufficient to determine the diagnosis of 
the eruption. 

** The scabby eruption that often appears on the 
face in secondary syphilis, has also been mistaken for 
Impetigo. In the latter disease, the crusts are large, 
thick, dark-coloured, very adhesive, and seated on a 
lurid or violet-coloured base ; and generally leave, 
when they fall, either deep ulcerations or permanent 
cicatrices. These characters aid sufficiently the diag^ 
nosis.'* 

In the incipient state of these two forms of Im- 
petigo, it is useful to administer Sulphur internally, 
in such quantities as not to induce purging; and 
if there is much irritability or inflammation of the 
cuticle, a portion of Soda, Nitre, or Crystals of 
Tartar, with which Conium, and Acids, as that of 
Lemons, Limes, or Barberries, may be advanta- 
geously combined. The Impetigo sparsa commonly 
yields to these medicines, particularly if diligent 



IMPETIGO. 183 

ablution with tepid water be at the same time em- 
ployed. But when the disease is of long standing, it 
requires a treatment somewhat similar to that re- 
commended for inveterate Psoriasis ; namely, the diet 
drinks, decoctions of Sarsaparilla and Cinchona, with 
the fixed Alkalies and Antimonials. The mercurial 
alteratives, however, in this affection are of essential 
assistance to this plan of cure ; such as small doses 
of Cinnabar, the Hydrargyrus cum Creta, or the pill 
of Dr. Hummer. " In those cases which have come 
under my care, I have seen more benefit from the 
occasional administration of from gr. v to gr. viij of 
Submuriate of Mercury at bedtime, and a brisk 
cathartic on the following morning, than from a con- 
tinued course of alteratives.*' 

The external applications adapted to these forms 
of Impetigo, especially to the figured species, are 
the mild desiccative ointments ; for, in the majority 
of cases, the irritable surface of the tetter will not 
bear stimulants with impunity. When the discharge 
is considerable, the ointments prepared with the 
Oxide of Zinc alone, or united with Saturnine 
Ointment, or with the white precipitated Oxide of 
Mercury, are the most efficacious, in allaying the in- 
flammatory condition of the excoriated surface, and 
in reducing the quantity of the discharge. When 
there is less of this irritability and exudation, the 
Tar Ointment most effectually relieves the itching ; 
the ointment of the Nitrate of Mercury, diluted with 
five or six parts of simple ointment, will also be bene- 
ficial. From the too active employment of this oint- 
ment, and still more of that of the Nitric Oxide of 
Mercury, and various other stimulant lotions and 
applications, by practitioners unacquainted with the 
character of the disorder, a great aggravation of the 
eruption and of the sufferings of the patient is some- 
times occasioned.* 

* Formerly a lotion made by macerating the root of the Water 
Dock (Lapathum) in vinegar was much employed. T. 

N 4 



1.84 PUSTULiE : 

In some instances, indeed, the skin, under this 
impetiginous affection, is peculiarly sensible to the 
stimulus of Mercury, whether employed internally 
or externally. I think I have observed this circum- 
stance most frequently in a few cases which were the 
sequelae of Lichen. But the most irritable of all the 
varieties of Impetigo are those in which vesicles 
abound ; in some of which the Zinc, and saturnine 
applications, and even simple lard, occasion an aggra- 
vation of the symptoms. In these cases, it is parti- 
cularly necessary to keep the parts covered, with a 
view to avoid the effects of friction from the clothes, 
as well as of heat, and of cold ; to wash the surface 
daily with some emollient fluid, such as milk and 
water, or an infusion of bran ; to interdict the use of 
soap ; and to besmear the parts with cream, or an 
emulsion of almonds. A lotion prepared by boiling 
Mallow, Digitalis, and Poppy-heads has been found 
serviceable where the parts are very painful. In 
many cases, however, the stiffness, which ensues upon 
the speedy drying of these lotions, renders it impos- 
sible to use them, and it is necessary to cover the 
part lightly with dry lint only, or to interpose be- 
tween it and the diseased surface a sprinkling of the 
Oxide of Zinc : sometimes, however, the application 
of linen dipped in melted suet affords relief, when no 
other greasy substance can be used. " The editor 
was induced, some years since, to apply the Hydro- 
cyanic Acid in the form of lotion in Impetigo, and 
found that it allayed the irritation more effectually 
than any other means. It has since been very gene- 
rally employed for this purpose. The following is 
the formula which he originally used : — 

9) Acidi H^drocyanici f 5iv, 
Aquae distillatae f 3vij> 
Alcoholis f 5iv ; 
Misce ut fiat lotio. 

" He has, however, lately found, that the efficacy 
of this application is greatly increased by the 



IMPETIGO. 185 

addition of sixteen grains of the Acetate of Lead. 
This lotion not only soothes the irritability of the 
part, but also disposes the skin to take on its 
healthy action. ^ Mr. Plumbe cautions against the 
external employment of Hydrocyanic Acid, and 
mentions that in two cases, of both legs, in which 
the eruption extended from the ancle to the knee, 
where it was employed, a considerable intermission 
of the pulse took place, which ceased on its being 
discontinued. " In my experience of the extemu 
use of Hydrocyanic Acid, I have seen no bad effects 
result from it.** 

In the drier and less irritable forms of the Impetigo, 
the use of the waters of Harrowgate is the most 
effectual remedy, and likewise the best preventive of 
its returns : under the same circumstances, the warm 
sea- water bath, followed by a course of bathing in the 
open sea, is productive of great benefit. But during 
the existence of any actual inflammation, the irritation 
of salt-water is decidedly injurious. " Nothing in 
the form # of bath is so successful as the Sulphur 
Vapour Bath.** 

Var. c. Impetigo scahida Crusted Running 

SpALL. 

Syn. Lepra Herpetica ( Sauvages) : Ecpyesis 
laminosa ( Oood). 

In this more rare and severe form of the disease 
(Plate XXXVI. of Bateman ; Plate 15. of Thom- 
soN*s Atlas), one or more of the limbs becomes 
encased in a thick, yellowish, scabby crust, not 
unlike the bark of a tree, which is accompAiied with 
a disagreeable heat and itching, and renders the 
motion of the affected limbs difficult and painful. 
This crust is the result of the concretion of an 
acrimonious humour, which is discharged in great 
abundance from numerous psydracious pustules, as 
they successively form, break, and ulcerate over the 
surface of the limb. The concretion commences 



186 PUSTUL-ffi : 

about the third or fourth week, when the discharge 
begins to abate, and invests the whole of the arm 
from the elbow to the wrist, or the leg from the 
knee to the ancle.* After some time longer, the 
scabby coating is divided by large cracks or fissures, 
from which a thin ichor exudes, and concretes into 
additional layers of scabs. If any portion of the scab 
be removed, the excoriated surface pours out its fluid 
SLgsaiiy and fills up the space with a new concretion. 
In the lower extremities the disease is most severe 
and obstinate, is ultimately conjoined with Anasarca, 
and often produces severe ulceration. The incrust- 
ation sometimes extends to the fingers and toes, 
and destroys the nails ; and, as in other similar 
instances, the new ones are thick, notched, and 
irregular, t 

The I. scahida requires the same internal medi- 
cines which have been recommended for the inve- 
terate forms of the preceding varieties, especially 
the sulphureous waters. The chief peculiarity of 
its treatment consists in clearing the surface of its 
incrustation, and correcting the morbid action of 
the superficial vessels. The thick scab can only be 
softened and gradually removed, by perseverance 
in the application of the steam of warm water to 
it, for a short time, daily ; or mild poultices. Those 
parts of the surface which are thus cleared must 
be covered with soft linen, after tepid ablution, 
twice a day ; and some of the Unguentum Zinci, or 
a much-diluted ointment of Nitrate of Mercury, 
with common cerate (containing, for example, a 



* Sauvages observes, that this affection is called Dartres encroutees 
by the French ; but he describes it under the appellation of Lepra 
herpetica. ^^ Cognoscitur ex herpetibus crustaceis, squamosis, albis, 
hyeme majoribus, et suppurantibus ; noctu intolerabiliter prurientibus : 
brachia ambo usque ad carpum, ambo femora tibiasque usque ad pedes, 
quandoque tegentibus; scaJptu cruentatur haec lepra; popliteset cubiti 
vix flecti possunt : praecesserunt non raro tineae mabgnae." Class x. 
gen. xxvii. spec. 7. , 

f See Lepra, above, p. 27. 



IMPETIGO. 187 

fourth or fifth part of the mercurial), or simply the 
Oxide of Zinc, or Calamine in powder, must be 
interposed. 

Var. d. Impetigo rodens. Corroding Running 

SCALL. 

Si/n. Ecpyesis Exedens ( Good). 

This is a rare but intractable species of the dis- 
ease, probably of a cancerous nature, in which the 
cellular membrane is affected, as well as the skin, 
and seems to shrink away as the ulceration and dis- 
charge go on. The disorder commences with a 
cluster of pustules, sometimes intermixed with ve- 
sicles, which soon break, and discharge for a long 
period of time an acrid humour, from open pores or 
from under scabs ; and the skin and cellular texture 
are slowly, but deeply and extensively, corroded^ 
with extreme irritation and pain, which are only to 
be alleviated by large doses of opium. The disease 
commonly begins on the side of the chest or trunk of 
the body, and gradually extends itself. I have not 
seen any instance of this disease, which is said to have 
always terminated fatally, and to have been benefited 
by no medicine, either external or internal, which had 
been employed. 

Far. e. Impetigo larvalisj Milk Scall. 
Syn. ^A,)(mq(Auct. Chrcec.) : Crusta lactea (Au€t. 
var. Lot.) I Tinea lactea (^Sauv.)i Scabies capitis 
simplex (Plenck) : Tinea benigna (^Auctorum) : 
Ecpyesis Porrigo, a. Crustacea ( Good) : Teigne mu- 
queuse. Tinea muciflua (Alibert): Porrigo larvalis 
Willariy Bateman) : die ICopfraude, der Milchgrind 
German) : Croute de Lait {F.)\ Munday Cdrapang 
Tamool). 

This is the Crusta lactea of authors (Plate 
XXXVII. of Bateman; PL 16. of Thomson's 
Atlas), and is almost exclusively a disease of in- 
fancy. "It is generally supposed to be non-corita- 



i 



iSS PUSTULE . 

gious ; but Alibert mentions the case of an infant who 
was inoculated with the complaint, and took it. The 
same author remarks, that it most commonly appears 
in those who have golden-coloured hair." ** The chil- 
dren of the poor, who are often permitted to eat ba- 
con, and other gross kinds of food, and are, at the 
same time, the victims of uncleanliness, often suffer 
from this species of impetigo.'* * It commonly ap- 
pears first on the forehead and cheeks, in an eruption 
of numerous minute and whitish pustules, which are 
crowded together, upon a red surface. These pus- 
tules soon break, and discharge a clear, viscid fluid, 
which concretes into thin yellowish or greenish scabs. 
As the pustular patches spread, the discharge is 
renewed, and continues also from beneath the scabs, 
increasing their thickness and extent, until the fore- 
head, cheeks, and even the whole face, become enve- 
loped, as by a mask (whence the epithet larvalis)^ 
the eyelids alone remaining exempt from the incrust- 
ation, t " The odour of the eruption is rank and 
peculiar.*' t The eruption is liable, however, to con- 
siderable variation in its course ; the discharge being 
sometimes profuse, and the surface red and exco- 
riated ; a state to which young infants are very liable : 
at other times the discharge is scarcely perceptible, so 
.that the surface remains covered with a diy and 
brown scab. When the scab ultimately falls off, and 
ceases to be renewed, a red, elevated, and tender 
cuticle, marked with deep lines, and exfoliating several 
times, is left behind ; differing from that which suc- 
ceeds to Impetigo scabida, inasmuch as it does not 
crack intcf deep fissures. 

* A case of it in an adult lately came under the care of the Editor, 
which could only be traced to continued excesses in drinking. The erup- 
tion covered the face, ears, neck, and breast. T. 

-|- *' Imo quandoque frontem occupant, et totam faciem, exceptis 
palpebris, larvd tegunt." Plenck, p, 77. 

% Celle du lait qui commence k s'aigrir ou k se putr^fier." Alibert, 
liv:i. p; 11. T. 



iMPETreo. 189 

Smaller patches of the disease not unfrequently 
appear about the neck and breast, and sometimes on 
the extremities : and the ears and scalp are usually 
affected in the course of its progress. In general 
the health of the child is not materially affected, 
especially when the eruption does not appear in 
the early period of lactation ; but it is always ac- 
companied with considerable itching and irritation,, 
which are most severe in young infants, and often 
greatly diminish the natural sleep, and disturb the 
digestion. ** In children of full habits, as Mr. 
Plumbe justly remarks*, when the eruption occu<« 
pies the fore part of the neck, * extending from 
the chin and angles of the lower jaw to the clavicles,' 
the pain and irritation are most distressing to the 
little sufferers :" and much debility sometimes ensues. 
The eyes and eyelids become inflamed, and purulent 
discharges take place from them and from the ears ; 
the parotid t and subsequently the mesenteric glands 
also inflame ; and marasmus, with diarrhoea and hectic, 
cut off the patient. 

Most commonly, however, the disease terminates 
favourably, though its duration is often long and 
uncertain. It sometimes suddenly puts on the ap-» 
pearance of cessation, and afterwards returns with 
severity ; sometimes it disappears spontaneously soon^ 
after weaning, or after the cutting of the first teeth ; 
and sometimes it will continue from two or three 
months to a year and a half, or even longer. Dr. 
Underwood says, " I never saw an infant much loaded 
with it, . but it has always been healthy, and cuts its 
teeth remarkably well.t In general, however, al- 
though it appears in the most healthy children, yet it 
is the consequence of repletion, and the irritation of 
undigested food upon highly excitable systems ; and 

* Practical Treatise on Diseases of the Skin, 2d edit. 1827, p. 220. 
f Plenck says, "Tumdae simul sunt glandulse jugulares raro paro« 
tides." Doct. de Morb. Cut. p. 77. T. 

J Underwood's Treatise on Diseases of Children, 8th edit. p. 170. 



; I 



190 PUSTULiE ; 

in these it probably prevents the attack of more for- 
midable diseases/' It is remarkable, that, whatever 
excoriation may be produced, no permanent deformity 
ensues. Dr. Strack has affirmed, that " when the 
disease is about to terminate, the urine of the patient 
acquires the odour of the urine of cats ; and that, 
when the usual odour remains unchanged, the disease 
.will generally be of long continuance.'* * " Dr. 
Strack's opinion, however, on this part of the prog- 
nosis is not to be depended upon, as he prescribed 
the Viola tricolor as a specific in this disease ; and it 
is well known that that plant communicates to the 
urine of those who take it the odour of the urine of 
cats.'* 

" The remote cause of this species of Impetigo is 
improper diet, either as respects quantity or quality, 
in strong and healthy children. I have been able, 
frequently, to trace it to too free use of acescent 
food, such as fruit tarts and puddings, sugar and the 
various articles of confectionary into which it largely 
enters, by children of full and gross habits of body. 
It frequently, also, appears to be the result of denti- 
tion, in children of full habits ; and in this case is al- 
ways beneficial.*' 

Jn the commencement of the Impetigo larvalis, 
while the discharge is copious and acrid, it is neces- 
sary to clear the surface two or three times a day by 
eyeful ablution with some tepid and mild fluid, as 
milk and water, thin gruel, or a decoction of bran t ; 
and to apply a mild ointment, such as the Unguen- 
tum Oxydi Zinci, or a combination of this with a 
Saturnine Cerate. " I have seen no ointment so 
quickly beneficial as the Unguentum Hydrargyri 
Nitratis diluted with seven parts of Spermaceti oint- 

* See his Dis. de Crusta lactea infantum, et ejusdem specifio remedio : 
— also Lond. Med. Journal, vol. ii. p. 187. 

f The Hindoo physicians foment the parts with a decoction of the 
Sida populifolin {tootHe elley) ; and touch excoriated parts, when the 
scabs are rubbed off, with " a little finely-prepared Castor oil." Ainslie's 
Mat. Indica, vol. ii. p. 550. T. 



I 



3 



IMPETIGO. 191 

• 

ment* To aid in removing the crusts, a cataplasm of 
oatmeal water and butter, with the juice of the Nas- 
turtium (Tropaeolum majus)y has been found very 

I serviceable/* The Saturnine Cerate will be useful to 
obviate excoriation, while the surface remains red and 

i tender, after the discharge has ceased. " I lately 
saw much benefit derived from the application of a 
weak solution of Nitrate of Silver, (gr. iij Nitratis and 
f^j Aquoe) in the cure of an adult, in whom the dis- 
ease spread over the whole of the face and the breast. 
Two days after the lotion was applied the in- 
flammation disappeared, and the swelling subsided.'* 
" Plenck *, and several Continental physicians, con- 
sider it dangerous to check suddenly the eruption by 
external applications ; and imagine that it is likely to 
produce diseasesof the head and chest ; as fever, ophthal- 
mia, swelled glands, cough, anasarca, hydrocephalus, 

\ and apoplexy. Dr. Granville thinks he has observed 

I this to be the case in the Dispensary for Children j 
but in my own experience, which has been extensive 
both in Dispensaries and in private practice, I have 
seen no injury result from checking the eruption.** 

The removal of the disease is much accelerated in 
adults by repeated very small bleedings, followed by 
the use of alterative doses of mercurial purgatives 
(especially where the biliary secretion is defective, the 
abdomen tumid, or the mesenteric glands enlarged), 
which should be continued for three weeks or longer, 
according to circumstances. " In children bleeding 
is unnecessary ; ^nd the use of the alteratives may be 
at once commenced ; ** small doses of the Submuriate 
of Mercury may be given twice a day, alone, or in 
combination with Soda and a testaceous powder ; or, 
if the bowels are very irritable, the Hydrargyrus cum 

• Plenck, under the title Crusta lactea infantum larvata, says, — " Re- 
pressis autem papulis crustasis morbi glandular urn, tussis, asthma, tabes 
saepe oriuntur." He also says, •* Scabies capitis retropuUa exigit sina- 
pismum, vel vesicatorium al^raso capiti imponendum, ut revocetur 
scabies, vel denique novam infectionem ope applicatae mitrae scabiosae." 
Doct, de Morb. Cutaneis, p, 76, 



192 PUSTULE : 

• 
CretA, or the Cinereous Oxide, may be substituted. 
But if the general health appear sound, the inflam- 
matory condition of the skin, and the profuse exuda- 
tion, may be alleviated by the internal use of Soda 
with precipitated Sulphur, or with the Testacea. "If 
the discharge be considerable and very acrid, the 
denuded surface should be washed with a solution of 
gij of Bicarbonate of Soda, f^k of Hydrocyanic Acid, 
f ^viij of Bitter Almond Emulsion. In young sub- 
jects the Hydrocyanic Acid should be omitted.*' 

When the state of irritation is removed, and the 
crusts are dry and falling off, the Unguentum Hy- 
drargyri Nitratis, much diluted, may be applied with 
advantage. And now some gentle tonic, such as 
Infusion of Calumba, the Decoction of Sarsaparilla, 
or the Decoction of the Water Dock, should be ad- 
ministered with Subcarbonate of Soda, or the Chaly- 
beates (which are more readily taken by children), 
especially the saturated solution of the Tartrate, or 
the Vinum Ferri. " The Solution of Sulphate of 
Quinine, or .the Decoction of Cinchojia Bark acidu- 
lated, have also proved beneficial.** 

I cannot speak from experience respecting the 
medicine recommended as a specific by Dr. Strack ; 
namely, a decoction of the leaves of the Viola tri- 
color of Linnasus, in milk.* In the course of the 
first week, this medicine is said to increase the erup- 
tion considerably ; but at the same time the urine 
acquires the smell above mentioned, and, at the 
end of a fortnight, the crusts begin to fall off, and 
the skin underneath appears clean. Professor Selle, 
however, has affirmed, that this plant is either noxious 
in this complaint, or wholly inert.t " When the 
milk is thick, if the infant be altogether nourished at 
the breast, the nurse must be changed. If it be fed, 

♦ He prescribes a handful of the fresh, or half a drachm of the dried 
leaves, to be boiled in half a pint of cow*s milk, and the whole to be 
taken night and morning. 

f Medicina Clinica, i. 185. 



IMPETIGO. 193 

much Care must be taken to repress a voi-acious appe- 
tite in the child, and to make the food as light as 
possible : avoiding the use of sugar^ and every fer- 
mentable substance." 

Species 2. iMPExiGO^t^o^a, Honeycomb Scall. 

Syn. Tinea favosa {Haiy Jbbas, Astruc. Sauv.) : 
Tinea volatica. Ignis volaticus. Mentagra Infantum 
(Atcct. Par.): Scabies, capitis favosa {Plenck) : Dartre 
crustacee flavescente ; Herpes crustaceus {AUberfS : 
Ecpyesis Porrigo, y favosa (Good): -Krj^iop (O.): 
Favus (JLat.) : Teigne faveuse (F.) : P6d6ghoo 
( Tarn.) : * Goorig {Duk.)i Podooghoo Kurapanie 
{Tel): Badkhora (Pers.) 

This species of the disorder (Plate XLI. of Bate- 
man; PI. 16. of Thomson's Atlas,) consists of an 
eruption of soft, straw-coloured pustules, denominated 
Jhvif without apparent previous inflammation. These 
are not in general globular, with a regularly circular 
margin; but somewhat flattened, with an irregular 
edge, and surrounded by a slight inflammation. They 
occur on all parts of the body ; sometimes on the scalp 
alone, in which case the pustules are small, and the 
pus, instead of exuding, dries under the cuticle ; some- 
times they appear on the face, or on the trunk and 
extremities only ; but most commonly they spread 
from the scalp, especially from behind the ears, to 
the face, or from the lip^nd chin to the scalp, and 
occasionally from the extremities to the trunk and 
head.* They are usually accompanied with consi- 
derable itching. Children from six months to four 
years of age are most liable to this eruption ; but 
adults are not unfrequently affected with it. Cooks are 
very liable, according to Alibert t, to this species of 
Impetigo.** 

The pustules, especially on the scalp, appear at 

* When it thus spreads from one part to another, the names Tinea 
volatica, Ignis volaticuty &c, have been given by Sauvages and others, 
f Mai. de la Peau, p. 88. T. 



194 PUSTULE : 

first distinct, though near together ; but on the fece 
and ^^treniities they generally rise in irregular t;lus- 
tei^s, becoming confluent when broken, and discharg- 
ing a viscid matter, which gradudily concretes into 
greenish, or yellowish, semi-transparent scabs, " which 
are very adhesive, sometimes remaining in a dry brit- 
tle state for months/' The disease extends, by the 
siuccessive formation of n^W blotches, which sometimes 
cover the chin, or surround the mouth, tod ^spread to 
the cheeks and nose * ; and, on the scalp, the ulcer- 
ation uhrimately extendi?, in a similar manner, over 
the whde head, with a constant disch^i^e, by which 
the hair and moist scabs are matted together : ** and 
a most disgusting odour is exhakd/* Under the 
last-mentioned circumstances, pediculi are often -ge- 
nerated in great numbers, and ^gravate the itchihg 
and ii^ritation of the disea^se. " The hair dften sepa- 
rates with the slightest touch, leaving the scalp bald/* 
" It has l)een, indeed, supposed, that the disease ori- 
ginates in the bulbs of the hair ; btit it is more pro- 
bable that the reticular tissue is the seat of the dis- 
ease, in which case, the hairs may be detached with- 
out being diseased/* On the face, too, a similar ag- 
gravation of the symptoms is occasioned, in children, 
by an incessant picking and scratching about the 
edges of the scabs, which the itching demands, and 
by which the skin is kept sore, and the ulceration 
extended ; while the scaffls are thickened into irre- 
gular masses, not unlike honeycomb, by the accumu- 
lating and concreting discharge. On the lower ex- 
tremities considerable ulcerations sometimes form, 
especially about the heels, and roots of the toes ; and 
the ends of the toes are sometimes ulcerated, the 
pustules arising at their sides, and even utider the 
nails. 

The ulcerating blotches seldom continue long, 

* Rayer says, " Je I'ai vue occuper toute la partiepost^rieure jusqu'au 
sacrum.*' Traits des Mai. de la Peau, tome i. p. 497. T. 



i 



IMPETIGO. 195 

or extepad far, before the lymphatic system exhibit^ 
marks of irritation, probably from tl^e acrimony q( 
the absorbed matter. When tI;Le scalp or face is the 
seat of the dis€|ase, the gla^^s on the sides of the ;neck 
exk\9fge and harden, being at first perceived like a 
chajin of litde tumours, lying loose under the skin ; 
and the submaxillary and parotid glands ,are oflen 
afiect^ed i|i a similar manner.* At length some pf 
tiiem inflame, the skin becomes discoloured, and they 
suppurate slowly, and with much pain aiid irritation. 
The ^eruption, in tjhese situations, is likewise of);en 
^companied by a discharge from behind the ears, or 
0*om tihe e^rs themselves, with a tumid upper 1^, 
and inflammation of the eyes, or obstinate ulcerations 
of the edges of the eyelids. When the eruptio9 
^ppe^s OB the trunk, although the pustules there ai;e 
smaller and less couflueut, apd t|xe scabs thinqor and 
less permanent, the axillary glands are liable to be 
affected in the isame way. 

The discharge from the ulcerated surfaces, ei^e- 
cially on the scalp, wheu the crui^ts aud coverings are 
removed, exhales an oflPepsive n^cid vapour, not only 
Meeting the organs of smell and t^te, but the eyes 
pf those whp exaiuine the diseased p^rts. t The acri- 
mpuy pf the discharge is also manifested by the ap- 
peanMice of inflammation, followed by pustules, u^c^r- 
^tion, and scabbing, on any portion of the sound 
i^iu, whiph comes into frpquent contact with the 
p^s diseased : thus, in young children, the bre^t is 
inoculated by the chin, and the hands ^d airms by 
contact with the face. The disease, is also contagious. 
The /arm and breasts of the nurse are liable to rpppive 



* Non critic^ non depurgtori^^ sed m^li c((;miinuniqitio9e^'' Loriy 
de Morb. Cutan. p. 466. T. 

j* It has been supposed that the similarity of the odour of this 
discharge to that or garlic (porrum) gave rise to the appellation of 
Porrigo, which the disease was formerly called. 

Rayer says that, after the application of poultices to detach the crust, 
this odour is ** naus^bonde, et analogue k celle des os qu'on a fait 
bouillir avec lenrs ligaraens." 1. c. p. 499. T. 

o 2 



196 pustule: 

the eruption ; but it is not so readily eommunieated 
to adults as to children. 

The duration of this form of Impetigo is very un- 
certain ; but it is, on the whole, much more manage- 
able than the I. scutulata and decalvans. Young 
infants often suflPer severely from the pain and irrita- 
tion of the eruption, and of the glandular affectionsF 
which it induces ; and those who are bred in large 
towns, and are ill fed and nursed, are thus sometimes 
reduced to a state of fatal marasmus. 

" This species of Impetigo occurs at all seasons of 
the year, in both sexes. It seems to originate from 
bad nourishment, and imperfect clothing, in strumous^ 
habits : and there can be no doubt that damp, ill-ven- 
tilated dwellings, and the miseries of poverty in all 
their forms, are its most common predisposing causes* 

" The only disease with which it is likely to be 
confounded is Imi^tigo furfur ans ; but, as every other 
part of the body, besides the hairy scalp, is likely to 
be affected, it is recognised.** 

The Impetigo favosa requires the exhibition of the 
same alteratives internally, which have been recom- 
mended for the cure of the Impetigo larvalisj in doses: 
proportioned to the age and strength of the patients* 
The diet and exercise should also be regulated with 
care : all crude vegetables and fruits on the one hand^ 
all saccharine preparations and stimulating substances^ 
whether solid or fluid, on the other, should be avoided ; 
and light animal food, milk, and puddings, should be 
alone recommended. *^ The exercise of the patient 
should be regular, but never carried to fatigue : and 
it should be taken out of doors only in dry, temperate 
weather.** If the patient be of a squalid habit, or if 
the glandular affections be severe, the Cinchona Bark 
and Chalybeates, " especially the loduret of Iron *^ 
in doses of two or three grains in two ounces of In- 

* The loduret is sold in solution^ or as a hydriodate, in the strength 
of gr. iij. to f5j of water, by Mr. Squires, Chemist, Duke Street^ Man-> 
Chester Square. It should always be kept in solution. 



IMPETIGO. 197 

fhsion of Orange Peel, or in the same quantity of 
water, to which gr.viij. of Bicarbonate of Potassa are 
added just before the dose is taken, so as to form 
Hydriodate of Potassa and Protocarbonate of Iron, 
will be found useful. In either mode of administration 
the loduret may be given three times a day.** Or the 
solution of Muriate of Baryta united with the former, 
will contribute materially to the restoration of health. 
" Those cases that have come under my care have 
generally yielded to the administration of the Hy- 
drargyrus cum Creta, in doses proportionate to the 
age of the patient, given every night ; with the Car- 
bonate or Subcarbonate of Soda, in full doses, given 
in the Infusion of Cinchona, or of Cascarilla Bark, 
three times a day.** 

There is commonly some degree of inflammation 
present, which contra-indicates the use of active sti- 
mulants externally. ** Sulphur baths have been found 
sometimes injurious: but the simple warm bath and 
fomentations are serviceable.** The Unguentum 
Zinci, or the Unguentum Hydrargyri praecipitati albi, 
mixed with the former, or with a saturnine ointment, 
will be preferred as external applications, especially 
where the discharge is copious : and the ointment of 
the Nitrate of Mercury, diluted with about equal 
parts of simple Cerate and of the Ceratum Plumbi 
Superacetatis, is generally beneficial ; but the pro- 
portion of the Unguentum Cerae must be varied ac- 
cording to the degree of inflammation. " The follow- 
ing is an old, but a useful ointment : 

g. Picis liquidae Jiv, 
Cerae flavfle 5iv, 

Solve lento ig^e, 
et sperge ante frigescat 

Sulphuris Vivi Jj. 

Tere ut fiat unguentum." 

All stiflF and rigid coverings, whether of oiled silk, 
or, according to a popular practice, of the leaves of 
Cabbage, Beet, &c. should be prohibited ; for they 

a 3 



198 PudTUtiB : 

often excite d irio^ severe iiritatidil. I have v^- 
nessed, ih sevenil itistances, an universd uleeratiofi, 
with copious purtiletit discharge, and a highly in£lam- 
inatorjr and paitiful statfe of the scalp, exdting even a 
cdnsidefatble degree of i^ympitomatic ffever^ prodtteed 
by such apj^lic^ions. The i^Ubstitiitioh of a poilltice, 
in these casijs, teihdvlBd this irritatite condition ill t\Vo 
or tht^e dayi^^ and the disease was speedily subdued by 
the treatnieht above recdtrimended. " The treatmetit 
of the brothers Mahon, in the Parisian hospitals, is 
^id to prdve most efficacious. The hair is first cut 
oflP, so as to leave it throughout only tWd inches lohg ; 
the crusts are next cleared away as completely as possi- 
ble by linseed meal poultices, and soap and water* This 
part of the treatment occupies four or five days. After 
having thus prepared the scalp, the aflPected parts are 
next to be covered with an ointment composed of 
Chalk, Silex, Alutn, Oxide df Iron, a small quantity of 
Subcarbohate of Potassa, some Lime, and a little Char- 
coal, rtibbfed up with lard : the proportions in this 
heterogeneous taass are kept secret* Thi^ oiiitnieht is 
to be applied on alternate days for upwards of a 
month: and oh the intermediate days a comb is 
pa^d jgehtly oVer the parts to detach the loo«^iied 
hairs with as little pain as possible. At the end of 
this time a powder composed of the same materials as 
the ointment, with the exception of the charcoal, is 
td be sprinkled over the effected parts ; and^ after 
usiiig me comb on the following day, the ointment is 
again resorted to ; and by cdntmuing this method the 
disease yields, and the i^in regains its natural and 
healthy condition. I have had no experience of this 
method of treating the disease.** 

" Many other ointments and pommades have been 
recdmraended. The influence of all of them is stimu- 
lant. In obstinate cases, the crusts have been removed, 
and a feather dipped in the mineral acids applied to 
ttie sores, bathing the parts immediately afterwards 
with cold Water.** 



IMPETIGQ. 199 

It may he mentioned, in conclusion, that an Erup- 
tion of ^vi is sometimes seen on the face (Plat^ 
XLII. of Bateman) j on the ears, neck, and occi- 
put, in adults * ; in whom it is preceded and accom^* 
panied by considerable derangement of the constitu* 
^iqn^ headach, pain of the stomach, loss of appetite, 
constipation, and some degree of fever. The pustules 
become confluent, discharge a viscid humoi;r, apd 
scab, as in the eruption just described ; but they are 
surrounded by more extensive inflammation, and be- 
come harder and more prominent, somewhat resem- 
bling, in this respect, the Ecthyma. Their course^ 
however, is more rapid than that of the Jlcthyma, or 
of the tubercular Sycosis, to which also the dise^s^ 
bears some affinity. A cathartic, followed by thp 
Pilula Hydrargyri Submuriatis comp. of the last 
Pharmacopoeia, or Dr. Plummer*s Pill, and a vege- 
table tonic, ei^ecially the Decoction of Sarsaparilla, 
will be found serviceable j and the mild external ap- 
plications, above mentioned, must be employed accord- 
ing to the degree of inflammation present. 

A sudden eruption of Impetigo^vo^a, accompanied 
by fever, occasionally takes place also in children. A 
considerable alarm was excited by such an occurrence 
in a family which I was requested to see, in which the 
disease was deemed to be some new or anomalous 
contagion. The first patient, aged five, was seized 
with severe fever, in which the pulse was at one time 
140, and continued at 110 for several days; at the 
same time, clusters of favous pustules appeared behind 
the ears, which were speedily followed by others on 
the scalp, and about the apertures of the nostrils, 
which they plugged up as the scabs were foinaaed. A 
few days after the commencement of this attack, ^ 
younger child, aged two years, was seized in a similar 



* Of this form of Impetigo favosa on the cheek, the 16th plate of 
M. Alibert appears to be a representation. He calls it " Dartre crustac^e 
ffavescente. 

o 4 



200 PUSTULJE : 

manner ; but in her, the pustules appeared also about 
the chest, the glands of the neck swelled, and the . 
d,bdomen became tumid. The contagion was imme- 
diately, though but locally, received by the mother 
and the nurse : the former of whom was inoculated 
about the mouth, by kissing the children ; the latter 
in the palm of the hand. These children were some- 
what squalid, and apparently ill nursed, especially in 
respect to cleanliness and exercise. 

** All the species of Impetigo are, sometimes, spon- 
taneously cured, even after they have long resisted all 
remedies. 

" Alibert mentions the case of a girl of sixteen 
who had a very obstinate attack of Impetigo favosa, 
: which yielded to no remedies, but disappeared soon 
j, after she was attacked with fever and Erysipelas.*' * 

Species 2. Impetigo Erysipelatodes. Erysi- 
pelatous Running Scajll. 

Syn. Ecpyesis Erythematica ( Good). 

This form of the disease, in its commencement, 
presents nearly the ordinary appearances of Ery- 
sipelas ; namely, a redness and puflfy swelling of the 
upper part of the face, with oedema of the eyelids ; 
and is accompanied with slight febrile symptoms for 
the space of two or three days. But on a minute 
examination, the surface, instead of the smooth polish 
of Erysipelas, is found to exhibit a slight inequality, 
as if it were obscurely papulated ; and, in a day or 
two, the true character of the disease is manifested, 
by the eruption of numerous psydracious pustules, 
over the inflamed and tumid skin, instead of the large 
irregular bullae of Erysipelas. These pustules first 
appear below the eyes, but soon cover the greater 
part of the face, and sometimes extend to the neck 
and breast ; they are accompanied with a distressing 
sense of heat, smarting, and itching. When they 

* Malad. de la Peau, p. 95. 



IMPETIGO- . 201 

break, they discharge a hot and acrid fluid, which 
adds to the irritation and excoriation of the surface. 
In this painful condition the face remains for ten 
days or a fortnight, when the discharge begins to 
diminish, and to concrete into thin yellowish scabs. 
But on the interstices between the scabs, fresh pustules 
arise at intervals, with renewed heat and pain, and 
subsequently, discharge, ulcerate, and form scabs like 
the former. The disease continues thus severe and 
troublesome for an uncertain period, from one to two 
or three months ; and ultimately leaves the cuticle in 
the same dry, red, and brittle state, which remains 
after the other forms of Impetigo. The constitution 
is scarcely disturbed during the progress of this 
disease, and is much less disordered in the outset 
than in Erysipelas. Its affinity with Impetigo has 
been further evinced, in some cases which I have 
seen, by the occurrence of the other forms of the 
eruption on the extremities during its course: 
occasionally, indeed, extending over the whole surface, 
a capite ad calcem. 

In the commencement of the disease, purgative 
medicines, with the antiphlogistic regimen, afford 
great alleviation to the symptoms; but when the 
copious exudation and scabbing take place, the 
Cinchona in considerable doses, alone or with the 
Sarsaparilla, or the mineral acids, is administered 
with the greatest benefit. The same local treatment 
is requisite as in the other forms of the eruption ; 
viz. tepid ablution, with emollient liquids; the 
application of the mildest ointments ; and the use 
of sea-bathing, or of the sulphureous waters, in its 
decline." I have seen more benefit derived from Ni- 
trate of Silver than any other topical application. 

Boohs which may he consulted on Impetigo. 

Plumbe on Diseases of the Skin, 2d edit. 1827. 
Rayer, Traits des Mai. de la Peau, 8vo. 1 826. 
WiLLAN, Practical Treatise on Impetigo, 4to. 1814. 



g02 FUSTUWB : 



Genus IL PORRIGO, 

Syn. Porrigo {Av4^. var.) : Crusta lactea (Aust, 
var.) : Pityriasis {Swediaur) : Ecpyesis porrigo 
( Good) : Phlysis porrigo ( Young) : Tinea (Aiujt, 
var.) : Aym (G,): Favus (Z/,) : der Kleiengrind 
( German): Hofdchilfers (Dutch) : Aspe (Dan.) : 
Kliskorf (Swed.) : Netek (Hebrew) : Gourme For- 
fere (Ital,): Carpa (^SJpaw.): Teign^ (F.); Moist 
ScalL 

Def. An eruption of straw-coloured pus^ 

TULES; CONCRETING INTO YELLOW OR BROWNISH 
CRUSTS OR CELLULAR SCABS. 

Porrigo * is a contagious disea^, which may 
occur at any period of life, although it is mor? 
common under the age of puberty. It is principally 
characterised, as the definitions tates, by an eruption 
of the pustules, denominated ^m and achores (Def. 
5. Cy d)y luiaccompanied by fever. The several ap- 

* This term is adopted, as a generic appellation, nearly in the same 
sense in which it was used by Celsus, who included the moist and ulcer- 
ating as well as the dry and furfuraceous eruptions of the scalp, under 
this denomination. (De Med. lib. vi. cap. 3.) The word Tinea is em- 
ployed in the same generic sense by Sauvages; but being a term of no 
Authority, and probably of Arabic origin f , it is properly superseded by 
the classical appellation. Numerous writers, ancient and modern, have 
designated the varieties of the disease by distinct names ; such as crusta 
lactea, alopecia, pityriasis, favi, achores, scabies capitis, &c,i but the 
most intelligent observers have pointed out the identity of the nature 
and causes of these various eruptions. See Seniiert. de Morb. Infant, 
p. ii. cap. 4.; and Pract. lib. v. p. iii. § ii. cap. 4. — Heister. Chirurg. p. i. 
lib. v. CM). X. — ^Tilingius, Lilium curiosum, cap. 17. — Vogel, de cogiios. 
et cur.Hom.M orb. class. viiL § 71J. — Stoll, Rat. Med. i. 49. 



i* Si eidera auctori ( Avicenna) credamus, ab humore melanchollco causam 
acdpt, cutcm comimpit atque corrodit, haecque est alvathim a quo nomine 
barbari, ut videiur, thim et thineum et tinean fiscerunt. Lorry de Morb, CiUa- 
neis, p. 46S. T. 



FORitiao. SOS 

pearances which the disorder asfumes may be arranged 
into three sections, containing four specific fornuu* 

Sect. !• VokkigOj tri$e porriginoics eruption. 

Sp* 1. p. lupinosa. 
Sect. II. Eczematous Porrigo. 

^v.l.v.furfurans. 
Sect. III. Anomalous Porrigo. 

Sp. 1. p. scutulata. 

Sp. 2. p. decalvans. 



SECTION I. 

true PORRIGO. 

Species 1. Porrigo lupinosa^ Lupine-like 

SCALL. 

Syn. Scabies capitis lupina (Plenck) : Tinea lu- 
pina (-dfefrwc. Sauv.): Teigne fiiveuset, Tinea fii- 

* In a note, subjoined in this place, in the two preceding editioni of 
this work, I remarked, that the non*^ontagious miality, and some other 
features of this disease, indicated an analogy to impetigo. My subse- 
quent experience has led me to question lUtogether the propriety wkh 
which Dr. Willan classed the crusta lactea under the genus Porrigo^ 
and to believe that Impetigo larvalU would have been the more correct 
ap|)elIation. Even on the face and scaip, the character of the eruption 
is impetiginous; the pustules being psyoracia, and not fari or achores; 
the crusts thin and laminated, not elevated and indented, like the 
honeycomb of Porrigo ; and the subsequent oozing of ichor, from nu- 
merous points, and the repeated recession and renewal of the inflam- 
mation and incrustation, still more completely establish the identity 
of this disease with Impetigo, as well as its universal attacks over the 
whole body and extremities, fixing especially in the flexures of the large 
joints, and returning occasionally for sevend years, «ven till the age of 
puberty, in the spring and autumnal seasons ; and from every succes- 
sive irritation from botli the processes of dentition, and other causes.— 
With these remarks, however, I leave the disease in its ori^nal place, in 
deference to my venerated preceptor, and in order to avoid the confu- 
sion of altered arrangement. 

The present Editor accords with the opinion of Dr. ^ateman, and 
therefore has removed P. larvalis ^nd favosa to Impetigo. P. scutulata 
and decalvans are also improperly placed under Porrigo : but they are 
too little understood to aamit of bemg properly arranged. 

-f Alibert says, " La Teigne faveuse est celle qui s'est !e plus fr^ 
quemment pr^ent^e k nos regards," p. 14. He also sa}^, ** J'ai observe 
cette affection sur des t^tes dont les cheveux ^toient noirs, blonds, et 
m^me rouges." Liv. i. p. 1 5. T. 



^04f PUSTUL-ffi : 

vosa (j4libert) : Teigne annulaire ; Teigne rugueuse ; 
Rache shche (i^.). 

" This species of Porrigo, (PL 15. of Thomson's 
Atlas,) which is occasionally congenital, and some- 
times hereditary *,** is characterised by the formation 
of dry, circular scabs, of a yellowish white colour, set 
deeply in the skin, with elevated edges and a central 
indentation or cup-like depression, sometimes con- 
taining a white scaly powder, and resembling, on the 
whole, the seeds of lupines t, or rather certain species 
of lichens. . These scabs are formed upon small sepa- 
rate clusters of achoreSj by the concretion of the pu- 
rulent fluid, which exudes when they break t ; and 
they acquire, when seated on the scalp, the size of a 
sixpence. Frequently there is also a thin white in- 
crustation, covering the intervening parts of the 
scalp, which commonly exfoliates ; but, if allowed to 
accumulate through inattention to cleanliness, it forms 
an elevated crustaceous cup. The disease, how- 
ever, is not exclusively confined to the head ; but 
sometimes appears on the chest, belly, shoulders, 
loins, and the extremities, where the little white 
and indented scabs do not exceed two lines in dia- 
meter. ** It is accompanied with great itching, and 
pediculi frequently infest the crevices of the crusts. 
The odour of the favi, Alibert compares to the urine 
of the cat ; or chambers which have been infested 
with mice." This variety of Porrigo is liable to in- 
crease much if neglected j and is usually tedious, and 
of long duration. " When neglected, the acrid pus, 
is absorbed, and swells the cervical glands. In old 



* Alibert mentions a case of it which appears to have been heredi- 
tary : *' son p^e," says he, " en ^toit atteint." Li v. i. p. 15. T. 

J From this resemblance, the same epithet was applied to the disease 
by Haly Abbas, who has distinguished six species. '' Quinta est /tfpt- 
nosa, sicca, et colore alba, lupino similis, k qua quasi cortices et squamae 
fluunt albae." (Theorice, lib. viii. cap. 1 8.) See also Guid. Cauliac. 
tract, vi. cap. 1. Sennert. lib. v. p. i. cap. 32. 

J Thenard and Vauquelin found that the purulent discharge in this 
species affords much albumen* 



PORRIGO. 205 

cases, in which the disease is abandoned to its pro- 
gress, complete baldness or alopecia occurs. 

The internal treatment in P. lupinosa does not 
diflPer from that necessary in Impetigo larvalis. The 
first object in the local management of this form of 
the disease, is to remove the crusts and indented 
scabs, by a diligent application of soap and water, 
** or by a poultice of oatmeal, or of brown soap and 
oatmeal half boiled,'* or other emollient applications. 
If the scalp be the seat of the disease, the previous 
removal of the hair will be necessary. If the scabs 
are not penetrable by these ablutions or by ointments, 
or if any thick intervening incrustation is present, a 
lotion of the Liquor Potassae *, or of the Muriatic 
Acid, or the Sulphuric Acid in a diluted state, 
may be employed. When the surface is cleared, 
" the rete mucosum is seen red and covered with 
numerous small ulcers, which exude a viscid, foetid, 
straw-coloured fluid. At this time '* the ointment 
of Cocculus Indicus may be applied to the red and 
shining cuticle ; and afterwards the more stimulant 
unguents, as in the case of P. furfurans, with regular 
daily ablution, will complete the cure. 



SECTION II. 

ECZEMATOUS PORRIGO. 

Species 1. VoB.'RiGOjfv,7furans.\ Furfuraceous 

SCALL. 

* An alkaline lotion may be made with the proportions of a drachm 
of the Aqua Kali Puri, two or three drachms of Oil, and an ounce of 
Water. — " Imprimis salia lixivia*^ says Prof. Selle, " ad crustam tam 
fir mam atque alias insolubilem emolliendam sunt apta.'* Medic. Clin. 
187. 

f Sennert de Curat. Infant, p. ii. cap. 4. — Sauvages, Nos. Method, 
class. X. gen. xxix. spec. 6. Plenck, Doctr. de Morb. Cut. class, vii. 
Alibert, plate ?., where it is well represented. It may be observed that 
the ^ T. amiantac^e" of this writer (plate 4.) appears to be a variety 
P. farfurans. It is, in fact, to a furfuracemu disease alone that the 
translators of the Greek physicians, and many modem Latin writers. 



g06 PUSTULE : 

Syn. Tinea furfiiracea (Sennert); Tioea porri- 
ginosa(^«^wc- Somv.): Porrigo furfuraeea (P&m;A:) : 
Ec^y^esis pcMrigo, g, furfuracea ( Oood) : Teigne fur- 
forae^e, Tiaea furiuracea (AUbert): Eczema de 
Guir €hemlu (3ietj Mayer.) : Rache farineuse (F.)* 

In this Ibrm of the disease, (Plate XXXVIIL 
of Batem-^n; PL 16. of Thomson's Atlas,) which 
cofamenees Wth im eruption of small achoresy the dis- 
chai^ from the pustules is moderate in quantity^ 
aind th^ excoriation slight ; the humour^ therefore, 
soon oeincretes, a^d separates in innumerable thin 
laminatjfed scaibs^ or scale-like exfoliations. At irre* 
gular paiods, the pu^^ules re-appear^ and the dis- 
ebfmge ibeing renewed, the eruption becomes moist ; 
but it soon dries again smd exfoliates. It is attended 
with :a good deal of itching, and some sQ^?€^ess of the 
scalp, to which tlie disease is often confined, ^^ al- 
though I have s^n it extend to the ears.'* " It fre^ 
quently appears first on the nape of the neck> at the 
nmifgin ;o£ the hairy scalp, and on the temples. The 
diadbai;ge is viscid, and exhales a nauseous odour ; it 
adheres to the hair ; and in drying forms a powdery 
scurf, which easily separates by slight friction.'' The 
hair, which partially falls off, becomes thin, less 
strong in its texture, and sometimes lighter in its 
colour.* Occasionally the glands of the neck are 



apply the term Porrigo, deeming it synonymous with the Greekjrcrvptaffic 
From the authority of Celsus, however, it is obvious that this is a mis- 
application of the term ; and it is improper to comprehend the single 
dandrifi^ and the contagious scall, under the same generic appellation. 
See. Pityriasis, above, p. 45. note, Plenck, though applying the term to 
both, marks the distinction, calling the contagious disease, Porrigo fur- 
furacea, aeu verOy — and the other P. farinosa, seu tpuria, which he 
considers as a mere accumulation of the secretion fr/sim the sebaceous 
glands. 

. ♦ Alibert correctly remarks, " Toutes les fois que nous avons d^- 
pouilM le cuir cl>evelu des ^cailles qui le recouvroient, nous avons ob- 
serve qu'il ^oit d^nu^de son epiderme, qu'il avoit une couleur ros^e, 
etoffroit une. surface lisse, polie, luisante, comme vernis^e." Liv. 1. 
p. 7. He f^o remarks that it is most common in those who have bright 
chesnut-coloured hair. T. 



PORRIGO. 207 

swelled and painful, €fmng to the acnd pus toonfined 
under the scales being absorbed. 

The P. fuifurans occurs principally in adults*, 
especially in females, of a lymphatic temperament, in 
whom it is not always easily distinguished from the 
scaly ^diseases. Pityriasis, Psoriasis, or LemtL affect- 
mg the oapillitiQ«i. It usually commeices A achores 
SO minute, axid containing transparent pus, that they 
are often mistaken for vesicles ; and the disease re- 
garded as Eczema. The circumstances just enumer- 
ated, howevei*, will serve to establifdi the diagnosis : 
as in those i^eases, no pustules appear in the b^in- 
tting, — there is no moisture or ulceration, -—and 
the hair is not detaclied, nor changed in texture and 
colour ; — neither are they communicable by contaot. 

< < Although no general treatment is supposed to be 
requisite in this species of Pcarigo, yet it is rardy 
effectually removed without the aid x^a light akeiv 
ative course of intemal medicine, ^nd occasidnal 
small bleedings, followed by six or eight g;rains of 
calomel and a brisk cathartic. The best ah^^ative for 
an adult is gr. viij. of Hydrargyrum cum Cretl^ and 
twenty or thirtyfminims of (Liquor PotasssB, three times 
a day, gradually augmenting the dose to one hundred 
drops. The best vehicle is milk, or table*beer.'' 

In the local treatment of the P. furfurans, it is 
supposed to be absolutely necessary to keep the scalp 
closely shaven. " Many objections, however, are 
often made to shaving the head, which may not be 
absolutely requisite, if the hair be cut short, and the 
following lotion employed : — 

1^ Potassse ISulphureti (recentis prep.) 5uj» 
Saponis Mollis 5j* 
Aquae Calcis f 5viij. 
Spir. Rect. fsij. M. fiat lotio." 

The branny scabs should be removed by gentle wash- 

* Alibert nevertheless says, *' Je n'ai jamais observe que la Teigne 
furfurac^e attaqu&t les adultes.'' Liv. 1. p. 7. T. 



208 pusTULiE : 

ing, with some mild soap and water, twice d day ; 
and an oil-silk cap should be worn, partly for the 
purpose of keeping the surface moist as well as warm, 
and partly for the convenience of retaining an oint- 
ment in contact with it. 

The nature of the ointments employed in this, as 
in the other species of Porrigo, must be varied, ac- 
cording to the period of the disease, and the irrita- 
bility of the part aflFected. In the commencement of 
the eruption, when the surface is moist, tender, and 
somewhat inflamed, the Oxyd of Zinc ointment 
should be applied ; or, when inflammation is present, 
an ointment prepared with the Coculus Indicus, in 
the proportion of two drachms of the powdered berry 
to an ounce of lard. But when the scalp becomes 
dry and irritable, in the progress of the complaint, it 
may be washed with the common soft soap and water ; 
or with a lather made by mixing equal portions of 
soft soap and Unguentum Sulphuris in t^arm water. 
More stimulant ointments will then be requisite, 
such as the Unguentum Hydrargyri Nitratis, Un- 
guentum Hydrargyri Nitrico-oxydi, the Tar and 
Sulphur Ointments, or the Unguentum Acidi Ni- 
trosi of the Edinburgh Pharmacopoeia. These and 
other stimulant applications^ succeed in diflFerent 
individuals in the inert state of the- P. furfurans ; 
but they must be intermitted, in case the inflamma- 
mation and discharge return. 

" The diet should be mild and nutritive, and all 
salted meats, pork, and fish avoided." 

• 

* A long catalogue of stimulants, of similar quality, may be collected 
from the writings of the Greeks, as remedies for the furfuraceous Por» 
ripo : such as liniments of frankincense and vinegar, or the same gum 
with wine and oil ; others prepared with oil of rue, litharge, and vine- 
gar ; or with stavesacre and oil ; lotions of the decoction of foenugreek, 
the roots of beet, and of the cucumis silvestris, &c. See Oribas. Synops. 
lib. viii. cap. 25. Aetius, tetrab. ii. serm. ii. cap. 76. Alex. Trail, lib. i. 
cap. 4. 



PORRIGO. 209 



SECTION III. 

3. ANOMALOUS PORRIGO. 

Species 4. Porrigo scutulata^ Scalled Head, 
or Ringworm of the Scalp. 

S^. Tinea ficosa (Astruc. Sauv.) : Achores, 
seu Scabies Capitis (Plenck) : Tinea granulata (^/«- 
son): Ecpyesis Porrigo, 6*, Galeata { Good) i Teigne 
granul^e (Alibert): Shiirine (Arab.): Kel (Pers. 
Turh.)\ Grind; Haarschuppen (German): T6te 
Teigneuse (F.). 

(Plate XXXIX. of Bateman ; PL 16. of Thom- 
son's Atlas). This species of Porrigo appears in 
distinct and even distant patches, of an irregularly 
circular figure, upon the scalp, forehead, and neck.* 

It commences with clusters of small light yel- 
low pustules, which soon break and form thin scabs 
over each patch, which, if neglected, become thick 
and hard by accumulation.! If the scabs are re- 
moved, however, the surface of the patches is left 
red, and shining, but studded with slight elevated 
points, or papulae, in some of which minute globules 
of pus again appear, in a few days. By these repeti- 
tions of the eruption of achores j the incrustations 
become thicker, and the areas of the patches extend, 
often becoming confluent, if the progress of the dis- 
ease be unimpeded, so as to a£Pect the whole head. 
As the patches extend, the hm covering them be- 
comes lighter in its colour, and sometimes breaks off 
short ; and as the process of pustulation and scabbing 
is repeated, the roots of the hair ai-e destroyed, and 

# ** Les eofans ies plus sujets ^ la Teigne granui^e, sont ceux dont la 
peau est brune ou basan^e." Alibert, p. 15. T. 

f Thenard and Vauquelin found the crusts in this species of Porrigo 
to be wholly gelatine. 

P 



210 PUSTULiE : 

at length there remains uninjured only a narrow 
border of hair round the head. ** Sometimes the 
achores are not perceptible in the commencement of 
the disease ; but the rallii^off of the hair is the first 
notice of its existence. The pustules are often pre- 
ceded by erythematic patches, which itch ; and, as M. 
Biett first observed, when viewed with a lens, each 
pustule has a central depression, and is generally 
traversed with a hair. The pustules, indeed, are 
generally seated at the roots of the hairs, which, as 
M. Biett has observed, are found penetrating the 
achores.*' 

This very unmanageable form of Porrigo generally 
occurs in children of three or four years old and up- 
wards, and often continues for several years. Whether 
the cu*cles remain red, smooth, and shining, or be- 
come dry and scurfy, the prospect of a cure is still 
distant ; for the pustules will return, and the ulcer- 
ation and scabbing will be repeated. It can only be. 
considered as about to terminate, when the rediiess 
and exfoliation disappear together, and the hair 
begins to grow of its natural colour and texture. 

The disease seems to originate spontaneously in 
children of feeble and flabby habits, or m a state ap- 
proaching to marasmus, who are ill-fed, uncleanly, 
and not sufficiently exercised: but it is principally 
propagated " by contagion, both to the other parts of 
the head of the individual affected, by the conveyance 
of the matter from the diseased to the healthy parts," 
and to others, by the frequent contact of the heads of 
children, but more generally by the use of the same 
towels, combs, caps, and hats. Whence the multipli- 
cation of boarding schools appears to have given rise 
to an increased prevalence of this disease, among the 
more cleanly classes of the community, at the present 
time. For such is the anxiety of parents to regain 
the lost years of education, that they too often send 
their children to these schools, when capable of com- 
municating the infection, although supposed to be 



PORRIGO. 211 

cured ; against which no vigilance on the part of the 
superintendents can afibrd a sufficient security. 

" The duration of the disease is very uncertain ; and, 
even under the most favourable circumstances, the 
prospect of cure is always a distant one. If the surface 
appear red, smooth, and shining or scurfy, the dis. 
ease is still in progress ; but when redness and exfo* 
liation are absent, and the hair begins to grow in its 
natural form and colour, it may be regarded as on 
the decline.*' 

" The causes of the disease are not known. It 
often originates in weak, ill-nourished children : but 
in general it is propagated by contagion ; and there 
is much reason for thinking that it is one of the 
many evils bestowed upon us from our Oriental pos- 
sessions. It has been propagated chiefly in schools, 
and public establishments, where many children are 
brought together.*' 

The principles of local treatment already laid down, 
are particularly applicable in this species of Porrigo. 
While the patches are in an inflamed and irritable 
condition, it is necessary to limit the local applica* 
tions to regular ablution, or sponging, with warm 
water or with lime-water, or some emollient foment* 
ation.* Even the operation of shaving the head, 
which is necessary to be repeated at intervals of eight 

* This mode of treatment was recommended by some of the ancients. 
Oribasius observes, that *^ if there is much heat or inJiammaHon connected 
vrith the achores, this must be first alleviated by a moist sedative/* 
(Svnops. lib. viiL cap. 27.) Aetius also observes, ^ Quod si incideris in 
achores inflammatos et dolentes, dolorem prius liquido medicamento con* 
coctorio moUienteque ac leni mitigabis/'&c.(tetrab.ii. serm. ii. cap. 68.) 
And among the moderns, Heister has made a similar discrimination 
respecting the treatment of Porrigo. He recommends, in all instances, 
in the commencement of the disease, the use of mild emollient appli- 
cations ; as cream with cerussa, oleum ovorum, ^ ung. de enula, de ce- 
nissa, diapompholygos, aliudve simile satuminum," while moderate 
alteratives, of calomel, antimony, &c. are given internally. He affirms 
that the application of mercurial and sulphur ointments, in the first in* 
stance, is exceedingly pernicious. Chirurg. part. i. lib. v. cap. 10. Ried- 
Unus relates, that a gentlewoman whose son was afflicted with Porrigo 
had tried many applications in vain, and indeed had received no ben^t 
until she was recommended to cover the whole head with a cataplasm 

P 2 



212 PUSTULE : 

or ten days, produces a temporary increase of irrita- 
tion. At this time, the patient should wear a light 
linen cap, which should be frequently changed ; and 
all stimulant lotions and ointments, which tend only 
to aggravate the disease, should be proscribed. " I 
have seen much benefit derived from the continued 
application of linen rags dipped in cold or iced water ; 
and over these an oil-silk cap« Alibeit recommends a 
cataplasm of Hemlock ; but I have never seen any ad- 
vantage result from it, nor from Cataplasms of Hen- 
bane or of Belladonna. The latter produces great 
dilatation of the pupils and blindness, vertigo, and 
other nervous symptoms : it, therefore, should be used 
with caution.*' 

In the progress of the disorder, various changes 
take place, which require corresponding variations of 
the method of treatment. By d^rees the inflam- 
matory state is diminished, and a dry exfoliation and 
scabbing ensue: but the pustular eruption retui*ns, 
and the patches become again red and tender ; or, in 
some cases, without much redness, there is an acrimo- 
nious exudation, with considerable irritability of the 
scalp* In other instances, the surface becomes inert, 
and in some degree torpid, while a dry scaly scab 
constantly appears, and active stimulants M*e requisite 
to effect any change in the disorder. It is very ob- 
vious, as Dr. Willan used to remark, that the adoption 
of any one mode of practice, or of any single prcr 
tended specific^ under these varying circumstances of 
the disease, must be unavailing, and oflen extremely 
injurious. 

In the more irritative states, the milder ointments, 
such as those prepared with Cocculus IndicuSj " in 
the proportion of gij of the Pulvis Cocculi to 5j of 
Lard}*' or with the Submuriate of Mercury, the 



composed ofoatmeda water, and butter, which soon succeeded in curing 
tlie dis^9se, and restoring the healthy state of the scalp. Lin. Med. 
Ann. 6. Feb. 25. p^ 215. seq. 



PORRIGO. 213 

Oxide of Zinc, the Superacetate of Lead, or with 
Opium or Tobacco, should be employed ; or sedative 
lotions, such as decoctious or infusion of Poppy-heads, 
or of Tobacco, may be substituted. Where there is 
an acrimonious discharge, the Zinc and saturnine 
with the milder mercurid ointments, such as the Un- 
guentum Hydrargyri prascipitati albi, or the ointment 
of Calomel, or a lotion of Lime-water with Calomel, 
** or a soap composed of equal parts of soft Soap and 
of Sulphur ointment,'' dre advantageous. 

According to the different degrees of inertness 
^hich ensue, various well-known stimulants must be 
resorted to, and may be diluted, or strengthened, and 
combined, according to the circumstances. The Mer- 
curial ointments, as the Unguentum Hydrargyri 
nitrico-oxydi, and especially the Unguentum Hydrar- 
gyri nitratis, are ofteti effectual remedies: "Banyer's 
Ointment, which is composed of Ibss. of Litharge^ 
|n of burnt Alum, ^ss of Calomel, Ibss of Venice 
Turpentine, and Ibij of Lard, well ruWbed toge- 
ther, is much employed <m the Continent." Oint- 
ments prepared with Sulphur, Tar, Hellebore, Turpen- 
tine, and Sabidilla, the Unguentum Elemi, " or the 
Unguentum Sulphuris, witn a small addition of the 
Calx Hydrargyri alba,'* &c., separately or in combin- 
ation, occasionally succeed ; as well as preparations of 
Mustard *, Staves-acre, Black Peppei' t> Capsicum^ 
Galls, Rue, and other acrid vegetable substances t : but 
all have occasionally failed. *^ In India, where the 

* See Sennert. loc. cit. — Undenvood on the Dis. of Children, 
voy. ii. 

f There is an Uneuentum I^peris nigri ii^the Dublin pharmacopoeia, 
of the eftcacy of which Dr. Tuomy speaks highly.' See his Essay on 
the Diseases of Dublin. • 

j: The ancients were accustomed to employ a similar Collection of 
stimulants for the achores ; among which were Sulphur Vivum, Attra- 
mentum Sutorium (Sulphate of Iron), Tar, burnt Paper with Oil, Soap ; 
Oil of Rue and of Myrtle; Resin, Myrrh, and Frankincense, with Wine 
and Vinegar, &c. Vinegar was deemed an efficacious remedy. '^ Acetum 
vero acerrimum ad achoras omni tempore accommodatum est." See 
Oribas. Synops; lib. viii. 97. Aet. tet. ii. serm. ii. cap^68. 

p 3 



214* PUSTULJE : 

disease is very prevalent, an ointment composed of ^ j 
of powdered Galls, 9j of Sulphate of Copper, and ?j of 
Lauxl, or simple Cerate, is greatly recommended. In 
this country, one of the last local remedies in vogue is 
Kxeosote: I have used it, and seen it occasionally 
successful, but, like every other local application, it as 
frequently fails." Lotions containing the Sulphates 
of Zinc and of Copper, or the Oxymuriate of Mer- 
cury, in solution, are likewise occasionally beneficial. 
" Decoction of Tobacco has been recommended ; but 
it must be applied with caution. Nitric Acid rubbed 
up with Lard was tried by Alibert without permanent 
benefit. Underwood, in cases of long standing, ad- 
vises the scalp to be shaved, then well washed with a 
strong lather of soap ; and, afterwards, the Unguen- 
tum Picis made with Petroleum, instead of Pix liquida, 
to be rubbed in for nearly an hour at a time, using it 
hot, and covering the head with a bladder, both ta 
keep on the ointment and to promote the perspir- 
ation of the part. If the hairs loosen, they should 
be pulled out by the roots. * Desault {Joum. de 
Chirurg.) mentions a plaster composed of Ammo- 
niacum and Vinegar, which being spread on linen, is 
applied over the head, and left on it for two months. 
Alibert, who^ it has been stated, recommends, a cata- 
plasm of Hemlock, asserts that three cases out of four 
^re cured by this application in five months." 

In the very dry and inert state of the patches, the 
more caustic substances are oft;en extremely successftil. 
Thus I have seen a lotion, containing from three to 
six grains of the Nitrate of Silver in an ounce of dis- 
tilled water, effectually remove the disease in this con- 
dition. Touching the patches with the Tincture 
muriated of Iron, or with any of the mineral acids, 
" particularly the Sulphuric," slightly diluted, in 
some cases removes the morbid cuticle, and the new 
one assumes a healthy action.t The application of a 

* Treatise on Diseases of Children, 8vo. 8th edit. p. 454. 

f Mr. P. Fernandez mentioned to me an instance of speedy recovery 



PORRIGO. 215^ 

blister in like manner sometimes effectually accom- 
plishes the same end* But, in many instances, the 
effect of these renovations of the cuticle is merely 
temporary, and the disease returns in a week or two, 
upon the new surface. 

Professor Hamilton, of Edinburgh, who considers 
the ringworm of the scalp as " quite different from the 
scalled head," has affirmed, that he has seldom failed 
to cure the former by the use of the Unguentum ad 
Scabiem of Banyer. For delicate children, he dilutes 
this ointment with an equal portion of simple Cerate> 
and sometimes alternates the use of it with that of 
common Basilicon. 

These various applications are enumerated, because 
not one of them is always successful, singly, even 
even under circumstances apparently the same. They 
must be varied, and combined ; and the best criterion 
in the choice and combination of them, is the degree 
of existing irritation in the morbid parts, or in the 
general habit. The rude and severe employment of 
depilatories, which some practitioners have recom- 
mended, is not always to be advised, as often inflict- 
ing great injury to the scalp, and retarding, rather 
than expediting, the progress to recovery. " They 
have been adopted on the supposition that the bulb 
of the hair is the seat of the disease. They are, 
nevertheless, recommended by some who do not refer 
the disease to the roots of the hair, but regard them 
only as sources of irritation in the diseased part. Mr. 
Plumbe * recommends, as a preliminary step to any 
method of local management, to discharge the con- 
tents of the pustules, to remove the hairs, and to 
wash the matter from the scalp. Having removed 
the hairs and discharged the pustules, he recommends 



which followed a single application of the strong Sulphuric Acid, which 
was instantaneously washed off. A new and healthy cuticle succeeded. 
The Acetic Acid, or Aromatic Vinegar, which acts as a more gentle, yet 
very effectual caustic, has proved an effectual remedy in a few instances. 
* A Practical Treatise on Diseases of the Skin, p. 70, 

P 4 



> 



216 PUSTULE : 

the part to be rubbed with finely powdered Sulphate 
of Copper, which is afterwards to be washed off. This 
should be repeated as often as any new pustules make 
Uieir appearance. Should the pustules recur when 
new hair grows on the spots, he recommends pressure 
by adhesive straps and cold lotions. A more easy 
method of getting rid of the hairs is that recommended 
by Mr. M» Mahon in Impetigo^t?o«flf. Th6 hair is 
cut short, and the crusts and scurf removed by a ca- 
taplasm of Linseed meal applied every night for four 
or five days, and washing the scalp with soap and 
water. The affected parts are then to be anointed 
with a depilatory composed of weak (tiearly carbo- 
nated) Quicklime, Silex, Alum, and Oxyd of Iron, 
a small quantity of Carbonate of Potass, some Char- 
coal, and a sufficient quantity of Lard. During the 
time of applying this, the hairs and scurf are to be 
removed by washing with soap and water. I have 
seen nearly the same advantages from using a lotion 
composed of one part of Liquor Potassae, two parts of 
Alcohol, and two parts of Water. It is to be rubbed 
only on the diseased spot by means of a sponge." 

I have said nothing respecting the administration of 
internal medicines ; because the disease is often merely 
local, being communicated by cont^on tochUdren in 
other respects healthy. But in those in whom it appears 
in combination with cachectic symptoms, chalybeate 
medicines, or the decoction of Cinchona and alter- 
atives, must be prescribed, according to the particular 
indications ; and the diet, clothing, and exercise of 
the patient must be carefully regulated. " The feet 
in particular should be kept warm and dry; and every 
means adopted to maintain a due equilibrium of the 
circulation and the insensible perspiration ; at the 
same time all crude aliments, raw vegetable matter, 
and whatever is likely to irritate the stomach, should 
be carefully avoided. I have always found advantage 
from keeping the bowels open, by saline purgatives in 
stout children, and by those of a warm and tonic cha- 



PORRIGO. 217 

racter in scrophulous subjects. The tepid bath, also, 
used in the morning, is beneficial. 

Species 5. Porrigo decalvansy Bald or Ring- 
worm SCALL. 

Syn. Area ( Celsus) : Alopecia areata ( Sauv. ) : 
Trichosis Area ( Good). 

This singular variety of the disease (Plate XL. of 
Bateman: PL 16. of Thomson's Atlas,) presents 
no appearance whatever, except patches of simple bald- 
ness, of a more or less circular form, on which not a 
single hair remains, while that which surrounds the 
patches is as thick as usual. The surface of the scalp, 
within these areae, is smooth, shining, and remark- 
ably white.* It is probable, though not ascertained, 
that there may be an eruption of minute achores 
about the roots of the hair, in the first instance, which 
are not permanent, and do not discharge any fluid.t 
The disease, however, has been seen to occur, in one 
or two instances, in a large assemblage of children, 
among whom the other forms of the Porrigo prevailed. 
But in other cases, and also in adults, it has appeared 
where no communication could be traced or conjec- 
tured. The areae gradually enlarge, and sometimes 
become confluent, producing extensive baldness, in 
which condition the scalp remains many weeks, espe- 
cially if no curative measures are adopted. The hair 
which begins to grow is of a softer texture, and lighter 
colour, than the rest ; and in persons beyond the 
middle age, it is grey. ** It is diflScult to trace the 
cause of this curious disease. It seems to be some 

* CelsuSj and after him some other writers, have described this affec- 
tion under the appellation of '* Area." Under this generic term, he 
comprises two varieties, called by the Greeks Alopeday and Ophiasis ; 
tl}e former of which spreads in irregular patches ; and the latter in a 
serpentine form, round both sides of the head, from the occiput. — De 
Medicina, lib. vi. cap. 4. 

f It is not unfrequent in countries where the inhabitants live chiefly 
upon fish; as, for instance, formerly in the Shetland islands, where bald- 
ness from this cause was so common, that it was familiarly said, ^ that 
there was not a hair between them and Heaven." Sir R. Sibba/d^s 
Description of Shetland, fol. p. 25. 



218 PUSTUL.E : 

morbid condition of the secreting follicles of the hair, 
for there are no achores present that can be detected, 
nor any disease of the skin. The bald part, however, is 
pale and exsanguine, which seems to indicate some 
contracted state of the capillaries. There is occa- 
sionally a slight degree of itching, which seems to 
indicate some nervous excitement in the patches." 

If the scalp is cleared by constant shaving, and at 
the same time some stimulant liniment be steadily 
applied to it, this obstinate affection may be at length 
overcome, and the hair will regain its usual strength 
and colour. In fact, until this change takes place, the 
means of cure must not be intermitted.* Some of 
the more active ointments, mentioned under the pre- 
ceding head, may be employed with friction ; but lini- 
ments, containing an essential oil dissolved in spirit 
(for instance, two drachms of the oil of Mace, in 
three or four ounces of Alcohol), or prepared with 
Oil of Tar, Petroleum Barbadense, Camphor, Tur- 
pentine, &c. are more efficacious. 

Works which may be consulted on Porrig a. 

A Practical Essay on Ringworm of the Scalp. 8vo. Lond, 1821. 

Alibert, Maladies de la Peau, fol. 

Cazeneve et ScHEDEL, Abr^ Pratique des Maladies de la Peau, 
8vo. 1828. 

CqQ£M» W. on Tinea Capitis, 1810. 

CaAMPTON, Transactions of the King and Queen's College of Physi- 
cians, Dublin, 1824. 

DicTioNAiRE des Sciences M^. art. Teignes. 

Gallot, Recherches sur la Teigne, 8vo. 1805. 

(jraEEN, J. Practical Compendium, &c. 8vo. Lond. 1835. 

Haquenot . H. Tractatus de Morbis externis Capitis. Geneva, 8vo. 

~ 1759. 

H iLLAiRET. J. B. Expos6 dcs Mojeus employ^ dans le Traitement de 
^. la Teigne. P«rM. 4 to. 1814. 

I ■ .11. t 

* All that can be prescribed respecting the treatment of this affection 
has been expressed by Celsus with his usual terseness : — '* Quidam hsec 
genera arearum scalpello exasperant : quidam illinunt adurentia ex oleo, 
maximeque chartam combustum : quidam resinam terebinthinam cum 
thapsia inducunt. Sed nihil melius est, quam novacula quotidie radere : 
quia, cum paulatim summa pellicula excisa est, adaperiuntur pilorum 
radicular. Neque ante oportet desistere, quam fi*equentem pi turn nasci 
apparuerit. Id autem, quod subinde raditur, illini atramento sutorio 
satis est." Loc. cit. 



ECTHYMA, 219 

Oldenbourg, de Porrigine, 1 762. 

i'LUMBE on Diseases of the Skin, 2d edit. 1827. 

PoTEL, F. T. Considerations sur la Teigne, Paris. 8vo. 1804. 

Mahon jeune, M.,Recherches sur le Siege des Teignes. 8vo. Paris,l829 

Rayer, Trait^ des Maladies de la Peau, 8vo. 1826 

Strack. de Crusta Lactea Infantum, &c. 1779. 

Transactions of King and Queen's College, Dublin, vol. iv. 

Wilkinson on Cutaneous Diseases, 8vo. 1822. 

WiLLAN, A Practical Treatise on Porrigo, 4 to. 1814. 



Genus III. ECTHYMA.* 

Sf/n. E^edtijxa TeqfJLivQos 67nyriHis( Gfrcpcorum): Tere- 
binthus (L.) : Albotin, Schera, Botsor (Arabarum) : 
Termintnus ( Tf^isevnanj Turner^ Lorry y Plenck) : 
Epinyctis ( Sauvages) : Citemole flechte ( Spren- 
gel) : Phlysis Ecthyma ( Young)\ Ecpyesis Ec- 
thyma ( Oood) : Dartre crustacee, Faruncle atonique 
(JP.) Erbsen blattem {0.)i Papulous Scall. 

JDef. An eruption of large phlyzacious pus- 
tules ; EACH SEATED ON A HARD, ELEVATED RED 
BASE ; AND TERMINATING IN A THICK, HARD, GREEN- 
ISH OR DARK-COLOURED SCAB. ThEY ARE DISTINCT, 
SPARINGLY SCATTERED, AND NOT CONTAGIOUS. 

** The pustules sometimes appear in successive 
crops ; but generally they run an independent course, 
appearing and terminating at different times. 

* The term ixOvfia seems to have been used by the Greeks in a ge- 
neral sense, and nearly synonymous with t^avOtjfiay or eruption. Perhaps 
the more elevated and inflammatory eruptions were particularly called 
ecthymata ; since, as Galen has observed, in his Commentary on the 
third book of the Epidemics of Hippocrates, the term is derived from 
iKdvHv^ ** quod est sKopfiav (impetu erumpere) in iis quse sponte extube* 
rant in cute." ($ 51.) See also Erotian de voc. apud Hippoc ; — and 
Foes, CEconom. Hipp, ad voc. tKOvfiara. This view of the subject has 
led many authors, Femel, Par^, Vidus, Vidius, Sennert, Sebizius, &c. to 
believe, that the terms ecthymata and exanthemata were used specifically^ 
as the denominations of smallpox and measles. ^Variolas vocant 
tKOvfjiaTa, pustulas extumescentes, morbillos autem iiavQtjiiara nominant, 
maculas in cute apparentes," &c. See a learned Treatise of Melchior 
Sebizius, De Variof. et Morbil. Argent. 1642. These views sanction the 
appropriation of the term to the " pustulse extumescentes " of this 
genus. 



220 PUSTULE : 

" This eruption is, sometimes, but not always, pre- 
ceded by fever : but more generally by gastric irrita- 
tion/* It does not very frequently alone demand the 
assistance of medicine. It is commonly indicative of 
some state of distress, if that expression may be used, 
under which the constitution labours ; and, although 
it is not attended by actual fever, yet a degree of 
general irritation, or erethism, is often present with 
it, arising from great fatigue, defective nourishment, 
surfeits, imperfect clothing, ill-ventilated houses, sloth 
and filth. " Their developement is frequently accom- 
panied with very acute stingiiig pains, not unlike 
those that often precede Herpes Zoster. Their pro- 
gress is always slow : the suppuration being often im- 
perfect ; and the pus occupying only the apex of the 
pustule. On the extremities, however, the pustules 
are so generally suppurated as to assume the appear- 
ance of blebs. They terminate sometimes in thin 
white crusts ; sometimes in deep ulceration ; some- 
times in permanent indurations.'* 

" Ecthyma attacks all ages and constitutions : but 
young men are more liable to it than children of either 
iSex.** " The degree of strength of the constitution 
modifies greatly the progress of the pustule ; whei^ it is 
low, the suppurative process is imperfect ; the pus, from 
the relaxed state of the capillaries, is often mingled 
with blood, at least with red globules ; thence an im- 
perfect scab is formed : this becomes an irritating cause, 
so as to augment the exudation of the secretion, which 
accumulating, elevates and enlarges the scab.** It 
shows itself under three or four different forms, and 
is usually attributed to long-continued exertion and 
fatigue, to much watching, to anxiety of mind, to 
imperfect nutriment, to the influence of a cold and 
moist atmosphere, to an abuse of spirituous liquors, 
to a state of pregnancy, or to the debilitating effects 
of previous malignant fevers, especially of smallpox, 
measles, and scarlatina. It occurs most frequently on 
the extremities, but sometimes on the chest, " abdo- 



ECTHYMA. 221 

men, nates, loins, neck, rarely on the face, and scalp, 
and still more rarely on the trunk of the body." 

The diagnosis of this eruption from the contagious 
pustular diseases, as well as from some of the secondary 
appearances of syphilis, is of considerable importance 
in practice, which renders it necessary to notice this 
genus. " It may be mistaken for pustular scabies, 
from which, however, it is distinguished by the pus- 
tules appearing and running their course independent 
of one another, some being on the decline whilst 
others are just appearing ; and by never being mixed 
with intervening vesicles. There is no itching, but 
a stinging pain in Ecthyma. It has also been con- 
founded with Lichen and Furunculi." 

The genus comprehends four species : 

1 . E. vulgare. 3. E. luridum. 

2. E. infantile. 4. E. cachecticum.* 

Species 1. Ecthyma vulgare. 

Syn. Epinyctis vulgaris ( Sauvages) : Ecpyesis 
Ecthyma, a. vulgare (Good) : L'Ecthyma aigu 
[Rayer) : Psoris Crustacea acuta (Alibert) : Common 
Papulous ScalL 

This (Plate XLIII. fig, 1. of Bateman; PI. 17. 
of Thomson's Atlas,) is the slightest form of the 
disorder, and consists of a partial eruption of small 
hard pustules, on some part of the extremities, or on 
the neck and shoulders, which is completed in three 
or four days. In the course of a similar period, the 
pustules successively enlarge, and inflame highly at 
the base, while pus is formed in the apex ; and in a 
day or two more they break, pour out their pus, and 
afterwards a thinner fluid, which speedily concretes 
into brown scabs. " The progress of the pustules is 
attended with sharp stinging pains. In young sub- 

* Rayer objects to this arrangement, and proposes to divide the genus 
into two species — acute and chronic Ecthyma; and although I retain 
the classification of Dr. Willan, here adopted by Dr. Bateman, yet I 
am decidedly of opinion that Rayer's is preferable. T. 



222 PUSTULE : 

jects they are of a bright red colour/* In a week 
more, the pains, soreness, and inflammation subside, 
and the scabs soon afterwards fall off, leavmg no mark 
behind. " But sometimes they are for some time 
adherent, and leave, when detached, a dark red spot : 
occasionally the lymphatic glands in their neighbour- 
hood swell and inflame." 

This eruption commonly supervenes on a state of 
languor and general depression of some continuance, 
with loss of appetite, irregularity of the alvine evacu- 
ations, headach, and pains in the stomach or limbs, 
restlessness and watchfulness at night. There is some- 
times a sufiused state of the eye, and erysipelatous 
inflammation of the fauces. Young persons are prin- 
cipally subject to it, and children are sometimes 
affected with it, especially in the spring or summer, 
after being over-heated, or fatigued, or from disturb- 
ing the digeiftive organs by improper food. The con- 
stitutional derangement is not immediately relieved 
on the appearance of the eruption, but ceases before 
its decline. 

The use of gentle purgatives, in the early stage of 
the disease, and of the decoction of Cinchona, or of 
the Sulphate of Quinia, in combination with the di- 
luted Sulphuric Acid, after the maturation of the 
pustules, appears to comprehend all that is requisite in 
regard to medicine. " Mercurial preparations, if ex- 
hibited so as to affect the habit, invariably aggravate 
the disease, except where the alvine secretions are 
very unhealthy, in which case a few grains of Hy- 
drareyrum cum Cretd, with a few drops of Tincture 
of Opium may prove useful. I have lately seen 
the shower-bath highly beneficial.** 

Species 2. Ecthyma infantile. 

Syn* Ecpyesis Ecthyma, &. Infantile (Good): 
Infantile Pupulous ScaU. 

This species occurs in weakly infants, during the 
period of lactation, when an insufficient nutriment 



ECTHYMA. 923 

is afforded them. It sometimes appears after the 
first teeth are cut. The pustules are, in appearance, 
the same as those of the preceding species, and go 
through similar stages of progress, in the same time. 
But the disorder does not terminate here : fresh 
eruptions of phlyzacia continue to rise in succession, 
and to a much greater extent than in the E. vulgare 
appearing not only over th^ extremities and trunk, 
but on the scalp, and even on the face; in which 
situation the pustules do not occur, except, sometimes, 
in the fourth species of Ecthyma. " The pustules 
generally appear first on the abdomen below the um- 
bilicus, and afterwards in the groins, and the axilla ; 
on the nates and thighs before they attack the face 
and scalp." Hence, also, the duration of the eruption 
is much greater than in the preceding species, being 
occasiondly protracted for several months. Yet the 
patients usually remain free from fever, and the pain 
and irritation seem to be inconsiderable, except when 
a few of the pustules become very large and hard, 
with a livid base, and ulcerate to some depth : in this 
case, also, a sHght whitish depression is permanently 
left on the seat of the pustule. Improper nourish- 
ment, and cold and moisture, are the exciting causes 
of this species of Ecthyma. Plenck states that it is 
sometimes epidemic. 

The principal means of cure will be found in chang- 
ing the nurse, " or altering her milk by a change 
of diet, especially by leaving off the use of porter.*' 
And the advantages of better aliment will be aided by 
proper clothing and exercise, as well as by moderate 
alteratives, ** mild aperients," and by the Cinchona, 
the Sulphate of Quinia, or chalybeates. " If the 
pustules are irritable, they may be fomented with de- 
coction of Poppy heads ; or a solution of Chloride of 
Lime." 

Species 3. Ecthyma luridum. 

Syn. Terminthus(.4wc<. var.) ; Melasma (PfewcA:, 



224 PUSTULiE : 

Linn. Fogel) : Ecpyesis Ecthyma, y. Luridum 
(Good): L'Ecthyma chronique {Rayer): Lurid 
Papulous ScaU. 

The most obvious peculiarity of this variety of the 
phlyzacious pustule (Plate XLIII. fig. 2. of Bate- 
man ; PL 17. of Thomson's Atlas,) is the dark red 
colour of its base, which is likewise hard and elevated. 
But the pustules of Ecihyma luridum differ also from 
the two preceding varieties, in being of a larger size ; 
and from the first variety, in the slow but long suc- 
cession in which they arise, and in the extent of sur- 
face over which they spread, the face alone being, 
generally, but not always, exempt from their occur- 
rence. " Their suppuration is seldom completed in 
less than eight or ten days. In some instances, in- 
stead of suppurating, they pass into violet-coloured 
tubercles, which, if they suppurate, proceed to ulcer- 
ation, and leave irregular cicatrices in the skin.*' This 
form of the disease is most frequently seen in persons 
of an advanced age, who have injured their consti- 
tutions by hard labour, intemperance in the use of 
ardent spirits, and night-watching; and it is most 
severe in the winter season. 

Under all circumstances, the pustules, as might be 
expected, are slow in healing. They break in the 
course of eight or ten days, and discharge a curdly, 
sanious, or bloody matter : the ulcerated cavities, ex- 
tending beyond the original boundary, soon become 
filled with hard, dark scabs, and remain surrounded by 
a deep-seated hardness in the flesh, and dark in- 
flamed borders, until the scabs are about to separate, 
— a period generally of several weeks, and some- 
times of many months. The scabs are commonly 
firmly seated ; but if removed by violence, they are 
not speedily reproduced ; on the contrary, tedious 
ulcers, with callous edges and a sanious discharge, 
are often thus occasioned. " This species of Ecthyma is 
said to be always a symptomatic aflfection. It prevails 
chiefly in those of broken-down constitutions, pri- 



ECTHYMA. 225 

soners, and the victims of poverty and wretchedness. 
Unwholesome food, salted provisions, bacon, and the 
abuse of spirituous liquors, are its exciting causes." 

The treatment of this Ecthyma must be chiefly 
directed to the amendment of the constitution, by 
means of good diet, by rest, the occasional use of the 
warm bath, and by the Cinchona Bark, the Sulphate 
of Quinia, and tonic vegetable decoctions, internally. 
" Sea-bathing has been found to produce highly bene- 
ficial eflFects, as an adjunct to tonics ; and, when it 
cannot be obtained, nearly the same benefit may be 
procured from sponging the trunk of the body with 
tepid salt and water before getting out of bed in 
the morning.*' 

A symptomatic Ecthyma, which bears a consider- 
able analogy to the E. luridum, sometimes occurs 
during the cachectic state which follows the measles, 
and occasionally after the scarlet fever and small-pox. 
It is accompanied with a hectic fever, laborious respir- 
ation, and swellings of the glands ; and is attended 
with extreme pain and soreness, sometimes with a 
tedious sloughing, in some of the larger pustules, 
which, in children particularly, are productive of con- 
siderable distress. The phlyzacia arise in various 
parts of the extremities and trunk, and are highly 
inflamed at their bases, even after the scabbing takes 
place. " Mr. Plumbe remarks, that when this 
symptomatic Ecthyma follows measles and other 
eruptive fevers, it is usually seen in its very earliest 
stage about the waist. It exhibits a few reddened 
and slightly elevated spots, covered with a very thin 
lamina of cuticle, which readily separates. Some of 
these have a minute elevation in their centre re- 
sembling a vesicle : the latter, however, contains 
nothing like the serum of the herpetic vesicle, but a 
glutinous fluid, which dries upon the part, and forms 
with the morbid cuticle an elevated scab of a conical 
form, the basis of which, in a day or two, is sur- 

Q 



226 PUSTULE : 

rounded by a small inflamed areola.'"* The whole 
duration of the disease is often from one to two 
months ; and the majority of patients struggle through 
it. 

Opiates and the warm bath afford essential relief 
to the distressing irritation occasioned by this affec- 
tion ; and a liberal use of the Cinchona Bark, where 
it can be administered, and of other vegetable tonics, 
both shortens and alleviates the disease. 

Species 4. Ecthyma cachecticum, Cachectic 
Papulous Scall. 

An extensive eruption of phlyzacious pustules 
(Plate XLIV. of Bateman ; PL I7. of Thomson's 
Atlas) not unfrequently occurs, in connection with 
a state of cachexia, apparently indicative of the oper- 
ation of a morbid poison in the habit : for the phaeno- 
mena of the disease much resemble some of the 
secondary symptoms of syphilis, and it is often 
treated as syphilitic.t 

The disorder usually commences with a febrile 
paroxysm, which is sometimes considerable. In the 
course of two or three days, numerous scattered 
pustules appear, with a hard inflamed base, some- 
times first on the breast, but most commonly on the 
extremities : and these are multiplied day after day 
by a succession of similar pustules, which continue 
to rise and decline for the space of several weeks, 
until the skin is thickly studded with the eruption, 
under various phases. For, as the successive pus- 



* Plumbe on Diseases of the Skin, 2d edit. p. 440. 

f A disease indicated by copper-coloured blotches, the size of a six- 
pence, on the nates and the soles of the feet, arising from a syphilitic 
taint in the parents, is not uncommon in London. It closely resembles 
this species of Ecthyma; but requires the aid of Mercury for its removal. 
T have generally removed it with small doses of Hydrargyrus cum Creta; 
and minute doses of the Oxymuriate of Mercury in Decoction of Elm 
Bark, or Emulsion of Bitter Almonds ; and more lately with the Hydri- 
odate of Potassa, or the Hydriodate of Iron. The former may be com- 
menced with doses of gr. iij, and carried to gr. x, three times a day : the 
dose of the latter may be, at first, gr. ij, and carried to gr. v, three times 
a day. T. 



ECTHYMA. 227 

tules go through their stages of inflammation, sup- 
puration, scabbing, and desquamation, at similar 
periods after their rise, they are necessarily seen 
under all these conditions, at the same time ; the 
rising pustules exhibiting a bright red hue at the 
base, which changes to a purple or chocolate tinge, 
as the inflammation declines, and the little laminated 
scabs are formed upon their tops : when these fall 
off, a dark stain is left upon the site of the pustules. 
In different cases the eruption varies in its distribu- 
tion: it is sometimes confined to the extremities, 
where it is either generally diffused, or clustered in 
irregular patches ; but it frequently extends also over 
the trunk, face, and scalp. The pustules which oc- 
cupy the breast and abdomen are generally less pro- 
minent than those on the face and arms, contain less 
matter, and terminate rather in scales than in scabs. 

The febrile S3nnptoms are diminished, but not re- 
moved, on the appearance of the eruption ; for a 
constant erethism or hectic continues during the 
progress of the disease. It is accompanied by great 
languor, and by much depression both of the spirits 
and muscular strength. " Delirium occasionally 
attends the febrile state ; and in habits with a pre- 
disposition to insanity, the depression of spirits is 
occasionally so great as to lead to suicide.'* The 
fever is throughout accompanied by headach and 
pains of the limbs, which are described as rheum- 
atic ; and by restlessness and impaired digestion, 
with irregularity of the bowels. There is commonly ^ 
also some degree of ophthalmia, affecting both the 
conjunctiva and the tarsi ; and the fauces are the 
seat of a slow inflammation, which is commonly ac- 
companied by superficial ulcerations. 

The duration of this disease seems to be from two 
to four months, in the course of which time, by the 
aid of the vegetable tonics, Cinchona, Sarsaparilla, 
Serpentaria, &c., with Antimonials, and the warm 
bath, the constitution gradually throws off the mor- 

Q 2 



228 PUSTULE : 

bid condition which gives rise to it. The adminis- 
tration of Mercury is not necessary to its cure, nor 
does it appear to accelerate recovery.* 

* The success attending the treatment pursued in the following case 
induces me to' publish it. The patient, an unfortunate German gentle* 
man, having fallen ill of a fever, lost all his employment, and became so 
depressed both in mind and body, that he sunk into a cachectic state of 
habit, and was soon attacked with Ecthyma. He applied to me on the 
27th of June, 1828, two months after the disease had made its appear- 
ance. The eruption covered the whole of the body, with the exception 
of the hands and the face. The stinging sensation was also accompanied 
with itching, or rather a tingling, which induced an involuntary desire 
to scratch, by which not onl^ the heads of the pustules were rubbed off, 
but large portions of skin, m some places two inches in length, and 
nearly an inch in breadth, were torn off by the action of the nails during 
sleep. Those pustules which had run their course had left dark stains 
behmd, so that the greater part of the entire skin was covered with these 
and the crusted pustules. When the pustules were early rubbed, black 
dots of effused blood remained. The thighs were covered with ulcers. 
The bochr was greatly emaciated ; there was a regular evening exacerba- 
tion of rever ; the tongue was clean, but red and glazed : the skin felt 
dry and harsh ; and the patient stated that the delirium attending the 
fever and the depression of mind had driven him nearly to commit 
suicide. The bowels were irregular. The following medicines wer6 
ordered : — 

9). Pulv. Jacobi veri gr. iij, 
Extracti Stramonii gr. ^, 

Hyosciami gr. ijj : fiat pilulae ij, 

hora somni omni nocte sumendse. 

1^, Magnesise Sulphatis 5j« 

Magnesias Carbonatis 9j. M. 
pulvis omni mane sumendus. 

JL Acidi Sulphurici diluti fjxij, 
Tincturae Opii f^iv. M. 
Sumatur vy xx ex cyatho Decocti Corticis Cinchonae Cordi- 
foliae ter quotidie. 

When the irritation is severe, let the surface be sponged with hot 
water. Let the diet be milk, fresh-boiled vegetables, and a moderate 
share of mutton under-cooked. 

July 5th. Few fresh pustules have appeared ; and the dark colour 
of the blotches is much less. The new pustules contain a mild pus. 
The bowels are regiilated by the aperient ; and although the fever still 
returns every evening, yet the delirium which attended it has disap- 
peared. He feels, occasionally, as if a cloud had settled upon him, and 
cut him off from all external impressions. The tingling and irritation 
are less, and return only in paroxysms, during which he still tears off 
large portions of the skin. 

Cont. medicamenta. : 

9). Plumbi Acetatis ^s. 

Acidi Hydrocyanici f^iij, 

Ung. Cetacei Jiij- M. 
Fiat unguentum partibus cutis nudatis applicandum. 



ECTHYMA. 229 

The diagnosis between this disease and the syphi- 
litic Ecth3niia, is to be collected rather from the 
history of the disease, than from the prominent 
symptoms : unless, indeed, we are ready to concede 
to a recent writer, that this and similar affections 
are never the result of the true syphilitic poison.* 

Dr. Willan mentioned a topical variety of Ecthyma, 
occurring on the hands and fingers of workmen em- 
ployed among metallic powders, which I have never 
seen. As it commences in a vesicular form, and, 
though afterwards purulent, produces irregular patches 



18th July. He is much better in every respect, and the irritation is 
so much abated, that he can now sleep without excoriating his body. 
He is gaining both in flesh and strength. 
Perstet in usu medicamentorum. 

August 2d. The eruption is nearly gone, arid the skin is regaining its 
natural aspect. He complains of watchfulness, and great depression ; 
but the want of employment and distress of mind seem to be counter- 
acting the full powers of the medicines. 

Cont. medicamenta. 

9). Camphorae gr. v, 

Pulveris Jacobi gr. iij, 

Extracti Hyosciami gr. iij. 
Fiant pilulas ij. h. s. sumendae. 

From this time the disease rapidly abated, and having discontinued 
his visits to me, he became fat, got into health, and is now in Germany. 

The chief feature in the treatment of this case is the combination 
of the Tincture of Opium with the diluted acid, and the extenal appli- 
cation of the Hydrocyanic Acid, in the form of ointment. The Opium 
thus combined seemed to allay the irriution, and certainly augmented 
the tonic power of the Bark; whilst the ointment deadened the insup- 
portable itching which had caused the tearing of the skin. T. 

* See Part First of an " Essay on the Venereal Diseases, which have 
been confounded with Syphilis," by Richard Carmi6hael, President of 
the Royal College of Surgeons, Dublin, 1814. If T rightly comprehend 
this interesting but unfinished work, Mr. Carmichael maintains that the 
true syphilitic ulcer is followed exclusively by ow<? eruption^ the scaly 
copper blotch, or Lepra venerea, described by Dr. Willan. It will now 
scarcely be doubted, indeed, that the above-mentioned Ecthyma, and 
some other eruptive diseases of an analogous character, are frequently, 
though erroneously, pronounced syphilitic ; but we are not prepared, 
by the present state of the evidence, to limit the syphilitic eruptions 
thus narrowly. 

q3 



230 PUSTULiE : 

of thin scabs, it should perhaps have been referred 
to Eczema.* 

Books which may be consulted on Ecthyma. 

Cazeneve et ScHEDEL, Abr^^ Pratique des Maladies dela Peau, 8vo. 
Hewson, North American Med. and Surg. Journal, 1 826. 
'^Plumbe on Diseases of the Skin, 2d edit. 1827. 
Rayer, Trait^ des Maladies de la Peau, 8vo. 1827. 
Struve, L. A., Synopsis Morborum CutaDearum, fol. Berb'n, 1829. 
WiLLAN, on Ecthyma, 4to. 



Genus IV. VARIOLA, f 

Syn. Euphlogia (Rhazes) : Pocken, Blattem, 
Empyesis variola ( Good) : Variolae {Auct. var.) 
Febris variolosa {Hoffman^ Vogel) : Synochus vario- 
losa ( Young) : Kindspocken ( Germ.) : Kinderpok- 
jes, Pokjes, Kinderziecke {Dutch) : Kopper, Bime- 
kopper {Danish) : Kopper, Smakopper ( Swedish) : 
Vajuolo (Ital.) : Viruelas, Viruela (Spanish) : Petite 
verole, ricote {F»): Jedrie (Arabic): Perse ummay 
(Tarn.): Burriseetle (Duk.): P6aumma (TeL): 
Kruevan (Bali) : Masoorikeh (Sans.) : Kelumbuan- 
Chucur (Malay) : Gootry (Bengalese) : Smallpox:. 

Def. An eruption of pustules appearing 

FROM THE THIRD TO THE FIFTH DAY OF A CONTA- 
GIOUS FEVER, AND SUPPURATING FROM THE EIGHTH 
TO THE tenth: THE FEVER IS FREQUENTLY AC- 
COMPANIED WITH VOMITING AND PAIN WHEN PRES- 
SURE IS MADE ON THE EPIGASTRIUM. 

" Pariola^ as the definition states, is a contagious 
disease. The virus remains sometimes before it 
even induces fever, and after this commences the 
eruption is delayed for some time. It is seldom that 
any change is perceived by the patient on receiving 

* A topical variety of Ecthyma is produced by Tartar Emetic oint- 
ment, and similar irritating applications. T. 
f Variola, quasi parvi van. 



VARIOLA. 231 

the infection, although it is said that an unpleasant 
odour, or a feeling of giddiness, sickness, or some 
alarm, is experienced. The period between the re- 
ception of the infection and the sickening, or febrile 
st^e, is from twelve days to three weeks. A rigor 
then occurs, with pain or weakness of the back, some- 
times pain of the epigastrium, with nausea, vomiting, 
and vertigo. The prostration of strength is consider- 
able ; and sometimes epileptic fits supervene, especially 
in children, whilst adults become delirious. In forty- 
eight or fifty hours after the rigor or headach comes 
on, the eruption shows itself; but circumstances may 
lengthen that period. The eruptive fever is not 
always evident : towards its close, in infants, vomiting 
and convulsions are not unfrequent. The eruption 
attacks at once the skin and mucous membrane or the 
lungs and of the primae viae : appears first on the 
face, thence it extends to the neck, the trunk of the 
body and the arms, and lastly to the lower ex- 
tremities. It first shows itself in the form of small, 
hard, red papulae, which, about the fifth day, become 
whey-coloured pustules, with a depression in the 
centre, which is filled up on the eighth day. When 
the pustules are few in number, they appear in groups 
of four or five, which assume a crescent form. The 
pustules are now spherical, turgid with pus, and in- 
flamed at the base. About the eleventh day they 
spontaneously ooze out pus, which concretes to a 
crust ; this, after some time, falls oflF, and leaves the 
skin of a reddish colour, which remains for many days 
before the natural colour is restored. The real 
variolous pustule is cellular, and tied down in the 
centre * ; the vesicle of Chickenpox, Varicella, is a 

* Dr. Macartney of Dublin thus describes the change of structure to 
produce the smallpox pustule : " In the cellular tissue which surrounds 
the villi of the cutis, a few blood-vessels are perceived determining to a 
central point, and producing a pimple, which feels hard under the finger : 
this acuminates ; but by degrees the acumination disappears, and the 
centre of the pimple is depressed, and a cellular, radiated arrangement 
ensues. These cells, as well as the depression, are formed by the adhe- 

Q 4 



232 PtrsTULJE : 

single cell ; the pustule of modified smallpox is con- 
verted into a small homy button, on the fifth day 
from the coagulation of the gelatinous lymph. 

" Authors have spoken of two species of smallpox, 
the distinct^ and the confluent ; but these insensibly 
run into one another, and are mere varieties of the 
same disease, depending, in a great degree, on the 
habit of body of the individual who is infected. 
Another ' variety of less frequent occurrence, is 
marked by the pustules remaining solid throughout : 
this has been termed the JVarty smallpox^ Variola 
verrucosa.* 

" The eruption, when the disease is produced by 
infection, follows the general fever; when it is 
communicated by inoculation, there is a local aflFec- 
tion often extending beyond the points where the 
virus was introduced previous to the formation of the 
general fever. It cannot be communicated by the 
blood of an infected person, as was proved by the 
experiments of Sutton the inoculator.^' 

Var. 1. Variola discreta^ distinct Smallpox 
(Thomson's Atlas, PI. XVIII.). The fever, in this 
variety of smallpox, is of the inflammatory type. It 
is accompanied with pains of the back, limbs, and 
loins ; sometimes with pains, also, of the chest, dry- 
ness of the fauces, and coma. In the first day of the 
fever, the rigors are more or less prolonged, alternated 
with bursts of heat, general uneasiness, nausea, or a 
diminished appetite. On the second day, the nausea 
increases ; arising sometimes to bilious vomiting : 
and, at the same time, a bilious diarrhoea supervenes. 

sion of the central portion of the membrane to an inflamed part of the 
villous surface of the true skin." T. 

M. Velpeau, after many experiments on both the dead and living body, 
to discover the seat of the pustules, was led to conclude that they are 
developed chiefly in the sebaceous follicles. — Bull, de Soc. Philomath, 
Juin, 1825. T. 

* Dr. John Thomson has endeavoured to prove that variola and va- 
ricella are merely modifications of the same disease, and communicable 
by the same virus. As the question is still svh judiccy I refrain from 
hazarding my opinion regarding it in this place. T. 



VARIOLA. 233 

A little before the eruption appears, children are 
seized with an epileptic fit ; sometimes there is only 
a convulsive twitching of the mouth and face : the face 
is flushed; the eyes are impatient of light ; and there 
is an uneasy sense of oppression at the epigastrium, 
which is greatly increased by pressure. 

Roseola sometimes accompanies or follows the first 
appearance of the eruption. The pustules at first 
are small, red, isolated, distinct points like fleabites ; 
appearing on the face and hairy scalp, and extending 
over the whole body. This eruption is spread not 
only over the skin, but over the mucous membrane 
of the mouth, pharynx, and bowels, the prepuce and 
the vulva. On the second or third day of the erup- 
tion, the little tubercles are found to contain a fluid 
at* the apex, which is, at first, nearly colourless and 
semitransparent, and depressed in the centre : but 
the eighth day they become spherical, and evidently 
contain pus. The face swells, and as it subsides, 
about the tenth or eleventh day, the hands and feet 
swell and continue swelled for some days ; and if 
not in excess, these swellings are to be regarded 
indicative of a favourable tennination of the disease. 
When the pustules are few, they become opaque, 
white, and ultimately yellow ; and acquire the size 
of a small pea. After this, the shrinking and incrust- 
ation take place, as has been already described ; the 
swelling of the face and other parts disappears ; and 
a slight salivation and a hoarseness which accompany 
the swelling subside. The crusts generally drop 
about the fourteenth day of the disease, and leave 
brownish red blotches : convulsions seldom succeed 
to distinct smallpox. 

The fever, in mild cases, seems to disappear after 
the eruption is fully formed : but ** in severe cases, 
when the cellular matter is involved with the skin in 
inflammation, it continues, and is greatly aggravated. 
In general, this secondary fever" returns about the 
eleventh day j and when the pustules are numerous, is 



234 PUSTULE : 

sometimes more severe than the eruptive fever. " The 
secondary fever is sometimes accompanied with oph- 
thalmia; and, in very severe cases, the most aggravated 
affection of the conjunctiva supervenes, involving the 
structure of the eye, and completely destroying its 
organisation. Sometimes gangrenous inflammation 
of the genitals occur. The internal organs, namely, 
the lungs, the liver, the other abdominal viscera, 
and the brain, are all, more or less, involved in the 
secondary fever ; and, in severe cases, display their 
morbid state, by pleurisy, hepatitis, bronchitis, and 
erysipelas." 

Var. 2. Variola confluensy confluent Small- 
pox (Thomson's Atlas, PI. XVIII.), differs from 
the distinct, in the greater severity of all the symp- 
toms. The headach is violent, often accompanied 
with delirium. The eruption appears earlier, and is 
less elevated above the surface of the skin than in the 
distinct Variola ; the pustules are more numerous, 
sooner suppurate ; and on the face they become flat 
and run together, or are confounded with one another, 
and have no inflamed base. The face continues 
longer swelled than in the other variety, and when 
the incrustation takes place, the whole visage seems 
as if covered with a single scab. The fever assumes 
the typhoid character, and a peculiar odour exhales 
from the surface of the body of the patient. As the 
desquamation proceeds, the fever increases ; and, 
sometimes, coma suddenly supervenes, and carries off 
the patient in forty-eight hours. In this form of the 
disease, when the crusts fall, they are replaced by 
scales which not unfrequently ulcerate and leave pits. 

" The salivatiori is more distressing than in distinct 
Smallpox, the mouth and pharynx being covered with 
pustules : sometimes the cornea is the seat of a 
pustule, and becomes opaque, if it be not destroyed 
by the ulceration. Petechiae appear in this form of 
the disease, when the strength fails. The matter in 
the pustules, instead of becoming yellow, remains 



VARIOLA. 235 

white, or becomes brown, or almost black ; and is, 
sometimes, mixed with extravasated blood. It is 
occasionally so acrid as to ulcerate deeply, and to 
destroy even the bones of the face. When the pus- 
tules are about to be confluent, the purging is often 
considerable ; the stools are very foetid, and, some- 
times, mixed with blood. 

" Authors have pointed out several anomalous 
forms of Smallpox : but in a practical point of view 
these distinctions are of little value. 

" Measles and Smallpox, now and then, occur si- 
multaneously* ; but, in general, in such cases, the 
progress of the Smallpox is arrested until the Measles 
run their course, and then it goes on in the usual way. 

" Confluent Smallpox is apt to leave behind it very 
distressing consequences when it does not prove fatal : 
blindness ; a predisposition to inflammatory affections ; 
obstructions of the glands ; and pulmonary consump- 
tion, are not unfrequently the result of its attack. 
Dr. Tauchou has been led, by the result of many 
dissections, to attribute the fatal cases of Variola to 
inflammation of the arteries, extending from those on 
the surface to the large arterial trunks and the heart. 

"From these descriptions it will readily appear 
that the prognosis is not difficult in Smallpox. 
Danger is always to be dreaded in the confluent form 
of the disease ; and a fatal termination is, too fre- 
quently, the consequence when the fever assumes, 
early, a typhoid character. 

*' Confluence on the face is more to be dreaded than 
on the trunk or the extremities. Hoarseness, and 
copious spitting, when they occur early, are unfavour- 
able symptoms : and it is scarcely necessary to remark, 
that the same may be affirmed of restlessness, deli- 

* 

* M. Delagarde has lately recorded a case of this kind in the I3tb 
volume of the Medico-Chirurgical Transactions. Vogel mentions a case 
in which Smallpox attacked the right side of the body and Measles the 
left side, at the same time, the boundary of each disease being perpen- 
dicular, drawn through the middle of the body. T. 



236 PUSTULE : 

rium, moaning, and despondency. Grinding of the 
teeth in children ; vibices ; and the eruption appear- 
ing white and pasty on the face, indicate that danger 
is impending. 

" In forming a prognosis, the age of the patient 
should be taken into account: persons above forty 
always run hazard ; the most favourable age is from 
the seventh to the fifteenth year. Persons of plethoric 
habits, or predisposed to strumous diseases, or con- 
stitutionally weak, run additional risks. 

" The treatment of Variola is modified by the 
variety of the disease. The first object is to mo- 
derate the eruptive fever, so as to diminish the number 
of the pustules : but this is to be done with as little 
expense of strength as possible. Free exposure to 
cool air ; mild purging ; saline effervescing medicines ; 
and, if the fever run high, the cold effusion, are the 
most efficient means to keep down, if not cut short, 
the fever. In India, the cold bath has been employed 
by the natives during the eruptive fever, from time 
immemorial, with the best effects. Whether the 
bath be used, or the patient be merely exposed to 
cold air, it must always be kept in mind that the 
patient should suffer no sensation of cold. His com- 
plaining of cold should be sufficient to terminate the 
use of that remedy ; indeed, in every instance, 
caution is requisite. If the stomach is loaded, it 
ought to be relieved by an emetic ; after which, saline 
draughts given in a state of effervescence, with Nitre, 
or the Tartarized Soda, will be found very serviceable. 
A moderate catharsis is necessary in the eruptive 
fever of Smallpox ; but all drastic purgatives should 
be avoided ; and, indeed, much purging by any means 
is injurious. Sydenham recommended the free use 
of the lancet ; but there are few cases that require or 
can warrant blood-letting in the eruptive fever of 
Variola : and if it be not admissible in the com- 
mencement of the disease, it is much less so in the 
termination. Local blood-letting, however, either 



• . 



, VARIOLA. 237 

by leeches or cupping, is useful, when the head is se- 
verely affected ; it is proper, in such cases, to accom- 
pany the local bleeding with cold lotions applied to 
the shaved scalp ; and to follow them with aperients 
and anodynes. 

" Nothing is more useful in the eruptive fever than 
the use of the tepid bath, under 96°. It diminishes 
the febrile irritation; in general subdues the con- 
vulsions which precede the appearance of the erup- 
tion, particularly if the bowels have been previously 
cleared. When the stomach remains very irritable, 
and the eruption is tardy in appearing on the ex- 
tremities, a blister may be applied over the epigas- 
trium and the pediluvium, with mustard employed. 
The use of opiates is at least doubtful in the eruptive 
fever, unless there is reason to expect the confluent 
form of the disease : the pain is more effectually sub- 
dued, and the heat of surface diminished, by the use 
of the warm bath ; and this is equally useful, after 
the maturation of the pustules, for removing the 
crusts, and lessening the risk of pitting. 

" In the milder form of the disease, the patient 
need not be confined to bed : but in the confluent 
state, he should use no exertion, nor even be allowed 
to sit up longer than to have his bed made. In this 
form of the disease, also, cathartics are recommended 
to be cautiously employed, and given only to remove 
costiveness ; but whatever may be the form of the 
disease, cathartics are always beneiQcial in the erup- 
tive fever. I have found six or eight grains of 
Calomel, with twelve or fourteen of the powder of 
Jalap, form the best purgative, if the patient be not 
under six years of age : but this should not be re- 
peated, the saline purges being the most useful afler 
the intestines have been once freely evacuated. If 
the strength does not admit of purging, the bowels 
should be regulated by mild cathartic clysters. When 
local inflammations supervene, as, for example, in the 
chest, resembling bronchitis, moderate general blood- 



238 PUSTULiE : 

letting is then indicated : and it is equally so when a 
flushed face, headach, suffiised eyes, and beatings of 
the carotid and temporal arteries denote great deter- 
mination to the brain. In such a state the lancet 
should be freely used. The cold effusion is not ad- 
missible in the secondary fever ; which, on the con- 
trary, in the confluent form of the disease, requires 
the free exhibition of Wine, Baric, and other tonics. 
The Sulphate of Quinia, in the solution of the Con- 
fection of Roses, acidulated with the diluted Sulphuric 
Acid, is an excellent form of tonic in confluent 
smallpox. 

" It has long been a practice in eastern countries 
to pierce the pustules with fine needles, in order to 
lessen the violence of the secondary fever; for a 
similar reason, M. Serres has lately observed that 
Lunar Caustic, applied to the pustules on the fourth 
day, arrests their progress, cuts short the secondary 
fever, and prevents pitting. The pustule is directed 
to be opened, and the caustic introduced into it on 
the end of a silver stilet. I have had no experience 
of the utility of this practice. I have seen much ad- 
vantage derived from washing the surface during the 
state of incrustation of the pustules in Confluent 
Variola with a dilute solution of Chloruret of Soda 
of Labarraque. It lessens the acrimony of the pus- 
tular discharges, takes off* the foetor of the eruption, 
and, in every circumstance connected with the scab- 
bing process, greatly mitigates the sufferings of the 
patient. 

** When the fever has actually assumed the typhoid 
character. Cinchona Bark, or Sulphate of Quinia, 
Opium, and Wine are alone to be depended on. 
The empty vesicles are filled; the pus assumes a 
healthy appearance ; and petechias disappear. When 
vomiting is a troublesome symptom, and the ordinary 
effervescing draughts fail to relieve it. Camphor, with 
the Tincture of Calumba in a glass of sound Sherry, 
may succeed. If a retrocession of the eruption occur. 



VARIOLA. 239 

the best remedies are Wine and Opium; and the 
Semicupium should be employed, in conjunction with 
blisters, to the wrists and forearms."* 

Books that may he consulted on Variola, 

Adair, Candid Inquiry into the Effects of the Cooling Regimen in 
Smallpox, 8vo. 1790. 

Blackm pre, Sir R., A Treatise upon the Smallpox, 8vo. 1723. 

Bromfielp , Sir W., on the Treatment of Inoculated Smallpox, 8vo. 
1767. 

Clinch. W., on the Rise and Progress of the Smallpox, 8vo. 1724. 

CoTUNNij D'» De Sedibus Variolarum, 8vo. 1 775. 

CrosSj^. G., a History of the Variolous Epidwnic, Norwich, 1829. 

DiMSDALE, Baron, on Inoculation, &c., 8vo. 1767. 

i)oDD,nPiERCE, Several Cases of Smallpox after Inoculation, 8vo. 
1746. 

DioaFy^PTTFSy R, N., Avis sur la Petite Verole. 

Dcjarcun's Medical Commentaries, vol. i. 8vo. 1800'. 

Fuller, T., Oxaathemalogia, &c., 4to. 1 730. 

GuEBSENT Diet, de M^d. (art. Variola^ t.xxi.), 1828. 

Gregory, Cyclop, of Pract. Med. (art. Smallpox), vol.iv. 1834. 

HoFFMAN^C. L., Abhandlung von den Pocken, 8vo. 1776. 

Haygarth, J., An Inquiry how to prevent Smallpox, 8vo. 1785. 

J^, A^etch of a Plan to exterminate Smallpox from Great Bri- 
tain, 8vo. 1793. 

Lynn, W., Case of a Lady who communicated the Smallpox to the 
Foetus, 8vo. 1 786. 

M£AD« R., on Smallpox and Measles (translated by Stark), 8vo. 1748. 

MuDGE, J., on Inoculated Smallpox, 8vo. 1777. 

Moore, J., History of the Smallpox, 8vo. 1815. 

Monro, A., Observations on the different Kinds of Smallpox, 8vo. 
1818. 

Monfalcon, Diet, des Sciences M^d., t. Ivii. 1821. 

Paulit, J. J., Hist, de la Petite Verole. 12mo. 1768. 

Roe, C, on the Natural Smallpox, 8vo. 1780. 

Sutherland. A., on Smallpox, 8vo. 1750. 

Thompson, T., An Inquiry into the Origin of Natural Smallpox, 8vo. 
1752. 

Thomson, J., An Account* of the Variolous Epidemic at Edinburgh, 
8vo. 1820. 

TuRiN^i on the comparative Mortality of the Natural and Inoculated 
Smallpox, 8vo. 1723. 

Van Swieten, Commentaries, vol. v. p. 10. 

WALi^ Ry R., An Inquiry into the Smallpox, medical and political, 
8VO. 1790. 

WoosxjxxE, W., History of the Inoculation of Smallpox in Great, 
Britain, 8vo. 1796. 

* " It may naturally be expected that I should here notice not only 
the effects of Vaccination as a preventive of Smallpox ; but also that I 
should enter into the question of the nature of those cases which have 
occurred after vaccination, and have received the appellation * modified 
Smallpox.' I shall notice the first under Vaccinia ; and briefly state my 
opinion of the second under Varicella." 



240 PUSTULE : 



Genus V. SCABIES.* 

Syn. Kp7j<r[jLog-y \|/a)pa (Gr.): Pruritus, Scabies 
{Auct. var.) : Psora (Linn. Cull. Darwin^ Parr) : 
Ecpyesis Scabies ( Good) : Phlysis scabies ( Young) : 
die Kratze ( Germ.) : Kraxunju kraauw zel Schurft 
(Dutch): Swierzh (Polish): Scab, Kloe, Snat (Z>a- 
nish) : Skaab, Kliida ( Swedish) : Scabbia, Rogna, 
Raspa, Raschia (Italian) : Sarna Dona ( Spanish) : 
The Yuck (Scotch): La Gale (F.) : Nekeb (Arab.): 
Ch6ringoo ( Tarn.) : Chieri (Malayalie) : Ghejae 
(Tel.) Kharisht (Duk.) : Pama (Sans): The 
Itch. 

Def. A CONTAGIOUS ERUPTION OF MINUTE 
PIMPLES, PUPULAR, VESICULAR, PUSTULAR, OR IN- 
TERMIXED ACCORDING TO CIRCUMSTANCES ; APPEAR- 
ING CHIEFLY BETWEEN THE FINGERS, AND IN THE 
FLEXURES OF THE JOINTS ; TERMINATING IN SCABS, 
AND ACCOMPANIED WITH INTOLERABLE ITCHING. 

This troublesome disease, which, from its affinity 
with three orders of eruptive appearances, Pus- 
tules, Vesicles, and Papulae, almost bids defiance 
to my attempt to reduce it to an artificial classifi- 

* The Greek term Psora has been very generally, but incorrectly, 
adopted for the designation of this disease, in consequence of the ex- 
ample of some of the early translators, who considered Scabies (quasi 
tcafirities) as synonymous with \j/<»>pa, which we have already seen 
(page 10. note), was universally employed by the Greeks as denoting a 
scali/ or scurfy disorder of the skin, more rough than Lichen, but less 
scaly than Lepra. They did indeed occasionally use the term, in con- 
junction with the epithet cXicw^jje, or ulcerating, as applicable to a pus- 
tular disease, apparently the Impetigo: but when used alone, it inva- 
riably implied the dry scaly or scurfy tetter. Psoriasis. (See above, ord. ii. 
gen. 2.) Sir John Pringle, indeed, after noticing this inaccuracy, con- 
cludes that the itch was probably unknown, or at least uncommon, in 
ancient times: — "The Psora of the Greeks has generally been sup- 
posed to be the Itch ; but as this does not appear by the description 
they ^ve of it, I should conclude," &c. (On Diseases of the Army, 
part in. chap. 5.) 



SCABIES. 241 

cation *, is not easily characterised in few words. An 
extreme latitude in the acceptation of the term has 
indeed been assumed by writers, from Celsus down- 
wards ; and no distinct or limited view of the disease 
has been given, until near our own times. Celsus has 
included other forms of pustular disease among the 
different species of Scabies ; and some of the earlier 
writers, after the revival of learning, considered almost 
all the eruptions, to which the skin is liable, as modi- 
fications of this disease : even our countryman Willis, 
to whom the contagious nature of true Scabies, as well 
as its specific remedy, was well known, has not suffi- 
ciently separated it from some other pustular and pru- 
riginous affections, t 

The Scabies, or Itchj appears occasionally on 
every part of the body, the face only excepted tj 
but most abundantly about the wrists and fingers, 
the axillas, the fossa of the nates, and the flexures of 
the joints. § 

- Among the various forms which the disease 
assumes, four have been distinguished, with con- 
siderable accuracy, by the vulgar, who have, in- 
deed, the most ample opportunities of becoming 
acquainted with its character; and to these they 
have given the epithets of ranky watery ^ pocky j and 
scorbutic Itch. Their subdivision was adopted by 
Dr. Willan, with the appropriate titles, 

1. S. papuliformis. 3. S. purulenta. 

2. S. lymphatica. 4. S. cachectica. 

* Biett and Rayer class it with the Vesiculas; Dr. Paget with the 
Papulae. 

f See Celsus, lib. v. cap. 28. ; Plater, de Superfic.jCorp. Colorib. cap. 
7.; Hafenreffer, Nosodoch, lib. i. cap. 15.; Willis Pharmac. Rational, 
part i. § iii. cap. 6. 

% Some German authors, however, assert that they have seen Pus- 
tular Scabies affecting the ears and face. In one child who came under 
my care, it affected the side of the face, near the ear. T. 

§ " Scabies est pustularum purulentarum, vel saniosarum, vel papula^ 
rum siccaruniyex duriore et rubicundiore cute, eruptio, — pruritum, saepe 
Guoque dolorem, creans, — interdum totum corpus, facie excepta, inva- 
dens, — saepissim^ tamen solos artus externos, digitorum imprimis in* 
terstitia, occupans." — Callisen, Syst. Chirurg. Hodiern. i. § 824. 

R 



242 PtJSTUL-E : 

The characteristics of these species, and the dia- 
gnosis between them and the papular, vesicular, and 
pustular eruptions, which they resemble, I shall en- 
deavour to point out ; but must admit, at the same 
time, that the practical discrimination, in many of 
these cases, is more difficult than in any other Order 
of cutaneous disease. 

Species 1. Scabies papuliformisy Rank Itch. 

S^n. Scabies sicca (Plenck): Ecpyesis scabies, 
var. a. papularis ( Good). 

This species consists of an extensive eruption of 
minute intensely itching vesicles, which are slightly 
inflamed and acuminated, resembling papulse when 
examined by the naked eye. They commonly arise 
first about the bend of the wrist and between the 
fingers, or in the epigastrium ; on which parts, as 
well as about the axillse and nates, and in the flexures 
of the upper and lower limbs, they are at all periods 
most numerous, and often intermixed with a few phly- 
zacious pustules, containing a thick yellow matter. 
The itching is extremely troublesome in this form 
of Scabies, more especially when the patient becomes 
warm after getting into bed. The appearance of the 
disease is modified by the abrasion of the tops of the 
vesicles and pustules, and even of the rest of the skin, 
by the frequent scratching, which cannot be withheld. 
Hence long red lines are here and there left, and the 
blood and humour concrete upon the vesicles into 
little brown or blackish scabs. 

These mixed appearances, partly belonging to the 
disease, and partly the result of abrasion by the nails, 
being in some measure common to the Lichen and Pru- 
rigo, where much scratching is also often employed, 
render the diagnosis of the Scabies papuliformis more 
difficult than it would be from the mere similarity in the 
form of the eruption. But, as the most effi^ctual reme- 
dy for the Scabies is detrimental in the latter affections, 
the distinction is of great practical importance. 



SCABIES. 243 

With respect to the eruption itself, the unbroken 
elevations in Scabies papuliformis, when carefully ex- 
amined, are found to be vesicular, and not papular ; 
they are often intermixed, in particular situations, 
with pustules ; and, when they break, are succeeded 
by scabs : whereas in Lichen, the papulse terminate 
spontaneously in scurfy exfoliations. In Scabies, the 
eruption is unconnected with any constitutional or 
internal disorder, and the itching is severe : but in 
Lichen there is commonly some constitutional affec- 
tion, and a tingling sensation, as well as itching. The 
highly contagious nature of Scabies will, in many 
cases, have already manifested itself, and removed all 
doubt ; for the Lichen is not thus communicable.* 

In Prurigo, the papulse, where no friction has been 
applied, retain the usual colour of the skin, are com- 
monly flatter, or less acuminated, and present no 
moisture or scab, except when their tops have been 
forcibly abraded ; they are not particularly numerous 
in the parts above mentioned ; and they remain long 
distinctly papular, without showing any contagious 
property. The eruption which I have called Lichen 
urticatitSy and which often occurs in weakly children, 
and exhibits a troublesome series of papulae, some- 
times intermixed with minute vesicles, bears a close 
resemblance to Scabies, especially when it has been 
of some continuance. But the first appearance of 
these spots, in the shape of inflamed wheals, not 
unlike the inflammation produced by the bites of 
gnats, — their subsequent papular or vesicular ap- 
pearance, with little or no surrounding inflamma- 
tion, — the intermixture of these two states of the 
eruption, — the ultimate formation of a minute globu- 
lar brown scab, which is set firm in the apex of each 
elevation, — and the absence of contagion, will serve 
as diagnostic marks. 

* See the quotation from M. Lorry, supra, p. 12., note, 

R 2 



244 PUSTULE : 

Species 2. Scabies lymphatica^ Watery Itch. 

This form of Scabies (Plate XLV. of Bateman ; 
PL 18. of Thomson's Atlas) is distinguished by 
an eruption of transparent vesicles, of a considerable 
size, and without any inflammation at their base. 
They arise in succession, with intense itching, chiefly 
round the wrists, between the fingers, on the back of 
the hands, and on the feet and toes : they often occur 
also about the axillae, the hams, the bend of the el- 
bows, and fossa of the nates, where they are inter- 
mixed with pustules: but they do not frequently 
appear, like the papuliform species, over the breast 
and epigastrium, nor on the thighs and upper parts 
of the arms. 

In a day or two the vesicles break, and some of 
them heal, under the little scab that concretes upon 
them. But others inflame, and become pustules, 
which discharge at length a yellow matter, and ex- 
tend into small ulcerated blotches, over which a dark 
scab is ultimately formed : so that, during the pro- 
gress of the eruption, all these appearances are inter- 
mixed with one another ; the vesicles, and pustules, 
the excoriated blotches discharging pus, the minute 
dry scabs, and the larger ones succeeding the ulcer- 
ation, may be observed at the same time. This cir- 
cumstance constitutes one of the points of diagnosis 
between this and other vesicular diseases. Of these, 
however, the Herpes and Eczema, especially the latter, 
are alone liable to be confounded with Scabies lymph- 
atica : for the acute form and short course of all the 
varieties of Varicella render that eruption sufficiently 
distinct. The Herpes, likewise, differs materially 
from Scabies in the regularity of its course and termi- 
nation, and in the arrangement of its vesicles in clus- 
ters, which are commonly not numerous, and appear 
on those parts which*Scabies is not very apt to attack. 

The most difficult diagnosis relates to some of the 
varieties of Eczema, which closely resemble this, and 
sometimes the former species of Scabies ; so that it is 



SCABIES. Q4*5 

not so much from the mere appearances of the erup- 
tion, as from the consideration of the collateral cir- 
cumstances, that a decision is to be obtained. The 
Eczema can often be traced to distinct sources of ir- 
ritation affecting the skin, such as exposure to the 
solar rays, or to great heat, — and to the application 
of acrid substances, such as lime, sugar, mercury, can- 
tharides, &c. It sometimes becomes inflamed after 
the vesicles have discharged their lymph, but it does 
not produce the large phlyzacious pustules ; and, 
although the itching is sometimes intense, yet there 
is commonly a tingling and smarting pain with Ec- 
zema, that does not belong to Scabies : nor is it ever, 
like the latter, communicated by contagion. 

Species 3. Scabies purulenta^ Pocky Itch. 

S^n. Scabies humida (Plenck) : Empyesis scabies, 
var. y. purulenta. 

This species (Plate XLVI. fig. 1. of Bateman; 
PI. 18. of Thomson's Atlas) is often mistaken by 
those who confine their notion of the disease to the 
ordinary small and ichorous vesicle of the two former 
species. The eruption consists of distinct, prominent, 
yellow pustules, which have a moderate inflammation 
round their bases, and which maturate and break in 
two or three days, and then ulcerate, with increasing 
pain and inflammation. These pustules commonly 
appear first, and attain the largest size, on the hands 
and feet, especially about the knuckles and roots of 
the toes, between the fingers, and particularly be- 
tween the forefinger and thumb, and round the wrists. 
In these situations, the pustules often exceed two lines 
in diameter, and assume a prominent globular form : 
whence, from their general resemblance to the large 
well-maturated pustules of Smallpox * (and not from 



* " Licet interdum majusculse sint, cum fundamento rubro, et pure 
iinpleantur, fere tanqnam variola.** Heberden, Com. de Morb. Hist, et 
Curat, cap. 25. 

R 3 



246 PusTULiE : 

any allusion to Syphilis, as some have erroneously 
supposed), the popular term ^^ pocky** has been ap- 
plied to them. If the disease continue a few weeks, 
the pustules begin to appear on the other parts of the 
body which Scabies usually attacks, especially about 
the axillae, on the back and shoulders, and on the 
arms and thighs near the joints of the knee and el- 
bow, in the fossa of the nates, and sometimes, though 
of a smaller size, even about the epigastrium. " In 
one case, where it affected a whole family, it appeared 
on the side of the face in oife of the children, a boy 
of six years of age.** In several of these situations, 
where the pustules are largest and numerous, they 
coalesce, and form irregular blotches, which ulcerate 
to some extent, with hardness and elevation of the 
surface ; but at length hard and dry scabs are formed, 
which adhere tenaciously for a considerable time. 

The majority of the cases of Scabies purulenta, 
which I have seen, have occurred in children between 
the age of seven years and the period of puberty ; and 
in them it not unfrequently assumes this form. 

The Scabies purulenta cannot be easily mistaken 
for Impetigo, when it occurs in patches, in conse- 
quence of the large size, the greater prominence, 
and comparatively small number of its pustules ; not 
to mention the absence of the intense itching, and 
of contagion, in the former. * From Impetigo favosa 
affecting the extremities, it will be distinguished 
chiefly by its situation about the fingers, axilla, fossa 
natum, and flexures of the joints, and by the total 
absence of the eruption from the face, ears, and scalp ; 
by the nature of the discharge ; and by the thin, hard, 

* Sauvages has described a variety of Scabies, which he terms her- 
petica (spec. 4.); Herpes, in his language, as in that of many other 
writers, signifying the same with Impetigo in the nomenclature of Dr. 
Willan. "Cognoscitur ex signis herpetis et scabiei simul concurren- 
tibus, in amplos corymbos coeuntibus, papulis pruriginosis, rubris, quae 
squamas albas, farinaceas deponunt." But this termination in branny 
scurf, and the commencement in papulae, point out the eruption as a 
Lichen, probably the L. circumscriptus. 



SCABIES. 247 

and more permanent scab, which succeeds, instead of 
the soft, elevated, semitransparent scab, formed by 
the viscous humour of the favi. 

The only other disease, with which the Scabies 

Eurulenta has any aflHnity, is the Ecthyma : but the 
ard, elevated, vivid red or livid base, which sur- 
rounds the pustules of Ecthyma, — their slow pro- 
gress both towards maturity and in the course of 
suj^uration, — the deep ulceration, with a* hard 
raised border, and the rounded imbedded scab, 
which succeed, — as well as the distinct and separate 
distribution of them, — will afford the means of dis- 
crimination ; to which the incessant itching, and the 
contagious property of Scabies, may be added. 

Species 4. Scabies cachecttca. This variety of 
Scabies exhibits, in different parts of the body, all the 
appearances which belong to the three foregoing spe- 
cies. It is occasionally also combined with patches 
resembling Lichen, Psoriasis, or Impetigo, especially 
in adults, or young persons approaching the term of 
puberty ; whence it assumes an ambiguous character. 
In several instances, this form of Scabies has been 
obviously contagious in its double character; and 
after the scabious affection has disappeared, the im- 
petiginous patches have remained for some time, in a 
drier form, and yielded very slowly to medicine. For 
although this form of Scabies does not so readily 
spread by contagion, it is much more obstinate under 
the use of remedies, than the preceding. 

Another peculiarity of the S. cachectica is, that it 
often originates, independently of contagion, in weakly 
children, and also in adults, when the constitution is 
suffering under some chronic malady, or is debilitated 
by some previous acute disease * : and, however it is 

* Sir John Pringle observed, that, in military hospitals, the patients 
often became the subjects of itch after the crisis oi fevers. Loc. cit. 
p. iii. cap. 8. 

K 4 



248 PUSTULE : 

produced, it is liable to return at intervals, especially 
in the spring and autumnal seasons, after it has been 
to all appearance cured.* 

A severe degree of this ambiguous and combined 
form of Scabies is often seen in this country, in per- 
sons who have come from India : I have chiefly had 
occasion to observe it in children brought from that 
country. The eruption is exceedingly rank and ex- 
tensive, sometimes even spreading to the face, and 
giving a more dark and sordid hue to the skin than 
the ordinary Scabies : the intermixture of patches of 
an impetiginous character, where the pustules become 
confluent, is considerable. It is extremely contagious, 
and also obstinate in its resistance to the operation of 
remedies, t 

Another violent form of Scabies is excited by the 
contact of dogs, cats, hogs, and other animals, affected 
with mange. (Plate XL VI. fig. 2. of B axeman.) 
This also extends over the whole body, the pustules 
being very rank and numerous, and more inflamed 
and hard at the base than in the ordinary eruption ; 
the general surface of the skin is also rough, and of 
a browner hue ; and the excoriations and abrasions 
more extensive, in consequence of the more violent 
and irresistible application of the nails. 

The most ordinary cause of Scabies is contagion ; 

* '^ Quaedam est etiam ejus species, quae quanquain in ipso corpore 
non genita sit, sed aliunde advecta, quanquam et consuetis remediis 
primo sanata fuerit, tamen non cessat redire semel vel bis quotannis." 
Heberden, Commentar. Perhaps the Scabies herpetica of Sauvages 
may include some of these cases of S. cachectica. 

•f- Bontius, in his work de Medecina Indorum, lib. iii. cap. 17., has 
described this severe disease, under the appellation of " Herpes, seu 
Impetigo Indica," as frequent among the inhabitants of India, by whom 
it IS denominated Courap, which is equivalent to our term itch. The 
cure of it, he says, is generally much neglected there, in consequence 
of a prevalent notion, that it renders a person secure from all violent 
diseases : yet the itching is severe and incessant, and so much abrasion 
is produced by scratching, that the linen often adheres to the excoriated 
parts, so as not to be removed without drawing blood. — This is the 
Scabies Indica of Sauvages, spec. 6. 



SCABIES. 249 

the virus being communicated by the actual contact 
of those already affected with it, or of their clothes, 
bedding, &c., especially where there is much close in- 
tercourse. It seems to originate, however, in crowded, 
close, and uncleanly houses; and is, therefore, ex- 
tremely prevalent in work-houses, gaols, and hospitals, 
where the means of great cleanliness are not easily 
obtained, and is mostly seen among the families of 
the poor. * When the contagion has been introduced, 
however, into families, where every attention to clean- 
liness is enforced, it will frequently spread to all the 
individusds, children and adults, and continue, in spite 
of the utmost cleanliness, until the proper remedies 
are resorted to. 

Some writers have ascribed the origin of the itch, 
in all cases, to the presence of a minute insect breed- 
ing and burrowing in the skin ; while others have 
doubted the existence of such an insect.t Both these 
opinions appear to be incorrect ; and probably that of 
Sauvages is right, who considers the insect as gene- 
rated only in some cases of Scabies, and therefore 
speaks of a Scabies vermiculariSy as a separate 
species, t 

The existence of such an insect, in some cases of 
Scabies, has been fully demonstrated ; and, although 
never able to discover it in any patient myself, I have 
seen it, in one instance, when it had been taken from 
the diseased surface by another practitioner. In fact, 
it was first described by Abinzoar, or, as he is some- 
times called, Avenzoar, a Hispano- Arabian physician 
of the twelfth century, and subsequently by Ingrassias 
of Naples, by Gabucinus, Laurence Joubert, and other 



* Plenck adds, ''yictu acri, salso, pingui nascitur. Hsec difficilius 
quam acquisitu curatur. Doct, de Morh, Cut. p. 42. T. 

f Dr. Heberden never saw any of these insects; and he was informed 
both by Baker and Canton, who excelled in the use of the microscope, 
that they had never been able to detect them. Loc. cit. 

X Nosol. Method, loc. cit. spec. U. 



250 PUSTUL-3E : 

writers of the fifteenth and sixteenth centuries, who 
are quoted by our countryman Moufet.* These 
writers describe the insects as acarij that is, very 
minute and almost invisible animalcula, burrowing 
under the cuticle, and exciting small pustules, filled 
with a thin fluid, and intense itching. Moufet 
states, that they do not reside in the vesicles or pus- 
tules, but near them ; a remark which has been con- 
firmed by Linnaeus and Dr. Adams t, who ascertained 
that this acarus leaps ; that they are not of the same 
genus with lice, which live exterior to the cuticle ; — 
that they are similar to the acari, or miteSj of cheese, 
wax, &c., but are called wheal-worms in man ; — and 
that when they are pressed between the nails, a small 
sound is heard. Most of these points have been sub- 
sequently confirmed. The insects, first noticed (by 
Avenzoar,.were accurately ascertained and figured by 
the aid of the microscope) by Bonomot, in l683j 
whose account was afterwards published by Dr. Mead §, 
Schwiebe, Baker, and others : and Linna^s, DeGeer ||, 
Wichmann, &c. have since that period illustrated the 
subject of these Acari scabieL^ The latest authors 
particularly confirm the observation of Moufet the 
entomologist, that the insects are not to be found in 
the pustules, but in the reddish streaks or furrows 
near them, or in the recait minute vesicles : but I 
must acknowledge my own want of success to discover 
them in any of these situations. I am disposed, there- 

* See his "Theatram Insectorum," printed in 1634, cap. 24. "de 
Syronibus, Acaris, Tineisque Animalium.*' 

+ Observations, Szc, p. 296. 

j: See his Letter to Redi — (Mr. Kirkby remarks that his plates, as 
copied by Baker, are far from accurate) — also Miscell. Nat. Curios, 
ann. x. dec. 2. 

ij See Philosoph. Transact, vol. xxiii. for 1702. 
I De Geer*s figure is the most correct; vide vol. viii. t. 5. f. 12. 14. 
If See Linn. "Exanthemata Viva," 1757; — andAmoenit. Acad. vol. iii. 
p. 533., and vol. v. p. 95. — Wichmann, Aetiologie der Kraetze, Hanover, 
1786 ; also in the Lond. Med. Journal, vol. ix. p. 28. — De Geer, M6- 
moires pour servir k THist. des Insectes. 



SCABIES. S51 

fore, to believe, that the breeding of these Acari in 
the scabious skin is a rare and casual circumstance, 
like the individual instance of the production of a mi- 
nute Pulex in Prurigo, observed by Dr. Willan ; and 
that the contagious property of Scabies exists in the 
fluid secreted in the pustules, and not in the trans- 
ference of insects. " Such is also the opinion of the 
Editor, although the opinions of Redi, Wichmann, 
Osiander, Pringle, and Dr. Gales are in opposition 
to this idea, and strongly support the notion of a 
distinct animalcule as the direct cause of the disease. 
Dr. Gales's opportunities to ascertain this point at the 
Hospital of St. Louis were numerous, and he took 
every advantage of them. He examined, under the 
microscope, upwards of three hundred of these in- 
sects, and found that they agreed with the descrip- 
tions of Linnaeus and Latreille. He also produced 
the disease on himself, by transferring the insect to 
his own skin ; and he inoculated, in the same manner, 
three children, all of whom became covered with 
the eruption of Scabies. More lately, M. Suriray of 
Havre, and others, revived the discussion of this sub- 
ject, and denied the existence of such an insect ; an 
opinion supported by the investigations of Biett, Ca- 
zenave, and Schedel; but, on the other hand, M. 
Rennuic and M. Beaude have still more lately brought 
forward proofs of their existence. Mr. Plumbe, also, 
states that he has seen great numbers of the insects 
extracted with the point of a needle. He supposes 
that the insect is unable to live in the fluid, which is 
the result of the irritation it induces ; and therefore 
escapes from the vesicle.*'* 

" Whatever may be the cause of the disease and 
the medium of its communication, it is very evident 
that the same virus will produce all the varieties of 
the disease ; and consequently these depend on the 

* Plurabe on Diseases of the Skin, 2d edit. p. 306, 



252 PUSTULE : 

state of habit of the individual affected. In one 
family which the editor attended, the four younger 
children had the purulent form of the disease ; and, 
in two of them, the pustules were mingled with 
vesicles; while the parents and an elder sister had 
the ordinary papulous itch. In all, the^eruption was 
preceded by some degree of fever.'* 

Among the remedies appropriated to the cure of 
Scabies, Sulphur has long been deemed, both by the 
vulgar and the erudite, to possess specific powers. * 
The common people treated the disease with this 
substance alone, a century ago, administering it in- 
ternally in milk, and applying it externally in butter 
or Hog's -lard, t In the less violent degrees of Sca- 
bies, and in the purulent species affecting the hands 
and wrists, perhaps no improvement can be made 
upon this practice. The latter species, when it oc- 
curs in children, is often readily removed by the in- 
ternal use of this medicine alone, or in combination 
with a neutral salt, independently of any external 
application. X 

IJ Sulphuris (vivi dicti) Siij, 
Muriatis Ammoniae 5VJ) 
Adipis Suillae S^iij. 

Tere optim^. 
Anoint the parts twice a day before a good fire. 

" The great French specific, which was proposed by 
M. Helmerich, an army surgeon, and is now con- 
stantly and successfully employed at the Hopital de 
St. Louis, consists of two parts of Sulphur, one part 



^ See Willis, Pharmaceut. Rational, part. ii. sect. iii. cap. 6. 

tSee Turner, de Morbis Cutaneis. 
Writers in general agree in asserting the greater facility of curing 
the humid than the dry forms of Scabies. But under the term Scabies 
nccGy it is obvious that they describe the Prurigo, and even some scaly 
and furfuraceous eruptions, accompanied with itching, which are often 
more difficult of removal than any variety of true Scabies. See Sauvages 
and Sennert (loc. cit.), and Vogel, de curand. Horn. Morbi 



SCABIES. 253 

of Subcarbonate of Potassa, and eight parts of Lard. 
Another application, used in the Parisian hospitals, 
is Sulphuret of Lime, rendered semifluid by being 
triturated with a small quantity of Olive oil.** There 
are few cases of Scabies which will not yield to the 
steady employment of the Sulphur ointment, con- 
tinued a sufficient time, and rubbed on the parts 
affected, nightly, with assiduity. Five or six applica- 
tions are commonly sufficient for the cure of the dis- 
ease : but sometimes it is necessary to persevere in 
the inunction for the space of a fortnight, or even 
longer ; from which no detriment ensues to the con- 
stitution. " The quantity of the Sulphur ointment 
to be used, and the mode of using it, are of great 
consequence in the cure of this disease. I believe 
that if the whole body be well rubbed over with it, 
and the patient be kept in bed, in a flannel dress, for 
twenty-four hours, a second application will seldom 
be necessary. He should immediately afterwards 
take a warm bath, and cleanse the skin well with 
soap ; and be careful not to put on his former clothes 
until they have been several times fumigated with 
Sulphur.** 

The disgusting odour of the sulphur*, however, 
has led practitioners to resort to various other sti- 
mulating applications; some of which have been 
recommended from ancient times, for the cure of 
scabid and pruriginous eruptions. Among these 
the root of the white Hellebore is possessed of con- 
siderable efficacy, and may be applied in the form 
of the following ointment : — 

* Both the smell and sordid appearance of the Sulphur ointment may 
be in a considerable degree obviated by the following combination : — 

1^ Potassae Subcarbonatis ^ss. 
Aquae Rosae 5jj 

Hydrargyri Sulphuretti Rubri Jj, 
Olei Essentialis Bergamotae ^ss, 
Sul phuris-sublimati, 
Adipis Suillae a a ^ix. Misce secundum artem. 



i854 PUSTULiE : 

R Pulveris radicis Veratri albi ^8s> 
Hydrargyri prsecipitati albi 2o, 
Olei Citri Limonis f Jj, 
Adipis 5xiv. 

Tere ut fiat Unguentum, bis die utendum : 

or in that of decoction. In the latter form I have 
generally found it advisable to employ a stronger 
decoction than that which is recommended in the 
Pharmacopoeia of the College. Potass, in a state 
of deliquescence, was a favourite addition to these 
applications with Willis and his predecessors ; and 
Muriate of Ammonia, and some other saline stimu- 
lants, have been more recently used, and not without 
benefit. * The strong Sulphuric Acid, which was long 
ago recommended by CroUius, mixed with lard, in 
the proportion of fsss. to %j of lard, and applied by 
external friction, has also been employed t; and it 
certainly possesses the recommendations of being in- 
odorous and comparatively cleanly. But independ- 
ently of its corrosive action on the patient's clothing, 
it has appeared to me to be very uncertain in its 
effects. The Muriate of Mercury, and the white 
precipitated oxide, are very old remedies, and both 
possessed of considerable efficacy in the relief of Sca- 
bies. The testimonies in favour of the latter are 
very numerous, t It seems particularly well adapted 



* This salt, together with Hellebore, is said to constitute a part of a 
celebrated nostrum for Scabies, called the Edinburgh Ointment. 

+ See Hafenreffer de Cute, lib. i. cap. 14. The Sulphuric Acid was 
also recommended to be taken internally, as a remedy for Scabies, by 
Dr. Cothenius, who is said to have used it with success in the Prussian 
army, in 1756, See Edin. Med. Com. vol. i. p. 103. Dr. Albertus H. A. 
Helmich, of Berlin, also recommended it. The title of his treatise is, 
** Dissertatio Inauguralis Medica de usu interno Olei Vitrioli diluti in 
nonnullis Scabiei Speciebus." But subsequent experience has not con- 
firmed their reports. 

% See Willis, Vogel, Sauvages, Callisen, Heberden, &c. Prof. Selle 
affirms, " Scabies h contagio externo maxim^ ex parte per solum mere, 
prsecip. albi usum tollitur." Med. Clin. 191. See also Fordyce, Frag- 
menta Chirur^ca. Turner, Treatise on Dis. of the Skin, 4th edit. p. 58. 
He combined it with Ol. Tart, per deliquium. 



SCABIES. 055 

to the impetiginous form of the disease, which is liable 
to be irritated by the more acrid applications. The 
Muriate has probably derived some of its remedial 
character from its efficacy in the relief of Prurigo, 
and other eruptions, accompanied by itching, with 
little inflammation ; but it is not altogether destitute 
of power in Scabies itself. 

A committee of French physicians reported the 
result of some experiments made with the root of the 
Plumbago Europaea (pounded and mixed with boiling 
oil) to the Medical Society of Paris; from which 
they inferred, that it cured Scabies more speedily 
than any other remedy. The third or fourth inunc- 
tion with this substance, they affirm, is generally 
successful.* Several of the continental writers re- 
commend, in strong terms, the formula of an " Un- 
guentum ad Scabiem,** prescribed by Jasser, which 
directs equal parts of Sulphate of Zinc, Flowers of 
Sulphur, and Laurel Berries, to be made into a lini- 
ment with Olive or Linseed Oil : " about the size of 
a bean is to be rubbed upon the palms of the hands 
every morning and night.'* t From a few trials of 
this ointment, I am disposed to believe that it is pos- 
sessed of considerable efficacy. " Dr. G. Pellegrini 
has extolled highly the external use of Conium, either 
the recent juice, or a solution of the extract, or a de- 
coction of the dried plant. It is said to effect a cure 
in obstinate cases in five or six days. M. Derheims 
has found a solution of the Chloruret of Lime, in 
the, proportion of %j to Oj of water, used twice or 
thrice a day, very beneficial, t The most cleanly 
method of treating Scabies is the Sulphur vapour 
baths.'' 



* See M^moires de la Soc. Roy. de M^decine de Paris, torn. Hi.; also 
London Med. Journal, vol. v. 

f See Plenck, Doctr. de Morbis Cutaneis, p. 42. ; Callisen, Syst. Chi- 
rurg. Hodiern. 

:|: Joum. deChim. M^dicale, Decern. 1827. 



256 pusTULiE : 

Books which may be consulted ofi Scabies. 
Cazenaye et ScHEDEL, Abr^ pratique des Maladies de la Peau^ 8vo« 

1828. 

DicTiONNAiBE des Sciences M^dicales, torn. x?li* 

B TMULLER. de Scabie programma, 1751. 
AFENREFFEE, de Cute, SVO. 

Helmich, de usu interno Olei Vitrioli diluti in nonnulis Scabiei spe- 
ciebus, 4to. 1 762. 

Houghton, J., Cyclopaedia of Practical Medicine, vol. iii. 

_!CK, de Scabie periodica, 1701. 

iE RojQ C, Traits sur la Gale, &c., 12mo. 1809. 

^lenck, Doct. de Morbis Cutaneis, 8vo. 
Plumbe, on Diseases of the Skin, 2d edit. 1827. 
Ranque. M^m. et Obs. Cliniques sur un nouveau Proc^d^ pour la 
Gu^rison de la Gale, 8vo. 1811. 
RffiPEftER . de Scabie, 1710. 
Turner, de Morbis Cutaneis, 4to. 
ZiEGEE« de Scabie artificial], 1758^ 



257 



Order VL 

VESICULiE. 

SyN. Die Wasserblattem (German): V^sicules 
(F.): Presides. 

Vesicles are small elevations of the cuticle, con- 
taining a transparent, serous fluid. After some time 
the fluid is often absorbed, and the cuticle separates 
in the form of white scales, occasionally in the form 
of thin, yellow, laminated crusts. The vesicles are 
sometimes seated upon an inflamed base, at others 
they exhibit only a very slight inflammatory areola. 
They appear on every part of the body ; in some 
cases covering the entire surface ; in others, limited 
to certain parts. In general, vesicular diseases are 
not dangerous : in some instances they terminate by 
resolution : in others, the fluid exudes and concretes 
into yellowish crusts. The Order comprehends seven 
genera : — 

1. Varicella. 5. Miliaria. 

2. Vaccinia. 6. Eczema. 

3. Herpes. 7. Aphtha? 

4. RupiA? 



Genus I. VARICELLA.* 

Syn. Crystalli, Variola spuria (Auct. var.)i Va- 
riola lymphatica (Auct.) : Variolar pusillse (Heber- 

* Since the introduction of vaccination, considerable differences of 
opinion have existed among medical practitioners, respecting the.cha- 
racter of the eruption, which has occasionally appeared, after exposure 
to variolous infection, in persons previously vaccinated, some dehomi-. 
nating it Chicken-pox, and others Smallpox. The most careful observers 
must nave admitted the difficulty of establishing a decisive distinction in 

S 



258 VESicuL-ffi: : 

den) : Exanthema varicella (Parr) : Synochus vari- 
cella ( Young) : Cottamillie ummay ( Tarn.) : Kange 
nialm (Duk.): Cotttoiillie (Tel.): Pittamasoorika 
(Sans.): Ravaglione (ItaJ.): die unachten Kinds- 
pocken ( German) : Verole volante (F.) : Chicken- 
pox^ Water jags. 

Def. Accompanying a slight attack of fever, 

AN ERUPTION OF SEMI-TRANSPARENT GLABROUS VE- 
SICLES, SELDOM PASSING INTO SUPPURATION \ BUT, 
ON THE THIRD DAY, BURSTING AT THE TIP, AND 
CONCRETING INTO PUCKERED SCABS. 

This disease is usually so slight as to require little 
medical assistance ; but, in consequence of the re- 
semblance of the eruption, under some of its varieties, 
to the Smallpox, it becomes important, as a point of 
diagnosis, to establish its character with accuracy. 

Although its appearances were described by writers 
on the Smallpox three centuries ago, under the ap- 

{)ellation of Crt/stalli*; and at a period not much 
ater, it had even acquired popular names in Italy, 
France, and Germany, and subsequently in England t; 



many of these cases. A series of interesting observations, which have 
lately been made at Edinburgh, have led the ingenious Prof. John 
Thomson to believe that the Chicken-pox itself is in fact a modified 
Smallpox. While the question is still subjudice, 1 leave Varicella in its 
nosological seat; but many facts crowd upon my own recollection, 
which incline me to believe that this suggestion will ultimately prove to 
be correct. See Edin. Med. and Surg. Journ. Oct. 1818. 

* Vidus Vidius (De Crystallis) and Ingrassias (De Tumor, praet. Nat. 
lib. i. cap. 1.) describe these crystalli as white shining pustules, containing 
lymph, nearly as large as lupine seeds, and attended with little fever ; 
^* suntque hae minus periculosse (i.e. than smallpox), et saepe citra nota- 
bilem febrem infantes prehendunt." 

f We have the testimony of many writers, in proof of the prior dis- 
crimination of the vulgar, in respect to this eruptive disease. Sennertus, 
who was a professor at Wittenberg, at the commencement of the seven- 
teenth century, observes, in his treatise on smallpox and measles, that 
there are other varieties, *' praeter communes variolas et morbillos," 
which are popularly known, in jGrermany, by the terms Schaffshlattern 
(sheep-pox or vesicles), or W%ndpocten{vfm^iaox), See his Med. Pract. 
lib.iv. cap. 12. And Riverius, who was professor at Montpellier at the 
same period, speaks of the eruption as familiarly known by the common 
people, in France, by the appellation of Verolette. See his Prax. Med. 
cap. ii. In Italy it was callea Ravaglione. Ibid. — See also Diemerbroeck, 



VARICELLA, 25Q 

yet most of the systematic writers, down to the latter 
part of the eighteenth century, seem to have looked 
upon it as a variety of Smallpox, Dn Heberden, in 
the year 1767> pointed out the distinction with his 
accustomed perspicuity ; ** and stated that it affords no 
protection from Smallpox/** Perhaps, however, as 
this learned physician, in his posthumous work, con- 
tinues to designate the disease by the term Variola t, 
the emplojnnent of same term by the systematic 
writers above alluded to, with the epithets volaticaj 
spii/riatf &c. cannot be deemed evidence that they 
actually considered the disease as generically the same 
with Smallpox. ** So late as 1805 Dr, Frank of 
Vienna, and in 1809 Dr. Heim of Berlin, investi- 
gated this subject, and arrived at the same conclusions 
as Dr. Heberden.'* The discussion of this question 
has also been revived by Dr. John Thomson ; and 
his opinion, founded on his own extensive observation, 
is supported by many practitioners. " His chief 
arguments are, 1. that there are no records of Chicken- 
pox appearing as an epidemic without cases of Small- 
pox appearing at the same time : 2. that the most 
strictly vesicular eruptions have appeared after expo- 
sure to variolous contagion, and where the disorder 
could be referred to such a source : 3. that he had 
never witnessed Chicken-pox in those who had under- 



De Variolis et Morbis, cap. 2. — Fuller, in his " Exanthematologia," 
published in 1750, describes the eruption, and acknowledges himself 
indebted to the nurses for the appellation. '* I have adventured to think," 
he sa^s, " that this is that which among our women goeth by the name of 
chicken-pox," p. 161. And it is mentioned familiarly, at Edinburgh, in 
1735, as " the bastard or chicken-pox." See Edin. Med. Essays, vol. ii. 
art. 2. At Newcastle, and in Cumberland, it is popularly known by the 
name of Water-jags. See Dr. Wood, in the Med. and Phys. Journal, 
vol. xiii. p. 58. note, 

* See his paper in the Med. Transact, of the Coll. of Phys. vol. i. 
art. xvii. 

•f " Varioke pusilla,^* See his Comment, de Morbis, cap. 96. 

:(; See Vogel, de cognoscend. et cur. Horn. Morb. } 128. (edit. 1772). 
Burserius, Inst. Med. vol.ii. cap. 9. J 305. Sauvages, however, actually 
makes it a species of Variola, class, iii. gen. ii. spec.i. V. lymphatica, 

s 2 



260 vESicuLJE : 

gone Smallpox: 4, that tlie shades of difference 
between modified Smallpox and Chicken-pox were 
so indistinct as to render the diagnosis almost impos- 
sible/' Thus Dr. Thomson has remarked that the 
Variola, in its undoubted form, and Varicella, appear 
under the same exciting causes, whether the persons 
have been vaccinated or not : thence he concludes that 
they are merely varieties of the same disease. He also 
affiims that persons exposed to the contagion of Va- 
ricella have had Variola, and that Varicella never ap- 
pears in those whose constitutions have been modified 
by previous Variola. " The first of his positions has 
been refuted by the appearance of Varicella as an 
epidemic without Smallpox existing in Copenhagen, 
in 1 809 and several years afterwards.'* * But I believe 
vesicular Varicella has never been communicated by 
inoculation ; that children have Chicken-pox in the 
mildest form who have had Smallpox, or who after- 
wards take it. One might understand how Smallpox 
occurring a second time might be modified into 
Chicken-pox : but, if the majority of children have 
Chicken-pox in the mild form, under all circumstances^ 
I cannot accord in the opinion of Dr. Thomson. 
Besides, Varicella has never been prevented by vac- 
cination.'* 

The three principal species of Chicken-pox were 
well known a century ago, and were distinguished in 
the north of England, and in some counties of Scot- 
land, by the popular names of Chicken-pox, Swine- 
pox, and Hives. Dr. Willan proposed to distinguish 
them, according to the different forms of the vesicles, 
by the epithets, 

1. V. hntiformis. 

2. V. comformis. 

3. V. globularis*\ 

* 

♦ Mohl. de Variolibus et Varicellis, Copenhagen, 1817. 

\ See his treatise ** On Vaccine Inoculation,*' published in 1806, 
sect. vii. — Dr. Fuller, above quoted, described these three varieties under 
the appellations of Chicken-pox, Swine-pox, and Crystalli, p. 161-7. 



r 



VARICELLA. 26l 

Species !• Varicella lentiformis, Lenticular 
Varicella. 

St/n. Crystalli (aitct. var.) : Varicella lymphatica 
(Plenck) : Pemphigus variolodes vesicularis (Frank) 
Tliisspecies(PlateXLVII.XLVIII. of Bateman ;. 
PI. 18. of Thomson's Atlas) appears on the first 
day of the eruption, " and is seldom preceded by any 
febrile symptoms,** in the form of small red protu- 
berances, not exactly circular, but tending to an ob- 
long figure, having a nearly flat and shining surface, 
in the centre of which a minute transparent vesicle 
is speedily formed. " When the febrile sjrmptoms 
which precede the eruption are obvious, they consist 
of rigor, lassitude, short cough, broken sleep, furred 
tongue, sore throat, quick pulse, loss of appetite, and 
occasionally wandering pains. The best idea which 
can be given of the early appearance of the eruption 
is, that it resembles what might be conceived to be 
the effects of sprinkling boiling water over the skin 
from a loose brush.'* There is no hardness of base. 
On the second day of the eruption, the vesicle is filled 
with a whitish Ijnnph, and is about the tenth of an 
inch in diameter. On the third day it has under- 
gone no change, except that the lymph is straw- 
coloured. On the fourth day, those vesicles which 
have not been broken begin to subside, and are 
puckered at their edges. Few of them remain entire 
on the fifth day ; but the orifices of several broken 
vesicles are closed, or adhere to the skin, so as to con- 
fine a little opaque lymph within the puckered mar- 
gins. On the sixth day, small brown scabs appear 
universally in place of the vesicles. The scabs, on the 
seventh and eighth days, become yellowish, and gra- 
dually dry from the circumference towards the centrt. 
On the ninth and tenth days they fall off, leaving for 
a time red marks on the skin, without depression. 
Sometimes, however, the duration of the disease is 
longer than the period just stated, as fresh vesicles 
arise during two or three successive days, and s^o 

s 3 



262 vESicuLjE : 

through the same stages as the first. " The vesicles 
are seldom very numerous, and generally distinct * ; 
they appear first on the back, whereas the pustules of 
Smallpox appear first on the face, neck, and breast. 
The vesicles, even when they suppurate, rarely pit, or 
leave cicatrices.** " This form of Varicella is gene- 
rally distinguished by the absence of premonitory 
fever ; but as such may occur, this cannot be regarded 
as diagnostic : a much more valuable sign is the ab- 
sence of the hard base and the central depression that 
characterise even the mildest cases of modified Variola. 
As a physical distinction, it may be stated that, on 
puncturing a vesicle of Varicella, it falls to the level 
of the skin.'* 

Species 2. Varicella coniformis : Conoidal 
Varicella: Swine-pox. 

Syn. Varicella verrucosa (Plenck)f : Pemphigus 
variolodes (Frank.): Variola lymphatica (Sauv.): 
Hydrachnis (Citsson): V6rolette (F): Ravaglio 
(Itcd.) : Swine-poSj Water -pox. 

In this form of the disease the vesicles rise sud- 
denly, and have a somewhat hard and inflamed bor- 
der : they are, on the first day of their appearance, 
acuminated, and contain a bright transparent lymph : 
" the eruption is sometimes preceded by a slight cough, 
restlessness, and fever." On the second day they ap- 
pear somewhat more turgid, and are surrounded by 
more extensive inflammation : the lymph contained 
in many of them is of a light straw-colour. On the 
third day, the vesicles are shrivelled ; those which 
have been broken exhibit at the top slight gummy 
scabs, formed by a concretion of the exuding lymph. 
Some of the shrivelled vesicles, which remain entire, 
but have much inflammation round them, evidently 

• 

* Mr. Ring (Lond. Med. and Phys. Journal, xiv. 1805) has described 
a case of confluent Smallpox. 

■|- In Plenck's description of this species, he say», " supra cutem pro- 
mtnentes^ in quibus nullus humor est/' I. c. p. 53. T. 



VARICELLA. 263 

contain on this day whitish purulent fluid : every ve- 
sicle of this kind leaves, after scabbing, a durable 
cicatrix or pit. On the fourth day, thin dark-brown 
scabs appear intermixed with others, which are 
rounded) yellowish, and semi-transparent. These 
«cabs gradually dry and separate, and fall off in four 
or five days. A fresh eruption of vesicles usually 
takes place on the second and third day ; and, as each 
set has a similar course, the whole duration of the 
eruptive stage in this species of Varicella is six days. 
" In some cases minute red tubercles rise, but do not 
pass into vesicles, and disappear/* The last-formed 
scabs are not separated till the eleventh or twelfth day. 
" When the febrile symptoms are severe, and after the 
scabs fall off, in places subjected to pressure, inflam- 
mation and ulceration take place sometimes ; but 
there is no sloughing, as in Smallpox. These ulcers 
generally leave pits." 

Species 3. Varicella globularis : Hives. 

St/n. VaricellsB duree ovales ( Oerman). 

In this species the vesicles are large and globular^ 
but their base is not exactly circular. There is an 
inflammation round them, and they contain a trans* 
parent lymph, which, on the second day of the erup- 
tion, resembles milk-whey. On the third day, the 
vesicles subside, and become puckered and shrivelled, 
as in the two former species. They likewise appear 
yellowish, a small quantity of pus being mixed with 
the lymph. Some of them remain in the same state 
till the following morning ; but, before the conclu- 
sion of the fourth day, the cuticle separates, and thin 
blackish scabs cover the bases of the vesicles. The 
scabs dry and fall off in four or five days. 

Some degree of fever generally precedes the erup- 
tion of all the species of Varicella for a couple of days, 
which occasionally continues to the third day of the 
eruption. This is sometimes very slight, so that it is 
only recollected, as having been previously indicated 

s 4 



264 VESicuL^ : 

by fretfulness, after the eruption appeared.* ** The 
eruption usually commences on the breast and back, 
appearing next on the face and scalp, and lastly on 
the extremities. It i^ attended, especially in children, 
with an incessant tingling or itching, which leads 
them to scratch oflF the tops of the vesicles ; so that 
the characteristics of the disease are often destroyed 
at an early period. Many of the vesicles thus broken 
and irritated, but not removed, are presently sur- 
rounded by inflammation, and afterwards become pus- 
tules, containing thick yellow matter. These continue 
three or four days, and finally leave pits in the skin.** 

The eruption is sometimes preceded, for a few 
hours, by a general erythematous rash. It is usually 
fullest in the conoidal foim of Varicella, in which 
the vesicles are sometimes coherent, or seated close 
together, but seldom confluent.t The incidental 
appearance of pustules, just mentioned, among the 
vesicles, sometimes occasions a doubt respecting the 
nature of the eruption. The following circumstances, 
however, if carefully attended to, will afford suflScient 
grounds of diagnosis : — 

The " vesicle full of serum on the top of the pock,'* 
as Dr. Heberden expresses it, on the first day of the 
eruption ; — the early abrasion of many of these 
vesicles ; — their irregular and oblong form ; — the 
shrivelled or wrinkled state of those which remain 
entire, on the third and fourth day, and the radiating 
furrows of others, which have had their ruptured 
apices closed by a slight incrustation ; — the general 
appearance of the small scabs on the fifth day, at 
which time the Smallpox are not at the height of 
their suppuration, — sufficiently distinguish the erup- 

• Dr. Heberden observes, " These pocks come out in many without 
any illness or previous sign,'* ^- But Dr. Willan states, " I do not re- 
member to have seen any case of Varicella without some disorder of the 
constitution." Loc. cit. 

f See Dr. Willan's treatise. A case of confluent Chicken-pox, illus- 
trated by a coloured engraving, was published by Mr. Ring, in the Med. 
and Phys. Journal for 1805, vol. xiv. p. 141. 



VARICELLA. 265 

tion of Varicella, from the firm, durable, and slowly- 
maturating pustules of Smallpox. Dr. Willan also 
points out a circumstance, which is very characteristic ; 
viz. " that variolous pustules, on the first and second 
day of their eruption, are small, hard^ globular, red, 
and painful : the sensation of them to the touch, on 
passing the finger over them, is similar to that which 
one might conceive would be excited by the pressure 
of small round seeds under the cuticle. In the Vari- 
cella almost every vesicle has, on the first day, a hard 
inflamed margin; but the sensation communicated 
to the finger, in this case, is like that from a round 
seed, flattened by pressure.*' 

Dr. Willan remarks likewise, that, as the vesicles 
of the Chicken-pox appear in succession during three 
or four days, different vesicles will be at once in 
different states of progress : and if the whole erup- 
tion, on the face, breast, and limbs, be examined on 
the fifth or sixth days, every gradation of the progress 
of the vesicles will appear at the same time. But 
this circumstance cannot take place in the slow and 
regulated progress of the Smallpox. 

When the globular vesicles of the Hives appear 
(and they are occasionally intermixed both with the 
lenticular and conoidal vesicles), they afford a ready 
distinction from the Smallpox, to the pustules of 
which they bear little resemblance. 

There is a variety of Smallpox, which is occasion- 
ally produced by variolous inoculation, and which has 
usually appeared where vaccination had only partially 
influenced the constitution : this commonly dries up 
on the sixth or seventh day, without maturation. But 
the small, hard, tubercular form of this eruption is 
sufficiently distinct from every form of the vesicles of 
Chicken-pox. 

It is unnecessary to say any thing respecting the 
treatment of Varicella ; since nothing in general is 
requisite beyond an attention to the state of the 



266 vEsicuL^ : 

bowels, and abstinence from animal diet for two or 
three days. 

From some experiments made, in his own family^ 
by an eminent surgeon, and from others performed 
at the Smallpox Hospital, it appears that Varicella 
is communicable by inoculation with the lymph of the 
vesicles ; — that it may be introduced while the con- 
stitution is under the influence of vaccination, without 
impeding the progress of the latter, or being itself 
interrupted ; — that Smallpox, inoculated during the 
eruptive fever of Varicella, proceeds regularly in its 
course, without occasioning any deviation in that of 
the latter ; — but that, when variolous and varicellous 
virus is inserted at the same time, the Smallpox pro- 
ceeds through its course, while that of the Chicken- 
pox is in a great degree interrupted.* But the 
experiments have not been sufficiently numerous to 
warrant the accuracy of these general conclusions* 

Books which may be consulted on Varicella . 

Cazenave et ScHEDEL, Abr^^ pratique des Maladies de la Peau^ 8vo. 
Heberden, Med. Trans, of Col. of Phys., vol. 1. xvii. 
Heberden, Trans, of the Roy. Col. of Physicians, 8vo. vol. i. 1767* 
,X^Rayer, Trait^ des Maladies de la Peaa, 8vo. 
Ring, Med. and Phys Journ., vol. xiv. 
Thomson , Dr. J., on Varioloid Diseases, 8vo. 
WiLLAN on Vaccine Inoculation, 4to. 
Wilson on Febrile Diseases. 



Genus IL VACCINIA. COW-POX. 

S^n. Variola vaccina (Jenner) : Vaccina (Auct 
var!) : Exanthema vaccina (^Parr) : Synocha vaccina 
( Young) : Emphlysis vaccinia, y. Inserta ( Good)- 
Kuhpocken scnutzblattem (Oerm.): Koepokken 
(Dutch) : Vaccine (F.) : Vajuolo vaccino, Vaccina 
(itaL): Vacuna (Span*): Passuvoo ummay (ZJx- 

• See Dr. Willan's Treatise on Vaccination, pp. 97 — 105. 



VACCINIA. 267 

mul) : G^ke seetla (Dukanie) : Avoumma ( TeUin- 
goo) : Ghoomasoorikeh ( Sanscrit) : Inoculated Cow- 
pox. 

Def. A CIRCULAR, SEMI-TRANSPARENT, PEARL- 
COLOURED VESICLE, CONFINED TO THE PLACE OF 
PUNCTURE : DEPRESSED IN THE CENTRE; SURROUNDED 
WITH A RED AREOLA ; CONCRETING INTO A HARD 
DARK-COLOURED SCAB AFTER THE TWELFTH DAY. 

This disease appears naturally upon the teats of 
the cow, from which it is transferred to the human 
species ; either by natural inoculation, when the 
milkers have chopped hands ; or artificial, by insert- 
ing the virus, on the point of a lancet, under the 
skin. It appears on the day after that on which the 
inoculation took place, in the form of a small hard 
tubercle, which about the fourth day has assumed the 
character of a small semi-transparent pearl-coloured 
vesicle, with a circular or somewhat oval base ; and 
with the upper surface, until the end of the eighth 
day, more elevated at the margin than in the centre, 
and with the margin itself turgid, shining, and rotate, 
so as to extend a little over the line of the base. It 
is formed of a number of cells, the parietes of which 
secrete the lymph that fills the veside. This vesicle 
is filled with clear lymph, contained in the little cells, 
that communicate with one another. After the eighth 
or ninth day from the insertion of the virus, it is 
surrounded by a bright red circumscribed areola, 
which varies in its diameter, in different cases, from a 
quarter of an inch to two inches, and is usually 
attended with a considerable tumour and hardness of 
the adjoining cellular membrane. This areola de- 
clines on the eleventh and twelfth day ; the surface 
of the vesicle then becomes brown in the centre ; and 
the fluid in the cells gradually concretes into a hard 
rounded scab, of a reddish-brown colour, which at 
length becomes black, contracted, and dry, but is not 
detached till after the twentieth day from the inocula- 
tion. " In the agglutinising process, the cells become 



268 VESICUL.E : 

gradually consolidated ; and the fluid having become 
hard, a scab is formed, beneath which a small portion 
of the villi of the cutis is removed, and the loss of 
this causes the mark peculiar to the mild and regular 
vesicle/' It leaves a permanent circular cicatrix, 
about five lines in diameter, and a little depressed, 
the surface being marked with very minute pits or 
indentations, denoting the number of cells of which 
the vesicle had been composed.* 

A vesicle possessing these characters, and passing 
through these regular gradations, whether accom- 
panied by any obvious disorder of the constitution or 
not, was supposed effectually and permanently to 
secure the individual from the danger, and almost 
universally from the contagion, of Smallpox, t " This 
opinion, however, must be taken with great modifica- 
tion ; and even Dr. Jenner himself, before his death, 
had reason to be satisfied that Smallpox may occur 
after the most perfect vaccination. Whether this 
depends on what has been termed the variolous dia- 
thesis, we shall not attempt to determine. In some 
instances it may depend on pre-occupation of the skin 
by some cutaneous eruption, overlooked by the vac- 
cinator ; for it is a well-known fact, that the presence 
of Herpetic or Psoriastic eruptions will impede the 
constitutional influence of Vaccinia ; and thence the 
propriety of early vaccination. It cannot, neverthe- 
less, be denied that Smallpox has existed as an epide- 
mic in many parts of Great Britain since Cow-pox 
was introduced ; but it is satisfactory, in reviewing 
the history of these epidemics, to find, that of those 

* See Dr. Willan's Treatise on Vaccination, p. 9. 

t After so many years from the promulgation of the discovery, 
although this truth does not remain in full force, yet the very excep- 
tions to it (and what result of human research is free from exceptions r) 
may be said, without a solecism, to corroborate it. For, in the very 
small number of cases (such as that of the son of Earl Grosvenor) where 
an extensive eruption of Smallpox has occurred subsequent to vaccin- 
ation, the controlling influence of the Cow-pox has been invariably and 
strikingly manifested by the sudden interruption of the Smallpox m the 
middle of its course, and the rapid convalescence of the patient. 



VACCINIA. 269 

persons who were attacked with Smallpox who had 
not been vaccinated, the proportion of deaths was as 
one in four ; whilst of those who had undergone vac- 
cination, the proportion was not one in four hundred 
and fifty. It is sufficient if Vaccinia can modify 
Smallpox so as to moderate its violence ; the hope of 
eradicating it can scarcely be entertained.'* 

" When the disease proceeds regularly, the consti- 
tution becomes affected in the seventh day; fever, 
with restlessness, and deranged bowels, are the chief 
symptoms : they subside in two or three days. But 
in many instances, there is not even the slightest in- 
dication of fever ; the constitutional affection, although, 
when thus displayed, it indicates full effect of the 
virus upon the system, yet it is not essential that the 
symptoms should be so conspicuous to ensure the 
success of the process. Fever is more frequent in 
the adult than in the young patient : the vesicles also 
differ in some respects. They are more easily rup- 
tured, the lymph is more yellow, and the areola more 
extensive ; and the axillary glands swell, which rarely 
happens in the child.'* 

It is requisite that the vaccinator should attend to 
the irregular appearances which are produced either 
by the insertion of matter, that is so far corrupted or 
deteriorated as to be incapable of exciting the per- 
fect disease, or by the inoculation of proper lymph, 
under certain circumstances of the habit which inter- 
fere with its operation, and which will be mentioned 
presently. 

" When the progress of the disease is irregular, 
itching often attends the formation of the vesicle. 
But there is no uniform appearance which is cha- 
racteristic of imperfect vaccination — on the contrary, 
three varieties of irregularity have been noticed ; 
namely, pustules*, ulcerations, and vesicles of an 

• The pustules here mentioned occur on the inoculated part. Those 
pustules which appeared over the body, in the first experiments with 
the vaccine virus made in the Smallpox Hospital, by Dr. Woodville, and 



270 VESICULiE : 

irregular form. The pustule^ which is sometimes 
produced instead of the proper vaccine vesicle, is 
more like a common festering boil, occasioned by a 
thorn, or any other small extraneous body, sticking 
in the skin, according to Dr. Jenner ; and it throws 
out a premature efflorescence, which is seldom cir- 
cumscribed.* It is, as Dr. Willan has stated, of a 
conoidal form, and raised upon a hard inflamed base, 
with diflftise redness extending beyond it ; it increases 
rapidly from the second to the sixth day, and is 
usually broken before the end of the latter, when an 
irregular yellowish-brown scab succeeds, t Ulceration^ 
occupying the place of a regular vesicle, must be ob- 
viously incorrect: it probably originates from the 
pustules just mentioned, which, on account of the 
itching that is excited, are sometimes scratched off at 
a very early period ; or, being prominent and tender, 
are readily injured and exasperated by the friction of 
the clothes, &c. X 

With respect to the irregular vesicles^ " which do 
not wholly secure the constitution from the Small- 
pox,*' Dr. Willan has described and figured three 
sorts. The Jirst is a single pearl-coloured vesicle, 
set on a hard dark red base, slightly elevated. It is 
larger and more globular than the pustule above re- 
presented, but much less than the genuine vesicle : 
its top is flattened, or sometimes a little depressed, 
but the margin is not rounded or prominent. The 



ivhich puzzled the early vaccinators, were subsequently proved, and 
admitted by Dr. Woodville himself, to have been genuine smallpox, the 
result of the contagion of the place. 

* See Med. and Physical Journ. vol. xii. for Aug. 1804, p. 98. 

f This premature advancement was pointed out by Dr. Jenner as a 
characteristic of the irregular pock, in his Paper of Instructions for 
Vaccine Inoculation, at an early period of the practice. He also justly 
remarked, in respect to the *' soft amber-coloured " scab, left by these 
pustules, that *^ purtdeni matter cannot form a scab so hard and com- 
pact as limpid matter," loc, cU» p. 99. note. In other words, that the 
scab succeeding a pustule is less hard and compact than the scab which 
forms on a vesicle. 

t Dr. Willan, loc. cit. 



VACCINIA. 271 

second appears to be cellular, like the genuine vesicle ; 
but it is somewhat smaller, and more sessile, and has 
a sharp angulated edge. In the _first the areola is 
usually diffuse, and of a dark rose colour ; in the 
second, it is sometimes of a dilute scarlet colour, radi- 
ated, and very extensive, as from the sting of a wasp. 
The areola appears (earlier) round these vesicles, on 
the seventh or eighth day after inoculation, and con- 
tinues more or less vivid for three days, during which 
time the scab is completely formed. The scab is 
smaller and less regular than that which succeeds the 
genuine vesicle ; it also falls off much sooner, and, 
when separated, leaves a smaller cicatrix, which is 
sometimes angulated. The third irregular appear- 
Mice is a vesicle without an areola." * 

There are two causes, as I have intimated above, 
for these imperfect inoculations : the one is the inser- 
tion of effete or corrupted virus ; and the other, the 
presence of certain cutaneous eruptions, acute and 
chronic. " Certain states of the habit also predispose 
to irregularity, which is rendered evident by the 
fact, that the virus of an irregular vesicle transferred 
to a healthy subject will produce a regular vesicle." 
" The period of life for vaccination is also of conse- 
quence. It is not easy to determine why the period 

* It appears to me that Mr. Bryce, in his able and valuable work on 
the Jnoculation of Cow-pox, has, without any sound reason, impugned 
these observations upon the " irregular vesicles," and considered the 
introduction of the terms as productive of " much injury to the true 
interests of vaccination," and as serving " to screen ignorance or inat- 
" " " " ind that his own reasoning, which amounts 

lotlietical explanation (ana consequently an 
elevanl. He divides the vesicles " into con- 
it the same time admits that he knows no 
: to be distinguished. Gave the ultimate se- 
Kluced by the one, and not by the other, 
dil. 3d.] Now this is surely to screen ignor. 
ireeenting minute observation of appearances 
he more than compensates for this error of 
of a double inoculation, at the interval of 
has established, and which is sufficiently 
without any unusual nicety of observation 



272 vESicuL-ffi : 

of infancy between one and three months is the best, 
but experience has proved it to be so ; and, probably, 
it is owing to the habit of the infant being more sus- 
ceptible of that specific change which is requisite to 
secure it from Smallpox than that of the adult. It 
cannot be owing to the degree of febrile action ; for, 
in general, this is comparatively greatest in the adult.'* 

The lymph of the vaccine vesicle becomes altered 
in its qualities soon after the appearance of the in- 
flamed areola ; so that, if it be taken for the purposes 
of inoculation after the twelfth day, or after the 
vesicle has suppurated, it frequently fails to produce 
any effect whatever ; and in some cases it suddenly 
excites a pustule or ulceration, in others an irregular 
vesicle, and in others Erysipelas. If taken when 
scabs are formed over the vesicles (as in the case of 
the pustules of Smallpox), the virus is occasionally so 
putrescent and acrid, that it excites the same violent 
and fatal disease which arises from slight wounds 
received in dissecting putrid bodies. 

Again, the lymph, although taken from a perfect 
vesicle on the sixth, seventh, or eighth day, may be 
so injured before its application, by heat, exposure to 
the air, moisture, rust, and other causes*, as to be 
rendered incapable of exciting the true disease. " No 
lymph can be depended on which is taken after the 
eighth day. Many of the cases of Variola after Vac- 
cinia may be attributed to the neglect of this rule. 
But although many practitioners are of opinion that 
a vaccine vesicle produced by virus taken after the 
eighth day cannot be depended on for exciting that 
constitutional disease which is required for securing 
the habit from Smallpox ; yet. Dr. George Gregory 
thinks this opinion fallacious, and that a vesicle pro- 
duced by the scab, softened in water, is as good as one 
from recent six-day virus. The best period for taking 
the lymph is from the fifth to the ninth day. After 

* Dr. Willan, loc. cit. 




VACCINIA. 273 

« 

this time it becomes opaque and purulent, and cannot 
be depended upon, either for producing a vesicle, or, 
if this occur, for securing the individual from Small- 
pox. The virus ought not to be kept in a heat ex- 
ceeding 95° of Fahrenheit; for, when this is the 
case, the most active vaccine virus loses its power of 
communicating the disease. When it is necessary to 
keep the, virus, it should be preserved in little glass 
globules of the form or size of the marginal figure. 
The vesicle from which the virus is to be taken is 
punctured, and after warming the little ball, 
a, in the mouth to expel some of the air it 
. contains, the open orifice, 6, should be applied 
to the exuded lymph, and the ball wetted : as 
the contained air cools, the lymph ascends into 
the tube and ball. The end of the tube 6, 
li must then be hermetically sealed by melting 
it in the flame of a candle." 

*' In vaccinating, care should be taken to have the 
lancet as clean as possible, and perfectly sharp. When 
the lancet does not penetrate the skin easily, the 
lymph, if recent and semifluid, is thrown back on the 
lancet instead of entering the puncture. The skin 
should be kept tense when tlie puncture is made ; and 
three punctures, at an inch from each other, should 
be madie on the arm. The child should be in perfect 
health. The best age for vaccinating is from the 
sixth to the twelfth week after birth.*' 

The most frequent causes of the imperfections in 
the progress of the vesicle, seem to be " dentition, 
inflammatory fever, or inflammation of any viscus, 
hooping-cough," the presence of chronic cutaneous 
eruptions, or the concurrence of eruptive fevers, or 
even of other febrile diseases. The chronic cutane- 
ous diseases, which sometimes impede the formation 
of the genuine vaccine vesicle, have been described 
by Dr. Jenner under the ordinary indefinite term 
Herpes*, and Tinea capitis. In the more accurate 

* See his letter to Dr. Marcet, Med. and Phys. Journ. for May, 1803; 
also, the same Journal for Aug. 1 804. 

T 



274 VESicuLJE : 

phraseology of Dr. Willan, they are Herpes (includ- 
ing the shingles and vesicular ring'Worm)^ Psoriasis, 
and Impetigo (the dry and humid tetter)^ the Li- 
chen, and most frequently the varieties of Porrigo, 
comprising the contagious eruptions denominated 
by authors crusta^ lacteay area^ achoreSy andjhvi. 
Dr. Willan thinks that the Itch and Prurigo like- 
wise have the same influence. 

Of the interference of the eruptive fevers, Measles, 
Scarlet fever, and Chicken-pox, with the progress of 
the vaccine vesicle, when they occur soon after vac- 
cination, numerous instances have been recorded. 
The suspension of its progress, indeed, would be 
expected, under such circumstances, from the known 
facts respecting the reciprocal action of these con- 
tagious fevers on each other. But the action of 
the vaccine virus is not only suspended by these 
fevers, so that the vesicle is very slow in its progress, 
and the areola not formed till after the fourteenth 
day or later, and sometimes not at all ; but it is 
occasionally rendered altogether inefficient. Even 
Typhus fever, and the Influenza, have been ob- 
served to produce a sim^ar interruption in the pro- 
gress of vaccination. 

A vesicle without an areola takes place if the per- 
son inoculated have previously received the infection 
of Smallpox, or if he be affected with some other con- 
tagious disease during the progress of vaccination.* 

Other irregularities may probably have occurred. 
At all events, though the constitution is sometimes 
fully secured from the infection of Smallpox, even 
by the irregular vesicles ; yet, as it is more com- 
monly but imperfectly guarded by such vesicles, the 
propriety of Dr. Jenner's caution is obvious ; that, 
** when a deviation arises, of whatever kind it may 
be, common prudence points out the necessity of 
re-inoculation.*' t *^ Those who have been inoculated 

* Dr. Willan, loc. cit. 

f Paper of Instructions, before quoted. 



VACCINIA. 275 

for Smallpox in early life, and have had the disease, 
are usually unsusceptible of Cowpox, although often 
a kind of vesicle is formed : but the fluid it contains 
will not produce the genuine disease/' " Dr. Jen- 
ner believed Smallpox and Cowpox to be varieties of 
the same disease ; an opinion which was said to have 
been confirmed by some experiments lately made in 
Egypt, by which it has been discovered, that by 
inoculating a cow with Smallpox matter from the 
human body, active vaccine virus is produced. 
Children were successfully inoculated from this cow.* 
It is said, however, that experiments of a similar na- 
ture made at the Veterinary College failed. 

Books to be consulted regarding Cow-pox, 

Adams. J., Answers to all the Objections again«t Cow-pox, Svo. 1805. 

AiKiN, C. A., A concise View of all the most important Facts con- 
cerning Cow-pox, Svo. 1801. 

AuBERT y A., Rapport sur la Vaccine, Svo. 1800. 

Blane, G., a Statement of Facts, &c. &c«, Svo. 1820. 

Brown, T., An Inquiry into the anti-variolous Powers of Vaccination, 
Svo. 1809. 

Bryce 's Practical Observ. on the Inoculation of Cow-pox, 8vo. 1809. 

Coxe' s Pract Obs. on Vaccination, Svo. 1802. 

Cross. J.. History of the Variolous Epidemic at Norwich in 1819, &c., 
Svo. 1820. 

DuNNiKi >. R., Minutes of some Experiments to ascertain the perma- 
nent Security of Vaccination, 8vo. 1804. 

DrrvTT.T.ARD j E. E., Analyse et Tableaux de I'Influence de la Petite 
V^role sur la Mortality, 4to. 1806. 
JEfijifiiiSfili*. W., Letter to Sir H. Halford on Inoculation, Svo. 1825. 

GREEiijifly, T., An Estimate of the true Value of Vaccination, 8vo. 
1825. 

Gregory, G., Cyc of Practical Med., vol. iv. 1834. 

H^RNAND^ . R., Observaciones Historicas del Origen, Progresso y 
Estado Actual de la Vaccina in Minorca, 4to. 1804. 
y" JenneRt on the Variolae Vaccinae, 4to. 1800. 

Jenijer, E., on the Varieties of the Vaccine Pustule, &c., 8vo. 1819. 

Lay^ J. G., An Account of some Experiments on the Origin of Cow- 
pox, 8vo. 1801. 

Lee^e^ Ed.j An Explanation of the Causes why Vaccination has some- 
times failed to prevent Smallpox, 8vo. 1812. 

MAR§flAJ.L, J., Treatise on Vaccination, 8yo. 1830. 

MoqR£j.Ja8., History of Vaccination, 8vo. 1817. 

OdieRj^L., Mcmoire sur I'lnoculation de la Vaccine, 8vo. 1801. 

Pr arsqv ^ G., An Inquiry concerning the History of Cow-pox, 8vo. 
1798. 

* Letter from India. — London Medical Gazette, vol, i. p. 673. 

T 2 



276 VESicuL^ : 

RiNG^ J., Treatise on Cow-pox, 2 vols. 8vo. 1805. 
Sacco, Luiz, Trattato di Vaccinaziene, &c., 4to. 1 809. 
Thomson, J., Historical Sketch of the Opinions on the Varieties of 
Smallpox, 8V0. 1822. 

WiLLAN> Treatise on Vaccine Inoculation, 8vo. 1806. 

WooDviLLE. W., A Comparative Statement of Facts, &c., 8vo. 1800. 



Genus III. HERPES. * 

Syn. epTrrjg (Auct. Orcec): ^(oa-rrjo (Plim/) : Zona 
( Scriberif Sag. Russel) : Formica {Jivicenna) : Zona 
ignea {Hoff. Darwin) : Erysipelas phlyctaenodes 
(Cullen): Serpigo {Auct.)\ Cytisma Herpes 
( Young) : Lepidosis Herpes ( Good) : Herpes, Zona, 
Ignis Sacer (Lat.) : Zittermal, Flechte, der Yustel 
( Germ.) : Springend vuur {Dutch) : Herpe, la Jar- 
ti^re {Pr.)\ Erpete (Ital.): Herpes Sarpallido 
(Span.) : Neshr (Arabic) : Tetter. 

Def. Vesicles in distinct, irregular clus- 
ters, UPON AN INFLAMED BASE, EXTENDING A 
LITTLE WAY BEYOND THE MARGIN OF EACH CLUSTER: 
ACCOMPANIED WITH TINGLING I CONCRETING INTO 
SCABS, 

This appellation is here limited to a vesicular dis- 
ease, which, in most of its forms, passes through 
a regular course of increase, maturation, and decline, 
and terminates in about ten^ twelve, or fourteen days. 
The eruption is preceded, when it is extensive, by 
considerable constitutional disorder, and is accom- 
panied by a sensation of heat and tingling, sometimes 
by severe deep-seated pain, as if hot needles were 

* Actuarius explains the origin of this termi as well as of the appli- 
cation of the word^r^, to these hot and spreading eruptions. ** Herpa 
dicitur eo quod videatur ipTreiv (quod est serpere per summam cutem), 
modo hanc ejus partem, modo proximam occupans, quod semper, priore 
sanat^, propinqua ejus vitium excipiat ; non secus quam ignis qui prox- 
ima quaeque depascitur, ubi ea quae prius accensa erant, deficiente jam 
materia idonea, prius quoque extinguuntur." Meth. Med. lib. ii. cap. 1 2. 
— From this creeping progress, the disease was called Formica by the 
Arabians. 



HERPES. 277 

rim into the parts affected.* The lymph of the 
vesicles, which is at first clear and colourless, be- 
comes gradually milky and opaque, and ultimately 
concretes into scabs : but, in some cases, a copious 
discharge of it takes place, and tedious ulcerations 
ensue. " In some instances, as the vesicles concrete, 
and the crusts fall off in one part, fresh crops arise 
in the vicinity ; and thus the eruption creeps over a 
considerable part of the skin.*' The disorder is not 
contagious in any of its forms. 

The ancients, although they frequently mention 
Herpes,, and give distinctive appellations to its va- 
rieties, have nowhere minutely described it : hence 
their followers have not agreed in their acceptation 
of the term.t It has been principally confounded 
with Erysipelas, on the one hand, and with Eczema, 
Impetigo t, and other slowly-spreading eruptions, on 
the other. But if the preceding character be well 
considered, the diagnosis between these affections and 
Herpes will be sufficiently obvious. From Erysi- 
pelas it may be distinguished by the numerous, small, 

* This deep-seated pain has often been taken for Pleurisy, and 
thence, we hear of cases of this disease cured by a critical eruption of 
Herpes. 

f Although some of the ancients are more anxious to point out the 
nature of the morbid humour, to which the Herpes was to be imputed, 
than to describe its symptoms f yet, most of them speak of smali bulla, 
OT pJdyctcBnce^ as characteristic of the eruption. (See Galen de Tumo- 
ribus praet. Naturam ; — Aetius, tetrab. iv. serm. ii. cap. 60.; — Paulus, 
Jib. iv. cap. 20. ; — Actuarius, lib. ii. cap. 12.) Again, Scribonius Largus 
speaks of the most remarkable form of this vesicular disease (the Zoster, 
or shingles) as a species of Herpes. " Zona quam Graeci kp7rr)Ta dicunt." 
See Scribon. de Compos. Medicam. cap. 15. In describing the appear- 
ance of this disease, under the appellation of Ignis i^acer, Celsus has 
properly characterised it by the numerous and congregated eruption, 
the small and nearly equal size of the vesicles, and the situations which 
it more frequently occuj)ies, &c. " Exasperatumque per pustulas con- 
tinuas, quarum nulla alter^ major est, sed phirimse perexiguae : in his 
semper fere pus, et saepe rubor cum calore est : serpitque id nonnun- 
quam sanescente eo quod primum vitiatum est; nonnunquam etiam 
exulcerato, ubi, ruptis pustulis, ulcus continuatur, humorque exit, qui 
esse inter saniem et pus videri potest. Fit maxime in pectore, aut 
lateribus, aut eroinentibus partibus, praecipueque in plantis." Lib. v. 
cap. 23. § 4. 

X See Dr. CuUen's definition of Herpes. Nosol. Method, gen. i47. 

T 3 



278 VESicuL^ : 

clustering vesicles, by the natural condition of the 
surface in the interstices between the clusters, and 
by the absence of redness and tumefaction before the 
vesicles appear : and from the chronic eruptions just 
alluded to, by the purely vesicular form of the cuti- 
cular elevations in the commencement, by the regu- 
larity of their progress, maturation, and scabbing, 
and by the limitation of their duration, in general, 
to a certain number of days. 

The ancient division of Herpes into three varieties, 
miliary (^sy^piag), vesicular ((^XoxraivaiS^^), and 
eroding (s<rQio[xsi/og), may be properly discarded : 
for there appears to be no essential distinction be- 
tween the first two, which differ only in respect to 
the size of the vesicles ; and the last is incorrectly 
classed with Herpes, being perhaps referable rather 
to Pompholyx, or those larger bullae, which arise 
in bad habits of body, and are followed by ill-con- 
ditional ulcerations of the skin.* The various ap- 
pearances of Herpes may be comprehended under the 
six following species : — 

1 . H. phlyctcBnodeSy 4. H. labialiSy 

2. H. zoster^ 5. H. prceputialiSj 

3. H. circinaticSy 6. H. Iris. 

** The Editor conceives that the second, third, 

ourth, and fifth species of this armngement are 

merely varieties of the first, and, consequently, that 

the whole may be arranged under two distinct spe- 

* Celsus, has, in fact, made this distinction between the Herpes 
esthiomenos and the proper Herpes, ranking the latter under the head 
of Ignis Sacer; a term which most of the translators of the Greek 
writmgs have incorrectly substituted for Erysipelas. Whereas he speaks 
of the H. esthiomenos as a deep-spreading ulcer, of a cancerous cha- 
racter. " Fit ex his ulcus quod ipTrrjTa effOiofievov Grseci vocant, quia 
celeriter serpendo penetrandoque usque ossa, corpus vorat. Id ulcus 
inaequale est, coeno simile, inestque multus humor glutinosus, odor in- 
tolerabilis, mnjorque quam pro modo ulceris inflammatio. Utrumque, 
(scU. ^tjpiu)fjia et epTnjg) sicut omnis cancer, fit maxime in senibus, vel 
lis quorum corpora mali habitus sunt." Celsus de Medecina, lib. v. 
cap. 28. — See also Sennert. Pract. lib. v. part. i. cap. 17. 



HERPES. 279 

cies, namely, H. phlyctcenodes^ and H, Iris. The 
following arrangement, therefore, is that which he 
has adopted : — 

Species 1. Herfes phh/ctcenodes. 
Var. a* H. zoster, 

b. H. circinatus, 

c. H. labialis. 

d. H. prseputialis. 
2. Herpes Iris. 

Species 1. Herpes phlyctcBnodes^ Miliary 
Herpes. 

Syn. Herpes exedens, Serpigo (^Underwood): 
Herpes railiaris {Auct. var.) : Lepidosis Herpes, a. 
Miliaris ( Good) : Dartre phlyct6no*ide {Alibert) : 
die Flechte ( Oerman). 

This species of Herpes, (Plate XLIX. of Bate- 
man; PI. 20. of Thomson's Atlas,) including the 
miliary variety above mentioned, is commonly pre- 
ceded by a slight febrile attack for two or three 
days, accompanied by thirst, heat of stomach, and 
flatulence, and which is not always relieved by the 
appearance of the eruption, but, on the contrary, it is 
sometimes augmented after it shows itself. Small 
transparent vesicles then appear, in irregular clus- 
ters *, sometimes containing colourless, and sometimes 
a brownish lymph ; and, for two or three days more, 
other clusters successively arise near the former. 
The eruption has no certain seat: sometimes it 
commences on the cheeks or forehead, and some- 
times on one of the extremities ; " sometimes about 
the fingers or toe-nails;'* and occasionally it begins 
on the neck and breast, and gradually extends over 

* Occasionally, however, the patches are of a regular circular form, 
and the areae are completely covered with crowded vesicles : and in 
these cases the constitution is more violently disordered, and the heat 
and pain attending the eruption, amounting to a sensation of actual 
burning or scalding, are more severe than in any other form of Herpes. 
To this variety of the eruption more particularly the popular appellation 
of Nirles has been given. 

T 4 



280 VESicuL^ : 

the trunk to the lower extremities, new clusters 
successively appearing for nearly the space of a week. 
It is chiefly the more minute or miliary variety 
which spreads thus extensively ; for those which, at 
their maturity, attain a considerable size and an oval 
form*, seldom appear in more than two or three 
clusters together; and sometimes there is only a 
single cluster. " Biett remarks, that previous to 
the appearance of the vesicles, minute red points, 
^ very closely grouped, may be detected on the spot 
where the vesicles show themselves on the following 
day, on an inflamed base, resisting compression, and 
varying in size from that of a millet seed to that of a 
pea. I have seen red patches, which give a sensation 
of roughness when the. finger has been passed over 
them, but never the peculiar papular appearance 
that Biett has described. The skin between the 
clusters of vesicles retains its natural colour, although 
on the space occupied by the group, and for a small 
space beyond it, it is red.'* The included lymph 
sometimes becomes milky or opaque in the course of 
ten or twelve hours ; and about the fourth day the 
inflammation round the vesicles assumes a duller red 
hue, while the vesicles themselves break, and dis- 
charge their fluid, or begin to dry and flatten, and 
dark or yellowish scabs concrete upon them. These 
fall off about the eighth or tenth day, leaving a red- 
dened and irritable surface, which slowly regains its 
healthy appearance. As the successive clusters go 
through a similar course, the termination of the 
whole is not complete before the thirteenth or four- 
teenth day. 

The disorder of the constitution is not immediately 
relieved by the appearance of the eruption, but 
ceases as the latter proceeds. The heat, itching, and 

* One of Alibert's best plates contains a representiation of a vesicular 
disease of the face and neck, which might appear to be referable to this 
species of herpes; but, from his description of the disease, it is ob- 
viously a case of Pompholyx. He calls it " Dartre phlyct^noide con- 
fluente." See his plate 23. 



HERPES. 281 

tingling in the skin which accompany the patches as 
they successively rise, are sometimes productive of 
much restlessness and uneasiness, being aggravated 
especially by external heat, and by the warmth of the 
bed. 

The predisposing and exciting causes are equally 
obscure : " but there is almost always some previous 
deranged condition of the digestive organs. In 
some instances it has proved critical of a catarrhal 
attack, in which case the eruption may be regarded as 
a translation of diseased action from the mucous 
membrane to the skin.'' The eruption occurs in its 
miliary form, and spreads most extensively (some- 
times over the greater portion of the surface of the 
body) in young and robust people, who generally 
refer its origin to cold. But it is apt to appear, in 
its more partial forms, in those persons who are sub- 
ject to headachs, and other local pains, which are 
probably connected with derangements of the chy- 
lopoietic organs. 

" The diagnosis of Herpes phlyctcenodes is ob- 
vious ; pemphigus, the only disease with which it is 
possible to confound it, consisting of distinct solitary 
bullae, whereas Herpes consists of groups of vesicles 
on isolated surfaces." 

As the same treatment is requisite for this species 
as for its varieties, I shall postpone any mention of it 
until they have been described. " When this dis- 
ease appears in children. Dr. Underwood recom- 
mends the expressed juice of Sium nodiflorv/m* j 
Creeping Water Parsnep.'* From one to four or 
five table-spoonfuls mixed with one or more spoonfuls 
of new milk may be given three times a day, accord- 
ing to the child's age and the state of its stomach, 
regulating the bowels. In obstinate cases Hydrar- 
gyrus cum Creta will be found useful : and as a 

• Dr. Underwood terms it aquaticum^ which is the old name of 
Morison. It is common in rivulets, flowering in July and August. 
Underwood on the Diseases of Children, 8th edit. 8vo. p. 182. T. 



282 vESicuL^ : 

local application, the Unguentum Picis. Should the 
vesicles ulcerate, Solution of Sulphate of Zinc will 
be found useful ; whilst the little ulcers may be 
touched with Butter of Antimony, Decoction of 
Sarsaparilla is a useful alterative. 

Var. a. Herpes zoster*^ Shingles. 

Syn. Zoster {Pliny) : Formica {Avicenna) : Ignis 
sacer ( Celsus) : Zona ignea {Hoffmann) : Dartre 
phlyct^noide en Zone^ — Herpes phlyctenoides Zonce- 
formis (Alibert): Zona (Scrib. Sag. Russell) i 
Erysipelas Zoster (Sauv.) : Le Zone Ceinture dar- 
treuse (jP.) : die Fevergurtel ( German) : Shingles. 

This form of the eruption (Plate L. of Bateman ; 
PI. 20. of Thomson's Atlas), which is sufficiently 
known to have obtained a popular appellation, the 
Shingles ff is very uniform in its appearance, follow- 
ing a course similar to that of Smallpox, and the 
other exanthematic fevers of the nosologists. It is 
usually preceded for two or three days by languor 
and loss of appetite, rigors, headach, sickness, and a 



* Zbxrrrjp^ Zuvrjy a belt. These terms have been applied to this form 
of Herpes, from the situation which it always occupies on the trunk of 
the body. It has been called simply zofter (see Plin. Nat. Hist. lib. xxvi. 
cap. 1 1 .), and zona, or zona ignea, &c. by different writers ; and its symp- 
toms may be recognised, as I have stated above, in the first species of 
sacer ignis, described by Celsus. The disease has been described with 
different degrees of accuracy, by Tulpius (Obs. Med. lib. iii. cap. 44.), 
Hoffmann (Med. Syst. Rat. tom. iv. part. i. cap. 13. § 6. & obs. 6.), De 
Haen (De Divis. Febrium, p. 112, &c.), Callisen (Syst. Chirurg, Hod. 
tom. i. p. 424.), Burserius (Inst. Med. Pract. tom. ii. cap. Z.\ and others. 
Sauvages has included it under two genera, with the appellations of 
Erysipelas zoster and Herpes zoster. (Nosol. Method, class, iii. gen. 7. 
& class, i. gen. 7.) Dr. Cullen has classed it with the former disease 
under the title of Erysipelas phlyctce^iodes ; but at the same time ex- 
presses a doubt of the propriety of this classiUcation. (Nosol. Meth. 
gen. 31. spec. 2.) 

M. Alibert has given an indifferent representation of Herpes zoster, 
plate 24., under the title of " Dartre phlyct^noide en zone." 

f Is this a corruption from the Latin Cingulum? Johnson held the 
affirmative : and it seems not less distinctly deducible from this word, 
than the vulgar terms quinsey and megrim, from their Greek roots 
cynanche and hemicrania ; except that the latter had received a previous 
corruption by the French, in esquinancie and migraine, from which we 
doubtless took our words. 



HERPES. 283 

frequent pulse, together with a scalding heat and 
tingling in the skin, and shooting pains through the 
chest and epigastrium. Sometimes, however, the 
precursory febrile symptoms are slight and scarcely 
noticed, and the attention of the patient is first 
attracted by a sense of heat, itching, and tingling, in 
some part of the trunk, where he finds several red 
patches of an irregular form, at a little distance from 
one another, upon each of which numerous small 
elevations appear, clustered together. These, if ex- 
amined minutely, are found to be distinctly vesicular ; 
and, in the course * of twenty-four hours, they enlarge 
to the size of small pearls, and are perfectly trans- 
parent, being filled with a limpid fluid. The clusters 
are of various diameter, from one to two, or even 
three, inches, and are surrounded by a narrow red 
margin, in consequence of the extension of the in- 
flamed base a little beyond the congregated vesicles. 
During three or four days, other clusters continue to 
arise in succession, and with considerable regularity ; 
that is, nearly in a line with the first, extending 
always obliquely towards the spine at one extremity, 
and towards the sternum, or linea alba of the abdo- 
men, at the other, most commonly round the waist 
like half a sash, but sometimes like a sword-belt across 
the shoulder, never in a vertical position.* ** Instead 
of the trunk, the clusters sometimes beginning on the 
loins or the nates, extend, in an oblique direction, 
down the thigh to the knee.'* 

i * " Hac tamen perpetua lege," says De Haen, " ut ab anteriore parte 

^ nunquain lineam albani, nunquam a postica spinam, transcenderent." 

(De bivis. Febrium, p. 112.) This observation, however, is not without 

exceptions ; although the rarity of the occurrence probably gave rise to 

the popular apprehension, which is as old as Pliny, that if the eruption 

I completed the circle of the body, it would be fatal. " Zoster appellatur, 

I et enecat, si cinxerit." (Plin. loc. cit.) I have seen the clusters extend 

across the linea alba in front; and Turner asserts, that he has more 

than once observed it to surround the body. (On Dis. of the Skin, 

chap. V. p. 80.) Dr. Russell (De Tabeglandulari, hist. 55,) and Tulpius 

(Obs. Med. lib. iii. cap. 44.), also contradict the affirmation of Pliny. 

Plenck- says, '* Sub umbilico et in regione ischiadica usque ad genua 
hunc morbum vidi." Doctrina de Morbis ^^Cutaneis. Viennse, 1 785. 
p. 28. T. 



284 vESicuLiE : 

** Rayer mentions having seen a case in which the 
eruption extended from the face into the mouth. 
One half of the tongue was tumified, red, and covered 
with white, soft, irregular, patches; some of the 
vesicles resembled those on the skin, others were of 
large size, approaching to the character of BuUse : 
the saliva, which was secreted in large quantity, was 
thready, the breath foetid, but not like that produced 
by mercury/'* 

While the new clusters are appearing, the vesicles 
of the first begin to lose their transparency, and on 
the fourth day acquire a milky or yellowish hue t, 
which is soon followed by a bluish, or livid colour of 
the bases of the vesicles, and of the contained fluid. 
They now become somewhat, " but never com- 
pletely,** confluent, and flatten or subside, so that the 
outlines of many of them are nearly obliterated. 
About this time they are often broken, and for three 
or four days discharge a small quantity of a serous 
fluid ; which at length concretes into thin dark scabs, 
at first lying loosely over the contained matter, but 
soon becoming harder, and adhering more firmly, 
until they fall off about the twelfth or fourteenth day. 
The surface of the skin is left in a red and tender 
state ; and where the ulceration and discharge have 
been considerable, numerous cicatrices or pits are left. 
** They sometimes ulcerate, and Biett says that he 
has seen them pass into gangrene.** 

As all the clusters go through a similar series of 
changes, those which appeared latest, arrive at their 
termination several days later than the first ; whence 
the disease is sgmetimes protracted to twenty or even 
twenty-four days, before the crusts exfoliate. In one 
or two instances I have seen the vesicles terminate in 
numerous small ulcers, or suppurating foramina, 
which continued to discharge for many days, and 
were not all healed before the end of the fourth week. 

* Traits des Mai. de la Peaii. t. i. p. 250. 

f Can the fluid be now regarded sero-purulent ? T. 



HERPES. 285 

The febrile symptoms commonly subside when the 
eruption is completed ; but sometimes they continue 
during the whole course of the disease, probably from 
the incessant irritation of the itching and smarting 
connected with it. In many instances, the most dis- 
tressing part of the complaint is an intense darting 
pain, not superficial, but deep-seated in the chest, 
which continues to the latter stages of the disease, 
and is not easily allayed by anodynes*: sometimes 
^ this pain precedes the eruption. ** In old persons, 
i and those of a delicate habit of body, a feeling of 
pain or local burning often is experienced for a week 
■ or more previous to the eruption, on the appearance 
I of which it is relieved. This is sometimes so severe 
as to be mistaken for pleurisy, and treated by vene- 
section. I have seen great relief procured by a com- 
bination of Magnesia, wine of Colchicum, and tincture 
of Opium, taken at bed-time.*' 

Although the Shingles commonly follow the re- 
I gular course of fever, eruption, maturation, and 
decline, within a limited period, like the eruptive 
fevers or exanthemata of the nosologistst, yet the 
disorder is not, like the latter, contagious, and may 
occur more than once in tRe same individual, t The 
disease, on the whole, is slight ; it has never, in any 
instance that I have witnessed, exhibited any untoward 
symptom, or been followed by much debility : in the 



* Hoffmann observes, *' Inde quidem symptomata remiserunt, ex- 
cepto exquisito ardente dolore, qui tantus erat, ut nee somnum capere, 
nee locum affectum contingere posset." Med. Syst. Rat. torn. iv. part, i, 
cap. It?. § 6. obs. vi. 

f The regularity and brevity of its course have not been sufficiently 
attended to. Burserius has, however, observed, *' Zoster acuttis et brevU 
utplurimum morbus e^t; nam, quanquam Lorryus et chronicum, et 
interdum epidemicum esse existimet, (quod de igne sacro lat^ sumpto 
fortasse ei concedendum est) banc speciem tamcn diutinam non vidi." 
Inst. Med. Pract. torn. ii. cap. 3. } 52. 

J In the course of my attendance at the Public Dispensary, during 
twelve years, between thirty and forty cases of shingles have occurred, 
none of which were traced to a contagious origin, or occasioned the 
disease in other individuals. 



it 



286 VESicuLiE : 

majority of cases, it did not confine the patients to 
the house.* 

The causes of the Shingles are not always obvious. 
Young persons from the age of twelve to twenty-five 
are most frequently the subjects of the disease, although 
the aged are not altogether exempt from its attacks, 
and suffer severely from the pains which accompany it. 
f It is most frequent in the summer and autumn, and 
' seems occasionally to arise from exposure to cold, 
after violent exercise. Sometimes it has appeared 
critical, when supervening to bowel -complaints, or to 
the chronic pains of the chest remaining after acute 
pulmonary affections. Like Erysipelas, it has been 
ascribed by some authors to paroxysms of anger, t 
♦* It is not contagious." 
I " There is no diflSculty in the diagnosis. It re- 
1 sembles closely, in some instances, the H. phlyctce- 
\ nodes y of which, indeed, it is a variety: the absence 
' of puflSness, an^ of^the disappearance of the redness 
on pressure, readily distinguishes it from Erysipelas.** 
It is scarcely necessary to speak of the treatment of 
a disorder, the course of which requires only to be 
regukted, and cannot be shortened, by medicine. 
Gentle laxatives and diaphoretics, with occasional 
anodynes, when the severe deep-seated pains occur, 
and a light diet, seem to comprise every thing that is 
requisite in the cure. Experience altogether contra- 
dicts the cautionary precepts, which the majority of 
writers, even down to Burserius, have enjoined, in 
respect to the administration of purgatives, and which 

* Some authors, as Platner and Hoflfmann, have deemed the Zoster 
a malignant and dangerous disease; and Langius (Epist. Med. p. 110.) 
has mentioned two fatal cases occurring in noblemen. But they have 
apparently mistaken the disease. Lorry, Burserius, Geoffroy, and 
others, (Hist, de la Soc. Roy. de M^d. ann. 1777-8) more correctly 
assert that it is free from danger. 

f See Schwartz Diss, de Zand serpiginosA, Halae, 1 745 : he saw three 
instances, which followed violent fits of passion, p. 17.; and Plenck 
affirms that he saw it occur twice after violent anger, and a copious 
potation of beer. (De Morb. cutan. p. 88.) 



HERPES. 287 

are founded entirely uppn the prejudices of the 
humoral pathology.* 

In general, no external application to the clustered 
vesicles is necessary : *' the best plan is to prevent 
their breaking, by bathing the parts with a spirituous 
lotion, consisting of one part of Alcohol and four of 
distilled water ; or a solution of Nitrate of Silver in 
the proportion of two grains of the nitrate to one 
ounce of distilled water/' When they are abraded 
by the friction of the clothes, a glutinous discharge 
takes place, which occasions the linen to adhere to the 
affected parts, producing some irritation. Under these 
circumstances, a little simple ointment, " or that of 
the Oxide of Zinc spread on lint,'* may be interposed, 
to obviate that effect. With the view of clearing oflP 
the morbid humours, the older practitioners cut away 
the vesicles, and covered the surface with their un- 
guents f, or even irritated it with the Nitrico-oxyd of 
Mercury, notwithstanding the extreme tenderness of 
the parts, t These pernicious interruptions of the 
healing, process probably gave rise to ulceration, and 
prolonged the duration of the disease, and thus con- 
tributed to mislead practitioners in their views respect- 
ing its nature. § 

Var. b. Herpes circifiatus, Vesicular Ring- 
worm. 

S^n. Formica ambulatoria ( Celsus) : Herpes ser- 
pigo (/Saw?;.) : Annulus repens (^Darwin)*. Dartre 
encrout^e {P.). 

This form of Herpes (Plate LI. fig. 1. of Bate- 

* De Meza relates an instance of a repelled Herpes being imme- 
diately followed by an intermittent. — Act. Soc. Med. Hafn. T. 1. 
N. 10. T. 



+ See Turner on Dis. of the Skin, chap._5. 



Ilia autem ut inspicio," says Dr. Russell, " vesiculis depressis, 
et minimi tumentibus, at livescentibus inducta esse, (the natural decline 
of the eruption) atque acrem quendam ichorem substare cerno, proinde 
secantur vesiculae, et praecipitato rubro, cum unguento aur. et cerate, 
ut medicamenta fixa atque immota emanerent, curantur.** De Tabe 
glandular! , hist. 55. 

§ Plenck says, " Pinguia et humida, ut vidi, admodum nocent ;" 1. c. 
p. 21. T. 



288 VESicuLiE: 

MAN ; PI. 20. of Thomson's Atlas,) is vulgarly 
termed a Ringworm^ and is, in this country, a very 
slight aflFection, being unaccompanied with any dis- 
order of the constitution. It appears in small circular 
patches, in which the vesicles arise only round the 
circumference : these are small, with moderately red 
bases, and contain a transparent fluid, which is dis- 
charged in three or four days, when little prominent 
dark scabs form over them. The central area, in 
each vesicular ring, is, at first, free from any eruption ; 
but the surface becomes somewhat rough, and of a 
dull red colour, and throws oflF an exfoliation, as the 
vesicular eruption declines, which terminates in about 
a week with the falling oflF of the scabs, leaving the 
cuticle red for a short time. 

The whole disease, however, does not conclude so 
soon: for there is commonly a succession of the 
vesicular circles, on the upper parts of the body, as 
the face and neck, and the arms and shoulders, which 
have occasionally extended to the lower extremities, 
protracting the duration of the whole to the end of 
the second or third week. No inconvenience, how- 
ever, attends the eruption, except a disagreeable itch- 
ing and tingling in the patches. 

The herpetic ringworm is most commonly seen in 
children, and has been deemed contagious. It has 
sometimes, indeed, been observed in several children, 
in one school or family, at the same time : but this 
was most probably to be attributed to the season, or 
some other common cause ; since none of the other 
species of Herpes are communicable by contact. It 
is scarcely necessary to point out here the diflPerence 
between this vesicular ringworm, and the contagious 
pustular eruption of the scalp and forehead, which 
bears a similar popular appellation, " and for which 
it may be mistaken. The vesicular character of the 
eruption, the regular course which it runs, the hair 

* See Porrigo *cw/tt/a^fl, above, p. 169. 



HERPES. 289 

not falling off, and its contagious nature, distinguish 
H. circinaius from Porrigo scutulata.^*,* 

The itching and tingling in this variety are con- 
siderably alleviated by the use of astringent and 
slightly-stimulant applications, and the vesicles are 
somewhat repressed by the same expedients. It is a 
popular practice to besmear them with ink : but solu- 
tions of the salts of iron, copper, or zinc, or of borax, 
alum, &c. in a less dirty form, answer the same end. 
Dr. Underwood remarks, " the use of a flesh-brush is 
a good prophylactic, in habits accustomed to the 
complaint.** * 

Another form of Herpes circinatus sometimes 
occurs, in which the whole area of the circles is 
covered with close-s0t vesicles, and the whole is sur- 
rounded by a circular inflamed border. The vesicles 
are of a considerable size, and filled with transparent 
lymph. The pain, hea^, and irritation in the part are 
very distressing, and there is often a considerable 
constitutional disturbance accompanying the eruption. 
One cluster forms after another in rapid succession on 
the face, arms, and neck, and sometimes on the day 
following on the trunk and lower limbs. The pain, 
feverishness, and inquietude do not abate till the 
sixth day of the eruption, when the vesicles flatten, 
and the inflammation subsides. On the ninth and 
tenth days a scabby crust begins to form on some, 
while others dry, and exfoliate ; the whole disease 
terminating about the fifteenth day. 

All the forms of Herpes appear to be more severe 
in warm climates than in our northern latitudes ; and 
the inhabitants of the former are liable to a variety of 
herpetic ringworm, which is almost unknown here. 
This variety differs materially from the preceding in 
its course, and is of much greater duration, for it 
does not heal with the disappearance of the first 
vesicles, but its area continually dilates by the exten- 
sion of the vesicular margin. The vesicles terminate 

* Treatise ont e Diseases of Children, 8th edit. p. 459. 

U 



290 VESICULiE : 

in ulcerations, which are often of a considerable 
depth ; and while these undergo the healing process, 
a new circle of vesicles rises beyond them, which 
passes through a similar course, and is succeeded by 
another circle exterior to itself : and thus the disease 
proceeds, often to a great extent, the internal parts 
of the ring healing, as the ulcerous and vesicular 
circumference expands.* 

Var. c. Herpes labioMs, Herpes of the Lips. 

A vesicular eruption upon the edge of the upper 
and under lip, and at the angle of the mouth, some- 
times forming a semicircle, or even completing a circle 
round the mouth, by the successive rising of the 
vesicles, is very common, and has been described by 
the oldest writers. At first the vesicles contain a 
transparent lymph, which in the course of twenty- 
four hours becomes turbid, and of a yellowish white 
colour, and ultimately assumes a puriform appearance* 
The lips become red, hard, and tumid, as well as sore, 
stiflF, and painful, with a sensation of great heat and 
smarting, which continues troublesome for three or 
four days, until the fluid is discharged, and thick, 
dark scabs are formed over the excoriated parts. The 
swelling then subsides, and in four or five days more, 
the crusts begin to fall off; the whole duration being, 
as in the other herpetic affections, about ten or twelve 
days. 

The labial Herpes occasionally appears as an idiopa- 
thic affection, originating from cold, fatigue, &c., and 
is then preceded for about three days by the usual 
febrile symptoms, shiverings, head-ach, pains in the 
limbs and the stomach, with nausea, lassitude, and 
languor. Under these circumstances, a sort of her- 
petic sore-throat is sometimes connected with it ; a 

* Celsus appears to have described this form of Herpes as his second 
species of I^nis sacer. ** Alterum autem est in summae cutis exulcer- 
atione, sed sine altitudine, latum, sublividum, inaequaliter tamen : niedi- 
unique sanescit, extremis procedentibus; ac saepe id, quod jam sanum 
videbatur, itenim exulceratur, &c. loc. cit. § 4. 



HERPES. 291 

similar eruption of inflamed vesicles taking place over 
the tonsils and uvula, and producing considerable 
pain and difficulty of deglutition. The internal vesicles, 
being kept in a state of moisture, form slight ulcer- 
ations when they break ; but these heal about the 
eighth and ninth days, while the scabs are drying upon 
the external eruption. 

The Herpes labialis, however, occurs most frequently 
in the course of diseases of the viscera, of which it is 
symptomatic, and often critical ; for these diseases are 
frequently alleviated as soon as it appears. Such an 
occurrence is most common in bilious Fevers, in 
Cholera, and Dysentery, in Peritonitis, Peripneu- 
mony, and severe Catarrhs ; but it is not unfre- 
quent in continued malignant Fevers, and even in 
Intermittents.* 

" This variety of the disease seldom requires any 
particular management ; it runs its course in a few 
days, and spontaneously disappears ; but, occasionally, 
it has proved obstinate, and resisted every form of 
management. I have, however, found that it yields 
rapidly to moderate doses of the Hydrargyrum cum 
Creta and James's Powder, in the proportion of six- 
teen grains of the former and three grains of the 
latter, taken every night at bed-time. During the 
day, it is necessary to give the Liquor Potassae in 
large doses, commencing with fifteen minims, and 
gradually ascending to one hundred, in a large cupful 
of Decoction of the Root of Rumex acutus^ or the 
obtusifolius. t This dose should be repeat^ed three 
times during the day : the food should be light and 
free from acidity. Milk and a light animal diet are 
to be preferred." The best topical application is the 
diluted ointment of the Nitrate of Mercury. When 
the disease is very obstinate, we must look for its 

* See Huxham, De Acre et Morb. Epid. vol. ii. p. 56, — Planck, Doct . 
de Morb. Cutan. p. 8.5. 

f The decoction is made by boiling one ounce of the root, tranS" 
versely sliced, in a quart of water, till it is reduced one third : then let 
it be strained. T. 

U 2 



292 vESicuL^ : 

causes in the visceral secretions ; and especially in the 
morbid condition of these, which follow grief and 
anxiety, and direct our remedies according to the 
nature of the general disease. 

J^ar. d. Herpes prceputialisj Herpes of the 
Prepuce. 

This local variety of Herpes (Plate LI. fig. 2. of 
Bateman, pi. 20. of Thomson's Atlas) was not 
noticed by Dr. Willan ; but it is particularly worthy 
of attention, because it occurs in a situation where it 
is liable to occasion a practical mistake of serious con- 
sequence to the patient. The progress of the herpetic 
clusters, when seated on the prepuce, so closely re- 
sembles that of chancre, as described by some authors, 
that it may be doubted whether it has not been 
frequently confounded with the latter.* 

The attention of the patient is attracted to the part 
by an extreme itching, with some sense of heat ; and, 
on examining the prepuce, he finds one, or sometimes 
two, red patches, about the size of a silver penny, upon 
which are clustered five or six minute transparent ve- 
sicles, which, from their extreme tenuity, appear of 
the same red hue as the base on which they stand. 
In the course of twenty-four or thirty hours, the ve- 
sicles enlarge, and become of a milky hue, having lost 
their transparency ; and on the third day, they are 
coherent, and assume an almost pustular appearance. 
If the eruption is seated within that part of the pre- 
puce which is in many individuals extended over the 
glans, so that the vesicles are kept constantly covered 
and moist (like those that occur in the throat), they 
commonly break about the fourth or fifth day, and 
form a small ulceration upon each patch. This dis- 
charges a little turbid serum, and has a white base, 

• As a similar description of this eruption will be found under the 
article Herpes, in Dr. Rees's New Cyclopaedia, I might perhaps, in this 
as in some other instances, incur the charge of plagiarism, if I did not 
slate that the articles ** in Medicine*' contained in that work, from letter 
C inclusive, were written by myself. 



HERPES. 29s 

with a slight elevation at the edges ; and by an inac- 
curate or inexperienced observer it may be readily 
mistaken for chancre ; more especially if any escha- 
rotic has been applied to it, which produces much 
irritation, as well as a deep-seated hardness beneath 
the sore, such as is felt in true chancre. If no irritant 
be applied, the slight ulceration continues till the 
ninth or tenth day nearly unchanged, and then begins 
to heal ; which process is completed by the twelfth, 
and the scabs fall oflP on the thirteenth or fourteenth 
day. " An affection very similar in every respect 
sometimes occurs on the labia pudendi." 

When the patches occur, however, on the exterior 
portion of the prepuce, or where that part does not 
cover the glans, the duration of the eruption is short- 
ened, and ulceration does not actually take place. 
The contents of * the vesicles begin to dry about the 
sixth day, and soon form a small, hard, acuminated 
scab, under which, if it be not rubbed off, the part is 
entirely healed by the ninth or tenth day, after which 
the little indented scab is loosened, and falls out. 

This circumstance suggests the propriety of avoiding 
not only irritative, but even unctuous or moist appli- 
cations, in the treatment of this variety of Herpes. 
And accordingly it will be found, that, where ulcer- 
ation occurs within the prepuce, it will proceed with 
less irritation, and its course will be brought within 
the period above mentioned, if a little clean, dry lint 
alone be interposed, twice a day, between the prepuce 
and the glans. 

I have not been able to ascertain the causes of this 
eruption on the prepuce. Mr. Pearson is inclined to 
ascribe it to the previous use of mercury.* " It sel- 
dom appears in young men ; the editor has traced it 

ft 

• Soon after the publication of the last edition, my friend, Mr, Cope- 
land, surgeon, of Golden Square, informed me that he had observed 
this affection of the prepuce to be connected with an irritable state, or 
with actual stricture of the urethra ; and that by the removal of this 
condition, by means of the bougie, the recurrence of the Herpes had 
been prevented. 

u 3 



294 VESICULJE : 

occasionally to an irritable state of the urethra accom- 
panying stricture : but he has seen it where no mer- 
cury had been taken, and no stricture of the urethra 
existed. Like the other species of Herpes, it evi- 
dently depends on some sympathy with the digestive 
organs, which are always in fault when this species of 
Herpes occurs. In some persons it occurs whenever 
the secretion at the root of the glans becomes acrid, 
and is immediately relieved by merely washing the 
parts with tepid mild soap and water.*' Whenceso- 
ever it may originate, it is liable to recur in the same 
individual, and often at intervals of six or eight 
weeks. 

Species 2. Herpes 7m, Rainbow Ringworm. 

This rare and singular morbid appearance (Plate 
LII. of Bateman, PL 20. of Thomson's Atlas), 
which has not been noticed by medical writers, occurs 
in small circular patches, each of which is composed 
of concentric rings, of diflFerent colours. Its usual 
seat is on the back of the hands, or the palms and 
fingers, sometimes on the instep. Its first appearance 
is like an efflorescence * ; but when it is fully formed, 
not only the central umbo, but the surrounding rings 
become distinctly vesicular. The patches are at first 
small, and gradually attain their full size, which is 
nearly that of a sixpence, in the course of a week, or 
nine days, at the end of which time the central part 
is prominent and distended, and the vesicular circles 
are also turgid with lymph ; and, after remaining 
nearly stationary a couple of days, they gradually de- 
cline, and entirely disappear in about a week more. 
The central vesicle is of a yellowish white colour : the 
first ring surrounding it is of a dark or brownish red ; 
the second is nearly of the same colour as the centre ; 
and the third, which is narrower than the rest, is of a 

* Having at first seen it only in its incipient stage, Dr. Willan 
announced the Iris, on the cover of his second part, as a genus of the 
exanthematic order. 



HERPES. 295 

dark red colour ; the fourth and outer ring, or areola, 
does not appear until the seventh, eighth, or ninth day, 
and is of a light red hue, which is gradually lost in 
the ordinary colour of the skin. 

The H. Iris has been observed only in young peo- 
ple, and unconnected with any constitutional disorder, 
nor could it be traced to any assignable cause. In 
one or two cases, it followed a severe catarrhal affec- 
tion, accompanied with hoarseness, and also with an 
eruption of Herpes labialis. In others, it had re- 
curred several times in the persons affected, occupying 
always the same parts, and going through its course 
in the same periods of time. 

No internal medicine is requisite in the treatment 

of the different species of Herpes, except when the 

constitution is disordered (and then moderate bleeding 

and the general antiphlogistic plan must be adopted); 1 

\ for, like the other eruptive diseases, which go through 

j a regular and limited course, the eruptions cannot be 

! interrupted, nor accelerated in their progress, by any 

; medicinal expedient ; but their termination may be 

i retarded by improper treatment. " In obstinate cases 

the arsenical solution in combination with Liquor 

Potassae, administered in the decoction of Rumex o5- 

tusifoliuSy has proved beneficial. 

Works which may he comulied on Herpes* 

Bashel. J. B., Essai sur le Virus Herpetique, 8vo. 1803. 
' Beddoes, Considerations on Factitious Airs, &c« 8vo. 
Campfen 's Dissertatio de Herpete, Duisbury, 1802. 
Cazenave and Schedel, Abreg^ Pratique des MaL de la Peau, 

8VO. 1828. 
Goldbeck . Dissertatio de Herpete, 1 797. 
Hensler, J. D., De Herpete, 8vo. 1802. 

irschkeh ^ De Zostere, 1816. 

LEiN, J. T., Tentamen Herpetologias, 4to. 1755. 
MoNTAGNAN A. M. A., De Herpete, 4to. 1589. 
NymmanN t Dissertatio de Herpete, 1594. 
Plumbe on Diseases of the Skin, 2d edit. 8vo. 1827. 
Rayer, Traits des Maladies de la Peau, 8vo. 1827. 
Russell, ** De Tectu Glandularum," 8vo. 
Wedel . Dissertatio de Herpete, 1705. 

U 4 






296 vEsicuL-ffi 



Genus IV. RUPIA. 

Syn. Caephylis Rhypia ( Good). 

Def. An eruption of flat, distinct vesicles, 

WITH the' base slightly INFLAMED ; CONTAINING 
A SANIOUS fluid; scabs ACCUMULATING, SOMETIMES 
IN A CONICAL FORM ; EASILY RUBBED OFF, AND SOON 
REPRODUCED. 

The eruptive disease, to which this appellation is 
appropriated*, was not noticed in the enumeration of 
the genera, formerly given by Dr. Willan. For prac- 
tical purposes, it might have been included with the 
Ecthymata, as it occurs under similar circumstances 
with the Ecthyma luridum and cachecticwm ; but the 
different form of the eruption, for the sake of con- 
sistency of language, rendered the separation necessary. 

The RupiA is characterised by an appearance of 
broad and flattish vesicles, in different parts of the 
body, which do not become confluent : they are 
slightly inflamed at the base, slow in their progress, 
and succeeded by an ill-conditioned discharge, which 
concretes into thin and superficial scabs, that are easily 
rubbed off, and presently regenerated.! It compre- 
hends the three following species : 

1. R. simples. 

2. R. prominens. 

3. R. eschurotica. 

Species 1. Rupia simplex^ Simple Rupia. 

This species, which shows itself on many parts of 
the body (Plate LIII. of Bateman, Plate 21. of 
Thomson's Atlas), consists of little vesications, con- 
taining, on their first appearance, a clear lymph. In 

* This term is arbitrarily formed from pvTrog, gordes, as indicative of 
the ill smell and sordid condition of the diseased parts. 

f This circumstance serves to mark the distinction between Rupia 
and Ecthyma, independently of the pustular form, and highly-inflamed 
hard base of the latter : for the scab of Ecthyma is hard, deeply in- 
dented, and surrounded by a deep-seated hardness in the muscular flesh, 
especially in the larger forms of it. 



RUPIA. 297 

a short time, the fluid included in them begins to 
thicken, and becomes at length opaque and somewhat 
puriform : a slight ulceration of the skin takes place, 
with a sanious discharge, followed by scabbing ; and 
when this heals, it leaves the surface of a livid or 
blackish colour, as if from a thickening of the rete 
mucosum. 

Species 2. Rupia prominens, Conical Rupia. 

This curious form of the disease (Plate LIV. of 
Bateman, pi. 21. of Thomson's Atlas^ is dis- 
tinguished by elevated, conical scabs, wnich are 
gradually formed upon the vesicated bases. A fluted 
scab is first generated, and with some rapidity (e. g. 
in the course of the night), as the fluid of the vesica- 
tion concretes. This extends itself by the successive 
small advancement of the red border, upon which a 
new scab arises, raising the concretion above it, so as 
ultimately to form a conical crust, not unlike the 
the shell of a small limpet. This scab is quite su- 
perficial, and if it be rubbed off, a new incrustation 
covers the excoriated spot in the space of six hours. 
The ulceration, however, is not phagedenic, but at 
length heals ; although it often proves very tedious, 
especially in old and intemperate persons, in whom, 
and in young persons of delicate constitution, it most 
commonly occurs. ** The persons most liable to 
this species of Rupia generally belong to the lower 
classes of society ; and, if they be not intemperate in 
their habits, have, almost always, been in a half- 
starved state from extreme indigence ; or have long 
laboured under some chronic disease, which has 
wasted down the body." * 

These varieties of Rupia are to be combated by 
the means recommended for the cure of Ecthyma ; 
L e. by supporting the system, by means of good, 

* Mr. Plumbe says, '* In the cases of this kind answering to the 
Rupia prominens, wnich have come under my notice in the St. Giles's 
Infirmary, the patients have been not unfrequently the subjects of 
syphilis." Practical Treatise, 2d edit. p. 445. T. 



298 vESicuLJE : 

light, nutritious diet, " regulating the bowels/* and 
by the use of alterative and tonic medicines ; such 
as Plummer*s pill, Cinchona, or rather Sulphate of 
Quinia, and Sarsaparilla. " Sometimes, however, 
they will not yield except to a mercurial course, 
continued until the mouth is slightly affected ; after 
which the constitution should be supported, and the 
tone of the habit restored, by Sulphate of Quinia, or 
Decoction of Bark with diluted Sulphuric Acid. As 
the constitution improves, the local affection is ad- 
vantageously treated by the application of the Nitrate 
of Silver to the ulcerated surface, from which the 
crust has been removed. It stimulates the relaxed 
surface, and disposes to cicatrization." 

Species 3. Rupia escharotica, Cachectic Rupia. 

This species affects only infants and young chil- 
dren, when in a cachectic state, whether induced 
by previous diseases, especially the Smallpox, or by 
imperfect feeding and clothing, &c. ; whence, among 
the poor, where it is commonly seen, it often termi- 
nates fatally. « — The vesicles generally occur on the 
loins, thighs, and lower extremities, and appear to 
contain a corrosive sanies : many of them terminate 
with gangrenous eschars, which leave deep pits. 
Nothing can ward off the fatal termination of this 
species of Rupia, except change of air ; a good nutri- 
tious diet ; sea-bathing ; and the Cinchona Bark, or 
the Sulphate of Quinia, with the mineral acids. 

Works which may be comulted on Rupia, 

Cazenave and Schedel, Abr^g^ Pratique des Mai. de la Peau, 
8vo. 1828. 
Plumbb on Diseases of the Skin, Svo. 2d edit. 1827. 
Rayee des Maladies de la Peau, 8vo. 1837. 



Genus V. MILIARIA. 



Si/n. Miliaris (Sag. SauvJ\i Exanthema Miliare 
(Burser) : Miliaris, nova febris ( St/den.y PP^ebster) : 



MILIARIA. 299 

Purpura {Hoff.) : Febris Miliaris (Fogel^ IVebster) : 
Febris Purpurea (Trenck) : Febris Asserosa (Zctc. 
iMsit): Febris Punctularis (i2. a- Cast) i Morbus 
Miliarium {Allim.) : Exanthema Miliara {Parr) : 
Synochus Miliaria ( Young) : Emphlysisi Miliaria 
(Oood) : die Friselbattem der Friesel ( Oerman) : 
Frieselbattem, Frieselfieber, Gierskoorts (Dutch): 
Friesler (Dan.): Friesel, hirta Friseln (Swed.): 
Febre migliare (ItaL) : Milios, calentura miliar, tabar- 
dillo pintado (Span.): Millet, fifevre miliare (-P.) : 
Miliary Eruption. 

Def. An eruption op minute vesicular pim- 

PLES, FILLED WITH A COLOURLESS, ACRID FLUID J 
terminating in SCURF. 

An eruption of miliary vesicles (PI. LV. fig. 1. of 
Bateman, pi. 22. of Thomson's Atlas) is per- 
haps invariably symptomatic^ being connected with 
some feverish state of the body, previously induced ; 
and it has occurred in every species of fever, con- 
tinued, remittent, inflammatory, and contagious, as 
well as in other cases of disease, in which consider- 
able heat of the skin and much sweating had been 
accidentally excited. The physicians and nosologists, 
who have described a miliary fever, as an idiopathic 
eruptive fever like the Measles, Smallpox, and Scar- 
latina, have erred in different ways ; some of them, 
in supposing it to originate from a specific virus, 
or acrimony, like the contagion of the diseases just 
mentioned * ; and some by actually confounding the 
miliary euption with the efflorescence of Scarlatina, t 

• Of the writers who have committed this error, a numerous host may 
be referred to. See Sir David Hamilton, De Febre Miliari, 1710; — 
Allionius, De Miliarium Grig. Progressu, Nat. et Cur. 1758 ; — Fordyce 
(Joan.) Hist. Febris Miliaris, 1 758 ; — Collin, Epistle de Pust. Miliar. 
1 764 ; — Blackmore, on the Plague ; — Macbride, Introduct. to Theor. 
and Pract. of Med. part ii. chap. 17 ; — Baraillon, in M^m. de la Soc. 
Roy. de M^d. de Paris, tom. i. p. 195 ; — An Essay on the Cure of the 
Miliary Fever, by a Subject of Mithridates, 1751 ; — Sauvages, Nosol. 
Meth. class, iii. gen. 5.; — Burserius, Inst. Med. vol. ii. p. 2. cap. H. 
&c. &c. 

f In the history of the epidemic miliary fever, which occurred at 
Leipsic, about the year 1650, and which has been considered as the pro- 



SOO VESICULiE : 

The Miliaria, of which we here speak, is cha- 
racterised by a scattered eruption of minute round 
vesicles about the size of millet seeds*, surrounded 
by a slight inflammation, or rash, and appearing at 
an uncertain period of febrile disorders. The erup- 
tion is immediately preceded by unusual languor 
and faintness ; by profuse perspiration, which often 
emits a sourish odour ; and by a sense of great heat, 
with a prickling and tingling in the skin. It ap- 
pears most abundantly upon the neck, breast, and 
back, sometimes in irregular patches, and sometimes 
more generally diffused, and remains on those parts 
during several days: on the face and extremities, it 
is less copious, and appears and disappears several 
times without any certain order. The vesicles, on 
their first rising, being extremely small and filled 
with a perfectly transparent lymph, exhibit the red 
colour of the inflamed surface beneath them ; but, 
in the course of thirty hours, the lymph often ac- 
quires a milky opacity, and the vesicles assume 
necessarily a white or pearly appearance. This 
seems to have been partly the foundation of the 
epithets rubra and alba^ which have been applied as 
specific appellations to miliary fevers.t The tongue 
is furred, and of a dark red colour at the edges, and 
its papillae are considerably elongated ; and not un- 



totype of all miliary fevers, this mistake was obviously committed. See 
Godofr. Welsch, Hist. Med. novum istum puerperar. morbum continens, 
qui ipsis der Friesei dicitur; in Haller's Disput. Med. tom. v. } 174; — 
also Christ. Joan. Langius, Prax. Med. part. ii. cap. 14. § 9. De Pur- 

Eura; — Etmuller de Febribus ; — Schacher, de Febre acut. Exanthem. 
rips. 1723, in Haller*s Disp* v. } 175 ; — and Saltzmann, Hist. Purpuras 
Miliaris albse, ibid, § 176. 

• Whence the denomination of the disease, from rmlium^ the millet. 
t I say partly, because it appears that, among those physicians, who 
confounded the efflorescence ot Scarlatina with the miliary eruption, the 
terms of red and white Miliary Fever, or red and white Purpura, were 
used to denote the two eruptions repectively. And again, the miliary 
vesicles, like those of Varicella, were occasionally preceded by a diffuse 
efflorescence, which disappeared a few days after the rising of the ve- 
sicles ; whence the red Miliaria has been said to be occasionally clianged 
into the white* 



MILIARIA. 301 

usually apthous vesicles and sloughs appear at the 
same time in the mouth and fauces. 

The miliary eruption'aflFords no crisis to the fever in 
which it supervenes, nor any relief to the symptoms ; 
and its total duration, in consequence of a daily 
rising of fresh vesicles, is altogether uncertain ; but 
frequently from seven to ten days, and sometimes 
much longer. Indeed, under the former treatment, 
when the sick lay ** drowning in sweats" (as Sir 
Richard Blackmore says of one of his patients), it 
was not uncommon for these " crops'* of vesicles to 
be repeated a second, third, or even fourth time, 
and the whole disease to be protracted to nearly fifty 
days.* 

It is scarcely necessaiy now to enter into any de- 
tail of proofs, that the miliary eruption is the result 
of a highly heated and perspiring state of the skin ; 
and that in its severe and fatal degree, it is solely 
the eflFect of a stimulating regimen, in a confined 
atmosphere. The almost total annihilation of the 
disease, of late years, since the general adoption of a 
better practice, is of itself unequivocal evidence of its 
origin : while, on the other hand, the rarity of its 
occurrence, both before the abuse of hypothetical 
speculation had misled physicians from the path of 
observation, and in the practice of those who sub- 
sequently returned to that path, is an additional cor- 
roboration of the same truth. Hippocrates, whose 
mode of treatment in febrile diseases was not calcu- 
lated to produce excitement, has once or twice but 
casually mentioned the miliary eruption, t And 

again, at the latter part of the seventeenth century, 

* 

* Blackmore, loc. cit. — Brocklesby, in the Med. Obs. and Inquir. 
vol. iv. p. 30. 

f See especially the second book of Epidemics, sect, iii.; where he 
states that, in a hot and dry summer, fevers were in some instances ter- 
minated by a critical sweat, and about the seventh, eighth, and ninth 
day, miliary elevations (rpijx«<yft«^« ic«yxP^^*") appeared on the skin, 
and continued till the crisis. See also the book ot Prognostics, where 
be speaks of miliary sweats (c^p(i>rfc Ktyxpoti^uQ), 



302 vESicuLiE : 

when in the practice of the majority of physicians 
the miliary fever was a frequent and fatal occurrence, 
Sydenham witnessed no such fever; but mentions 
the occasional appearance only of miliary vesicles, 
which he ascribes to their proper cause,* More 
than half a century elapsed, however, before the doc- 
trine of Sydenham was established by De Haen, in 
Germany, and by Mr. White, of Manchester, Dr. 
CuUen, and others, in this country, t 

As a symptomatic eruption, the Miliaria frequently 
appears during dentition, in blotches about the face 
and neck. 

Among the various circumstances under which the 
Miliaria was formerly excited, the puerperal state 
appears to have been most frequently the source of it ; 
insomuch that it was first described as an epidemic 
among puerperal women. This is sufficiently ac- 
counted for by the treatment, which was unhappily 
pursued during the confinement after child-birth, 
and of which an impressive description is given by 
Mr. White. For not only was the mother immedi- 
ately loaded with bed-clothes, from which she was not 
allowed to put out " even her nose," and supplied 
with heating liquors from the spout of a teapot ; but 
to her room, heated by a crowd of visitors and a fire, 

* Sir Richard Blackmore states, that miliary fever was *' the most 
frequent in this country, of all the malignant kind ;" and that, when the 
eruption was copious, it was ** often fatal and always dangerous." (Loc. 
cit.) His contemporary, Sydenham, said of the miliary eruptions, " Licet 
sud sponte nonnunquam ingruant, saepius tamen lecti colore et cardiacis 
extorquentur." See his Sched. de Nov. Febris Ingressu. 

f See De Haen, Theses sistent. Febrium Divis. § 4. ; and again in his 
Rat. Medend. vol. ii. p. 8.; — White, on the Management of Pregnant 
and Lying-in Women, chap, ii,; — Cullen, First Lines, par. 725., and No- 
sol. Method. It appears, however, that, in the middle of the last cen- 
tury, the better educated members of the profession had already adopted 
the right opinions upon the subject. For a weak anonymous writer, 
of the Blackmore School, in 1751, in reprehending what he calls the 
" stupidity " and " unpardonable ignorance " of his brethren respecting 
the (fisease, ascribes it to " the prevailing opinion of some physicians 
that this fever is a creature of our own makings* which, he believes, had 
" run through the whole College, and from thence the dangerous in- 
fection been conveyed to the apothecaries," &c. See the Essay by a 
Subject of Mithridates, Pref, p. iv. 



MILIARIA. 303 

all access of air was denied, even through a key-hole. 
From these causes fever was almost necessarily in- 
duced, with the most profuse sweats, oppression, 
anxiety, and fainting ; and these again were aggra- 
vated by spicy caudles, spirits, opiates, and ammo- 
niacal medicines. That numbers should perish, under 
such management, with every symptom of malignity, 
and that many who survived it should escape with 
broken constitutions, will surprise no person who is 
acquainted with the baneful influence of over excite- 
ment in febrile complaints.* 

With other fevers, in which a similar method of 
treatment was pursued, though in a less degree, and 
which confined the patient to bed, the miliary erup- 
tioUj with its attendant languor and exhaustion, was 
frequently conjoined, especially with catarrhal and 
rheumatic fevers, and also with typhoid, remittent, and 
intermittent fevers. Whence the writers, who have 
described the miliary fever, speak of it as being dis- 
guised under or counterfeiting the character of these 
fevers respectively. In the summer, indeed, where 
ventilation and coolness are not sufficiently attained 
or attended to, a slight miliary eruption is even now 
occasionally seen: and a Miliaria clinicaj in fact, 
may be thus induced by any circumstance that con- 
fines a person to bed ; as an accident, or a surgical 
operation t, an attack of hysteria, a state of asthenia, 
&c. From the increase of cutaneous heat, connected 



* The occurrence of this fatal Miliaria roust be deemed one o^ the 
greatest opprohria medicorum ; for it was the direct result of a mischiev- 
ous practice, originating in a false hypothesis respecting the concoc- 
tion and expulsion of morbid matter : and when we recollect that there 
was not a febrile disease in which this mischief was not more or less 
inflicted on the sick, we must blush for the character of our art. ** Quid 
vero demum generi humano calamitosius/' exclaims De Haen, ^ quam 
quod, et plebe et medicis conspirantibus, tot melleni quotannis segri, 
ab ipso principio acutorum, in sudores symptomaticos agitentur, ac 
veluti fundantur, ut coacta omnino crisis, in plerisque aut lethalis aut 
periculosa saltem, producatur; interea dum salutaria Naturae molimina 
turbantur, confunduntur, ac penitus sufflaminantur. Faxit Deus, ut 
demum sapiant Phryges ! " — De Febrium Divis. 

f Mr. White, loc. cit. 



304 VESicuL^ : 

with the exanthematous fevers of the nosologists, 
some degree of Miliaria is liable to occur in them all, 
but more especially in Scarlatina ; and a few larger 
pearl-coloured vesicles also occasionally appear.* 

It is unnecessary to dwell upon the method of 
treatment applicable to Miliaria; since, under the 
full employment of ventilation, and a cool regimen, 
the symptom will very rarely be produced. The 
room, in which a puerperal woman, or a patient under 
any febrile disease, is confined, ought to be as free 
from all unpleasant odour as any other apartment ; 
and under the cordial influence of pure air, the sup- 
port of spirituous and vinous liquors is so far from 
being requisite, that a small proportion of these 
stimulants will produce even a deleterious excitement.t 
Extreme cleanliness, a frequent change of linen, cool 
diluent drinks, light diet, and the other circumstances 
of what has been called the antiphlogistic regimen, 
will always be attended to with advantage, where the 
miliary eruption shows itself. The mineral acids, if 
no other sympton contraindicate the use of them, are 
advantageous. 

Books which may be consulted on Miliaria , 

Allienht8 . C, Tract, de Miliarium Origine, &c., 8vo. 1758. 

Balguy , de Febre Miliari. 

Chanel, Diet, de Med. (art. MUiare), 1826. 

* See Fordyce (loc. cit), *' Nonnunquam bullae insignes, apice digit: 
non minores, hie elevantur.'* — Also the Anon. Essay on the Cure of 
Mil. Fever ; — and Brocklesby, he, cit. 

f Mr. White observes, that a woman in child-bed is so much exhausted 
by the mode of treatment before described, " that the highest cordials 
have been necessary to support her; nay, I have been credibly in- 
formed," he adds, " that under these circumstances a patient has 
sometimes drunk a gallon of wine in a single day, exclusive of brandy, 
and of the cordials from the apothecary* s shop^ and all this too without 
intoxication.'* loc, cit. chap. viii. — Similar enormous potations of wine 
have been recommended by later practitioners in typhoid fevers, who 
have not been aware that the very impunity with which these doses 
have been administered, has arisen from the artificial exhaustion of the 
patient by external circumstances, and not from the necessary tendency of 
the disease. Many facts have occurred to my notice, in the course of 
my attendance at the Fever Institution, v/hich have satisfied me of the 
correctness of this opinion, which I may probably illustrate at a future 
opportunity. 



£CZ£MA« d05 

Fischer , J. B. de, De Febre Miliaria 8vo. 1827. 
Fordyce, J., M. D. Historia Febris Miliaris, &c. 8vo. 1750. 
Hamilton , Sir David, A Treatise on Miliary Fever, 8vo. 1737. 
Hoffman, Fr. de Purpura Genuina Origine, 4 to. 1725. 
'^Menfalcon, Diet, des Sciences Med. (art. MiUare\ 1819. 
Rayer, Trait^ des Maladies de la Peau, 8vo. 1827. 
TwEEDiE, Cyclop, of Pract. Med., vol. iii. 1 834. 
Vasani^F., Storia Singulare d'una Febbre Miliare, 8vo. 1815. 
Welsch, G., Historia Morbi qui der Friesel Dicitur, 4to. 1655. 



Genus VI. ECZEMA.* 

Syn. Hidroa (Sauv. Vog.)'. Eczesis, Eczesma,, 
Eczesmus {AucL): Cystisma Eczema (Young's : 
Ecphlysis Eczema r G^oorf) : Aset (Arab.): Schweis- 
blattern ( Oerman) : Vrucrige piiisten (Dutch) : 
Echauboulure, Dartre vive (jF.) : Heat eruption. 

Def. An eruption of minute vesicles, not 

CONTAGIOUS,, CROWDED TOGETHER } AND WHICH, 
FROM THE ABSORPTION OF THE FLUID THEY CON- 
TAIN, FORM INTO THIN FLAKES OR CRUSTS. 

. This eruption is generally the eflFect of irritation, 
whether internally or externally applied, and is occa- 
sionally produced by a great variety of imtants, in 
persons whose skin is constitutionally very irritable. 
It diflPers from Miliaria, inasmuch as it is not the 
result of fever, and, unless it be very extensively 
diffused, is not accompanied with any derangement of 
the constitution : except in the most violent cases, 
the functions of the sensorium and of the stomach 
are seldom disturbed. " It may be confined to a 
small part of the surface of the body, or extended 
over the whole skin : it chiefly, however, affects the 

* Aetius observes, that an eruption of hot and smarting phlyctasnae 
arises in all parts of the body, without proceeding to ulceration. " Ea« 
£ic^€/iara ab ebulliente fervore, Graeci yulgo appellant" Tetrab iv. 
serm. i. cap. 128. According to Paulus (lib. iv. cap. 10.), and Actuarius, 
(lib. vi. cap. 8.), they were also called Trcpi^f/iara, and TripiZarfiaTa 
" quasi vehementer ferventiaP See Gorraeus, Defin. Med. ; and Sennert. 
Pract. Med., lib. v. part i. cap. 2. 

X 



906. VESicuL^ : 

inside of the thighs, the axilla, and those places in 
which the mucous follicles are most abundant in men ; 
the under parts of the mammas, the vulva, and the 
anus in women/^ When limited to the fingers, hand, 
and part of the fore-arm, it is not unfrequently mis- 
taken for Scabies : but it may be distinguished by the 
appearance of its acuminated and pellucid vesicles ; 
by the closeness and uniformity of their distribution ; 
by the absence of surrounding inflammation, and of 
subsequent ulceration; and, in many cases, by the 
sensations of smarting and tingling, rather than of 
itching, which accompany them. According to the 
nature of the irritating cause, the extent and form of 
the disease are somewhat various ; and constitute 
three species of the genus : — 

1. E. solars. 

2. E. impetiginodes. 
4. E. rubrum. 

Var. a. E. mercuriale. 

Species 1. Eczema solar e; Sun-heat. 

This form of Eczema (Plate LVI. of Bateman ; 
PL 22. of Thomson's Atlas, ^ occurs in the summer 
season, and is the eflFect of irritation from the direct 
rays of the sun, or from the heated air. Hence it 
anects almost exclusively those parts of the surface 
which are exposed to their influence ; as the face, the 
neck, and fore-arms, in women, but more particularly 
the back of the hands and fingers. The eruption is 
preceded and accompanied by a sense of heat and 
tingling, and these sensations are aggravated even to 
smarting, when the parts affected are exposed to 
the sunshine, or to tne heat of a fire. The whole 
fingers are sometimes swelled*, and so thickly beset 

* As this eruption about the fingers, the ball of the thumbs, and the 
nvristSy is often continued for several weeks, it is in this situation more 
particularly liable to be mistaken for the itch : but the circumstances 
just noticed, as well as those mentioned under the head of Scabies, will 
contribute to aid the diagnosis. 



ECZEMA. ; 307 

with the vesicles, as to leave no interstice of the 
natural appearance of the skin, nor any intervening 
redness. The vesicles themselves are small, and 
slightly elevated ; they are filled with a thin, milky 
serum, which gives them a whitish colour, or some- 
times with a brownish lymph ; and they are without 
any surrounding inflammation. On the upper part 
of the arm, however, and, in women, on the breast, 
neck, and shoulders, the eczematous vesicles are some- 
times surrounded by an inflammatory circle ; when 
they are popularly termed heat-spots. It sometimes 
happens, indeed, in men of sanguine temperament, 
who use violent exercise in hot weather, that these 
vesicles are intermixed, in various places, with actual 
phlyzacious pustules, or with hard and painful tu- 
bercles, which appear in succession, and rise to the 
size of small boils, and suppurate very slowly. This, 
however, is a more frequent occurrence in the more 
local forms of the disease, included under the second 
head. 

The eruption is successive, and has no regular 
period of duration or decline : it commonly continues 
for two or three weeks, without any particular intern^ 
disorder. The included lymph becomes more milky, 
and is gradually absorbed, or dried into thin brownish 
scales, which exfoliate, or into brownish yellow scabs, 
of the size of a small pin's head, especially when the 
vesicles are broken. But successive eruptions of the 
vesicles are apt to appear, which terminate in a similar 
manner by exfoliation or scabbing ; and in those per* 
sons who, by the peculiar irritability of their skin, 
are much predisposed to the disorder, it is thus con- 
tinued many weeks, to the end of autumn, or even 
prolonged to the winter. When this happens, the 
vesicles generally pour out an acrid serum, by which 
the surface is inflamed, rendered tender, and even 
slightly ulcerated, and the disease assumes the form 
of Impetigo. 

The course of this disorder does not appear to be 

X 2 



308 VESicuLJE ; 

materially shortened by the operation of medicine. 
The mineral acids, with a decoction of Cinchona, or 
other vegetable tonic, and a light but nutritious diet, 
seem to be most eflPectual in diminishing the eruption. 
When it has occurred after long-continued travelling, 
or any other severe fatigue, and appears to be accom- 
panied with some degree of exhaustion of the powers 
of the constitution, a course of Serpentaria, or Sars- 
aparilla, is exceedingly beneficial. Active and re- 
peated purgation is adverse to the complaint. Simple 
ablution with tepid water contributes to relieve the 
smarting and tingling of the parts aflPected, which do 
not bear unguents, or any stimulant application. 

Species 2. Eczema impetiginodes^ Impetiginous 
Eczema. 

A local Eczema (Plate LV. fig. 2. of B axeman; 
PI. 22. of Thomson's Atlas,) is produced by the 
irritation of various substances, and, when these are 
habitually applied, it is constantly kept up in a chronic 
form, diflFering from the JLmpetigo only in the ab- 
sence of pustules. Small separate vesicles, containing 
a transparent fluid, and, like the psydracious pustules, 
imbedded in the skin, or but slightly elevated, arise, 
and slowly increase : they are attended with pain, 
heat, smarting, often with intense itching, " and with 
swelling of the aflFected part." When>they break, 
the acrid lymph, that is discharged, irritates and in- 
inflames the surrounding cuticle, which becomes 
thickened, rough, reddish, and cracked, as in the 
impetiginous state. The alliance, indeed, of this 
aflFection with Impetigo is further proved by the 
circumstance, that, in some cases, vesicles, and psy- 
dracious pustules are intermixed with each other ; 
and, in diflFerent individuals, the same irritant will 
excite a pustular or a vesicular eruption respectively ; 
the vesicular disease being always the most painful 
and obstinate. Of this we have an example in the 
affection of the hands and fingers, produced by the 



ECZEMA* 309 

irritation of sugar, which is commonly called the 
grocer* s itch; and which is in some persons vesicu- 
lar, in others pustular. The acrid stimulus of lime 
occasions similar eruptions on the hands of brick- 
layers : and one of the most severe cases that I ever 
witnessed, occun'ed on the hands of a file-maker j 
being occasioned perhaps by the united irritation of 
the heat of the forge and the impalpable powder of 
steel, with which they were constantly covered during 
his work. In like manner, both vesicular and pus- 
tular affections are excited by the local irritation of 
blisters, stimulating plasters, and cataplasms of Mer- 
cury, the Ointment of Tartarized Antimony, the 
Oil of the Cashew nut, the Indian Varnish, Arsenic, 
Valerian root, &c.* These often extend to a con- 
siderable distance beyond the part to which the 
irritants were immediately applied, and continue for 
some time, in a successive series, after the stimulus 
has been withdrawn, especially in irritable and cha- 
chectic habits. Thus, when a blister is applied to 
the pit of the stomach, an eruption of vesicles, inter- 
mixed often with ecthymatous pustules, and inflamed 
tubercles and boils, extends in some cases over nearly 
the whole abdomen, or to the top of the sternum ; 
or, if the blister be applied between the shoulders, 
the whole of the back and loins becomes covered with 
a similar eruption. These tubercles and boils sup- 
purate very slowly and deeply in some habits, and are 
ultimately filled with dry, dark scabs, which do not 
soon fall off; and when the sores are numerous, they 
produce some degree of feverishness, and much pain 
on motion. In other respects, the constitution suffers 
no injury from this tedious eruption ; although from 
its duration, which is sometimes extended to two or 
three weeks, it occasions more inconvenience than the 
original applications. 

" When this species of Eczema appears on the 

* See Impetigo. 

X 3 



SlO VESICULiE : 

Ivrists, the back of the hand, and between the Angers, 
it is often mistaken for itch* The stinging sensation 
of Eczema, however, is sufficient to distinguish it 
from itch, were it not otherwise distinguishable : in 
itch the itching returns in paroxysms j in Eczema 
the stinging sensation is continued. It is, also, dis- 
tinguished by its non-contagious character/' 

The first step towards the cure of these varieties of 
Eczema is to remove the irritating cause, where that 
is obvious. The eruption, however, is not easily re- 
moved : but the painful sensations connected with it 
are greatly alleviated by simple poultices, and by 
frequently washing the parts with warm gruel, and 
milk or bran and water, " or with the Emulsion of 
Bitter Almonds, containing, besides the quantity 
natural to it, some Hydrocyanic acid, to the extent 
of at least fjj to f^viij of the Emulsion. Cloths, 
also, moistened with a dilute solution of acetate of 
Lead, should be applied over the parts, when the 
vesicles break, and ooze out their serum. A French 
author, M. Guillemineau, recommends strongly a 
solution of Nitrate of Silver.* The sulphur baths 
have been employed ; but are too irritating. Simple 
warm baths are more beneficial." 

Where there is any other evidence of a cachectic 
condition of the patient, a tonic treatment must be 
prescribed for the improvement of the general health, 
as recommended in Ecthyma.! ** Diluting, acidu- 
lated drinks must be prescribed* Nothing is more 
useful than diluted Sulphuric Acid, given in Infusion 
of Roses. — Calomel should be at first given, and 
afterwards a gentle purgative, every morning/' 

* De PEmploi du Nitrate d^ Argent fonder dans le Traiteinent de 
qUelques Maledies. 4to. Paris, 1826. T. 

•f- The irritation produced by the attrition of the tight parts of our 
dress, as about the knees, neck, &c., which commonly produces a mere 
Intertr^Oi occasions, in some persons,. an eczematous eruption. Sau- 
vages has hence made two species of Herpes, excited by the garter and 
the bandages of the neck, which he calls Herpes perisceUs and H. 
coUarit, 



ECZEMA. 311 

Species 3. Eczema Tijihrvm.* Inflamed Eczema. 
Syn. Djtt'tf e squameuse humide {Aliberi) : Hy- 
drargyria {Alley) X Erythema Mercuriale {AwA. 
f^arJ) : Lepra Mercuriale {Moriarty.) 

The most remarkable variety of the Eczema rubrum 
is that which arises from the irritation of mercury.t 
(Plate LVIII. of Bateman ; PI. 22. of Thomson's 
Atlas,) But tBie disease is not exclusively occa- 
sioned by this minerd, either in its general or more 
partial attacks : it *^ is oflen associated with gastro- 

! intestinal inflammation^ without any mercurial pre- 
paration having been taken t;'^ and it has been 
observed to follow exposure to cold, and to recur in 
the same individual, at irregular intervals, sometimes 
without any obvious or adequate cause.$ 

i The Eczema rubrum is preceded by a sense of 
stiffiiess, burning heat, and itching, in the part where 

i it commences, which is most frequently the upper and 
inner surface of the thighs, and about the scrotum in 
men ; but sometimes it appears first in the groins, 
axilla, or in the bend of the arms, or about the wrists 
^nd bands, or in the neck. These sensations are 
4soofi followed by an appearance of redness, and the 
sur&ce is somewhat rough to the touch. This, how- 

* There is, perhape, a little incongruity in this species of Eczemt 
V when the generic character is considered ; but in every resjject, except 
: the surrounding redness, it accords with the genus, differing equally 
/ from the mere rash of the Erytfaemata, and from the tymptomatic and 
^ febrile Miliaria. 

f Whence the disease has been called Eceema mereuriale (see Mr. 
ePearson^s ^ Ofos. on the Effects of var« Articles of the Mat. Med. in 
Lues Ven." chap. xiii. 2d edit.) ; — Erythema mercuriale (see Dr. SpeDs 
and Dr. M'Mullins in the Edin. Med. and Surg. Joum. vol. i. and ii.) ; — 
Hydrargyria (see Dr. Alley's *^Obs.on the Hydrargyria, or that vesicular 
Disease ari^g from the Exhibition of Mercury,'' Load. 1810.)j-^and 
mercurial Lepra (see a Tract of Dr. Moriarty of Dublin). 

± Sec Medico-(3iirui«. Trans, vol. ii. p. 73. T. 

§ See a description of two cas» by Dr. Rutter (Edin, Med. and Sur|« 
Journal, vol. v. p. 143.), and Dr. Marcet (Medico-Chirurg. Trans, vol. ii. 
art. ix.), under the appellation of Erythema, which recurred several 
times in both the patients to a severe degree. It is worthy of remark, 
however, that, in both these instances, the jfirst attack of the disease 
occurred after a gonorrhoea; for which, in the one, some mercury had 
certainly, and in the other had, probably, been administered. 

X 4 



312 VESICULJE r 

^ver, is not a simple Erythema ; for on examining it 
minutely between the light and the eye, or with a 
convex glass, the roughness is found to be occasioned 
by innumerable, minute, and pellucid vesicles, which 
, have been mistaken for papulae. In two or three 
days, these vesicles, if they are not raptured, attain 
the size of a pin's head ; and the included serum 
^hen becoming somewhat opaque and milky, the cha- 
xacter of the eruption is obvious. It soon extends 
itself over the body and limbs in successive large 
patches, and is accompanied by a considerable swelling 
of the integuments, such as is seen in smallpox and 
other eruptive fevers, and by great tenderness of the 
skin, and much itching. When the vesicles begin to 
lose their transparency, they generally burst, and 
discharge, from numerous points, a thin acrid fluid, 
which seems to irritate the surface over which it 
, passes, and leaves it in a painful, inflamed, and exco- 
riated condition. The quantity of this ichorous dis- 
charge is very considerable ; and it gradually becomes 
thicker and more adhesive, stifiening the linen which 
absorbs it, and which thus becomes a new source of irrit- 
ation : it emits, also, a very foetid odour. This process 
tskes place in the successive patches of the eruption, 
until the whole surface of the body, from head to foot, 
is sometimes in a state of painful excoriation, with deep 
fissures in the bends of the joints, and in the folds of 
the skin of the trunk ; and with partial scaly incrust- 
ations, of a yellowish hue, produced by the drying of 
the humour, by which, also, the irritation is augmented. 
The extreme pain arising from the pressure of the 
weight of the body upon an extensive portion of such 
a raw surface is sufficient to give rise to an acceler- 
ation of the pulse, and white tongue ; but the func- 
tions of the stomach and of the sensorium commune 
are not evidently disturbed by this disease.* 

♦The experience of the Editor obliges him to differ from this 
opinion of Dr. Bateman. In almost every case, which has come under 
his notice^ there has been evident constitutional derangement^ quick 



ECZEMA* S13 

' The duration of this excoriation and discharge is 
uncertain and irregular : when only a small part of 



pulse, furred tongue, and impaired appetite, with considerable nervous 
irritability. Indeed, the latter state has been so frequently present, as 
to induce the Editor to regard an irritable state of the nervous system, 
such as produces hysteria in females, to be the predisposing cause of thb 
disease when it occurs during a mercurial course. The following case 
will illustrate this opinion : — 

A young woman was seduced from her parents and brought to London 
by one of those unprincipled men who sacrifice every moral and social 
feeling on the altar of self-gratification. Desire and the pleasure of 
possession having subsided, the wretched victim of unbridled passion 
was soon deserted, and fell into & course of life, which any deviation from 
the paths of virtue usually produces in the female sex thus situated. 
She went upon the town, as the term is, and in that wretched and pre- 
carious state of life contracted syphilis, for the cure o f which she was 
placed under a course of mercury. Her father, whose paternal feelings 
were not destroyed by the stain which the misconduct of his child had 
affixed on the character of his family, had followed her to town ; and in 
vain had endeavoured to discover her retreat. At length he met her 
in the street, when she was labouring not only under disease, but when 
her habit was charged with mercurv for its relief; and when she was 
reduced to a state of extreme indigence. Her eye met that of her 
parent, and she fled as rapidly as she could from an interview which she 
dreaded; and although her father closely followed her, yet she secured 
her retreat to her lodgings for that night. On the following day she 
was too ill to move ^om home ; her mouth was affected, and the sali- 
vation considerable ; when late in the evening of that day she heard her 
father's voice at the door of the house in which she lodged. She In- 
stantly left her bed, and escaped into another room as he entered the 
one in which she had been lymg, and ran into the street in a half-naked 
condition, during a heavy snower of rain. I was requested to see her 
on the following day. She was then covered in patches with an erup- 
tion, which, to the unassisted eye, much resembled that of scarlet fever. 
She complained of great heat, stiffness, and tingling upon the inner and 
upper surface of the thigh, and round the neck ana waist. In these 
parts patches of extremely minute vesicles were apparent, gradually ex- 
tending themselves over the whole body. The stinging and irritation 
increased to a degree almost insupportable. There was a fever, which 
in a few days assumed an intennittent character ; and a very fcetid 
odour exhaled from the body. The viscid fluid which oozed from the 
patches dried and crusted, and the cuticle peeled off in large pieces. In 
this state the disease continued for ten days. The warm bath, anodyne 
fomentations, liniments of linseed oil and lime-water, were externally 
applied; whilst saline purgatives, refrigerants, decoction of Cinchona 
bark, the mineral acids and opium were internally administered, without 
any beneficial result. In fifteen days from the commencement of the 
attack, the wretched girl died, in a state of suffering which no language 
can correctly describe. 

In this case, the mental alarm had predisposed the body, under the 
influence of the mercury, to be excited by the sudden exposure to cold 
and damp in a peculiar manner ; for that it was not cold and damp alone 



814 VESicuLiE : 

the body is affected, it may terminate in ten days ; 
but when the disorder has been universal, the patient 
seldom completely recovers in less than six weeks, 
and is often afflicted to the end of eight or ten weeks. 
By so severe an inflammation the whole epidermis is 
destroyed in its organisation ; and when the discharge 
ceases, it lies loose, assuming a pale brown colour, 
which changes almost to black before it falls off in 
large flakes. As in other superficial inflammations, 
however, the new red cuticle that is left is liable to 
desquamate again, even to the third or fourth time, 
but in smaller bi-anny scales, of a white colour ; and 
a roughness sometimes remains for a considerable 
period, like a slight degree of Psoriasis. In- some 
mstances, not only the cuticle, but the hair and nails 
are also observed to fall off; and the latter, when 
renewed, are incurvated, thickened, and furrowed, as 
in L^pra. 

The Eczema rubrum, however, even from the 
irritation of Mercury, is often limited to a small 
space ; and then the discharge is slight, and its whole 
duration short. Similar local attacks of it occur in 
irritable constitutions, especially in hot weather, affect- 
ing the hands and wrists, the neck and external ear, 
and other parts, but without any constitutional dis- 
order. Successive crops of the vesicles arise, in 
irr^ular patches, with a red blush around them, 
which produce partial incrustations, as the ichor, that 
issues, is dried : and by these vesications and desicca- 
tions of the matter the affection is kept up for some 
weeks. 

The treatment of this species of Eczema may be 
comprised in few words j for it is principally palliative. 



Is probable from the fact that tbe poor creature had been driven by 
strong necessity to walk the streets in all states of the weather, during 
the whole penod in which she had been taking mercurials^ without 
suffering, until the nervous system received the shock which has been 
described. T. 



ECZEMA. 815 

But although medicine may not possess the power of 
shortening the period of its duration, yet, the omis- 
sion of the palliative measures will allow an extreme 
aggravation of the sufferings of the patient to take 
place, and probably prolong it beyond its natural 
course, as well as contribute to wear out the vigour 
of his constitution. 

" The first step is to omit the further use of the 
Mercury, and to remove the patient from the atmo- 
sphere in which the disease was generated, and to 
soothe every anxiety of the mind as far as possible." 

The misery and exhaustion, resulting from the 
excessively tender and irritated state of the skin, may 
be greatly alleviated by frequent ablution or foment- 
ation with warm gruel, or strained bran and water j 
or by the frequent use of the warm bath, which has 
the advantage of cleansing the surface, without occa- 
sioning any abraision by friction, A constant appli- 
cation of poultices has produced considerable ease to 
the patient, when the affection was confined to the ex- 
tremities. Where the cuticle has exfoliated, Mr. Pear- 
son recommends the application of a mild cerate, con- 
sisting of litharge plaster, wax, and oil, spread thickly 
on linen rollers, and renewed twice a day. With the 
same view of diminishing the irritation of the surface, 
the bed and body linen of the patient, which becomes 
hard and stiff as the discharge dries upon it, should 
be frequently changed. 

Every additional irritation from stimulating food 
and drink should be avoided ; the bowels should be 
kept open by the administration of occasional laxatives; 
and some saline diaphoretic, or an antimonial, should 
be given regularly, to which an opiate may be added, 
for the purpose of soothing the sensations of the 
patient. The Sulphuric Acid is grateful and refresh- 
ing ; and, in the decline of the swelling and discharge, 
it may be combined advantageously with the liberal 
exhibition of Cinchona, or the Sulphate of Quinia, 
and Sarsaparilla. 



ai6 VESICUL^ 



Books to be consulted on Sczetj§a, 



Alle y, Observations on the Hydrai^gyria, 8vo. 1810. 

, Essay on an Eruptive Disease arising from Mercury, Svo. 1804. 

BuTTER^s Treatise on the Venereal Rose, 1799. 
Edinburgh Med. and Surg. Joum. vol. ii. 
/^MoRiARjy, A Description of Mercurial Lepra, Svo. 1804. 
Mathias, (And.) on the Mercurial Disease, 8vo. 1811. 



Genus VII. APHTHA. 

S^n. ''Acjifla^, ( Or.) : Aphtha {Auct. var.) : 
Apthae (Fog.) : Aphtae (Pinel): Febris Aphthosa 
{Vogel): Typhus Aphthoid6us (Young): Emph- 
lysis Aphtha ( Oood) : Pustulae oris (Holy Abbas) : 
Schivamrachen, mehlhund, schule, saar; die Mund- 
schwamchen ( Oer. ) : Mendepzwar sprouw (Dutch) : 
Torsk (Swed.): Troske (Dan.): Afte (Ital.): 
Aflas (Span.): Achirum, Parititooroo (Tarn.): 
Achir (Duk.) : Acherum ( Tel.) : Mookapakum 
(Sans.): Ninanwan (Hind.): Aphthes, Mugnet, 
M\\iet(F.): Thrush. 

Def. An eruption of granular, pearl-co- 
loured VESICLES*, ON THE INSIDE OF THE CHEEKS, 
AND OF THE LiPS, EXTENDING OVER THE WHOLE OF 
THE MOUTH, THE FAUCES, AND INTO THE INTESTINAL 
CANAL, TERMINATING IN SLOUGHS, OR WHITISH 
CRUSTS. 

* The vesicular character of the aphthous eruption has been pointed 
out b^ several accurate observers; especiailj by Van Swieten, in com- 
menting upon the word ulcuscida used by Boerhaave, aph. 978. ; by 
Sauvages, who considers their character as pM^ctcsnous ; and by Prof. 
Arnemann, who describes them as small elevations, of a sreyish^white 
colour, " serosa quodam liquore referti." (Comment, de Apbthis, } ii.) 
See also Welti, Diss, de Exanthem. Fonte Abdominali, ^ vi. ; Callisen, 
Syst. Chir. Hod. $ 854. ; and Plenck, Doctr. de Morb. Cutan. class, x., 
who still more distinctly describes them. ^'Incipiunt aphthse sub forma 
^sicularum miliarium albarum, quae in apice foraminufura gerunt, dein 
coUabuntur et aliquantum latescunt." •^- Some English writers have 
called them " little white specks" (see Underwood, vol. i. p. 62.) little 
white " specks or slouehs," (Armstrong on the Man. of Children, p. 18.) 
or merely " a white fur," (Syer, on Man. of Infants, p. ii. chap. 5.) 
having attended only to the ultimate state of the eruption^ 



APHTHiE. SI7 

This aflPection of the mouth, which has been de- 
scribed by medical writers from Hippocrates down- 
wards, has been almost universally noticed as a 
frequent occurrence during the period of infancy*, 
and generally ascribed to disorder of the first passages, 
or considered as the result of gastric and eruptive 
fevers. In truth, it occurs in connection with various 
states of disease, both acute and chronic, and at all 
ages, where great debility is induced. It consists of 
the following species : — 

1. A. lactantivm. 

2. A. adultorum. 

3. A. anginosa. 

Species 1. Aphtha lactantium t, Infantile 
Thrush. 

Syn. Aphtha infantiles (Plenck) : Aphtha infan- 
tum ( (7w/fe7^) : Aphtha lactucimen(>S'awt;.): Emphly- 
sis Aphtha : a. infantum ( Good) : TVhite Thrush. 

Aphthous eruptions are most frequently seen in 
infants, in whom they sometimes appear without any 
considerable indisposition ; but they are often accom- 
panied by restlessness and slight febrile symptoms, 
especially when the stomach and bowels are much 
deranged. The nurse is led to suspect their occur- 
rence by the difficulty and apparent pain with which 
the infant sucks, and by the heat of its mouth, as 
perceived by the nipple, which at length becomes in- 
flamed, and even excoriated. The Aphthae appear 
first on the edges of the tongue, or at the angles and 
inside of the lips, and often extend over the whole 
surface of the tongue, palate, inside of the cheeks, 
and into the fauces : the surface on which . they arise 

* Hippoc. aph. 24. sect. iii. &c. — Celsus, lib. ii. cap. 9. and lib. viii. 
cap. 42. — Aetius, tetr.ii. serm.iv. cap. 39. — Julius Pollux, Onomast. 
lib. iv. cap. 24. 

f The appellation of lactumina, or lactucimina, was given to the in- 
fantile Aphthae by Amatus Lucitanus (Curat. Medic, cent.v.), upon the 
supposition that they originated from a vitiated condition of the milk. 



318 vEsicuLJE : 

is of a red or purplish hue ; the tongue is sometimes 
slightly tumid, and its papillae, especially near the 
extremity, are elongated and inflamed, protruding 
their red tips above the rest of the surface, nearly as 
in scarlet fever. The aphthous vesicles are of a white 
colour, and semiopake, and speedily put on the 
appearance of minute fragments of curd, adhering to 
the surfaces just mentioned. At various periods, 
from twelve hours to several days, these specks be- 
come loose and fall off, leaving the surface smooth and 
red. Others, however, commonly spring up, and go 
through a similar course, while at the same time new 
ones appear on other parts ; so that at length the 
whole surface of the tongue and mouth is often 
covered with a sort of whitish granulated crust, 
formed of the coherent Aphthae. Sometimes these 
crops are renewed several successive times ; and not 
unfrequently the removal and repuUation are only 
partial, and the general crust remains for several 
weeks. The Aphthae appear to extend down the 
oesophagus, and are supposed to aflPect the internal 
surface of the stomach, and of the whole intestinal 
canal, when tenesmus ensues, with a redness and 
partial excoriation about the anus : these latter 
symptoms, however, may be occasioned by the irrit- 
ation of the morbid excretions from the bowels, 
which are usually discharged under the occurrence of 
severe aphthous eruptions. The trachea is occasion- 
ally affected with the Aphthae ; but they very rarely 
extend to the cavity of the nose.* 

The Aphthae of infants are most commonly the 
result of disorder in the stomach and bowels, com- 
bined with debility. Hence they occur in sucking 
infants, where the supply of milk afforded by the 
nurse is inadequate, or imperfect in its qualities j "a 
consequence not unfrequently of an over-anxious and 
irritable temper in a nursing mother,'* but still more 

* Cfdlisen^ loc. cit. 



APHTHJS. 319 

frequently and severely, where a child is brought up, 
without being suckled, upon unnatural or improper 
food. In either case, the tendency to Aphthae is in- 
creased by whatever contributes to impair the general 
health ; as want of cleanliness, confined air, neglect 
of giving exercise, allowing the child to sleep too 
much under the bedclothes, &c. Indigestion and its 
consequences, especially acidity, are occasioned by 
giving the food too thick, too hot, or too sweet, or in 
any other way widely different from that which the 
provision of nature suggests. 

The Aphthae of infants, when accompanied with 
3light general indisposition, or only with acidity at 
the stomach, and especially when they are few and 
scattered, are not indicative of danger, nor productive 
of much inconvenience. But when they are very 
copious, coalescing into an extensive coating over the 
tongue, mouth, and throat, or are accompanied with 
a red, shining appearance of the tongue, with an 
obstinate and irritating diarrhoea, fever, and restless- 
ness, — or when they supervene on the state of de- 
bility and emaciation which is left by measles. Erysi- 
pelas, and other acute diseases, or on a chronic 
marasmus, — they not only betoken a dangerous state 
of constitutional distress, but contribute, by the in- 
ability of taking nourishment which they occasion, to 
augment that state. They are also unfavourable 
when they assume a dark hue. 

In the milder degrees of Aphtha lactantium, just 
mentioned, slight remedies are sufficient to alleviate 
or remove the disease. The acidity in the first pas- 
sages is often readily corrected by some testaceous 
powder, which, if the bowels be not irritable, may be 
joined with a little Rhubarb or Magnesia ; or by the 
Pulvis Contrayervae compositus, if they are in the 
opposite state, and the child weakly. "In the latter 
case, I have derived more benefit froin a mixture of 
Carbonate of Soda and Calumba in powder, and in 
doses proportionate to the age of the infant, than 



320 VESicuLiE : 

from any other remedy. It is requisite to clear the 
bowels with a dose of Castor Oil every morning, 
which prevents diarrhoea. When the alvine discharges 
are so acrid as to cause heat and soreness round the 
anus, much comfort is derived from glysters composed 
of equal quantities of mutton broth and starch.'* At 
the same time, the nutriment of the patient should 
be regulated, by attending to the diet and general 
health of the nurse, " who should abstain from the 
use of wine and porter or ale." If the child be not 
suckled, a wet-nurse should be procured, where that 
is practicable, which often speedily cures the com- 
plaint. " If the infant be suckled by the mother, it 
is of importance to inquire into the state both of the 
health of the body and the quietude of the mind of 
the mother ; and, in all cases when the disease does 
not yield to the usual remedies, and the strength of 
the infant fails, the nurse, whether mother or a 
hireling, should be changed ; for in many instances 
little more is required than a sufficient supply of 
healthy nutriment for the effectual removal of the 
disease." 

Various local applications have been employed for 
the removal of Aphthae from the earliest times, of a 
gently astringent nature; and when they are not 
made too stimulant, especially in the commencement 
of the eruption, they not only serve the good purpose 
of coagulating and removing the mucous and clammy 
discharge, but also diminish the tendency to resprout 
in the aphthous surfaces. The most effectual deter- 
gent of this kind is Borax, recommended by Mr. 
Gooch, of Norwich *, and now in the hands of every 
nurse. It is conveniently combined with water, mu- 
cilage, syrup, or honey, in the proportion of one 
twelfth, or even one eighth part of the salt. It is 
unnecessary to describe the compositions of honey of 
Roses, syrup of Mulberries, &c. with small propor- 

♦ See his Surg. Observations. 



APHTHJE. 821 

tions of Muriatic or Sulphuric Acid, or of the Sul- 
phate of Zinc, or of some absorbent powder, which 
different practitioners have preferred. Where the 
surface is exceedingly tender and excoriated, some 
mild and lubricating application, such as the com- 
pound of cream, with the yolk of eggs and Syrup of 
Poppies, recommended by Van Swieten*, should be 
first employed, and the restringents gradually intro- 
duced, as the irritability is diminished. 

At a later period of infancy, the Aphthae partake 
more of the nature of those which appear in adults : 
they seldom occur, except as symptomatic of some 
more serious derangement of the organs of nutrition, 
or as the sequelae of febrile disease ; and are conse- 
quently indicative of great danger, and more difficult 
of cure. If the child have been long at the breast, 
it is probable that the milk has become deteriorated 
in quality, or insufficient in quantity ; and weaning, 
or a change of nurse, may be necessary. If a state 
of marasmus, with emaciation, tumid abdomen, and 
morbid excretions from the bowels, have supervened, 
the usual course of absorbents and alteratives, the 
Hydrargyrus cum Creta, or the grey Oxide with 
Soda and testaceous powder, must be carefully ad- 
ministered, and followed by mild tonics. Where 
the Aphthae assume a brown hue, or appear in the 
state of debility consequent on acute diseases, the 
general strength must be supported by light tonics 
and cordials, with proper diet ; such as a weak decoc- 
tion of Cinchona or Cascarilla, or the solution of the 
Tartrate of Iron and Potassa, with Rhubarb, light 
animal broths, and preparations of milk with the 
starches.t 

• 

Species 2. Aphtha adultorum: Thrush of 
Adults. 

Syn. Aphtha maligna {Sauv.)'. Emphlysis Aph- 
tha, f . maligna ( Oood) : Black Thrush. 

• Comment, ad Aph. 990. f Such as Arrow-root, Tapioca, Sago. 

Y 



322 VESICULiE : 

lu children grown up, and in adult personSj Aph- 
thae occur under a great vaiiety of circumstances, 
being symptomatic of numerous diseases, both acute 
and chronic. They not only occur after Smallpox, 
Measles, Erysipelas, and Scarlet Fever ; but seldom 
ail to appear, whenever the constitution has been 
weakened by old age, by long confinement from 
wounds and accidents, from dropsical, gouty, and 
dyspeptic complaints, from diarrhoea, chlorosis, con- 
sumption, and hectic fever of every kind * ; in the 
latter diseases, indeed, the Aphthse are usually indica- 
tions of the approach of dissolution. The particular 
tendency of autumnal fevers, in cold and damp sea- 
sons, to produce Aphthae, especially when combined 
with affections of the bowels, or occurring in puer- 
peral women, has been noticed by many writers ; as 
well as the connection between the aphthous and 
miliary eruptions, under a heating regimen.t The 
Aphthae, like the Miliaria, when they supervene in 
these fevers, never produce any amendment of the 
symptoms, as the continental writers have stated, but 
rather seem to aggravate them, and to prolong their 
duration. They always, indeed, imply a dangerous 
state of the system, when they accompany other dis^ 
eases ; and especially when they appear first in the 
j^rynx, and ascend from the stomach ; when there 
is much anxiety, pain, and heat of the praecordia, with 
sickness and hiccup ; and when they are among the 
sequelae of fevers, the pulse at the same time remain- 
iBg small and frequent, and the appetite failing to 
return. 



* See Callisen, loc. cit. — " Neque infrequenter (aphthae) in adultk 
metastasi imperfectse, infidae, in febribus continuis, exanthematicis, pu- 
tridis, inflanimatoriis, lends, a suppuratione internd sen pure resorpto, 
vel alvifluxu, vires pessundanti inductse, dehentur." — See also Willan, 
Reports on Dis. of London, p. .114., and Arnemann, loc. cit. } iii. de 
Aphthis adultorum. 

f See Arnemann and Willan, ibid, — Van Swieten ad Aph. 985. — 
Sydenham, sect. iv. cap. iii. — StoU, Rat. Med. torn, ii. p. 167. — Hux- 
ham, de Acre et Morb. Epidem. lib. ii. p. 29.-- Frank, de curand. Hom. 
Morlns, lib. iii. §366, 



APHTHA. 323 

The principal objects of medicine, in these cases, 
are to restore the energy of the constitution, and re- 
lieve the local complaint. The former indication is 
to be fulfilled by means of Cinchona and the mineral 
acids, where the bowels will admit of them, by light 
but nutritious diet, and by the exercise of gestation, 
when it can be obtained. For the latter, frequent 
ablution of the mouth and throat with cold water, 
and the use of the various linctuses and lotions, before 
enumerated, must be resorted to. 

Species 3. Aphtha anginosa, Aphtha of the 
Throat. 

This appellation may be given to a species of sore 
throat, which is not unfrequently observed during 
damp and cold autumnal seasons, especially in women 
and children. It is preceded by slight febrile symp- 
toms, which seldom continue many days : on the 
second or third day, a roughness and soreness are 
perceived in the throat, which, on inspection, is found 
to be tumid, especially the tonsils, uvula, and lower 
part of the velum pendulum, and considerably in- 
flamed, but of a purplish red colour. The same 
colour extends along the sides of the tongue, which 
is covered in the middle with a thin white crust, 
through which the elongated and inflamed papillse 
protrude their red points. Small whitish specks form 
on these parts, which usually remain distinct, and 
heal in a few days, but occasionally coalesce, and pro- 
duce patches of superficial ulceration. The complaint 
is sometimes continued three weeks or a month, by 
successive appearances of tKe Aphtha, but without 
any constitutional disturbance. 

This disease appears to arise from the influence of 
cold and moisture, unwholesome diet, and acrid 
effluvia taken into the lungs. In the latter mode, it 
is produced in persons who attend on patients affected 
with confluent Smallpox, Scarlatina anginosa, or other 
malignant fevers. Although there is no clear evi- 

Y 2 



324 VESLC^. 

dence of its propagation by contagion, it is frequently 
seen to attack several children in the same family 
about the same time, or in very quick succession. 

There appears to be no danger in this affection, 
and medicine does not materially abbreviate its 
duration. A light diet, with diluent drinks, and 
gentle laxatives, where there is a disposition to in- 
activity in the bowels, constitute the only treatment 
required for its cure. When the debility is considerr 
able, ammonia should be administered; and more 
particularly if dentition be proceeding. Leeches and 
blisters seem to be rather detrimental than advan- 
tageous ; and Cinchona, with mineral acids, to be 
useless, until the decline of the disorder, when they 
contribute to restore the strength.* 

• 

Boohs which may be constdted on Aphtha, 

AaNEMANN, Commentis de Aphthis, 1787. 
Baillie, Series of Engravings, &c. Fasc. iii. 
DiEZ. Dissertatio de Aphthis, 8vo. 1771. 
DuGEs, Diet, de Med: Frat. t.iii. 1829. 
Harris, de Morbis Acutis Infantum. 
IIeberden, Commentarii de Morborum, &c. 8vo. 
' Robertson, Cyclop, of Pract. Med., vol.i. 1852. 
Underwood, Treatise on the Diseases of Children, 8vo. 1828. 
Wilson, A Treatise on Febrile Diseases, 8vo. 1804. 

* See Dr. Willan's Reports on Dis. in London, p. ill.; — and my 
Reports of the Public Dispensary, Edin. Med. ana Surg. Journal for 
Jan. 18IJ. 



325 



Order VII. 

TUBERCULA. 

TUBERCLES. 

SYN. Des Knotes {Germari)\ Bouton, Inflamma- 
tion Tuberculeuses {F>\ 

Def. Small, hard, superficial tumours, cir- 
cumscribed AND PERMANENT^ OR SUPPURATING 
PARTIALLY. 

The Order of Tubercles comprehends nine genera: 
but as some of them require only surgical treatment, 
some are of rare occurrence, and some are unknown in 
this country, they will not require a very ample dis- 
cussion in this place. The following are the Genera 
of Tubercles : — 

1. Phyma. 6. Lupus. 

2. MoLLuscuM. 7- Elephantiasis. 

3. Vitiligo. 8. Framboesia. 

4. Acne. 9. Ichthyosis.* 

5. Sycosis. 



Genus I. PHYMA. 

Syn, Die Erbsenblattem ; Eiter-blasem(G^^rm.): 
Charbon {¥.). 
Def. Imperfectly suppurating cutaneous or 

* The Editor has left out Verruca from this list, as it cannot be con- 
sidered in any other light than as a dermal alteration, unconnected in 
any degree with the condition of the system. He has placed, on the other 
hand, ichthyosis in this order, because, although he regards each of the 
hardened points, or elongated or hardened tubercles, the aggregation of 
which constitutes the external characteristic of the disease, as so many 
permanent cuticular excrescences, yet this state is connected with a 
morbid condition of the system, as much as the other genera classed 
under the order. 

Y 3 



326 TUBERCULA : 

SUBCUTANEOUS TUMOURS : FORMING AN ABSCESS 
THICKENED AND INDURATED AT THE EDGE, OFTEN 
WITH A CORE IN THE CENTRE. 

Under the genus Phyma*, Dr. Willan intended 
to comprise the Terminthus, the Epinyctis, the lesser 
species of boil (Furunculus), and the carbuncle of 
authors. These tubercular affections are commonly- 
treated of in chirurgical works, and I have nothing 
to add to the general information on the subject. 



Genus II. MOLLUSCUM. 

Syn. Encyst is (Fog. Parr): Lupia (Sauv*): 
Steatoma (Sharp): Emphyma encystis (Good): 
Atheroma \Auct) : Wen. 

Def. A MOVABLE TUMOUR ; LITTLE SENSIBLE ; 
OFTEN ELASTIC TO THE TOUCH. 

This form of tubercular disease is noticed rather 
as a singularity, which occasionally occurs, and of 
which a few instances are recorded, than as an ob- 
ject of medical treatment. It is characterised by the 
appearance of numerous tubercles, of slow growth 
and little sensibility, and of various sizes, from that 
of a vetch to that of a pigeon*s egg. (Plate LX. 
Fig. 1. of Bateman ; PI. 21. of Thomson's Atlas.) 
These contain an atheromatous matter, and are of 
various forms, some being sessile, globular, or flattish, 
and some attached by a neck, and pendulous. The 
growth of the tubercles is apparently unconnected 
with any constitutional disorder ; they show no ten- 
dency to inflammation or ulceration; but continue 

* According to Paulas, the term ^w/ia was employed to signify in 
general a suppurating tumour, but in particular a suppurating tumour 
in a glandular part, (De Re Med. lib. iv, cap. 22. See also Oribas. de 
Morb, Cur. lib. iii. c. 34. ; and Actuar. Meth. JVf ed. lib. ii. cap. 12.) Hip- 
pocrates uses the term in the general sense (aph. 20. § iii. and aph. 82. 
§ iv.), and speaks also of scrofulous phymata, ^vfiara xoipoiJca, in 
Praedict. lib.ii. Jii. 77. Foes. See also Celsus, lib, v. cap. 18. 



MOLLUSCUM. 327 

through life, having apparently no natural termin- 
ation. A very extraordinary instance of this cuta- 
neous deformity, which occurred in a poor man, who 
was living in good health, at Muhlberg, in 1793, and 
whose body, face, and extremities were thickly studded 
with these atheromatous tubercles, has been described 
by Professor Tilesius, who has given portraits of the 
naked patient in three positions, in a pamphlet, 
edited at Leipsic, in that year, by Professor Ludwig. 
Since the second edition was printed, a patient was 
sent to me by a distinguished physician, affected with 
a singular species of moUuscum, which appears to be 
communicable by contact. (Plate LXI. of Bate- 
man ; PI. 21. of Thomson^s Atlas.) The face and 
neck of this young woman were thickly studded with 
round prominent tubercles, of various sizes, from that 
of a large pin^s head to that of a small bean, which 
were hard, smooth, and shining on their surface, with 
a slight degree of transparency, and nearly of the 
colour of the skin. The tubercles were all sessile, 
upon a contracted base, without any peduncle* From 
the larger ones a small quantity of milk-like fluid 
issued, on pressure, from a minute aperture, such as 
might be made by a needle's point, and which only 
became visible on the exit of the fluid. The progress 
of their growth was very slow : for the first tubercle 
had appeared on the chin a twelvemonth ago, and 
vonly a few of them had attained a large size. Some 
of the latter had recently become inflamed, and were 
proceeding to a slow and curdly suppuration ; and 
the cervical glands, lying under those on the neck, 
were also swollen, and discoloured, as if proceeding 
to suppurate. The eruption was still increasing much, 
and not only disfigured her greatly, but had recently 
impaired her general health, and occasioned a con- 
siderable loss of flesh, by the irritation which it pro- 
duced. 

/ She ascribed the origin of this disease to contact 
with the face of a child, whom she nursed, on which 

y 4 



828 TUBERCULA : 

a large tubercle of the same sort existed ; and on a 
subsequent visit she informed me, that two other 
children of the same family were disfigured by similar 
tubercles ; and besides, that the parents believed that 
the first child had received the eruption from a ser- 
vant, on whose face it was observed. Since my atten- 
tion was drawn to this species of tubercle, I have seen 
it in another instance, in an infant brought to me 
with Porrigo (Impetigo) larvalis ; and, on investiga- 
tion, it was found that she had apparently received it 
from an older child, who was in the habit of nursing 
it. In this case the milky fluid issued from the tu- 
bercles, and may be presumed to be the medium of 
the contagion. 

Of the best mode of managing this singular Mol- 
luscum I have not had sufficient experience to speak. 
Nothing remedial was administered to the children ; 
but, in the adult patient, I had the satisfaction to 
find, that, after the liquor arsenicalis had been taken 
in small doses for a month, the tubercles were uni- 
versally diminished both in number and magnitude, 
most of them having gradually subsided : a few, 
especially on the neck, had suppurated. 



Genus III. VITILIGO. 

Syn. Epichrosis leucdsmus ( Good). 

Def. White, shining, smooth tubercles aris- 
ing IN THE SKIN, ABOUT THE EARS, NECK, AND 
FACE ; TERMINATING WITHOUT SUPPURATION. 

Dr. Willan adopted this generic term from Cel- 
sus, but proposed to appropriate it to a disease 
somewhat different from those to which that classi- 
cal writer applied it, and which is not of frequent 
occurrence. There is, indeed, a substantial reason 
for not adopting the term in the acceptation in 
which it is used by Celsus j namely, that he has 



VITILIGO. 3^ 

comprehended under it three forms of disease, two 
of which are generically distinct from the third* 
The two former, alpkos and melas, are superficial, 
scaly diseases, i. e. only slighter varieties of Lepra 
and Psoriasis ; whereas the last, Leuce^ deeply aflFects 
the skin and subjacent structure, occasioning a loss of 
sensibility, and ultimately of vitality, in those parts.* 
The disease which is here intended to be desig- 
nated by the term Vitiligo, (Plate LX. Fig. 2. of 
Bateman; pi. 21. of Thomson's Atlas,) is, as I 
have already stated, somewhat rare, and pernaps but 
little known. It is characterised by the appearance 
of smooth, white, shining tubercles, which rise on the 
skin, sometimes in particular parts, as about the 
ears, neck, and face ; and sometimes over nearly 
the whole body, intermixed with shining papulae. 
They vary much in their course and progress : 
in some cases they reach their full size in the 
space of a week (attaining the magnitude of a large 
wart), and then begin to subside, becoming flattened 
to the level of the cuticle in about ten days : in other 
instances, they advance less rapidly, and the eleva- 
tion which they require is less considerable ; in fact, 
they are less distinctly tubercular. But in these cases 
they are more permanent; and as they gradually 
subside to the level of the surface, they creep along 
in one direction, as, for example, across the face or 
along the limbs, chequering the whole surperficies 
with a veal-skin appearance, t All the hairs drop 
out, where the disease passes, and never sprout 
again, a smooth shining surface, as if polished, being 

* See Lepra alphoides, above, p. 4L After having described the cha> 
racteristics of the three forms of Vitiligo, Celsus thus points out th& 
circumstances which mark the greater severity of the last: ^* Alphas et 
Melas in quibusdam variis temporibus et oriuntur et desinunt : Leuce 
quern occupavit, non facile dimittit. Priora curationem non difiicilli- 
mam recipiunt ; ultimum vix unquam sanescit ; ac siquid ei vitio demp* 
tum est, tamen non ex toto sanus color redditur/* DeMedicind, lib.v, 
cap. 28. 

f This white and glistening appearance, bearing some resemblance to' 
the flesh of calves (vituli), seems to have given rise to the generic term.. 



330 TUBERCULA Z 

» 

left, and the morbid whiteness remaining through 
life. The eruption never goes on to ulceration. 

There is no considerable constitutional disorder 
combined with this affection ; but it has proved 
exceedingly unmanageable under the use of both 
internal and external medicines. The mineral acids 
internally, and the application of diluted caustic and 
spirituous substances externally, have been chiefly 
employed, but with little obvious effect. 

Book which may be consulted on VitUi^o, 
Blanckarett. (E. L.) de Vitiligine, 4to. 1764. 



IV. ACNE.* 

Syn. Varus {Auct. var.) : Bauhia (Linn.) : 
Gutta rosea ( Sauv. P^eg. Darwin) : Phymatosis 
acne ( Young) : lonthus varus et corymbifer ( Good) : 
Dartre pustuleuse {Alihert) : Phyma faciei (Swe^ 
deaur): Vari lonthi (Atict): PsydraciaAcne(/Saz^v.) 
Axv>3, G.) : Boutons (jP.) : die Finnen, Rothyesicht 
( German) : Vinnen, steenpuistyes {Dutch) : Acne 
(itaL Span.) I Whelks, Maggot pimple. 

Def. Tubercular tumours; slowly suppurat- 
ing ; CHIEFLY COMMON TO THE FACE. 

This genus, as the definition describes, is charac- 
terised by an eruption of distinct, hard, inflamed 
tubercles, which are sometimes permanent for a 
considerable length of time, and sometimes sup- 
purate very slowly and partially. They usually 
appear on the face, especially on the forehead, tem- 
ples, and chin, and sometimes also on the neck, 

* This term is borrowed from Aetius, who mentions it as a synonyme 
of iov9oc,hy which most of the Greek writers designate the disease, 
Aet. tetrab. ii. serm.iv. cap. 13. The Latins denominated the tubercles 
vari. See Celsus, lib..vi. cap. 5* — Plin, Hist. Nat. lib. xxiii. — Sennert 
haying spoken of the affinity of vari with the pustules about the head, 
called psydracia by some writers, Sauvages made the eruption a species 
of the latter, Psydracia acne. Nosol. Afeth. class i. ord.ii. gen. 9. See 
Jul. Pollux^ Onomasticon, lib. iy. cap. 25. 






ACNE. 831 

shoulders, and upper part of the breast ; but never 
descend to the lower parts of the trunk, or to the 
extremities. " When they appear on the face, the 
back, and shoulders are rarely affected, and, on the 
contrary, the face has rarely any of these tubercles 
when they are seated on the back.'* As the progress 
of each tubercle is slow, and they appear in succes- 
sion, they are generally seen at the same time in the 
various stages of growth and decline ; and, in the 
more violent cases, are intennixed likewise with the 
marks or vestiges of those which have subsided. 
The eruption occurs almost exclusively in persons of 
the sanguine temperament, and in the early part of 
life, from the age of puberty* to thirty or thirty- 
jGve ; but in those of more exquisite temperament, 
even later. It is common to both sexes; but the 
most severe forms of it are seen in young men. t 
There are three species of this eruption : — 
1. A. simplex. 2. A. induratcu 

Var. a. A. punctata. 3. A. rosacea. \ 

Species 1. Acne simplex ^ Simple Pimple. 

Syn. Dartre pustuleuse miliaire : Herpes pustu- 
losus miliaris (^Alibert^. 

This is an eruption of small vari, which appear 
singly, and are not very numerous, nor accompanied 
by much inflammation, nor by any intermediate af- 
fection of the skin. They occur chiefly on the 

* From this circumstance, both the Greek appellations appear to 
have originated ; lovOog, from its occurring during the growth of the 
lanugo, or first beard, which the word also signifies ; — and aicvrj, quasi 
aKfirjf from its appearance at the acvie^ or full growth and evolution of 
the system. ** lonthi, flores cum papulis circa faciem, vigoris signum," 
is the definition given by Julius Pollux (loc. cit.). And Cassius, in his 
53d problem, explains, ^' Cur in facie vari prodeunt fere in ipso aetatis 
flore vigoreque (quapropter et aKfiog, id est, vigores, idiotarum vulgus 
eos nuncupat) ? " 

f Alibert and Brett regard Acne as a pustular affection : the Editor 
cannot accord with these distinguished writers : they are slowly sup- 
purating tubercles ; and in some cases they never suppurate. T. 

]: Ahbert has not figured any specimen of Acne, unless an ill-defined 
plate (22d), representing what he calls ^ Dartre pustuleuse miliaire/^ on 
the forehead, be intended for Acne simplex. 



832 TUBERCULA ! 

temples, forehead, shoulders, and upper part of the 
thorax, (Plate LXII, of Bateman ; PL 23, of 
Thomson's Atlas.) When it has continued some 
time, indeed, a little roughness of the face is pro- 
duced where the larger tubercles have disappeared, 
in consequence of a slight cracking or disposition 
to exfoliate in the new cutick ; but these marks are 
not permanent. 

Many of the tubercles do not proceed to sup- 
puration ; but gradually rise, become moderately 
inflamed, and again slowly subside, in the course of 
eight or ten days, leaving a transient purplish red 
mark behind. But others go on to a partial suppur- 
ation, the whole process of which occupies from a 
fortnight to three weeks. The tubercles are first 
felt in the skin, like a small hard seed, about the 
size of a pin*s head, and enlarge for three or four 
days, when they begin to inflame : about the sixth 
or seventh day they attain their greatest magnitude, 
and are then prominent, red, smooth, and shining, 
and hard and painful to the touch. After two or 
three days more, a small speck of yellow matter ap- 
pears on the apices of some of the tubercles ; and 
when these afterwards break, a thinner humour is 
secreted, which soon dries into a yellowish scab. 
The inflammation now gradually declines, the size 
and hardness of the tubercles diminish, and the small 
scab becomes loosened at the edges, and at length 
falls off about the third week. '* When the tuber- 
cles occupy the shoulders the suppuration, although 
not more rapid, yet is succeeded by a thicker scab, 
which is soon detached by the friction of the clothes." 
The individual tubercles, which rise and suppurate in 
succession, pass through a similar course. 

This eruption recurs frequently, at short intervals, 
in some individuals, who have it partially; but in 
others, who are more stongly predisposed to it, it is 
more extensive, and never wholly disappears, but is, 
at uncertain periods, more or less troublesome. ^* In 



ACNE. 339. 

femaks it is very troublesome at the menstrual 
periods. It seems closely connected with atony of 
the secreting function of the uterus, as well as that 
of the liver/* Persons subject to Acne simplex 
often enjoy good health, and cannot refer the cu- 
taneous complaint to any obvious exciting cause; 
whence Dr. Darwin* has constituted it a distinct 
species, with the epithet, "hereditary;** which, in 
fact, is to ascribe it solely to the temperament of the 
patient, or to consider the predisposition, arising 
from the great vascularity of the skin in sanguine 
habits, as adequate to give rise to the eruption, under 
ordinary stimulation. There appears, however, to 
be no clear distinction between the stomachic and 
hereditary cases of Acne, as Dr. Darwin supposes ; 
for it is only where there is a strong constitutional 
predisposition, that substances which disorder the 
stomach excite the eruption of Acne ; and in those: 
who are so predisposed, the vari occasionally appear 
after eating heartily, or drinking an unusual portion 
of wine, or from any slight cause of indigestion ; as 
well as after any inordinate excitement of the cuta- 
neous circulation from violent exercise in hot wea- 
ther, or in heated rooms, especially when followed 
by a copious draught of cold liquor. " Errors and 
excesses in diet ; irritating cosmetics ; vexation of 
mind ; gusts of passion, and other strong mental 
emotions, may also be named amongst the exciting 
causes of Acne simplex J^ In some cases, a sort of 
critical eruption of vari has suddenly occurred, after 
severe indigestion, or continued pains in the stomach, 
which have been immediately relieved ; and in such, 

• Dr. Darwin names the genus Gutta Rosea, of which he savs, 
there are three species : — 1. The Gutta Ko%e2i hepatica^ connected with 
diseased liver in drunkards : 2. G. R. stomaticay which is occasioned by 
taking cold drink, eating cold raw turnips, &c. when the body is much 
heated by exercise ; and 3. The G. R. hereditaria^ or Puncta Rosea 
(the Acne simplex), which consists of smaller pimples, that are less 
liable to suppurate, and which seems to be hereditary, *' or at least has 
no apparent cause, like the others." See Zoonomia, class ii. 1. 4. 6.— 
and class iy. 1, 2. 15. and 14, 



334 tubercula: 

instances, there is occasionally also an eruption of 
lichenous papulae on the body and limbs. 

** The diagnosis is violent : it somewhat resembles 
Ecthjrma, but the tubercles of Acne differ from 
phlyzacious pustules of Ecthjrma by the indurated 
base which remains after the suppuration/* 

Being generally, however, a local disease, the 
Acne simplex is to be treated chiefly by external 
applications. Except in females, indeed, this variety 
of the eruption seldom calls for the attention of 
medical men. Celsus observes, that, in his time, the 
Roman ladies were so solicitous of maintaining their 
beauty, that he deemed it necessary to mention 
the remedies for this affection, which otherwise he 
considered as too trifling for the notice of the 
physician.* 

" The Editor does not accord with the author in 
regarding Acne as altogether a local disease. It is 
evidently a sjrmptomatic eruption, always indicating 
some morbid affection of the secreting or assimilat- 
ing functions. Thence the state of the system must 
be carefully examined before we can expect to cure 
the eruption. In very plethoric habits small bleed- 
ings, with a course of purgatives, will be found bene- 
ficial ; especially in females in whom the uterus is 
in a deranged condition. The blue pill, with pilula 
Aloes cum Myrrha, is a good aperient ; and at the 
same time the preparations of Iron, especially the 
Hydriodate of Iron may be administered, if the 
patient display a leucophlegmatic aspect. The 
diet should be light, and of easy digestion. I have 
found the Liquor Potassae in full doses useful.*' 

With regard to topical applications, the ancients 
agree in recommending a number of stimulant sub- 
stances, with the view of discussing the " thick 
humours" which were supposed to constitute the 

♦ ** Pene ineptiae sunt, curare varos, et lenticulas, et ephelidas : sed 
eripi tamen foemims cura cultus sui non potest/' De Med. lib. vi 
cap, V. 



ACNE. 335 

Vari. Lotions and liniments containing vinegar and 
honey, sometimes combined wiih an emulsion of Bit- 
ter Almonds, and sometimes with Turpentine, Resin, 
Myrrh, and other gums, or with Alum, Soap, and 
Cimolian earth, or the bruised roots of the Lily, 
Cyclamen, Narcissus, &c. were the substances which 
they principally employed, * They were, doubtless, 
correct as to the principle ; as a gentle stimulus to 
the skin is the most safe and effectual remedy. The 
apprehensions, which have been strongly expressed 
by the humoral pathologists, of producing internal 
disorder by the sudden repulsion, as it has been 
called, of these cutaneous eruptions, are not alto- 
gether hypothetical. Headache, and affections of the 
stomach and bowels, have sometimes been thus pro- 
duced, which have ceased on the re-appearance of 
the eruption : but, on the whole, as far as my ob- 
servation goes, this alternation of disease is less fre- 
quent and obvious in this form of Acne, than m 
the pustular and crustose eruptions of the face and 
head. 

The stimulant applications, which are most easily 
proportioned to the irritability of the tubercles, are 
lotions containing Alcohol, which may be reduced or 
strengthened, according to circumstances, by the ad- 
dition of any distilled water. It is not easy to de- 
scribe the appearances of the eruption, which indicate 
any certain degree of strength in the lotion ; but a 
little observation will teach this discrimination. If 
the tubercles are considerably inflamed, and a great 
number of them pustular, a dilute mixture will be 
requisite ; containing, for example, equal parts of spi- 
ritus tenuior, and of Rose or Elder-flower water. 
The effect of a very acrid lotion, under such circum- 



• See Celsus, loc. cit. — Oribas. Synops. lib. viii. cap. 34. ; and De 
Loc. Affect, lib. iv. cap. 51. — Aetius, tetrab. ii. serm. iv. cap. 13. — 
Paulus, lib. ill. cap. 25. — Actuarius, lib. iv. cap. 12. By the older mo- 
dern writers, who were chiefly their copyists, the same applications were 
prescribed. See Hafenre£fer, Nosodocliium, lib. it. cap. 14. 



336 TUBERCULA : 

stances, is to multiply the pustulus, to render many of 
them confluent, and to produce the formation of a crust 
of some extent, as well as to excite an inflammatory 
redness in the adjoining skin.* A slight increase 
of the inflammation, indeed, is sometimes occasioned 
by the first applications of a weak stimulus ; but this 
is of short duration, and the skin soon bears an 
augmentation of the stimulant ; until at length the 
pure spirit is borne with advantage, as the inflamma- 
tory disposition subsides. Under the latter circum- 
stances, even a considerable additional stimulus is 
often useful ; such as from half a grain to a grain or 
more of the Muriate of Mercury, in each ounce of the 
spirit ; or a drachm or more of the Liquor Potassse, 
or of the Muriatic Acid, in six ounces : " perhaps 
the best vehicle for either the Chloride of Mercury 
or the Liquor Potassae is the Emulsion of Bitter 
Almonds, containing ten minims of Hydrocyanic 
acid to each fluid ounce of the Emulsion.** Acetous 
acid, as recommended by the ancients, and the 
Liquor Ammoniae Acetatis, afford also an agreeable 
stimulant, in proper proportions. Sulphur yields a 
small portion of its substance to boiling water, 
poured upon it, and allowed to infuse for twelve or 
fourteen hours, a quart of water being added to 
about an ounce of broken Sulphur. A lotion of 
this nature has been found advantageous in slight 
cases of Acne simplex, and especially in removing 
the roughness and duskiness of the face connected 
with it.t 

* It must be admitted, however, that the eruption is sometimes ma- 
terially diminished, after the violent action of an irritating application 
has subsided. I lately saw a lady, who considered herself much bene- 
fited after a severe inflammation, and even excoriation, of the face, 
which had been produced by a poultice of bruised parsley. Dr. Darwin 
affirms that blistering the whole face, in small portions, successively, 
is the most effectual remedy for this Acne (loc. cit.). But the " cura 
cultus 8ui " generally renders patients of this class unwilling to employ 
harsh remedies. 

f This lotion has been recommended by Dr. Clarke of Dublin, as 
containing a sufficient impregnation of sulphur for the cure of Scabies 
in children. See Med. Facts and Observ. vol. viii. p. 275. 



ACNE. 337 

Species 2, Acne punctata^ Maggot Pimple. 

Syn. Punctae mucosae {Darwin) : lonthus varus 
punctatus ( Oood) : Crimones ( Underwood) : Orubs. 

The eruption, in this variety of the disorder, 
(Plate LXII. of Bateman ; PI. 23. of Thomson's 
Atlas,) consists of a number of black points, sur- 
rounded by a very slight raised border of cuticle. 
These are vulgarly considered as the extremities of 
small worms or grubs, because, when they are pressed 
out, a sort of wormlike appendage is found attached 
to them : but they are, in fact, only concreted 
mucus or sebaceous matter, moulded in the ducts 
of the sebaceous glands into this vermicular form, 
the extremity of which is blackened by contact 
with the air. In consequence of the distention of 
the ducts, the glands themselves sometimes inflame, 
and form small tubercles, with little black points on 
their surface, which partially suppurate, as in the 
foregoing species ; but many of them remain sta- 
tionary for a long period, without ever passing into 
the inflammatory state. Not unfrequently they are 
intermixed with a few tubercles, in which the puncta 
have not appeared. 

These concretions may be extracted, by pressing 
on both sides of the specks with the nails, until the 
hardened mucus is sufficiently elevated to be taken 
hold of. A blunt curved forceps may be employed 
with advantage for this purpose.* When the puncta 
are removed, the disease becomes Acne simplex, 
and requires the same treatment with the preceding 
species. 

Dr, Underwood has recommended the use of a 
solution of Carbonate of Potass internally, in these 
cases t; and Dr. Willan was in the habit of occa- 

* Such a forceps has been contrived by a surgeon's instrument- 
maker, of the name of Hattersley, in South-Molton Street. 

f See some observations relative to " crinones^ or grubs,'* which, he 
says, he had often found troublesome, especially m females, about 
the time of puberty. Treatise on the Dis. of Children, vol.ii. p. 167. 
5th edit. 



838 TUBERCULA : 

sionally prescribing the Oxymuriatic Acid. One or 
two tea-spoonfuls of this liquid, taken in a glass of 
water three times a day for a considerable period, 
has sometimes appeared to benefit the health, and 
improve the colour and smoothness of the skin ; 
but, on the whole, it is not easy to discover any 
sensible operation of this medicine, and its only 
eflFect is, perhaps, that of a tonic to the stomach. 
Medicines of this nature are more adapted to the 
subsequent species of the complaint, especially to the 
A. rosacea.* 

Species 3. Acne induratay Stone-pock. 

In this form of Acne (Plate LXIII. of Bate- 
man; PI. 22. of Thomson's Atlas,) the tubercles 
are larger, as well as more indurated and permanent, 
than in A. simplex. They rise often in consider- 
able numbers, of a conical, or oblong conoidal form, 
and are occasionally somewhat acuminated, as if 
tending to immediate suppuration, being at the same 
time of a bright roseate hue : yet many of them 
continue in a hard and elevated state for a great 
length of time, without any disposition to suppu- 
rate. Others, however, pass on very slowly to sup- 
puration, the matter not being completely formed in 
them for several weeks, and then only a small part 
of the tubercles are removed by that process. Some- 
times two or three coalesce, forming a large irregular 
tubercle, which occasionally suppurates at the se- 
parate apices, and sometimes only at the largest. 
In whatever mode they proceed, the vivid hue of 

* The Editor cannot concur in this opinion of Dr. Bateman : he has 
seen the skin completely cleared by the use of the following Alkaline 
Tonic for six weeks ; at the same time regulating the bowels : — 

^ Sulphatis Zinci gr. xxiy. 

Liquoris Potassse fS^ij. Solve. 
Sumantur guttse xxx ex cyatho aquse bis quotidie. 

^ The skin should be well cleaned with soap and hot water, or a solu« 
tion of pure Potass, or Ox-gall ; and well rubbed with a rough towel, 
night and morning. 



ACNE. 339 

the tubercles gradually becomes more purple or even 
livid, especially in those which show no tendency to 
suppurate. Slight crusts form upon the suppurating 
tubercles, which after some time fall off, leaving 
small scars, surrounded by hard tumours of the same 
dark red colour; and these sometimes suppurate 
again at uncertain periods, and sometimes slowly 
subside and disappear, leaving a purple or livid dis- 
colaratiou, and occasionally a slight depression, which 
is long in wearing oflF. 

The tubercles, even when they do not suppurate, 
but especially while they continue highly red, are 
always sore and tender to the touch ; so that wash- 
ing, shaving, the friction of the clothes, &c. are 
somewhat painful. In its most severe form, this 
eruption nearly covers the face, breasts, shoulders, 
and top of the back, but does not descend lower 
than an ordinary tippet in dress : yet this limitation 
of the disorder is independent of the exposure of 
those parts; for it occurs equally in men and wo- 
men. In a few instances in young men, I have 
seen an extensive eruption of Acne indurata affect- 
ing these covered parts, while the face remained 
nearly free from it. By the successive rise and pro- 
gress of the tumours, the whole surface, within the 
limits just mentioned, was spotted with the red and 
livid tubercles, intermixed with the purple discolor- 
ations and depressions left by those which had sub- 
sided, and variegated with yellow suppurating points 
and small crusts, so that very little of the natural 
skin aj^eared. Sometimes the black puncta of the 
sebaceous ducts were likewise mixed with the vari 
and their sequelae. 

The general health does not commonly suffer,, 
even under this aggravated form of the eruption.* 

* Forestus, and several other physicians of the sixteenth century, 
assert that vari are the precursors of Elephantiasis, and indicate its ap- 
proach. Sennertus asserts the same of vari, that are accompanied with 
puffy swelling (inflatio) of the face, and hoarseness. But these assertions 

Z 2 



340 TUBERCULA : 

If a fever or other severe disease should take place, 
indeed, the tubercles often subside and disappear; 
so that their recurrence, under such circumstances, 
is to be deemed a sign of returning health. I have 
seen the erethism of a mercurial course, admini- 
stered for other purposes, occasion the disappearance 
of this Acne, which returned with the restoration of 
flesh and strength, after the omission of the medi- 
cine. Many persons, however, who are affected 
with the eruption, are liable to disorders of the 
bowels and stomach, to Haemorrhoids, and some to 
Phthisis pulmonalis. Its first appearance, too, is 
commonly ascribed to some irregularity of diet, or 
to some cold substance swallowed when the person 
had been overheated, and was in a free perspir- 
ation. Hence the first eruption is not unfrequently 
sudden. 

The Acne indurata is often much alleviated " in 
the "first or inflammatory stage of the eruption by 
poultices, made with the decoction of Poppy Cap- 
sules, boiled until they are quite soft, and then 
strained by pressure through a cloth. After the 
tubercles have suppurated and discharged their con- 
tents, or have been opened,'* the disease is some- 
times entirely removed by the steady use of external 
stimulants, combined with a proper regulation of the 
diet and exercise. The eruption will bear a more 
acrid stimulus, even from the beginning, than the 
inflamed Acne simplex. A spirituous lotion, at first 
a little diluted, and containing the Oxymuriate of 
Mercury, in the proportion of a grain or somewhat 
less to the ounce of the vehicle, is often extremely 
beneficial. Gowland's lotion, an empirical prepar- 
ation, which is said to contain this mercurial salt in 



are obviously either the result of mere hypothesis, founded on the re- 
iemblance of the larger vari to the incipient tubercles of Elephantiasis; 
or of practical error, in applying the appellation of vari to the early 
fymptoms of the latter disease. See Forest. Obs. Chirurg. lib. v. obs. 7. 
Seonert. Med.Pract. lib. v. partii. cap. 2 J. 



ACNE. 341 

an emulsion of Bitter Almonds *, is popularly used ; 
and where its strength happens to accord with the 
degree of irritability in the eruption, and it is not 
applied to the other varieties of it, it is doubtless 
beneficial. Many other stimulants, some of which 
have been already named, may be substituted, of 
course, with similar effect ; but it is unnecessary to 
specify them. It will be proper to remark, that, in 
general, it is requisite to augment the activity of all 
these applications in the progress of the treatment, 
partly in consequence of the diminished effect of an 
accustomed stimulus, and partly on account of the 
increasing inertness of the tubercles, as the infiam- 
matory state subsides, which must be determined by 
the appearances. 

Frequent purgatives, which are often resorted to 
in these cases, especially by unprofessional persons, 
among whom the dregs of the humoral pathology 
still remain, are of no advantage ; but, on the con- 
trary, often augment the disease in feeble habits. 
" On the contrary, even where the tongue is furred, 
and indicates the use of an alterative, a tonic taken 
in conjunction with five or six grains of Plummer*s 
Pill at bed-time, for ten or twelve successive nights, 
proves often highly beneficial. As far as my ex- 
perience has enabled me to decide, the Carbonate of 
Soda, in doses of a drachm in twelve fluid drachms 
of Infusion of Cascarilla Bark, taken at noon and 
about four o'clock in the afternoon, daily, is the best 
tonic in this affection. The irritability of the stomach 
is allayed at the same time its tonic power is aug- 
mented." The copious use of raw vegetables in diet, 
which the misapplication of the term " scurvy" has 

* The bitter Almond was a favourite application with all the ancient 
physicians in inflammatory cutaneous eruptions. Its emulsion is pre- 
scribed, as a vehicle of more active substances, in every tract which tiiey 
have left on these subjects. Yet it is probably a mere agreeable 
mucilage. 

" This note was written before the fact that the Bitter Almond con- 
tains a large portion of Hydrocyanic Acid was known." T. 

z 3 



342 TUBERCULA : 

introduced, is to be deprecated, as well as the free 
use of vegetable acids, especially in constitutions that 
are predisposed to indigestion. These substances 
not only afford little nutriment, under such circum- 
stances, but tend to increase the indigestion : and it 
is a fact, which it may not be easy to explain, that 
under many modifications of cutaneous inflammation, 
especially about the head and face, that inflammation 
is immediately increased in sympathy with the of- 
fended stomach, when these substances are eaten. 
It were totally superfluous to remind professional 
men of the very opposite nature of inflammatory 
and suppurating affections of the skin, to that of 
petechiae and ecchymoses, the mere eflRisions of extra- 
vasated blood under the cuticle, which belonged to the 
proper, or, as it has been called, the putrid scurvy. 
And this negative inference at least must be deduced 
from the fact, that it is almost impossible that these 
two opposite states of disease should be benefited by 
the same remedies. The diet, in these cases of 
Acne, should be good, ^. e, light and nutritious, but 
not stimulating ; consisting of animal food, with well- 
dressed vegetables, and the farinaceae ; wine and fer- 
mented liquors being omitted, or taken with great 
moderation. 

Internally, medicines effect little ; but 1 have had 
an opportunity, in several severe cases of Acne tu» 
berata, of witnessing the increased amendment of the 
disorder, under the external treatment already men- 
tioned, when small doses of Soda, Sulphur, and Anti- 
mony were at the same time administered ; by which 
plan the skin has been totally cleared. 

Species 4. Acne rosacea*, Rosy Drop. 
Si/n. Bacchia (Linri). : Gutta Rosea (Sauv. 
Darwin) : Gutta Rosacea OEnopotarum (Plenck) : 

* This is the Gutta rosea, or rosacea of authors ; some of whom, 
however, (as Dr. Darwin, to whom I have already referred,) comprehend 
all the varieties of vari under that appellation. 



ACNE. 3i}3 

lonthus Coryrabefer ( Good) : Roth-gesicht, Roth- 
nase Kupferbandel ( Oerman) : Couperose Rougeurs, 
Goutte Rose (i^.) : Carbuncled face. 

This form of Acne (Plate LXIV. of B axeman ; 
PI. 23. of Thomson's Atlas,) differs in several 
respects from the preceding species. In addition to 
an eruption of small suppurating tubercles, there is 
also a shining redness, and an irregular granulated 
appearance of the skin of that part of the face which 
is affected. The redness commonly appears first at 
the end of the nose, and afterwards spreads from both 
sides of the nose to the cheeks, the whole of which, 
however, it very seldom covers. In the commence- 
ment it is not uniformly viyid ; but is paler in the 
morning, and readily increased to an intense red after 
dinner, or at any time if a glass of wine or spirits be 
taken, or the patient be heated by exercise, or by 
sitting near a fire. After some continuance in this 
state, the texture of the cuticle becomes gradually 
thickened, and its surface uneven or granulated, and 
variegated by reticulations of enlarged cutaneous 
veins, with smaller red lines stretching across the 
cheeks, and sometimes by the intermixture of small 
suppurating variy which successively arise on different 
parts of the face. 

This species of Acne seldom occurs in early life, 
except where there is a great hereditary predisposition 
to it : in general it does not appear before the age of 
forty ; but it may be produced in any person by the 
constant immoderate use of wine and spirituous liquors. 
The greater part of the face, even the forehead and 
chin, are often affected in these cases ; but the nose 
especially becomes tumid, and of a fiery red colour ; 
and, in advanced life, it som^imes enlarges to an 
enormous size, the nostrils being distended and patu- 
lous, or the alae fissured, as it were, and divided into 
several separate lobes.* At that period of life, too, 

• 

"* Sennert mentions a case, in which the enlarging nose made such 
an approximation in magnitude to Strasburg steeple, as to impede the 

Z 4 



344 TUBERCULA : 

the colour of the Acne rosacea becomes darker and 
more livid ; and if suppuration takes place in any of 
the tubercles, they ulcerate unfavourably, and do not 
readily assume a healing disposition. 

In young persons, however, who are hereditarily 
predisposed to this complaint, irregular red patches 
not unfrequently appear in the face, which are often 
smooth, and free from tubercles, and sometimes 
throw oflF slight exfoliations at intervals. These 
patches may be gradually extended, if great tem- 
perance both in food and drink be not observed, 
until the whole face assume a preternatural redness. 

As this eruption is chiefly sympathetic of some 
derangement of the chylopoietic viscera, or of a 
peculiar irritability of the stomach, little advantage 
can be expected from local applications : and, in 
fact, the stimulants, which are beneficial, under 
proper regulations, in most of the other forms of 
Acne, are generally prejudicial in this, and aggra- 
vate the complaint. The misapplication of the 
nostrum, before mentioned, to this variety of the 
eruption, is one among the numerous practical 
errors which originate from the indiscriminate re- 
commendations of empiricism. On the other hand, 
all strong sedatives or restringents, if they succeed 
in repressing the eruption, are liable to aggravate 
the internal disorder. 

The perfect cure of Acne rosacea is, in fact, 
seldom accomplished ; for, whether it originate in 
SL strong hereditary predisposition, or from habitual 
intemperance, the difficulties in the way of cor- 
recting the habit of body are almost insurmount- 



exercise of vision, and to require lopping. " Sumunt tubercula ista 
interdum incrementum, ut fades in aequalis et horrida evadat, et nasus 
yalde augeatur. Vixit superiori adhuc anno, non procul a Dresdd, vir, 
ciii hoc malo affecto, nasus ita incrementum sumsit, ut eum in legendo 
impediret; quod malum ipsum eo adegit, ut anno 1629 particulas 
quasdam de naso sibi amputari curaret.** Pract. Med. lib. v. part. i. 
cap. Jl. 



SYCOSIS. 345 

able. The regulation of the diet, in both cases, is 
important ; " the bowels should be kept lax by 
gentle aperients ; for instance, the Hydrargyrum 
cum Creta, in doses of from ten to twelve grains, 
may be given every night at bed-time : ** and when 
the stomach or liver is disordered, the symptoms may 
be sometimes palliated by the Liquor Potassse, or 
other antacids, which seem also to have some 
influence in lessening inflammatory action in the 
skin. " The Editor is of opinion that much of the 
difficulty attending the treatment of Acne rosacea 
has arisen from giving the Liquor Potassae in too 
small doses : he has seldom seen it fail to relieve 
the disease when the dose has been gradually car- 
ried to sixty or eighty drops three times a day. 
The best vehicle for giving the Liquor Potassae in 
is the Bitter Almond Emulsion.'* When the habit is 
weak, the Hydriodate of (Iron, in doses of ftj, which 
is equal to gr. iij of the loduret, will be found useful. 
The gentlest astringents should be used externally 
to the patches of reticulated veins ; such as very dilute 
spirituous or acetous lotions, with or without a small 
proportion of the Acetate of Lead j or simple oint- 
ments combined with Alum, Acetate of Lead, &c., in 
small quantities. The more purely local and pri- 
mary the eruption appears to be, the more active 
may be the astringency of the substances applied 
to it. 



Genus V. — SYCOSIS. 



Syn. Ulcus (roxaxng (Celsus): Sycoma, Ficus, 
Phymus, Condyloma, Herpespustulosus(^wc<. J^ar.): 
Montagna (Plenck): Sycosis (Pog. Swed.)\ Phyma 
sycosis ( Good) : Sycose, Montague, Dartne pustu- 
leuse (^•)- Feigwarzen (^Gei\) i Vyggezweel 
{Dutch) \ Vhxk {Scotch). 



346 TUBERCULA : 

Def. An eruption of inflamed, fleshy, dark- 
ish-red TUBERCLES ON THE BEARDED PORTION OF 
THE FACE, AND ON THE SCALP ; GREGARIOUS ; OFTEN 
COALESCING ; DISCHARGE PARTIAL, VISCID, AND 
SANIOUS. 

Although this eruption was not mentioned in 
the enumeration of Tubercles, on the cover of 
Dr, Willan's publication, I believe he intended, 
after the example of the old writers, to introduce it 
in this place, in consequence of its aflBnity to Acne. 
Britt, Rayer, and Alibert regard it as of pustular 
origin ; and the tubercles are arising during the pro- 
gress of the disease. 

Celsus has correctly stated, that some diflFerence 
takes place in the appearance and progress of the 
eruption, when it is seated in the chin, and in the 
scalp ; whence it may be divided into two species * : 

1. S. menti. 

2. S. capillitii. 

It sometimes appears on the pubes. 

SpeciesI. Sycosi^\ mentiy Sycosis of the Beard. 
Syn. Sycosis Barbae (Cfe&i^): Mentagra(P/e7icA;): 

* " Sub eo vero duae sunt species. Altera ulcus durum et rotun- 
dum est ; altera humldum et inaequale. Ex duro exiguum quiddam 
et glutinosum exit : ex humido pus, et mali odoris. Fit utnimque in 
iis partibus quse pilis conteguntur: sed id quod callosum et rotundum 
est maxime in barba; id vero, quod humidum, praecipue in capillo/' 
loc. cit. 

\ This denomination has been given to the disease, from the gra^ 
nulated and prominent surface of the ulceration which ensues, and 
which somewhat resembles the soft inside pulp of a fig {(tvkov), " Est 
etiam ulcus^ quod a fid similitudine avKiaaig \ Graecis nominatur, quia 
caro in eo excrescit." Celsus, lib. vi. cap. 5. The later Greeks, how- 
ever, apply the terms <jvKa and oyKoi cvKiodeig {fid, and fieose tu^ 
mours,) to excrescences of the eyelids, as well as to the proper Si/cosit 
of Celsus. See Aetius, tetrab. i. serm. ii. cap. 80. & 190.; — also tetr. ii. 
serm. iii. cap. 47. ; Paul. ^gin. lib. iii. cap. 22. ; — and Actuarius, lib. ii. 
cap. 7. Paul, however, describes the Sycosis of the face as an erup- 
tion of" round, red, somewhat hard, painful, and ulcerating tubercles.'* 
(Lib. iii. cap. 3.) And Aetius,^ in another place, mentions the eruption 
as " one of the affections of the chin, which," he says, " differs from 
Acne, in the nature of the humour which it discharges, and in its 
greater tendency to ulceration." (Tetrab, ii. serra.iv. cap. 14.) 



SYCOSIS. 347 

Dartre pustuleuse mentagre ; Herpes pustulosus 
mentagra (^Ubert) : Boutons bilieux (M. lietz.) : 
Phyma Sycosis Barbae ( Good) : der Kieferaustatz 
(German) : Pluky chin (Scotch). 

In this species (Plate LXV. of Bateman ; PI. 
24. of Thomson's Atlas,) the tubercles, ** which are 
preceded by an irritable state of the skin of the face,*' 
arise first on the under lip, or on the prominent part 
of the chin, in an irregularly circular cluster ; but 
this is speedily followed by other clusters, and by dis- 
tinct pustular tubercles, each penetrated by a hair, 
which appear in succession, along the lower part 
of the cheeks up to the ears, and under the jaw 
towards the neck as far as the beard grows.* The 
tubercles are red and smooth, and of a conoidal 
form, and nearly equal to a pea in magnitude. 
Many of them continue in this condition for three 
or four weeks, or even longer, having attained their 
full size in seven or eight days ; but others sup- 
purate very slowly and partially, discharging a 
small quantity of yellowish-white thick matter, by 
which the hairs of the beard are matted together, so 
that shaving becomes impracticable, from the tender 
and irregular surface of the skin. This condition of 
the face, rendered rugged by tubercles from both ears 
round to the point of the chin, together with the 
partial ulceration and scabbing, and the matting 
together of the unshaven beard, occasions a con- 
siderable degree of deformity; and it is accom- 
panied also with a very troublesome itching. " Some- 
times the pustular tubercles extend over the hairy part 
of the neck.'* 

This form of the Sycosis occurs, of course, chiefly 
in men ; but women are not altogether exempt 
from it, though it is commonly slight when it ap- 
pears in them. " Its exciting causes also, namely, 

* An indifferent representation of this disease is given by Alibert, 
plate 20., under the appellation of " Dartre pustuleuse mentagra." 



848 TUBERCULA : 

luxuries of the table, and the use of alcoholic liquors, 
are more likely to occur in men. Persons who are 
much exposed to fire heat, such as cooks, glassblowers, 
and such like, are also subject to this eruption : but 
the most causes of it are diseased conditions of the di- 
gestive organs. It has been supposed that the disease 
is seated in the sebaceous follicles ; but although these 
may be aflFected, yet it is by no means certain that 
they are its original seat. In the minute dissections 
of M. Gendrin, these follicles were unaffected : the 
rete mucosum was infiltrated by a yellowish jelly-like 
substance, exuding from a vascular net-work.* Its 
duration is very uncertain : it is commonly removed 
in about a fortnight ; but sometimes the slow suj^u- 
ration goes on for many weeks ; and sometimes the 
suppurating tubercles heal, and again begin to dis- 
charge. Occasionally the disease disappears for a 
season, and breaks out again* 

Species 2. Sycosis capillitiif. Sycosis of the 
Scalp. 

St/n. Sycosis capilli ( Celsus) : Phjona sycosis ca- 
pilli ( Good) : Pian ruboide (Alibert). 

This species (Plate LXVI. of Bateman ; PI. 23. 
of Thomson's Atlas,) is seated chiefly about the 
margin of the hairy scalp, in the occiput, or round 
the forehead and temples, and near the external ear, 
which is also liable to be included in the eruption. 
The tubercles nse in clusters, which affect the circular 
form ; they are softer and more acuminated than those 
on the chin; and, they all pass into suppuration in 
the course of eight or ten days, becoming confluent, 
and producing an elevated, unequal, ulcerated surface, 
which often appears granulated, so as to afford some 
resemblance to the internal pulp of a fig. The ul- 
ceration, as Celsus states, is generally humid j for 

* Hist. Anat. des Inflammations, t. i. p. 457. 

•|- M. Alibert has figured a disease of the scalp, under the appellation 
of *' Pian ruboide,'* in plate 35., which resembles the Sycosis of the scalp, 
if it be not a case of neglected or mismanaged Porrigo favosa. 



SYCOSIS. 349 

there is a considerable discharge of a thin ichorous 
fluid, which emits an unpleasant rancid odour. 

The Sycosis, under its first-mentioned form, may 
be distinguished from Acne indurata by its seat 
being exclusively on the bearded part of the face, 
— by the softer, more numerous, and clustered 
tubercles, — and by the ulceration which they tend 
to produce. And, under its second form, in which 
it is somewhat assimilated to the eruption of favous 
pustules, or Porrigo favosa, affecting the face and 
the borders of the capillitium, it may be discrimi- 
nated by the tuberculated and elevated base of the 
suppurating tumours ; not to mention the adult 
age of the patient, and the absence of contagion. 

The cure of Sycosis is generally much more 
easily accomplished than that of Porrigo favosa ; 
but the method of treatment required for it is not 
very different. " With regard to local applications. '* 
when the tubercles are numerous, inflamed, and con- 
fluent, and especially when the suppuration is either 
beginning or considerably advanced, the most speedy 
benefit is derived from the application of poultices at 
night, of linseed powder, bread and milk, or omer 
simple ingredients.* In the less severe forms, warm 
ablutions or fomentations may be substituted : <* or the 
topical vapour bath containing sulphur : and then 
the parts bathed with the black wash. The tubercles 
should be punctured, and the hairs extracted.'* When 
the inflammatory symptoms are reduced, and in cases 
where they are from the first moderate, the healing 
process is much promoted, and the discharge moderated 
and restrained, by the application of the Unguentum 
Hydrargyri Nitratis, diluted with three or four Parts 
of simple ointment, or by the Ung. Hydrargyri prae- 
cipitati united with an equal portion of the Zinc Oint- 
ment, or the Cerate of Acetate of Lead, " or lotions of 

• 

* Super utrumque oportet imponere elaterium, aut lini semen con- 
tritum et aqua coactum, aut ficum in aqua decoctam. — Celsus, T. 



350 TUBERCULA : 

the Sulphate of Zinc. The ulcerated tubercles nmy 
be touched with Sulphate of Copper, or, what is 
better. Nitrate of Silver. As general remedies, it is 
useful to prescribe Antimonials, with alterative doses 
of Mercury, followed by Cinchona, or Serpentaria, 
and the fixed alkalies, especially where there appears 
to be any affection of the digestive organs, which, not 
unfrequently, concurs with this eruption. " In ob- 
stinate cases the Arsenical Solution is a useful tonic.** 

Books which may he consulted on Sycosis . 

Alibert, Maladies de la Peau, fol. 1814. 
BiETT, Dictionnaire de M^decine, art, Mentagra . 
,x'^LUMBE (Sam.), a Practical Treatise of the Diseases of the Skin, 8vo. 
1827. 
Rayeb, Traits des Maladies de la Peau, 8vo. 1826. 
ScHEDEL et Cazenave, Abrege pratique des Maladies de la Peau, 1828. 



Genus VL LUPUS. 

Syn. Cancer Lupus (^Sauv.): Ulcus Tubercu- 
losji^ ( Good) : Formica corrosiva : Ignis sacer ; 
Noli me tangere (Auct. J^ar.) : Dartre rongeante 
idiopathique, Herpes exedens idiopathicus (^Aliberf) : 
Dartre rongeante (i^.). 

Of this disease I shall not treat at any length ; 
for I can mention no medicine which has been of 
any essential service in the cure of it, and it requires 
the constant assistance of the surgeon, in conse- 
quence of the spreading ulcerations, in which the 
original tubercles terminate.* (Plate LXVIL of 
Bateman.) 

The term was intended by Dr. Willan to com- 

• Alibert has two admirable portraits of Lupus in the face, in plates 
\9h%s, and 21 ; the former of Noli me tangere, which he calls ** Dartre 
rongeante scrophuleuse ;" and the latter of a less malignant variety, 
which he terms " Dartre pustuleuse couperose." His 19th plate is ap- 
parently an incipient Lupus of the ala nasi, under the appellation of 
« Dartre rongeante idiopathique." 



LUPUS. 351 

prise, together with the " noli me tangere^^ affecting 
the nose and lips, other slow tubercular affections, 
especially about the face, commonly ending in ragged 
ulcerations of the cheeks, forehead, eyelids, and lips, 
and sometimes occurring in other parts of the body, 
where they gradually destroy the skin and muscular 
parts to a considerable depth. Sometimes the disease 
appears in the cheek circularly, or in the form of a 
sort of ringworm, destroying the substance, and 
leaving a deep and deformed cicatrix : and I have 
seen a similar circular patch of the disease, dilating 
itself at length to the extent of a hand-breadth or 
more upon the pectoral muscle. " Alibert mentions 
having seen instances in which it attacked the loins ; 
and in one case the thigh was the site, and the disease 
proved fatal/' 

^Y surgical means, i.e. by the knife or the caustic, 
a separation has sometimes been made of the morbid 
from the sound parts, and the progress of the disease 
arrested. ** I have employed the Nitrate of Silver 
with much advantage in some cases, extending the 
application beyond the limits of the ulceration. " In 
one case, in which disease was rapidly cured, the Hy- 
driodate of Iron was internally administered in doses 
of sixty minims of a solution containing three grains 
in the drachm, in the Infusion of Quassia : and much 
of the rapidity of the cure was undoubtedly attribut- 
able to the Hydriodate.*' Mr. Plumbe states that 
in two cases he applied the Nitric Acid freely, and 
produced a healthy sore which readily healed. 

In some cases, where the ulceration was very slow, 
and unaccompanied by much inflammation, the inter- 
nal use of Arsenic has been found beneficial. " M. 
Dupuytren has lately found that it is a specific when 
externally applied, in conjunction with Calomel. 
His formula is the following powder : 

gL. Hydrargyri submuriatis praecip., partes 199 ; 
Oxidi Arsenic! albi, partem 1 : 

Tere optime. 



S5^ TUBERCULA : 

" If any crust cover the surface, let it first be re- 
moved by a poultice or other means ; then sprinkle 
the sore with the above powder, by means of a 
little puflF. The sore puts on a healthy character 
and heals under this management. If the powder 
do not adhere, it may be mixed with Gum Arabic 
in powder, augmenting the quantity of the Ar- 
senic/* The circumstance that Arsenic cures Lupus 
has, probably, given rise to the opinion that Cancer 
has been cured by that mineral. " In both diseases, 
much caution is requisite in the application of Ar- 
senious Acid to a denuded or ulcerated surface. The 
acid is absorbed, and may display its secondary or 
constitutional influence when least expected ; and be 
followed by the most dangerous results.*' In three or 
four less severe cases of lupous tubercles in the face, 
which had made no progress towards ulceration, I 
have seen the Solution of Muriate»of Barytes, taken 
internally, materially amend the complaint. 

Books which mat/ be consulted on Lupus. 

Patrix, PArt d'appliauer le Caustique Arsenical, S^o, 1817. 
Plumb£ on Diseases ot the Skin, 8vo. 1827. 
Rayer, Traits des Maladies de la Peau, 8vo. 1826. 



Genus VII. ELEPHANTIASIS. 

y^sopriatrigf ^JXcbcXe/ov Tra^og (O.): Vitiligo ( CelsiLs) : 
Ulcus universale {Paul. Egin.) : Elephantiasis {Sag. 
Cull. Swed.): Elephantiasis Indica (Sauv.): Ele- 
phanta Arabum ( Fog. ) : Elephantiasis Arabica, Lepi- 
dosis lepriasis (Oood) : Lepra Elephantiaca seu Ara- 
bica (^z^c^.): Malmort, Mai rouge-l^pre des jointures 
(i^.): Koostum {Tam.)\ Ruggit pittee \Duk.)i 
Pedda-rogum( Tel.)\ Vh^nghum, Koosthum(iS'a/w.): 
Dzudham {Arab.) : Khorah {Hind.) : Der Elefan- 



ELEPHANTIASIS. 35S 

tenaussatz, der Aussatz, die Feldsucht ( Oerman) : 
Fattenbruch, Oilschenkel (Dutch) : Lazery, olifants 
zickte (Dan.) : Spedalshed (Swed.) : Lebbra, olefan- 
tiasi (Ital.) : Msd de la rosa (Span.) : Radesyge, 
Syedalsahed (Norwegian) : Black Leprosy. 

As the Elephantiasis is almost unknown in this 
country, and I have only seen four instances of 
the disease, I must speak of it principally as it is 
described in books; and should have omitted the 
subject altogether, had it not appeared to me that 
some comment on the mistakes of translators and 
their followers, as well as on the history of the disease 
in general, might contribute to put the matter in a 
clearer light than that in which it now stands. 

The Elephantiasis (Plate LXVIIL of Bateman) 
(as described by the Greeks*) is principally cha- 
racterised by the appearance of shining tubercles, 
of different sizes, of a dusky red or livid colour, ou 

* The terms kXt^aq and k\i<ltavTiaat,Q were applied to this tubercular 
disease by Aretaeus, and the succeeding Greek writers, partly, perhaps, 
on account of some resemblance of the diseased skin to that of tne 
elephant ; but principally from the formidable severity and duration of 
the disease. '* For it is disgusting to the sight," says Aretseus, " and 
in all respects terrible, like the beast of similar name." (De Diutum. 
Morb. lib.ii. cap. 15.) And Aetius observes, '' Elephantiasis quidem \ 
magnitudine et diuturnitate nomen accepit." (Tetrabibl. iv. serm. i. 
cap. 1 20.) So also the poet : — 

*^Est leprse species, elephantiasisque vocatur, 
Quse cunctis morbis major sic esse videtur 
Ut major cunctis elephas animantibus exstat." 

Macer de Herbar. Virtut. 

The same disease was described by the Arabians, under the appellation 
of Juzam or Judam, and is still designated by similar terms in Arabia 
and Persia, viz. Dsjuddam, and Madsjuddam, according to Niebuhr. 
(Description de I'Arabie, tom. iii. p. 119.) The translators, however, of 
the works of the Arabian physicians into Latin, committed an extras 
ordinary blunder, in rendering this appellation by the Greek term Lepra ; 
by which they misled their brethren (who henceforth called Elephan- 
tiasis the Arabian Leprosy)^ and contributed to introduce much con- 
fusion both into medical and popular language in the use of the term. 
The Arabians have not employed the word Lepra ; but have designated 
the varieties of scaly and tubercular diseases by appellations in their 
own language, as distinct and definite as those oi the Greeks. (See 
Avicenna, lib. iv. fen. 5. tract. 3. — Alsaharavius, tract. 31. — Haly Abbas^ 
Theoric^ lib. viii. cap. 15., and Pract. cap. 14. — Avenzoar, lib. li.) 

A A 



S54 TUBERCULA : 

the face, ears^ and extremities ; together with a 
thickened and rugous state of the skin, a diminution 
or total loss of its sensibility, and a falling off of all 
the hmr, except that of the scalp. 

The disease " is said seldom to appear in youth ; 
but the only case of it which the editor ever saw, 
was that of a boy of fourteen years of age, a native of 
Jamaica, in whom the disease developed itself two 
months after he arrived in this country/' It is 
described as very slow in its progress, sometimes 
continuing for several years, without materially de- 
ranging the functions of the patient. During this 
continuance, however, great deformity is gradually 
produced. The alse of the nose become swelled 
aad scabrous, and the nostrils dilate ; the lips are 
tumid ; the external ears, particularly the lobes, are 
enlarged and thickened, and beset with tubercles ; 
tlie skin of the forehead and cheeks grows thick and 
tumid, and forms large and prominent rugse, espe- 
cially over the eyes : the hair of the eyebrows, the 
beard, the pubes, axillse, &c. falls off; the voice be- 
comes hoarse and obscure ; and the sensibility of the 
parts affected is obtuse, or totally abolished,, so that 
mnching or puncturing them gives no uneasiness.* 
This disfiguration of the countenance suggested the 
idea of the features of a satyr or a wild beast j whence 
the disease was by some called Sdtyriasisf, and by 
others Leontidsis .% 

* From an interesting account of the Elephantiasis by Mr. Robinson, 
a resident in India, it appears that this insensibility occurs only in the 
Barat or Leuce; his description of which will be found in a subsequent 
page. 

f The term Satyriasis, or Satyriasmos, was also deemed applicable to 
the disease, on account of the excessive libidinous disposition siud to be 
connected with it. See Aretseus, loc. cit. ; and Aetius, tetrab. iv. serm. i. 
cap. 120. But in all the cases which I have seen, they produced the 
contrary condition, destroying both the power and the appetite. Mr. 
Robinson, however, says that its first effect is an increase of the vene- 
real passion, which becomes lost during its progress. 

•f- The two Greek writers, just quoted, attribute this name to the 
laxity and wrinkles of the skin of the forehead, which resembles the 
prominent and flexible firont of the Uon, But the Arabian writers 



ELEPHANTIASIS. 355 

As the malady proceeds, the tuhereles begin to 
cracky and at length to ulcerate : nlcerations also 
appear in the throat, and in the nose, which some- 
times destroy the palate and the cartilaginous sep- 
tum } the nose falls ; and the breath is intolerably 
offensive : the thickened and tuberculated skin of the 
extremities becomes divided by fissures, and ulcer- 
ates, or is corroded under dry sordid scabs, so that 
the fingers and toes gangrene, and separate joint 
after joint. * 



ascribe it to a different source. Haly Abbas says the counteaance wa» 
called leonine, because the white of the eyes becomes livid, and the eyes 
of a round figure ; and Ayicenna observes that the epithet was applied 
to the disease, because it renders the countenance terrible ta loot at, 
and somewhat of the form of a lion's visage : loc> cit. These appellations 
prove that the allusions were entirely metaphorical, and did not refbr 
to any resemblance in the skin of patients to the hide of these heart Sb-;- 
M. Alibert has figured two varieties of Elephantiasis; viz. in plate 5^^ 
under the title of *' Lepre tuberculeuse," where it is incipient on the 
eyebrows; and, in plate 54., affecting the nose and Ifps, where it is 
called " Lepre leontine." His ** L^pre elephantifviis," plate 23., is the 
Barbadoes leg. 

* Alsaharavius thus states the symptoms of the Jtizamy when fiilly 
formed:*-^'* The colour of the skin is changed, the voice is Iqsl^ the 
h^s have entirely disappeared ; the whole simace of the body is ulcer- 
ated, discharging a putnd sanies, with extreme foetor ; the extremities 
begin to fall off, and the eyes weep profusely.' - Lib. Practice, tract. 31. 
cap. 1. 

" The accuracy of this description is confirmed by Dr. Kinnis^s very 
minute detail of the symptoms of the disease, as it appears in the Isle 
of France.* He describes the tubercles as differing in form, being flat, 
oval, and irregular : larger on the forehead and bridge of the nose, but 
smaller and more confluent on the cheeks, * which,' he remarks, ' some- 
times hang down from the bones, stretching and depressing the corners 
of the mouth.' He further says, * the lips, when affected, were pene^ 
trated by hard, whitish bodies, like recently*formed cicatrices.' The 
tumours are not confined to the external surface, but, according to 0r, 
Kinnis, are observed in the mouth, on the palate, uvula, fauces, an4 
tonsils, of a yellowish-rpd or a red colour, smooth, shining, and about 
the size of a split pea: yet so little inconvenience was experienced by 
the affected from these tubercles in the mouth, that * one or two were 
not even aware of their existence previous to examination.' It is a 
curious fact, that the palms of the hands and the soles of the feet were 
seldom tuberculated in those cases which Dr. Kinnis examined. He found 
the pulse generally weak, ' and above a hundred in a minute.'" T, 



'*' Edinburgh Med, and Surg. Jouru. vol. xxil. pp. 286— '294. 

A A 2 



356 TUBERCUI.A : 

Aretaeus and the ancients in general consider Ele- 
phantiasis as an universal cancer of the body, and 
speak of it with terror : they depict its hideous and 
loathsome character, its contagious qualities, and its 
unyielding and fatal tendency, in strong metaphorical 
language, which, indeed, tends to throw some doubt 
on the fidelity of their description. The very ap- 
propriation of the name is poetical ; and Aretaeus 
has absurdly enough prefixed to his description of 
the disease an account of the elephant, in order to. 
point out the analogy between the formidable power 
of the beast and of the disease. It is probable that 
his terrors led him to adopt the popular opinion re- 
specting the] malady, without the correction of per- 
sonal observation : for, although his account has been 
copied by subsequent writers *, and the same popular 
opinions have been constantly entertained, there is 
much reason to believe that some of the prominent 
features of his portrait are incorrectly drawn. 

Notwithstanding the care with which the sepa- 
ration and seclusion of lepers have been enforced, in 
compliance with the ancient opinion, there is great 
reason to believe that Elephantiasis is not contagi- 
ous. t M. Vidal long ago controverted that opinion, 
having never observed an instance of its communi- 
cation from a leprous man to his wife, or vice versdts 

* It is impossible to read the description of this disease (as said to 
•ccur at Barbadoes) by the learned Dr. Hillary, without a convictioii 
that that respectable physician had in his mind the history detailed by 
the eloquent Greek (Aretaeus), and not the phenomena of the disease, 
as he had himself seen it. See his Obs. on the Air and Dis. of the . 
Island of Barbadoes, p. 322., sd edit. 

f Turner quotes from several ancient autliors to prove its contagious, 
nature. — Treatise on Diseases of the Skin, 4th edit. p. 1 4, 1 5. T. 

t See his Recherches et Obs. sur la Lepre de Martigues, in the M^m. 
de la Soc. Roy. de M^d. tom.i. p. 169. — Dr. Joannis, a physician at. 
Aix, who investigated the disease in the lazar-house at Martigues, in 
1755, also asserts the rarity of its communication between marned per- 
sons. See Lond. Med. Obs. and Inquiries, vol. i. p. 204. — Indeed, 
several able physicians, two centuries before, though bending under the 
authority of ancient opinion, yet acknowledged their astonishment at 
the daily commerce or lazars with the healthy, without any communi- 



ELEPHANTIASIS. SS7 

although cohabiting for a long series of years. Dr. 
T. Heberden daily observed many examples of the 
same fact in Madeira, and affirms that " he never 
heard of any one who contracted the distemper by 
contact of a leper.*' Dr. Adams has given his testi- 
mony to the same truth, remarking, that none of 
the nurses in the lazar-house at Funchall have shown 
any symptoms of the disease ; and that individual 
lazars have remained for years at home, without in- 
fecting any part of their family.* " Dr. Whitlaw 
Ainslie, who saw many cases of the disease in India, 
is decidedly of this opinion ; but he regards it as 
hereditary. Its non-contagious nature is also con- 
firmed by Dr. Kinnis.'* 

With respect to the libido inexplebilis, which is 
said to be one of the characteristics of Elephantiasis, 
the evidence is not so satisfactory. Its existence, 
however, is affirmed by most of the modem writers, 
with the exception of Dr. Adams " and Dr. Kinnis.'* 
MM. Vidal and Joannis mention it among the symp- 
toms of the disease at Martigues.t Dr. Bancroft, 
senior, states its occun'ence in the Elephantiasis of 
South America t: and Professor Niebuhr asserts, that 
it appears in the Dsjuddam of Bagdat.§ But Dr. 
Adams observed, on the contrary, in the lazars of 
Madeira, an actual wasting of the generative organs 



cation of the disease. See Fernel, de Morb. Occult, lib.i. cap. 12. : 
Forest. Obs. Chirurg. lib. iv. obs. 7. : also the works of Fabricius, 
Plater, &c. Fernel, indeed, admits that he never saw an instance which 
proved the existence of contagion. 

* See his Obs. on Morbid Poisons, 2d edit. chap. 1 8. 

f M. Vidal particularises the case x)f Arnaud, a sailor, who had been 
afflicted with the tubercular Elephantiasis six months, when he died of 
putrid fever. •* II n'avoit cess^, presque jusqu' k sa mort, de ressentir 
les ardeurs d'un assez violent Satyriasis." 

J " Lepers are notorious for their salacity and longevity." Nat. Hist, 
of Guiana, p. 385. 

§ Loc. cit. The story related by Niebuhr, of a lazar gratifying this 
propensity by infecting a woman by means of linen sent out of the 
lazar-house, and thus obtaining her admission, appears, however, to be 
entitled to little credit. 

A A 3 



S58 TUBERCULA I 

in men who had been seized with the malady sub- 
sequent to the age of puberty, and a want of the 
usual evolution o£ them in those who had been 
attadced previous to that period.* Is the El^han- 
tissis in Madeira now less virulent than tb^ of 
former times ? has it undergone some change in its 
char^ter? or is the ancient account of the disease 
incorrect ? " Elephantiasis is very prevalent in the 
island of Java ; and a Dutch physician, on whose 
authority this is stated, observed that . it attacked 
women more rarely than men/' 

It is generally affirmed, that the Elephantiasis was 
extensively prevalent in Europe, in the middle ages, 
especially subsequent to the crusades ; and it is cer- 
tain that every country abounded with hospitals, 
established for the exclusive relief of that disease, 
from the tettth to the sixteenth century t ; and that, 
an order of knighthood, dedicated to an imaginary 
St. Lazants, was instituted, the members of which 
had the care of lepers, and the control of the laza- 
rettoes, assigned to them, and ultimately accumulated 
immense wealth. From these facts, however, nothing 
satisfactory is to be collected, respecting the actual 
prevalence of Elephantiasis at those periods. For 
although it is obvious, from the nature of the exa- 
mination instituted by the physicians of those laza- 
rettoes, that the tubercular disease was the object of 
their iliquiry, yet it is also evident that, in con- 
se^ence of the general application of the term, 

* Dr. Kinnis saw no instance of this in the Isle of France, ** the 
testicles in males, and the breasts in females, being constantly of their 
natural size/' T. 

f The number of these establishments, however, has been greatly 
misrepresented, in consequence of an error of quotation from Matt. 
Paris, which has been echoed by several authors. That historian has 
been made to assert, that, in the thirteenth century, there were 19,000 
lazarettoes in Christendom ; whereas he only states that the Knights 
Hospitalers were then in possession of so many manors. ^ Habent Hos- 
pitaiarii novemdecim millia maneriorum in Christianitate,*' are his 
words. See his Histor. Angl. ad ann. 1244; also Du Cange, Gloss, yoc. 
Lazari ; Mezeray, Hist, de France. 



ELEPHANTIASIS. 359 

leprosy t to the Elephantiasis, to the leprosy of the 
Jews *, to the proper scaly Lepra, and even to other 
cutaneous afi^tions, which have no affinity with 
either of the diseases just mentioned, almost every 
person, afflicted with any severe eruption or ulcer- 
ation of the skin, was deemed leprous^ and was re- 
ceived into the lazarettoes. This fact, indeed, is 
acknowledged by many of the physicians to these 
hospitals, in the sixteenth century and subsequently. 
Gregory Horst, who was one of the appointed exa- 
miners at Ulm, towards the close of that century, 
and who has given a minute detail of his investiga- 
tions, admits that, " where the tubercles of the face, 
die thick lips, acuminated ears, flattened nose, round 
eyes {the essential symptoms of Elephantiasis) are 
absent ; yet if the patients are affected only with a 
dry and foul Scabies, with pustular eruptions, fissures, 
and branny exfoliations, which constitute the Pmra 
of the Greeks, — or even with great itching, emaci- 
ation, ulceration, and exfoliations of thicker scales, 
which are the Lepra of the Greeks, — neverthelessf, 
they ^ire sent to the lazarettoes, if they are poor, fw 
the means of subsistence. Hence it happ^is," ha 
adds, " that, here and elsewhere, very few inda/nces 
jof real Elephantiasis are found in the lazarettoes, 
while many are there affect^ only with an obstinate 

* This appears to have been the Letice of the Greeks, the white 
Saras of the Arabians, and the third species of Vitiligo of Celsus. (See 
Hippocrat, Ilfpt Uadtav. Avicen. loc. cit. — Cels. de Med. lib. v. cap. 28.) 
The two characteristic symptoms of the Hebrew leprosy, whicn are 
pointed out in the Mosaic account, are the whiteness of the hair of the 
parts affected, and the depression of the skin. " And if the hair of the 
plague is turned white, and the plague in sight be deeper than the skin 
of his flesh, it is a plague of leprosy," &c. (Leviticus, chap, xiii.) Thus 
also Avicenna : " There is this difference between the white Alguada 
(Alphos) and the white Baras ; the hairs grow upon the skin affected 
with the former, and they are of a black or brown colour : but those 
which grow in the Baras are alwai/s white, and at the same time the 
skin is mo7*e depressed or sunk than the rest of the surface of the body.** 
(Loc. cit.) And Celsus: " \iVKri habet quiddam simile alpho; sed 
magis albida est, et altius descendit ; in eaque albi pUi sunt, et lanugini 
similes. ' 

A A 4 



S60 TUBERCULA : 

Psora or Lepra Graecorum/' * Forestus, who held a 
isimilar office at Alcmaer and Delft, in the same 
century, affirms that a very small proportion of the 
persons who wandered about the Low Countries, as 
lepers and beggars, were true lepers ; but were merely 
affected with Scabies, or some external defoedation of 
the skin. " Nay," he says, " not one in ten of 
them is truly a leper, or afflicted with the legitimate 
Elephantiasis." t Kiedlin makes a similar observation 
respecting the patients admitted into the leper-hospi- 
tal at Vienna, t Indeed, there is little doubt that 
every species of cachectic disease, accompanied with 
ulceration, gangrene, or any superficial derangement, 
was deemed leprous; and hence that, in the dark 
ages, when the desolation of repeated wars, and the 
imperfect state of agriculture, subjected Europe to 
almost constant scarcity of food, the numerous modi- 
fications of Scurvy and Ignis sacer, which were epi- 
demic during periods of famine, and endemic wherever 
there was a local dearth, were in all probability classed 
among the varieties of leprosy ; more especially as 
the last stage of the Ignis sacer was marked by the 
occurrence of ulceration and gan^ene of the extre- 
mities, by which the parts were mutilated, or entirely 
separated, f " With regard to the causes of this 
disease, independent of its hereditary taint, nothing 
satisfactory has been suggested. The Vytians of 

* See his Obs. Med. lib. vii. obs. xviii. epist. J. H. Hopfnero. 

t See his Obs. Chirurg. lib. iv. obs. vii. schol. 

j: '' Sicuti vero non nisi rarissimd inveniuntur, quibus Leprosi nomen 
merito et revera attribui posset, uti quidem leprosi a plerisqueauctoribus 
describuntur ; sed plerumque hisce domibus iili includuntur, qui Scabie 
sicc^ faeda, et diu jam instante, laborant," &c. D. V. Riedlm, Line® 
Med. vol.iiL Ann. 1697. Mens.Maio. 

f It would be foreign to my purpose to enter into any detail here 
respecting the history and symptoms of the Ignis sacer, which was cor- 
rectly ascribed by Galen (de Succor. Bonit. et v itio, cap. 1. — DeNatur. 
Humor, lib. ii. cap. 3., &c.) to the use of unsuitable food. It has been 
well described by Lucretius, lib. vL In more recent times, it has been 
erroneously supposed to originate from various deleterious substances 
taken with the food, and not from actual deficiency of nutriment. See 
above, p. 134, 135. 



ELEPHANTIASIS. 36l 

Lower India," says Dr. Ainslie, " reckon eighteen 
varieties of leprosy, all of which they conceive to be 
produced by one or other of the following causes : 
1. Drinking milk after eating fish to excess ; 2. eating 
flatulent food ; 3. eating to excess the grain of the 
Dolichos lablab ; 4. drinking cold water after having 
perspired much ; 5. eating to excess the seed of the 
Sesamum Orientcde ; 6. checking vomiting so as to 
allow undigested matter to get into the bowels ; 7. 
sensual indulgence in the daytime ; 8. habitual cos- 
tiveness ; 9. the bites of a cat, and of certain snakes, 
.a certain lizard, and certain wasps ; 10. worms. Such 
are the absurd causes to which the natives of a coun- 
try, in which the disease prevails, ascribe Elephan- 
tiasis. Dr. Ainslie says, it is more common on the 
coast than in the interior ; and he supposes that this 
may arise from the natives eating a bad kind of fish ; 
or too much salt fish, of which they are very fond. He 
adds, that he never knew a native of Great Britain or 
Ireland to have the disease ; but had seen a Swede, 
two Danes, and a German labouring under it.*' 

Under the head of Elephantiasis, Dr. Winter- 
bottom appears to have*described the Leuce^ and not 
the Elephantiasis of the Greeks ; the JBaras^ and 
not the Juzam of the Arabians. The principal 
symptoms which he witnessed were the pale colour 
of the skin (in black subjects) and its loss of sen- 
sibility, which are distinctly stated as the leading 
symptoms of Leuce, by Celsus, and by the other 
Koman and Greek physicians, as well as of Baras by 
the Arabians.* Some of the Greeks and Arabians, 
indeed, seem to consider the Leuce, or Baras, as 
possessing an affinity with Elephantiasis, and some- 
times terminating in itt ; and, if they be not modi- 

* See Celsus de Medicina, lib. v. cap. 28. — Aetius, tetrab. iv. serm. i. 
cap. 123.— Paul. -^inet. lib. iv. cap. 5. — Actuarius, Meth. Med. lib. ii. 
cap. 11. 

-|* Avicenna applies the term Baras, with the epithet black, to the 
rugged and sca^ state of the skin in Elephantiasis (lib. iv. fen. 9. 



362 TUBERCULA : 

fications of the same disease, it is probable that some 
of the symptoms of the one (Leuce), such as the 
insensibility, and change of the colour and strength 
of the hair, may have been transferred in description 
to the other. * The numerous large tubercles of the 
nose, forehead, and ears, which are deemed charac- 
terii^ic of Elephantiasis, did not appear in the dis- 
ease seen by Dr. Winterbottom* The swellings or 
tuberosities of the joints of the hands and feet, which 
terminate in ulcerations, that occasion the fingers and 
toes to drop oflP, appear also to belong to the two 
diseases in common, and afford another proof of their 
affinity. Nevertheless, as we have nowhere any ac- 
count of the regular successicm of the tubercular 
state (Elephantiasis or Juzam) to that of mere dis- 
coloration and insensibility (Leuce or Baras), we are 
not warranted in drawing the conclusion that they 
are but degrees or stages of the same disease.! Ac- 
curate histories of the Elephantiasis, Leuce, and other 
modifications of the formidable cutaneous diseases 
that occur in hot climates, emd. especially where agri- 
culture and the arts of civilisation are imperfectly 



tract. 5. cap. i. — and fen. 7. tract. 2. cap. 9.), and Alsabaravius ex- 
pressly states, that when the disease arises from putrid phlegm, it com- 
mences with Baras, or with white Bohak (Alphos of the Greeks), and 
becomes Juzam in its advanced stage. Lib. Pract. tract. 31 . cap. 1. See 
also Dr. Thomas Heberden's account of Elephantiasis in the Island of 
Madeira. (Med. Trans, of the Coll. of Physicians, vol.i. p. 27.) 

Plenck describes it under the name Lepra der Aussatz. Victe Doct. 
de Morb. Cutan., p. 67. 

* This conjecture has been confirmed by Mr. Robinson^ in the paper 
above alluded to. 

t It is curious that the Foolas, on the coast of Africa, employ the 
Arabian terms ; but, if Dr. Winterbottom was correctly informed, in an 
inverted sense. They divide the disease into three species, or rather 
degrees : 1. the damadi/an^, or mildest leuce, when the skin is merely 
discoloured and insensible m patches ; 2, the didyarn (sometimes written 
sghidam, dsjuddam, and juzam,) when the joints of the fingers and toes 
are ulcerated and drop of^ the lips are tumid, and the alse nasi swell 
and ulcerate ; and, 5. the barras, when these symptoms are increased, 
and, from ulcerations in the throat and nose, the voice becomes hoarse 
and guttural. See his Account of the Native Africans in Sierra Leone, 
vol, ii. chap. 4. 



ELEPHANTIASIS. 363 

advanced, must be denned still among the desiderata 
of the pathologist* 

. While the fifth edition of this work is i|i the press 
{Dec* 1818), I have had the satisfaction of perusii^ 
a valuaWe paper, written by Mr* Robinson, a medicid 
practitioner in India, which confirms the accuracy of 
my description of the tubercular Elephantiasis, and 
supplies the desWeratum above noticed, by furnish- 
ing a clear and distinct history of the Baras, or 
white leprosy, as well as the notice of a remedy ade- 
quate to its cure* 

This paper will probably appear in the 10th vol. 
of the Transactions of the Med* and Chirurg. So- 
ciety of London ; but I am permitted to extract the 
following description : — " One or two circumscribed 
patches appear upon the skin, (generally the feet or 
hands, but sometimes the trunk or face,) rather 
lighter coloured than the neighbouring skin, neither 
raised nor depressed, shining and wrinkled, the fur- 
rows not coinciding with the lines of the contiguous 
soimd cuticle. The skin thus circumscribed is so 
entirely insaisiblft, that you may with hot irons bum to 
the muscle, before the patient feels any pain. * These 
patches spread slowly until the skin of the whole of 
the legs, arms, and gradually often the whole body, 
becomes alike devoid of sense : wherever it is so af- 
fected, there is no perspiration ; no itching, no pain, 
and very seldom any swelling. Until this singular 
apathy has occupied the greater part of the skin, it 
may rather be considered a blemish than a disease : 
nevertheless it is most important to mark well these 
appearances, for they are the invariable commence- 
ment of one of the most gigantic and incurable dis- 
eases that have succeeded the fall of man ; and it is 
in this state chiefly (though not exclusively) that we 

* In the cases of real tubercular Elephantiasis, described by Dr. Kin- 
nis, '* the parts affected with the disease were benumbed, or, as the 
patients sometimes expressed it, ' asleep,' but they had never entirely 
lost their sensibility." — Edin. Journ. 1. c. T. 



S64 TUBERCULA .' 

are most able to be the means of cure. The next 
symptoms (which occur in some patients at two 
months, but in others not till after five or six years) 
are the first which denote internal disease or derange- 
ment of any functions. The pulse becomes very 
slow (from 50 to 60), not small but heavy, * as if 
moving through mud ; ' the bowels are very costive, 
the toes and fingers numbed, as with frost, glazed 
and rather swelled, and nearly inflexible. The mind 
is at this time sluggish and slow in apprehension, and 
the patient appears always half asleep. The soles of 
feet and the palms of the hands then crack into fis- 
sures, dry, and hard as the parched soil of the coun- 
try; and the extremities of the toes and fingers 
under the nails are encrusted with a furfuraceous sub- 
stance, and the nails are gradually lifted up, until 
absorption and ulceration occur. Still there is little 
or no pain; the legs and fore-arms swell, and the 
skin is every where cracked and rough. Contempo- 
rary with the last symptoms, or very soon afterwards, 
ulcers appear at the inside of the joints of the toes 
and fingers, directly under the last Jbint of the meta- 
tarsal or metacarpal bones, or they corrode the thick 
sole under the joint of the os calcis, or os cuboides. 
There is no previous tumour, suppuration, or pain, 
but apparently a simple absorption of the integuments, 
which slough off in successive layers of half an inch 
in diameter. A sanious discharge comes on ; the 
muscle, pale and flabby, is in turn destroyed; and 
the joint being penetrated as by an auger, the ex- 
tremity drops, and at length falls a victim to this 
cruel, tardy, but certain poison. The wounds then 
heal, and other joints are attacked in succession, 
whilst every revolving year bears with it a trophy of 
this slow march of death. Thus are the limbs de- 
prived one by one of their extremities, till at last 
they become altogether useless. Even now death 
comes not to the relief of, nor is it desired by, the 
patient, who, * dying by inches,' and a spectacle of 



ELEPHANTIASIS. 365 

horror to all besides, still cherishes fondly the spark 
of life remaining, and eats voraciously all he can pro- 
cure : he will often crawl about with little but his 
trunk remaining, until old age comes on ; and at last 
he is carried oflp by diarrhoea or dysentery, which 
the enfeebled constitution has no stamina to resist. 
Throughout the progress of this creeping but inve- 
terate complaint, the health is not much disturbed j 
the food is eaten with appetite, and, properly, though 
slowly, digested. A sleepy inertness overpowers 
every faculty, and seems to benumb, almost annihilate, 
every passion as well of the soul as of the body, 
leaving only sufficient sense and activity to crawl 
through the routine of existence.** 

Mr. Robinson adds, that he has never seen this 
disease attack the larger joints, destroy the nose, nor 
affect any of the bones, except those of the hands and 
feet ; and that the tuberculated Elephantiasis, though 
it sometimes supervenes, is by no means connected 
with, caused by, or necessarily subsequent to it. 

Mr. Robinson affirms, that the cure of this disease 
may be generally accomplished in the early stage, by 
the use of a plant which grows abundantly in India, 
and which appears to possess remedial qualities which 
entitle it to an introduction into the Pharmacopoeias 
of Europe, namely ; the asclepias gigantea^ espe- 
cially in combination with alterative doses of mercury 
and antimony, and with topical stimulants. 

By the surgeons of the present day the appella- 
tion of Elephantiasis is appropriated to a disease, 
altogether different from the malady originally so 
called by the Greeks ; namely, to an enormously 
tumid condition of the leg*, Arising from a repeated 
effusion and collection of a lymphatic and gelati- 
nous matter in the cellular membrane under the 
skin, in consequence of inflammation of the lym- 

* Si^n, — Elephantiasis {Auct, var.)i Bucnemia {Good): Anay kaal 
(Tarn!): Huttie ka pawny (D^A:.) : Yeanugay kaloo(7V/.): Gh^japadha 
\B.y oo iSans,): Dail ^\(Arab.): Drusenkrankheit (G^nwa») : Yara-^kiq 
{Polt/nes Isles) : Barbadoes leg {Hillary) : Cochin leg. 



366 TUBERCULA : 

phatic glands and vessels. The skin itself is much 
thickened in the protracted stages of this exten- 
sion, and its vessels become much enlarged; its 
surface grows dark, rough, and sometimes scaly. • 
This condition of the surface, together with the 
huge misshapen figure of the limb, bearing some 
resemblance to the leg of an elephant, suggested 
the application of the term.t As the effiision first 
takes place after a febrile paroxysm, in which the 
inguinal glands of the side about to be a£^ted are 
inflamed, and the limb is subsequently augmented 
in bulk by a repetition of these attacks. Dr. Hendy 
termed the malady " the glandular disease of Bar- 
badoes,'* in which island it is endemial.t In Eng- 
land it is often called " the Barbadoes 1^.**§ Ex- 
cept when these paroxysms occur, the functions 
and constitution of the patients are not materially 
injured, and they often live many years, incom- 
moded only by carrying about " such a troublesome 
load of leg.^ll 

* See Alibert's plate of '^ Lepra elephantiasis," Ifo. 53., where this is 
well represented. 

f The appellation o^ elephant, or elephant^isease, was, in fact, applied 
to this aroction by the Arabians, confessedly from this resemblance 
(see Haly Abbas, Tneor. lib. viii. cap. 18.; — Avenzoar,lib.ii. cap. 26.;^ 
Alsaharavius, Pract tractat. xxviii. cap. 11., &c.) hence the translators; 
Were puzzled, and misinterpreted Juzam by the Greek term Lepra. 
The translator of Haly Abbas was alone correct in rendering the Arabic 
names : having given the proper classical appellation of Elephantiam to 
the tubercular Juzam, he translates this name (denoting the elephant4eg 
by the term Elephat (loc. cit.; — also Theoric^ lib. viii. cap. 15.; and 
Practic^ cap. 4.). For, as this disease had not been noticed by the 
Greek physicians, even by those of the eastern empire, there was no 
classical term by which it could be rendered. 

% See his inaugural dissertation, and subsequent treatise on the sub« 
ject, London, 1784 ; also RoUe's " Remarks on the Disease lately de- 
scribed by Dr. Hendy," &c 1 785. 

§ The disease is not exclusively confined to the leg; it sometimes 
appears in the arms, and even on the ears, breast, scrotum, &c. Hillary 
on the Diseases of Barbadoes, p. 515. ; — Hendy, part. i. sect. 2. 

||See Hillary on the Climate and Dis. of Barbadoes. It is affirmed 
by Dr. Clarke, however, and by Dr. Winterbottom, that the agility of 
the patients, who are affected with this unseemly deformity, at Cochin, 
and on the Gold Coast, is not impaired by it. (See Clarke's Obs. on the 
Dis. in Long Voyages to Hot Climates; Winterbottom, loc. cit. p. 115.) 



ELEPHANTIASIS : 3^ 

In this country the disease is only seen in its in- 
veterate stage, after repeated attacks of the fever 
and effusion have completely altered the organisa- 
tion of the integuments of the limb, and rendered 
it altogether incurablcr In this state, the swelling 
is hard and firm, does not pit on pressure, and is 
entirely free from pain. The skin is thickened 
and much hardened ; its blood-vessels are enlarged, 
particularly the external veins, and the lymphatics 
distended; and the celluar substance is flaccid, 
and sometimes thickened, and its cells much loaded 
with a gelatinous fluid. The muscles, tendons,* 
ligaments, and bones, are generally in a sound 
state*-— In this advanced stage, the disease is al- 
together irremediable ; and indeed little success 
seems to have attended the practice employed in 
the earlier stages, which has been chiefly directed 
to alleviate the febrile paroxysms by laxatives and 
diaphoretics, and subsequently to strengthen the 
system by Cinchona. Local bleeding has never 
been employed; for there are no leeches in Bar- 
badoes, according to Dr. Hendy ; but after the fever 
and inflammation have subsided, he strongly recom- 
mends the binding of the limb in a tight bandage, 
as the means of exciting absorption, and of reducing 
the swelling. * 



Dr. Hendy observes that, in consequence of the gradual augmentation 
of the bulk, patients are not in general sensible of the weight, except 
when they are debilitated by indisposition. 

* While this sheet was in the nands of the compositor, I was fa- 
voured by Mr. J. Mason Good, a gentleman distinguished by his know- 
ledge of the oriental languages, with some observations relative to the 
original Arabic appellations of these diseases, which, while they confirm 
the views which I .had entertained in general, throw additional light on 
the subject. 

** The Leprosy of the Arabs," he says, " appears to have been called 
by themselves immemorially, and is still called juzam and juzamlyh, 
though vulgarly and more generally judam and judamif/k, from an Ara- 
bic root, which imports erosion, truncation, excision. The term juzam 
has passed from Arabia into India, and is the common name for the 
same disease among the Cabirajas^ or Hindu physicians, who also oc« 



368 TUBERCULA : 

In conclusion, then, it will be seen that the 
terms Elephantiasis and Lepra have been thus con- 
founded. The word Lepra (which should be con- 
fined to a scaly disease) has been erroneously ap- 
plied to the proper Elephantiasis (a tuhercukir 
disease). Elephantiasis again, which is so dis- 
tinctly described by the Greek writers, has beei^ 
transferred, by the Latin translators of the Arabian 
writers, to the local aflPection of the leg, (the efe- 
phas of these writers, the Barhadoes leg, and the 
glandular disease of Dr. Hendy,) and is commonly 
used in that acceptation by practitioners at present. 
But it has been also misapplied to the white -dis- 
ease of the skin, called by the Greeks, Romans, and 
Arabians Leuce, Vitiligo, and Baras (or Beras)^ 
respectively: and thence, by an easy step, it has 



casionally denominate it Fisddi kMn^ from its being supposed to infect 
the entire mass of blood, but more generally khora** 

I learn also from this communication, that the original Arabic term, 
^hich was used to denote the tumid leg above mentioned, was dal JU^ 
which is literally elephant disease ; and further, that ** dalJU is the com-* 
mon name for the swelled leg in the present day among the Arabians,^ 
who sometimes contract it to^ alone, literally elephas** 

But although the Arabians in general distinguish the Juzam from 
other diseases; yet I have observed that they sometimes mentioned 
the baras {leuce) as having an affinity with it, calling some forms of the 
Juzam black baras. Mr. Good remarks, that ^^jvzam itself has occa- 
sionally been employed in the same Ibose manner; and has been made 
to import leuc^ or vitiligo, as well as proper or black judam ; though in 
the former case it is Commonly distinguished by the epithet merd, i. e. 
pUis carens, ns merd-juzam, bald .juzam. The proper and more, usual 
name for this last disease is beras or aberas, sometimes written alberas^ 
though less correctly, as this last is beras^ with a mere prefix of the de-^ 
finite article." 

Mr. Good adds, " that one of the most celebrated remedies for this- 
disease (juzam) employed by the Cabirajas, or Hindu physicians, i& 
arsenic (Shuce, in India sane* hya) mixed in pills with black pepper," six 
parts of the latter being added to one of the former: the pills are 
ordered to be of the size of small pulse, and one of them is to be swaU 
lowed morning and evening, with some betel leaf. 

Since the publication of the former editions, I have had an oppor- 
tunity of seeing two cases of Elephantiasis, which have been under treat- 
ment in London during the greater part of the present year (1814); 
and in both the arsenic had been fully tried, and proved to be entirely 
void of any remedial power. 



ELEPHANTIASIS. 369 

been again transferred, by some unlearned persons, 
even to the scaly Lepra ; while the term Lepra has 
been often indiscriminately applied to all these af- 
fections. I trust, the foregoing statements may con- 
tribute to elucidate this matter. " With regard to 
the remedial treatment of Elephantiasis, our experi- 
ence in this country aflPords us little assistance. 

" Among the multifarious remedies proposed and 
employed by the ancients, one of the most likely to 
prove useful was Decoction of Elm Bark in the pro- 
portion of ^iv of the bark to lb iij, boiled down one 
half. After bleeding and purging, Willis recom- 
mended a Mixture in which the sharp-pointed Dock, 
Rumex dcutus ( Oxylapathum)^ was the most active 
ingredient.* This plant was also used along with 
Bryony, Scabious Mallow, and Chamomile flowers 
in the formation of a bath ; and it also entered a 
liniment. In India the chief reliance is placed on a 
powder (termed mudar) prepared from the root of 
the Esclepias Qigantea t, a plant described by Dr. 
Ainslie in- the Mat. Med. of Hindostan. This 
author, in a letter to the Editor, says, " I found, 
when the disease was taken early, that mercurials, 
judiciously administered in small doses, were almost 
the only remedy that did good. I thought that in 
two or three cases, treated in this way, I entirely re- 
moved it. Nothing can be done without the frequent 
use of the tepid bath, so that the skin may be kept in 
the cleanest state possible.** 

Books that may he constdted on Elephantiasis. 

Adams, Dr., On Morbid Poisons, 8vo. 1807. 
Alaret . Hist, de TEl^phant. des Arabes, 1800. 
Asiatic Researches, vol.ii. 
BouiLLAUD, J., Archiv. G6n, de M^d. t. vi. 1854. 
Cyclop, of Pract. Mei>. (art. E. Arabum), 1835. 
Edinburgh Med. and Surg. Journ., vol. iii. p. 18. — vi. p. 161. 
Oct., 1824. 



* Willis de Impetigine sive Lepra Graec. Sect. 3. c. 7. T. 
f Edin. Med. & Chir. Trans., vol.i. p. 4 14. T. 

B B 



gr/O tubercula: ^ 

FALflOWMk W^ On Lepra Giwcorum (M^m* TS/ifid^ iii.), gVo. 1799., 

GouBLAt, W., Observations on Madeira, Svo. 1811. 

HtBER^B^, Th., On the Elepbanfiasis of Madeira (Med. Trans., vol. i.> 
1768. 

Hendt, J., On Glandulaf EKseases of Barbadoes, Svo. 1784. 

HiLLAHT, W., On Changes of Ah* in BarbadOes, 5 to. 1759. 
''^jAcKWiN'sf Account of Marocco, 8to. 18 Jo. 

JoANNis, Medical Obs. and In^., vol.i. 1757. 

London Med. and Chir. Trans., vol. x. 

Raisin^ J. A., Sur TElephantiasis des Grees^ 4to, 1899. 

Ray^r, Traits des Malad. de la Peau, 8v6. 1826« 

Raymonb, Hist, des Elephantiasis, 1767. 

Rechercuks Asxatiques, 4to. 180.^. 

Robinson, J., On Elepiwmtiask in Hnidosteii (Med. Chir^ Trans.y jt.)^ 
1819. 

RtJE'^tR. Essd sar TEMphatftiasis, svo, isas. 

Town, R^ Treatises on Diseases most f^eijaent In the West Indam^, 
svo. 1796. 

ViDAL, Mem. de la Soc. Roy. de M^d. de Paris, 1783. 

VooEL, Von, Encye. WcJrterb^, b. x. JBerL 1854. 

WiLsoNy H. H.^ Cakutta Med, Trans<^ t 8vo. 1^25. 



i mi*<t» 



Genus VIII. FftAMBCEdlA. 

Yaws. 

J§yn. FratnboBsIa {Autct. P^ar.J t Lepra ftrngifeilEt 
( Cartheitserus) : Gattoo^ Yaw (Afric.y. Antnfack 
rubula (Good): Phymatosis framboesra (Young) t 
Thytniosis (Swedeaur): Viaxi (Afhtive American)! 
Aev Schwammformige Aussatz ( German): Fram- 
boasia (Itcd.): Frambuesa (Span.): Yaws. 

Def. Imperfectly suppurating tumours, gra- 
dually INCREASING FROM SPECKS TO THE SIZE OF 
A RASPBERRY|; WITH A FUNGOUS CORE I ONE TUMOUR 
GENERALLY GROWING LARGER THAN THE OTHERS. 
FEVER SLIGHT BUT CONTAGIOUS : OCCUilRING ONCE 
ONLY DURING LIFE. 

The nature of this disease, which is indigenous in 
Africa, and has been thence conveyed to the West 
Indies and America, }ias been imperfectly investi- 
gated by European practitioners ; and as it is perhaps 



FRAMBCESIA. S7I 

never seen in England^ a very brief account of it here 
will be sufficient.* 

The eruption of the Yaws sometimes commences 
without any precursory symptoms of ill health ; but 
it is generally preceded by a slight febrile state, with 
languor, debility, and pains of the joints, resembling 
those of rheumatism. t The whole skin at this period 
seems as if dusted with flour. After several days, 
minute protuberances t appear on various parts of the 
skin, at first smaller than the head of a pin, but 
gradually enlarging, in some cases to the diameter of 
a sixpence, and in others even to a greater extent : 
they are most numerous, and of the largest size, in 
the face, groins, axillae^ and about the anus and pu- 



* Yaws, sihbens, raged in Scotland in the 17th century; atld even at 
this period it is occasionally met with in the Shetland Islands. T. 

M. Alibert has figured two diseases as examples of Framhoesia, under 
the titles of " Pian ruboide," and ** P. fungoide," which were seen at 
the hospital St. Louis at Paris ; but they are obviously not Yaws. The 
first of them .appears to be a n^lected Porrigo, or a Sycosis, of the 
scalp (plate 55.); and the other a species of wen (plate 56,). 

Dr. James Thomson objects to the disease being classed with the Tu- 
bercula. The eruption is at first papular, then pustular, and ultimately 
fungoid. — Edin. Med. and Surg. Journ., vol. xv. p. 322. T. 

•j" The earlier writers on this disease assert, that the general health 
is not impaired by this eruption during the first stages. But on the 
authority of Dr. Winterbottom, and of Dr. Dancer, I have stated that 
a febricula is the ordinary precursor of the Yaws. Dr. Winterbottom, 
indeed, observes that the successive eruptions which occtir are also 
usually preceded by slight febrile paroxysms, sometimes by rigotS. See 
his account of the Nat. Africans of Sierra Leone, vol. ii. chap. 8. ; — and 
Dancer's Medical Assistant. 

J It is not easy to discover the precipe character of this eruption, 
from the varying language of authors. An anonymous writer, who gave 
the first explicit account of the disease (see Edin. Med. Essays, vol. v. 
part. ii. art. 76.), says they are at first " level or smooth with the skin," 
but soon " become protuberant like pimplei" Dr. Hillary, who has 
copied much from this writer, describes them as ** pimples^*' though 
smooth and level with the skin, but soon becoming " protuberant puS' 
tules," (On the Dis. of Barbadoes; p. 359.) And Dr. Winterbottom, 
who has given, on the whole, the most perspicuous description of the 
disease, calls them "pustides " from their first appearance. Again, as 
to the contents of these eruptions, the anonymous author and Dr. Hil- 
lary say that no pus, nor any quantity of ichor, is found in them, but 
speak of a little ichor as drying upon the surface ; while Dr. Winter- 
bottom says, they are " filled with an opake whitish fluidj** and whed 
they burst, " a thick viscid matter is discharged." 

B B 2 



372 TUBERCULA : 

denda* But the crop is not completed at once ; new 
eruptions appear in different places, while some of 
the earlier ones diy off. When the cuticle is broken, 
a foul crust is formed on the surface, from under 
which, on the larger protuberances, red fungous 
excrescences often spring up, which attain different 
magnitudes, from that of a small raspberry to that 
of a large mulberry, which fruit they somewhat re- 
semble from their granulated surfaces.* " The period 
which these shoot is very uncertain; varying from 
one month to three months.'* When the eruption is 
most copious, these tubercles are of the smallest size : 
and when less diffuse, they are lai^st. " In de- 
bilitated habits they bleed on the slightest touch.** 
Their duration and progress are various in different 
constitutions, and at different periods of life. Children 
suffer less severely than adults, and are more speedily 
freed from the disease : in them, according to Dr.Win- 
terbottom, the duration of the Yaws is from six to nine 
months ; while, in adults, it is seldom cured in less 
than a year, and sometimes continues during two or 
three. " The fungous tubercles attain their acme, ac- 
cording to Dr. Thomson, and the anonymous writer 
already quoted, more rapidly in the well-fed negroes 
than in those who are ill-fed and thin ; and they 
likewise acquire a larger size in the former than in the 
latter.** They are not possessed of much sensibility, 
and are not the seat of any pain, except when they 
appear upon the soles of the feet, where they are 
confined and compressed by the hard and thickened 
cuticle : in that situation they render the act of walk- 
ing extremely painful, or altogether impracticable. 
They never suppurate kindly. Dr. Winterbottom 
says, but gradually discharge a sordid glutinous fluid, 
which forms an ugly scab round the edges of the 

• Hence both the popular appellation of Yawt which in some African 
dialect signifies a raspberry^ and the nosological title, Frambcesia, from 
the French Framboitey which denotes the same fruit. See Sauvages, 
NosoU M^th., class X. ord.iv. gen. 25. 



FRAMBCESIA. 873 

excrescence, arid covers the upper part of it, when 
much elevated, with white sloughs. When they ap- 
pear on any part of the body covered with hair, 
this gradually changes in its colour froni black to 
white, independently of the white incrustation from 
the discharge. " It frequently falls off, and never 
grows again.*' They leave no depression of the 
skin.* 

The period, during which the eruption is in progress, 
varies from a few weeks to eight months. *' When 
no more pustules are thrown out,'* Dr. Winter- 
bottom observes, ** and when those already upon the 
skin no longer increase in size, the disease is sup- 
posed to have reached its acme. About this time it 
happens, on some part of the body or other, that one 
of the pustules becomes much larger than the rest, 
equalling or surpassing the size of a half-crown piece : 
it assumes the appearance of an ulcer, and, instead 
of being elevated above the skin like others, it is 
considerably depressed; the surface is foul and 
sloughy, and pours out an ill-conditioned ichor, which 



* The anonymous writer in the Edin. Med. Essays, and after him 
Dr. Hillary and others, have deemed the Frambcesia to be the Hebre\v 
leprosy, described by Moses. (Leviticus, chap, xiii.) In some respects, 
and especially in the appearance of what is called ** raw flesh,'* in the 
leprous spots, together with whiteness of the hair, the description of the 
leprosy of the Jews is applicable to the Yaws. But the leprosy is de- 
scribed by the great legislator as beginning in several ways, or appear- 
ing under several varieties of form, in only one of which this rising of 
'^ raw flesh " is mentioned: and the two circumstances, which all these 
varieties exhibited in common, were a depression of the skin, atid white- 
ness of the hair. Now this change in the colour of the hair is common 
to the Framboesia, and to the Leuce, as stated ; and it is conjoined, in 
the latter, with cutaneous depression. It seems pretty obvious, indeed, 
that the term leprosy was used, in the Scriptures, to denote several 
diseases of the skin, against which the law of exclusion was enforced, 
and others, to which it did not apply. An instance of the latter occurs 
in Geha2i, whom we 6nd still in the employment of Elisha, and even 
conversing with the king, after the leprosy had been inflicted lipoti him, 
** and his seed for ever.'* (2 Kings, chap. v. & vi. & chap. viii. ver. 4.) 

Dr. Hibbert (Edin. Jouru; of Med. Science, vol.i. p. 287.) has satis- 
factorily proved, that the great Gore, Pox^ or Morbus G'dllicus of the 
15th century, was Frambodsia. The name Sibbens, by which it is 
known in Scotland, is a corruption of the Gaelic word Siwens, wild 
rash. T. 

B B 3 



374 TUBERCULA ! 

spreads very much, by corroding the surrounding 
sound skin : this is what is called the master j or mo? 
ther-yaw ; " Mama-pian, by the negroes. When 
arrived at its acme, however, the eruption continues 
a considerable time without undergoing much alter- 
ation, often without very materially injuring the 
functions ; and it seldom proves dangerous, except 
from the mischievous interference of ill-directed 
art.* 

The Frambcesia is propagated solely by the conta- 
gion *of the matter, discharged from the eruption, 
when it is applied to the wounded or broken ^in of 
another person, who has not previously undergone 
the disease. t " It may be communicated by using 
the same spoon, by kissing, and by coition when its 
seat is in the genital organs, in which case it is often 
mistaken for syphilis.*' Like the febrile eruptions, 
the Frambcesia affects the same person only once 
during life; but, unlike them, it is not propagated 
by effluvia. In Africa it is usually undergone during 
childhood. The period, which elapses between the 
reception of the contagion and the commencement of 
the disease, is nowhere mentioned ; but in the case 
of a Dane, whom Dr. Adams saw at Madeira, the 
patient had been ten months absent from the West 
Indies before he felt any indisposition. 1: 

With respect to the treatment of Frambcesia, no- 
thing very satisfactory is to be collected from the 
writings of the practitioners to whom we are indebted 
for the history of the disease. The native Africans, 

* ** All this tune the patient is ia good health, does not lose his appe- 
tite, and seems to have no other uneasiness but what the nastiness of 
the sores occasions," &c. Edin. Med. Essays, vol. v. p. 789. The fact 
is stated by Hillary in the same words, p. 343, 

f The complaint is sometimes inoculated by flies, in those hot coun- 
tries where the skin both of the diseased and the healthy remains un* 
covered. Hence, Dr. Bancroft says, " none ever receive it whose skins 
are whole; for which reason the whites are rarely infected ; but the 
backs of the negroes being often raw by whipping, and suffered to re- 
main naked, they scarcely ever escape it." Nat. Hist, of Guiana, p. 385. 
See also Winterbottom, pp. 141 — 145. 

f See Memoirs of the Med. Soc. of London. 



FRAMB(£SIA. S^S 

according to Dn Wmterbottom, ** never attempt to 
cure it, until it has nearly reached its height, when 
the fungi hare acquired their full size, and no more 
pustules appear/* And the practitioners in the West 
Indies soon learned by experience, that active evacu- 
ations retard the natural progress of the disease; 
and that mercurials, although they suspended it, ami 
cleared the skin of the eruption, yet left the patient 
still susceptible of, or rather still impregnated with 
the virus, which speedily evinced its presence, by a 
reappearance of the symptoms more severe and tedi- 
ous than before. In truth, the disease, it would seem, 
like the pustular and e^^anthematous fevers of our 
own climate, will only leave the constitution, afiber it 
has completed the various stages of its course, and 
removed the susceptibility of the individual to future 
infection ; and no medicine, yet discovered, has had 
any influence iu superseding this action, or in acce* 
lerating its progress. Unless, therefore, any urgent 
symptoms should require alleviation (which seloom, 
if ever, happens), it is advisable to dispense with the 
administration of medicine, and to be content with 
restricting the patient to a moderate and temperate 
regimen, during the first stage of the malady.* When 
the eruptions begin to dry, or a^ soon as they cease 
to multiply and enlarge, .the disease appears to require 
the same managemait as other slow and superficial 
ulcerations, accompanied with a cachectic state of the 
system 9 viz. a light, but nutritious diet, a dry and 
wholesome air, warm clothing, moderate exercise, and 
a course of tonic medicine, especially of Sarsaparilla, 
or Cinchona, with the mineral acids, or with Anti- 
monials and small doses of Mercury, according to the 



* The anonymous wnter in the Edin. Essays recommends the fi>llow« 
ing bolus every night until the yaws are at tiieir height, 
{L Florum Sulphuris 9j. 
Oamphorse gr, v. 
Theriacae Andromachi Jj. 
Syrupi Croci q. s. ft. bolus, q. q. nocte hor4 somnl «utteodus* T. 

B B 4 



376 TUBERCULA : 

circumstances of the individual habit, with the free 
use of the compound decoction of SarsaparilJa. The 
effects of Mercury, however, exhibited so as to ex- 
cite salivation *, as the early West Indian practitioners 
recommend, seem to be of a very questionable na- 
ture, especially when it is unaccompanied by the ve- 
getable decoctions; and it is certain that patients 
have, in some cases, soon recovered under the use of 
the latter, when the mercurials were omitted, t The 
native Africans employ decoctions of the bark of 
two or three trees, which are gently purgative, as 
well as tonic, and likewise wash the sores with them, 
after carefully removing the crusts, t As topical ap- 
plications Dr. Wright recommends covering the sores, 
when small, with the leaves of the Cissus cici/eides, 
or those of the Jatropha curcas : when large, with 
poultices containing sugar and the pulp of the Seville 
orange roasted. A combination of Carbonate of Iron 
and Citric acid is also much used in the West Indies, 
and is said to be very efficacious. 

The master-t/aw sometimes remains large and 
troublesome, after the rest of the eruption has alto- 
gether disappeared. It requires to be treated with 
gentle escharotics, and soon assumes a healing appear- 
ance under these applications. Paring off the cuticle, 

* This treatment is often followed by a train of harassing symptoms, 
called by the negroes the bone-etck. " The unhappy sufferer is tormented 
with deep-seated pains in the bones, especially round the joints, which 
are occasionally aggravated to a violent degree; the periosteum becomes 
thickened, inflamed, and painful, and nodes are formed on the bones. 
Wlien these symptoms have continued for some time, the bones are 
affected with caries, and even become soft and lose their form.'* 

f See Dr. Winterbottom's *' Account," &c. vol.ii. pp. 158, 159.; and 
Schilling, De Framboesia, quoted by him. 

± In a very short but able account of this disease, which I lately saw 
in MS., the mercurial treatment was said not only to be unsuccessful, 
but to aggravate the affection of the skin; and much advantage was 
ascribed to strong decoctions of the woods of Vervain, wild Senna, &c. 
when the scabs began to fall off; and to the frequent ablution of the 
diseased parts with warm water, and to the use of lime-water as a drink 
previously. These decoctions were also found to relieve " the small 
eruption, bone-ach, and joint-evil often consequent on the bad treat- 
ment, or mere palliation," by Mercury. 



ICHTHYOSIS. 377 

and tlie stronger caustics, are requisite for the cure of 
the crab-yawSy or tedious excrescences, which occur 
on the soles of the feet. 

Books which may he consitUed on Frambopsia. 

Chopitre. E., Sur le Pian, &c^ 4to. 1804, 
CuLLERiER, Diet, dcs Scicnces M^d., 8vo. 1822. 
Frank, Jas., Prax. Med. Univ., vol. iii. chap. 56. Taur, 8vo. 1821. 
Grainger, J., On West India Diseases, 8vo. 1764. 
Hillary, W., On Diseases of Barbadoes, 8vo. 1761. 
Hume, J., Edin. Med. Essays, vol. vi. 12mo. 1744. 
/^ Mace, p. M., Sur le Yaw, Pian, ou Frambcesia, 4to. 1804. 

Peyrilhe, B., Precis Th^orique et Pratique sur le Pian, 8vo. 178 J. 
Thomson, J., Edin. Med. and Surg. Journ., xv. xviii. 8vo. 1819-22. 



Genus IX. ICHTHYOSIS. 

Syn. Lepra Ichthyosis ( SauvA : Lepidosis Ich- 
thyosis ( Young) : Lepidosis Icnthyasis ( Oood) : 
Ichthyose (i^.) • der Fischsckuppen-penansatz (O*) : 
Fish Skin. 

Def. A PAPILLARY, INDURATED, HORNY CONDITION 
OF THE SKIN TO A GREATER OR LESS EXTENT. 

The Ichthyosis, or Jish-shin disease^ is charac- 
terised by a thickened, hard, rough, and in some 
cases almost horny texture of the integuments of 
the body, with some tendency to scaliness, but 
without the deciduous exfoliations, the distinct and 
partial patches, or the constitutional disorder, which 
belong to Lepra and Psoriasis. 

" The disease appears to be seated in the papillae 
of the skin, which elongate into horny cones, and 
sometimes spread so as to acquire broad irregular 
tops. Dr. Good supposes that the incrustation, as 
he terms it, is formed by the cutaneous excretories 
throwing out an excess of calcareous matter, which 
is deposited in the cutis, rete mucosum, and cu- 



S78 nvMzncvtA I 

tide* ; but in our oj^moxif the diaea^e is m i^ 
papillm, which assume a state nearly resembUug 
that which constitutes the common wart/' 
There are two species of Ichthyosis : 

1. L mnplex» 2. I. cornea.\ 

Species 1. Ichthyosis simplex : Simple Fish- 
Skin. 

Syn. Ichthyosis simplex ( Good) : Ichthyose 
nacr^e {F.). 

In its commencement this disease (Plates XVI. 
and XVII. of Bateman ; PL 7. of Thomson's 
Atlas) exhibits merely a thickened, harsh, and dis- 
coloured state of the cuticle, which appears, at a little 
distance, as if it were soiled with mud. When fur- 
ther advanced, the thickness, hardness, and roughness 
become much greater, and of a minute warty cha- 
racter, and the colour is nearly black. The rough- 
ness, which is so great as to give a sensation to the 
finger passing over it, like the surface of a file, or the 
rou£chest sh^reen, is occasioned by innumerable 
ru^ed lin^and points, into which the surface is 
divided. These hard prominences, being apparently 
elevations of the common lozenges of tlie cuticle, 
necessarily di£Per in their form and arrangement in 
^ijBPerent parts of the body, according to the variations 
of the cuticular lines, as well as in different stages and 
cases of the complaint. Some of than appear to be 
of uniform thidmess from their roots upwards ; while 
others have a short narrow nedc, and broad irregular 
tc^wsL The former occur where the skin, when 
healthy, is soft and thin ; the latter, where it is 
coarser, as about the olecranon and patella, and thence 
along the outside of the arms and thighs. On some 
parts of the extremities, however, especially about the 

• Study of Medicine, yol. iv. p. 598* 

f Both Willan and Bateman have erred in placing Ichthyosis in the 
order s^tianus : notwithstanding the minuteness of the morbid papill»> 
it certainly is more allied to the Tubercula. T. 



: ICHTHYOSIS. 379 

ankles, and sometimes on the trunk of the bodjr, 
these excrescences are scaly, flat, and large, and 
occasionally imbricated, like the scales of carp: 
*< but it is probable that this imbricated state may 
depend on the pressure of the clothes." In other 
cases, they have appeared separate, being inter- 
sected by whitish furrows. 

This unsightly disease appears in large continuous 
patches, which sometimes cover the greater part of 
the body, except the flexures of the joints, the inner 
and upper part of the thighs, and the furrow along 
the spine. " These patches are sometimes gradually 
lost in the healthy skin ; at other times, they terminate 
abruptly." The face is seldom severely affected ; but 
in one case, in a young lady, the face was the exclusive 
seat of the disorder, a large patch covering each cheek, 
and communicating across the nose. (Plate XVIII. 
of Bateman. •) The mamm», in females, are some- 

* The Editor consulted Dr. Bateman respecting the case of a young 
lady so exactly similar to that which is represented in the 18th Plate of 
Bateman*8 Delineations, that, were he not certain of the contrary, he 
would imagine that plate to be a representation of the same case. The 
following ai*e the particulars of the case : < — 

The patient was about fifteen years of age in the spring of the year 
1810, when the disease was first observed. She had previously been 
subject to headaches, flatulence, disordered bowels, cold feet, and flush- 
ing of the cheeks. The first symptom was little more, to use her own 
words, than a soiled appearance of the cheeks, which was easily washed 
off with warm water and soap; and it was not until the autumn of 
1812, that this soiling began to increase and adhere more firmly; and 
in the course of a few months it became so considerable, that the pa- 
rents of the patient consulted the late Dr. James Gregory of Edinburgh. 
After the use of some acrid applications, which produced inflammation 
and ulceration. Dr. Gregory succeeded in clearing the skin in ten days. 
This improvement, however, was of short duration : the disease re- 
turned ; when Steel and Aloetics, Mercury carried to salivation, warm 
sea-water baths, shaving ofi* the incrustation, an ointment composed c^ 
Carbonate of Soda, Spirit of Turpentine, Sugar, and Resin Ointment ; a 
strong lotion with Oxymuriate of Mercury, and various other mean« 
were successively employed to clear the skin, for three years, but with- 
out success ; when she came to London for further advice. 

The eruption at this period extended over both cheeks, and across 
the bridge of the nose : it was of a dirty olive-brown hue, and greatly 
disfigured a face which was naturally very beautiful. It had much th« 
appearance and the hai'shness of shagreen. Under Dr. Bateman's caret, 
the patient took Pitch pills, and employed various internal and external 



380 TUBERCULA t 

times encased in this rugged cuticle. The whole 
skin, indeed, is in an extremely dry and unperspirable 
condition, and on the palms of the hands, and the soles 
of the feet, it is much thickened and brittle. The 
disease often commences in childhood, and even in 
early infancy. " In some instances it is hereditary* : 
but even when this is the case, the disease does not 
show itself in all the children of the same family/* 

This aflFection has been found to be very little 
under the control of medicine t : stimulating oint- 
ments and plasters have been industriously em- 
Eloyed, with no material eflFect ; and the disorder 
as been known to continue for several years, with 
occasional variations. — Dr. Willan trusted to the 
following palliation by external management : " When 
a portion of the hard scaly coating is removed," he 
says, " it is not soon produced again. The easiest 
mode of removing the scales," says Dr. Willan, " is 
to pick them off carefully with the nails from any part 



remedies, but without any permanent benefit, for six months ; when, 
becoming tired of medicine, she resolved to return to Scotland uncured. 
The Editor, however, having persuaded her to remain in the metropolis, 
after the empirical trial of many remedies, succeeded in completely 
removing the eruption, by means of a decoction of the root of the sharp- 
pointed Dock, Rumex acutus, taken internally. In eight days the skin 
acquired its natural texture and appearance ; but, the use of the decoc- 
tion having been discontinued, at the end of ten days more the eruption 
re-appeared ; it was again removed by the decoction ; and in this man- 
ner it was combated at successive intervals for .several months, always 
returning a short time after the decoction was discontinued. Conceiv- 
ing that the return of the eruption depended on a habit acquired by 
the skin from the long continuance of the disease, the face was blistered 
with the Cantharides plaster immediately after the eruption was again 
cleared off^ and the cure became permanent. T. 

* Rayer r^ards Ichthyosis as a congenital disease ; and cases con- 
firming this opinion have been published by Dr. Girdlestone (Med* and 
Phys. Joum., vol. viii.), and Mr. Martin (Med. Chirurg. Trans., vol. ix. 
p. 52.) T. 

f For examples of Ichthyosis the reader may refer to Panarolus (Pen- 
tecoste V. obs. 9.) ; Van der Wiel (obs. xxxv. cent. 2.) ; Marcel. Do- 
natus (Mirabil. lib. i. 3,); or Schenck, Obs. Medic. Rarior., p. 699., where 
the same case is related); and Philos. Transact., vol. xiv. no. 160., — 
and vol. xliv. for 1755. See also the 37th plate of Alibert, in which 
the I. simplex is well represented. His appellation is " Ichthyose 
nacr^e." 



ICHTHYOSIS. 381 

of the body, while it is immersed in hot water. — The 
layer of cuticle, which remains after this operation, is 
harsh and dry ; and the skin did not, in the cases I 
have noted, recover its usual texture and softness : 
but the formation of the scales was prevented by a 
frequent use of the warm-bath, with moderate friction.'* 
^^ In the limited practice of the Editor, this method 
of proceeding has never proved beneficial ; indeed, it 
is not likely that the removal of the corneous cuticle 
would be of any use whilst the disease which first 
produced it remains unsubdued. Blistering haa 
been found serviceable, particularly when the disease 
is of long standing. Mr. Plumbe relates two cases 
in which the incrustation, which was confined to the 
leg, was removed by the application of pressure by 
means of adhesive straps and bandages, and keeping 
the part constantly cool with a lotion applied over 
these. At the end of four or five days the straps were 
removed, when * the eruption was found liberated 
from its attachment to the cutis, and came off in large 
flakes nearly through its whole extent, exposing a 
white and ill-formed cuticle, which might be scraped 
oflF without pain.* By persevering in this plan the 
skin gradually acquired a healthy texture." * 

I have known the skin cleared of this harsh 
eruption by bathing in the sulphureous waters, and 
rubbing it with a flannel or rough cloth, after it 
had been softened by the bath ; but the cuticle 
underneath did not recover its usual condition; it 
remained bright and shining: and the eruption 
recurred. " The sulphurous fumigating baths are 
more certain in clearing the skin, and more per- 
manent in their eflFects.** Internally the use of pitch 
has in some instances been beneficial, having occasioned 
the rough cuticle to crack, and fall oflF, and left a 
sound soft skin underneath. This medicine, made 
into pills with flour, or any farinaceous powder, may 

* Practical Treatise on Discaes of the Skin, 1st edit. p. 334. 



S8S TUBERGULA : 

be taken to a great extent^ not only Without injury, 
but with advantage to the general health ; and affords 
one of the most effectual means of controlling the 
languid circulation, and the inert and arid condition 
of the skin.* Upon the same principle, the Arsenical 
Solution has been employed in Ichthyosis : in one case, 
in a little girl affected with a moderate degree of the 
disease on the scalp, shoulders, and arms, this medicine 
produced a complete change of the condition of the 
cuticle, which acquired its natural texture ; but in 
two others no benefit was derived from it* The de- 
coction of the inner bark of the elm has been said to 
be a specific for Ichthyosis, by Plenck ; bnt this origin- 
ated in a misconception as to the use of the term.t 
** The most beneficial internal remedy certainly is the 
decoction of the root of the sharp-pointed Dockj Ru- 
mex a€tUM^9 either alone or conjoined with Arsenic. 
It is prepored by slicing one ounce of the recent root, 
and boinng it in two pints of water down to one 
pint^ and then straining. The dose is a wine-glass 
full three times a day. Sometimes it purges rather 
too briskly, which should be checked by the addition 
of a few drops of tincture of Opium to each dose of 
the decoction/* t 

Species 2* Ichthyosis cornea. Houny Fish- 
Skin. 



* A lady took for a considerable time from three Rachitis to half an 
ounee of pitch daily, with the most salutary effect both on her skin and 
general hestlth. She had commenced with four pills, of five grains each, 
three times a day, and gradually augmented the dose. -^ It may be re- 
marked, that the unpleasant pitchy flavour of the pills is materially 
diminished, if they are kept for some time after being made up. 

•j* The definition of Ichthyosis given by Plenck, as well as the de- 
scription of " Lepta ichthyosis," by Dr. Lettsom, on whose authority 
Plenck has mentioned this remedy, obviously refers to the Lepra vuU 
garis. See Plenck, Doctrina de Morb. Gutan., p. ^9; — Lettsom, Med. 
Memoirs of the Gen. Dispensary, sect.iii. p. 152. 

J A case of Ichthyosis, detailed by Turner under the idea that it was 
Lepra Graecorum, was cured by Mercury, Antimony, and a diet drink, 
in which this Rumex acutus was a principal ingredient. — Treatise on 
the Di»e»se9 of the Skin, 4th edit. p. 30. T. 



/ 



,d 



ICHTHYOSIS. 383 

Spn. Icbthyiasis comigera ( Oood) : Cornua cu- 
tanea (Plenck) : Appendices conies (JRayer) 5 
Coriiey Ichthyose conile (F,y 

Several caset? af a rigi^ and honsy gtate of the 
iiitegUmentSy sometimes partial, but sometilnei^ 
extending nearly over the whole body, have been 
recorded by authors^ * i and occasionally such a con-^ 
dition of the cuticle has been accompanied with the 
actual production of excrescences of a homy texture^ 
Thes^, however, are rare occurrences j and all the 
cases on record have been congenital. 

The ordinary fcwmation of homy excrescences 
in the human body, of which many examples have 
been described front the time of the Arabians down- 
wards, is, however, unconnected with any general 
rigidity of the cuticle. These exjcrescences have been 
improperly called horns ; for they are purely of 
cuticular growth, having no connection with the bones 
or other parts beneath, and consisting of a laminated 
callous substance, contorted and irregular in form, 
and not unlike isinglass in appearance and texture* t 
They originate from two or three diflFerent diseased 
conditions of the cuticle } as from warts, encysted 
tumours, steatomata, &c. Morgagni has mentioned 
the growth of a horn on the sinciput of an old 
man, the basis of which was a wart; and other 
authors have noticed the same fact, t In the most 

* See Philos. Trans, no. 176. no. 297. and roLxWiii. pt. ii. p.580.— 
Also Zacut. Lusitan. Prax. Hist. obs. 188. — Ephem. Acad. Nat. Cuf^ 
dec.], p. 89i — Alibert has figured a singular case of ** Ichthyose cor« 
n^ " (plate 38.), which resembles the case of the " porcupine matt/* 
described by Mr. Baker, Philos. Trans., rol. xlix. p. 1, 

•|- " Cornua certe, quae hoc mererentur nomen, minquam yidi j" says 
M. Lorry, '* sed vartas excrescentias in corpore et cute hiimana innas* 
centes, et extra cutem forma singular! succreseenteSj quis non vidit ?*' 
De Morbis Cutan., p. 520. Yet our credulous countryman. Turner, 
declines treating of horns, because, he affirms, ** they are generally much 
deeper rooted than in the skin, arising from the cartilages or ligaments^ 
or the bones themselves.*' On Diseases of the Skin, p^l. ch.xii. at 
the end. 

J Morgagni de Sedib. et Cans. Morbor. epist.Ixv. art. 2. — Avicenna^ 
who noticed the growth of horns on the joints, considered them as 
verrucous. Canon i v. fen. 7. tract, iii. cap. 14. See al8oLorryyp..519A 
— Plenck de Morb. Cut., p. 98. 



384 TUBERCULA : 

numerous instances, however, they have arisen from 
the cavity of encysted tumours, of very slow growth, 
which were lodged under the cuticle of the scalp, or 
over the spine, after the discharge of their contained 
fluid. • In one case, a horn of this sort was the result 
of inflammation and discharge from a small steatoma- 
tous tumour of many years' continuance, t Nearly 
the whole of these examples have occurred in women 
of advanced age. 

If these excrescences are sawed or broken off, 
they invariably sprout again. Excision, with the 
complete destruction of the cyst, or morbid se- 
creting surface, is the only effectual remedy, when 
they have appeared, and a preventive during the 
growth of the primary tumour* 

Works which mat/ be consulted on Ichth yosis^ 

Alibert, Dis. des Maladies de la Peau, fol. 1806. 
Archives Generales de M^decine, torn. v. 
Fnr.T.PT. Rech, sur I'Ichthyose corn^e, 4to. 1815. 
GooD^s Study of Medicine, vol. iv. 
X^ JouLHiA (P. G.), Diss, sur Tlchthyose nacr^e, 4to. 1819. 
[jsT. de la Soc. Roy. de Paris, for 1776. 
Lorry, de Morbis Cutaneis, 4to. 
Medico-Chirurgical Trans, of London, vol. ix. 
Mem. della Societa Italiana, tom.xvi. 
Medical Facts and Observations, vol. ill. 
Philosophical Transactions, vol. xiv. xlviii, xlix. and Ixxxi. 
Rayer, Traits des Maladies de la Peau, torn. 2. 
ScHENCK, Obs. Med. Rarior, p. 699. 
WiLLAN on Cutaneous Diseases, 4to. 1 805. 

1 - — — — ■ 

* See two cases of this sort described by Mr. (now Sir Everard) 
Home in the Philosophical Transactions, vol. Ixxxi. p. 1.; and refer- 
ences to nine other cases of similar origin, in which the homy excres- 
cences were from four or five to twelve inches long: one of them eleven 
inches in length, and two inches and a half in circumference, is pre- 
served in the British Museum. See also Medical Facts and Observ- 
ations, vol. iii. — Eph. Acad. Nat. Curios, dec. i. an.'i. obs. 30.; and 
dec.iii. an. v. app. — Hist, de la Soc. Roy. de Med. de Paris, for 1776, 
p. 516. — Bartholin. Hist. Anat. Rar. cent. i. 78. 

f See Memoirs of the Medical Society of London, vol. iv. app. 
p. 391. The reader will find other examples of horny excrescences m 
the works of Ingrassius, de Tumor, praet. Natnram, torn. i. p. 336. : 
Fabric. Hildan. cent. ii. obs. 25, 26., and many more referred to by 
Haller, Elem. Physiol, torn. v. p. 30. note. Malpighi has figured similar 
excrescences, originating from a morbid growth of the nails. Opera 
Posthuma, p. 99. and tab.xix. fig. 3 — 6. 



385 



Order VIII. 

M A C U L iE. 

This Order comprises those discolorations of the 
skin which are permanent, and most of which are 
the result of an alteration of the natural texture 
of the part. It comprehends, therefore, several 
varieties of connate and acquired disfigurations of 
the skin, some of which are not capable of being 
removed, and most of them are removable only by 
surgical means. The various maculse, that have 
been described in medical and surgical writings, 
are included under the terms Ephelis, N^vus, 
Spilus, and moles, with other appellations applied 
to the more anomalous appearances. 

There is one affection of the skin, which has 
hitherto remained permanent, and for which no satis- 
factory explanation, except one hazarded by the 
Editor*, has yet been given ; namely, the leaden hue 
diffused over the skin, in some individuals to whom 
the Nitrate of Silver has been internally administered. 
It does not occur frequently ; and it does not seem 
to depend on the quantity of the medicine which has 
been taken, but upon some condition of the habit of 
the patient. It appears to the Editor that, as the 
Nitrate is taken into the circulation undecomposed, 
and conveyed in that state to the cuticular capillaries, 
it is probable that, in those persons in whom the 
Muriate of Soda is thrown off in greater quantity than 
usual by these capillaries, the salt is decomposed in 
the skin, and being converted into Muriate or Chloride 
of Silver, which is insoluble in the animal juices, it is 
deposited and permanently retained in the rete mu- 

* A. J. Thomson's Elements of Mat. Medica and Therapeutics, 1st 
ed. 1832. 

C C 



386 MACULJE : 

cosum. We know that the Chloride of Silver acquires 
a leaden hue^ whenever it is in contact with animal 
matter ; and we also know that insoluble substances, 
such as charcoal, smalt, vermilion, &c., deposited by 

CQCturing the cuticle, in the manner practised in the 
vant, remain there for life. It is probable that 
the addition of diluted Nitric Acid to the Nitrate, 
when it is internally prescribed, might tend to pre- 
vent this decomposition ; but this is a mere suggestion, 
which requires to be verified by experience. After 
the deposition has taken place, no means, hitherto 
employed, have been able to remove the stain of the 
skin. Except in point of appearance, no injury is 
done to the skin, which performs its functions as 
naturally as before the colouring matter was deposited 
in it. 



Genus I. EPHELIS. 

Syn. Ephelis ^ sole (Sauv.) : Nigredo a sole 
( Sennert) : Epichrosis Ephelis ( Good) : Sommers- 
prose ; die Leberflecke ( German) : H^le {F.) : Sun 
Burn. 

Def. The cuticle spotted with dark frec- 
kles, CONFLUENT OF CORYMBOSE ; DISAPPEARING 
IN THE WINTER. 

The term Ephelis denotes not only the freckles^ 
or little yellow lentigines^ which appear on persons 
of fair skin, and the larger brown patches, which 
likewise arise from exposure to the direct rays of 
the sun, as the name imports ; but also those large 
dusky patches, which are very similar in appearance, 
but occur on other parts of the surface, which are con- 
stantly covered.* (Plate LXIX. of Bateman.) Lory 

* " Nomen inditum airo m lyXie, non quod ^ sole tantum vitia illa in 
cute contrahuntur, sed quod a reliquis mducta causis, similem asperita- 
tem et colorem habeant." Gorrasi Defin. ad voc. e^rjXiv. — This accept- 



EPHELIS. 387 

and some other writers have endeavoured to make 
distinctions between Lentigines and Ephelides ; but 
there does not appear to be any essential diflFerenee 
between them, and all the ancient writers have pro- 
perly treated of them together.* 

The larger Ephelides, especially those which 
occur on the sides, abdomen, and other covered 
parts, sometimes diflFer little from the Pityriasis 
versicolor, or actually degenerate into it ; the cuti- 
cle becoming rough with minute furfuraceous scales. 
The brief description of the Ephelis given by Celsus 
is, indeed, equally applicable to both. " Nihil est 
nisi asperitas quaedam, et durities, mali coloris."t I 
have occasionally known the dingy hue of these 
maculae, as well as of the patches of Pityriasis, give 
rise to a suspicion of syphilitic infection. But inde- 
pendently of the history of the previous symptoms, 
the paucity of these patches, their want of elevation 
or depression, their permanency, and their final evan- 
escence, without any tendency to ulceration, or even 
to inflammation, will enable those, whom a habit of 
inspecting such appearances has not suflBiciently 
instructed, to discriminate them. 

Celsus apologizes, as has been already observed. 



ation of the term is sanctioned by the authority of Hippocrates, who 
gives the same appellation to the spots which sometimes occur in preg- 
nant women, and to those occasioned by the solar rays. " Quse utero 
gerunt in facie maculam habent,quam £0Y}Xtv vocant." — Lib. n^pt a<popuiv. 
Also ITfpc yvvaiKHuiv, lib. ii. Sauvages has improperly classed with 
Ephelis the mottled and dusky red hue of the shins of those who ex- 
pose their legs constantly to strong fires in the winter ; and also the 
livid patches of scurvy which arise from extravasation of blood under 
the cuticle. Nosol. Meth. class, i. gen. iii. spec. 4. & 6. — See also 
Plenck de Morb. Cut. class, i. spec. 2. ; and Plater has, by an extra- 
ordinai7 mistake, called the pustules of Scabies Ephelides. De Superiic. 
Corp. Dolore, cap. 1 7. 

* See Oribas. de Loc. Affect. Cur. lib. iv. cap. 52., and Synops. viii. 
33. — Aetius, tetr. ii. serm.iv. cap. 11. — Actuar. Meth. Med.iv. cap. 15. 

f De Medicina, lib. vi. cap. 5. — M. Alibert has thought the common 
freckle and the larger Ephelis worthy of two beautiful engravings; the 
former, in plate 26, is called *' Ephelide lentiforme ;" and the latter, in 
plate 27, ^ Ephelide hepatique." 

c c 2 



388 MACULJE : 

for prescribing the treatment of Epbelides and 
freckles, and such trifling discolorations of the 
skin ; and the same apology must still be urged : 
" eripi tamea foeminis cura cultus sui non potest/* 
The uniform practice both of ancient and modern 
authors has been to apply some gentle astringent 
and discutient lotion or liniment to the parts affected.* 
From the time of Hippocrates, bitter almonds have 
been recommended, as possessed of such discutient 
properties. t They have probably no virtues, "ex- 
cept those of a sedative nature,*' which are not pos- 
sessed by the ptisan, decoctions of Tares, and some 
other mucilaginous and detergent applications, recom- 
mended by the same authors. Some gentle restrin- 
gent or stimulant is commonly advised, however, by 
these writers. Celsus employed resin, with a third 
part of fossil salt, and a little honey ; — and Actu- 
arius combined vinegar, honey, and bitter almonds, 
for the same purpose, t Wine was likewise recom- 
mended as a vehicle for these and other substances. 
" Geoffroy praises a combination of bullock's gall, and 
solution of rotassa (Oleum tartari per deliquium et 
aqua. )" § Solutions of White Vitriol and precipitated 
Sulphur have also been used. 

The principle of these applications was correct ; 
but it may be pursued in a more simple and effectual 
manner by lotions of Alcohol, in its pure state, or 
diluted with some distilled water, " or with the 



* In the remedies adapted to ail these superficial and cuticular dis- 
colorations, according to Oribasius, " mediocri adstrictione et abster- 
sione opus est." Synops. lib. viii. cap. 35. The same obsenration is 
stated from Crito, by Aetius, tetr.iu serm. iv. cap. 11. See also Actu- 
arius, Meth. Med. lib.iv. cap. IJ. 

f Hippoc. Utpt yvvaiKsiiov, lib. ii. Oribasius says, '* Amygdalae amarae 
sunt facultatis perspicu^ attenuantis, ut ephelin expurgent." De Virtute 
Simplic. lib. ii. cap. i. 

J Celsus, loc. cit. — Actuarius, loc. cit. — Dr. Withering recommends 
an infusion of horseradish in milk, as a cosmetic. See his Botan. 
Arrang. of Brit. Plants. Of these cosmetic lotions, however, we may 
say with Celsus, " pene ineptiae sunt." 

§ M^m. de TAcad. des Sciences. 



Niivus, ETC. 389 

■ 

addition of a few drops of Hydrocyanic Acid," if 
the skin be irritable ; — by dabbing the spots two or 
three times a day with the diluted miiieral acids, in 
the proportion of about a drachm of the strong Sul- 
phuric Acid to a pint of water, or the same quan- 
tity of Muriatic Acid to half a pint ; by using, in a 
similar manner, the Liquor Potassae diluted with 
about twenty times its quantity of water ; " or, a 
solution of Perchloride of Mercury ( Corrosive Sub- 
limate)y in the emulsion of bitter almonds, in the pro- 
portion of one grain of the salt and six fluid ounces of 
the emulsion/* 



Genus IL N^VUS, &c. 

S^n. Maculae Matemae; Naevi, Spili {Auct var.)\ 
Metrocelis ( Oood) : Khal {Arab,) : Bak ( Turc.) : 
En vie; Tache cong^nitale (i^.): die Muttermahle 
( German) : Mother Spots. 

Def. Congenital spots and discolorations op 

THE SKIN. 

The various congenital excrescences and disco- 
lorations of the skin, to which the appellations of 
Naevus, SpUus, moles, &c. have been applied, may 
be' conveniently treated of together. They exhibit 
many peculiarities of form, magnitude, colour, and 
structure, and are seen on almost every part of the 
surface of the body in different instances. Some of 
them are merely superficial, or stain-like spots, and 
appear to consist of a partial thickening of the rete 
mucosum, sometimes of a yellow, or yellowish-brown, 
sometimes of a bluish, livid, or nearly black colour. 
To these the term Spilus * has been more particularly 

* '2'KiKoQy macula. This discoloration seems to be included by Sau- 
vages under his first species, Nsevus sigillum, and by Plenck, under 
N. lenticularis, spec. i. of his Arrangement. See Sauvages, Nos. Meth. 
class. ] . gen. 4. ; Plenck, Doctrina de Morb. Cutan., p. 37. 

c c 3 



- *-' 



y 



890 MACULJE : 

appropriated. Others, again, exhibit various degrees 
/ of thickening, elevation, and altered structure of the 
skin itself*, and consi^ of clusters of enlarged and 
contorted veins, freely anastomosing, and forming 
little sacs of blood. These are sometimes spread 
more or less extensively over the surface, occasionally 
covering even the whole of an extremity, or one-half 
of the trunk of the body ; and, sometimes, they are 
elevated into prominences of various form and magni- 
tude. Occasionally, these marks are nearly of the 
usual colour of the skin ; but, most commonly, they 
are of a purplish-red colour, of varying degrees of in- 
tensity, such as the presence of a considerable collec- 
tion of blood-vessels, situated near the surface, and 
., covered with a thin cuticle, naturally occasions. 

The origin, which was anciently assigned to these 
marks by physicians, and to which they are still 
ascribed by the vulgar {viz. the influence of the 
imagination of the mother upon the child in utero), 
has occasioned their varieties to be compared with the 
diflFerent objects of desire or aversion, which were sup- 
posed to operate on the passions of the mother : 
whence the following Naevi have been described. The 
flat and purple stains were considered as the represent- 
ative of claret, or of port wine (Plate LXXI. Fig. 1. 
of Bateman) t ; and sometimes of a slice of bacon, 
or other flesh. Sometimes the stains are regularly 
V < ^i formed, like a leaf, with a very red border, and lines, 
Y ' / t like veins, across from a central rib, forming the Nae- 
YM^foliacetis (Plate LXX. of B>teman) ; and, some- 
times, a smsdl red centre with branching lines, like 
legs, has suggested tiie idea of a spider, or N. araneus% 
(Plate LXXI. Fig. 2. of Bateman). But those 
Naevi which are prominent have most commonly been 

* Sauvages comprehends all these excrescences under Naevus mO' 
iemiu, spec. 2. ; and Plenck under his four remaining species, N. flank' 
meus, ivherctUotuff cavemosut, and mallgnus, 

JNsvus flammeus {Plenck) : Feverraahl {German), 
See the Plate of Pateman, fig. 8. j:. 



c^-^ f 



NiEVUS, ETC. 391 

' compared to diflPerent species of fruit, especially to 
cherries, currants, and grapes, when the surface is 
smooth and polished ; or to mulberries, raspberries, 
and strawberries, when the surface is granulated: 
whence the Naevus cerewis (Plate LXXI. Fig. 1. of 
Bateman), ribeSy moruSy rubicSy JragariicSy &c. * 
(Plate LXXII. of Bateman). 

Some of these excrescences are raised upon a 
neck or pedicle ; while some are sessile upon a 
broad base. Some of them again, although vivid ,/ ^ K 
for some time after birth, gradually fade and dis- 
appear: some remain stationary through life, but 
commonly vary in intensity of colour at different 
seasons, and under circumstances easily explained ; 
and others begin to grow and extend, sometimes 
immediately after birth, and sometimes from inci- 
dental causes at a subsequent period, and from small 
beginnings become large and formidable bloody 
tumours, readily bursting, and pouring out impe- 
tuous and alarming haemorrhages, which, if they 
do not prove suddenly fatal, materially injure the 
health by the frequent depletion of the system.t 

• See Bierling Adversaria Curios, obs. ix. — Valentin. Prax. Med. 
Infallib. cap. 1. — Strobelberger de Curand. pueril. Affects cap. 17. — 
Septalius de Nsvis. 

J A most striking case of this kind came under the notice of the Editor 
about ten years since. The little patient was born without any ap- 
parent mark upon the body, nor did any appear for dght days after 
birth, when a small point, resembling a red minute tubercle, appeared 
on the forehead, and gradually increased to the size of a crown-piece, 
when it was showed to the Editor. This spot was sunrounded by many 
small points, at different distances from the main spot ; and these gra- 
dually enlarging ran into one another, forming larger spots; which again 
in turn coalesced with others, until they finally were added, as their dia» 
meters increased, to the main spot, (Atlas, pi. xxv.) The extent 
which the whole occupied, and the eye being also involved in the 
disease, prevented extirpation from being proposed or attempted; and the 
only curative measure resorted to was an effort to obliterate the Naevua, 
by exciting ulceration in various parts 6f it. This partially succeeded; 
but, before the plan had advancea beyond the second sore, the child was 
attacked with Hydrocephalus and died. A post mortem examination 
explained satisfactorily the nature of the disease. The arterial system 
was natural ; but the venous was so thin in the coats of the vessels, that 
there was not sufBcient power to return the blood, which of course accu- 

C C 4 



I 

»; 



392 maculje: 

(Thomson's Atlas, p. xi^v.) Sometimes, however, 
after having increased to a certain degree, they cease 
to enlarge, and thenceforth continue stationary, or 
gradually diminish, till scarcely any vestige remains.* 

In some instances,, however, these preternatural 
enlargements and anastomoses, which constitute the 
Naevi, are not merely cutaneous. A similar mor- 
bid structure may take place in other parts : it 
sometimes occupies the whole substance of the 
[ cheek, according to Mr. Abemethy, and has 
occurred in the orbit of the eye : and Mr. John 
Bell affirms, that it affects indifferently all parts of 
the body, even the viscera.t 

The origin of these connate deformities is equally 
inexplicable .with that of other anomalous and 
monstrous productions of nature ; but it would be 
insulting the understanding of the reader to waste 
one word in refutation of the vulgar hypothesis, 
which ascribes them to the mental emotions of the 
mother ; an hypothesis totally irreconcilable with 
the established principles of physiology, and with 
the demonstrable nature of the connection between 
the foetus and the parent, as well as with all sober 
observation. 

It is important, however, to know, that very 



mulated in the veins ; and those in the vicinity gradually assumed the 
same diseased state. The most remarkable part of the case, and on 
account of which it is mentioned in this place, was the extension of the 
disease to the bones of the cranium. The Edhor is not aware of any 
case of a similar kind being on record : the scull-cap is in the Museum 
of Anatomy of Dr. Alexander Monro, of Edinburgh, to whom the 
Editor presented it ; and an accurate engraving of it will be found in 
the Atlas of Plates attached to this edition of the Synopsis. T. 

* See Mr. Abernethy's Surgical Works, vol. ii. p. 224. et seq. 

f The ordinary Naevi appear to consist of venous anastomoses only : 
but some of them, even when congenital, are of that species of morbid 
structure which Mr. John Bell has denominated " aneurism by anas- 
tomosis," and which, he says, is made up of **a congeries of small and 
active arteries, absorbing veins, and intermediate cells," somewhat ana- 
logous to the structure of the placenta, or of the gills of a turkey-cock. 
See his Principles of Surgery, vol. i. discourse xi. ; also Bflr. Abernethy*8 
Surg. Works, loc. cit. 



HJMVUSf ETC. 39s 

slight causes of irritation, such as a trifling bruise, 
or a tight hat, will sometimes excite a mere stain- 
like speck, or a minute livid tubercle, into that dis* 
eased action, which occasions its growth. This 
growth is carried on by a kind of inflammatory 
action of the surrounding arteries ; and the vary- 
ing intensity of colour arises from the different 
degrees of activity in the circulation. Thus these 
marks are of a more vivid red in the spring and 
summer, not in sympathy with the ripening fruit, 
but from the more copious determination of blood 
to the skin, in consequence of the increase of the at- 
mospheric temperature. The same increased deter- 
mination to the surface is also produced temporarily, 
and, with it, a temporary augmentation of the florid 
colour of the Naevi, by other causes of excitement to 
the circulation ; as by active exercise, by heated 
rooms, or the warmth of the bed, by drinking strong 
liquors, or high feeding, by emotions of the mind^ 
and, in women, by the erethism of menstruation. 

These considerations will serve to suggest the 
proper means of treating the Naevi and Spili, where 
any treatment is advisable. When they are merely 
superficial, without elevation, which would render 
them liable to accidental rupture, and without any 
tendency to enlarge and spread, there appears to * 
be no good reason for interfering with them. The 
applications mentioned by the older writers were 
doubtless as futile as they were disgusting ; such as 
saliva, the meconium of infants, the lochial blood 
of women, the hand of a corpse, &c. : and the 
severe resource of the knife, even if the deformity of 
a scar were much less than that of the original mark, 
is scarcely to be recommended. 

But when the Naevi evince a tendency to enlarge, 
or are very prominent excrescences^ and either 
troublesome from their situation*, or liable to be 

* A cherry-navus on the lip, for instance^ has prevented the act of 
sucking. 



^^1 



394f macvlm: 

ruptured, some active treatment will then be required. 
Either their growth must be repressed by sedative 
applications, or the whole morbid congeries of vessels 
must be extirpated by the knife. " The latter is the 
^li^ only certain plan of cure. It has been recommended 
9J ' to inclose them with a liga ture under the skin ; and 

thus cutting oflP their supply of blood, destroy their 
^ growth J and, where they are sufficiently early at- 

tended to, no plan is better : but, if more advanced, 
there is no security but in the complete extirpation, 
by dissection, of the diseased part.*' 

All strong stimulants externally must be avoided, 
as they are liable to produce severe inflammation, 
and even constitutional disorder. 

The consideration of the mode in which these 
vascular excrescences grow, by a degree of inflam- 
matory action in the surrounding vessels, suggested 
to Mr. Abemethy the propriety of maintaining a 
constant sedative influence upon those vessels, by 
the steady application of cold, by means of folded 
\H linen kept constantly wet. This practice has suc- 

f- ^ ceeded, in several instances, in repressing the 

growth of these unnatural structures, which have 
afterwards shrunk, and disappeared, or ceased to 
t^ be objects of any importance. •^— Pressure may, in 
iV*- some instances, be combined with this sedative 
Vv^ application, and contribute to diminish the dilata^- 

tion of the vessels. " I have seen Naevi under 
parts of the dress, which exerted a constant pressure 
upon them, completely obliterated by this means ; '* 
but in the majority of cases, pressure is the source of 
great irritation to these maculae, and cannot be em- 
ployed. — The temporary enlargement of these pro- 
minent Nsevi by every species of general excitement, 
would teach us to enjoin moderation in diet, exercise, 
&c. during the attempts to subdue them. 

The mode of extirpation is within the province of 
the surgeon ; and the proper choice of the mode, 
under the different circumstances, is directed in sur- 






:^ 



NJBVUS, ETC. 395 

gical books. From the days of Fabricius Hildanus *, 
the propriety of radically removing every part of 
the diseased tissue of vessels has been inculcated : 
" and where there is any doubt of this having been ' 
effected, the bottom of the wound should be rubbed 
with Nitrate of Silver, or some other escharotic ; ^* 
but Mr. John Bell has most satisfactorily stated the 
grounds of that precept, by explaining the struc- 
ture of these excrescences, as well as the source of 
the failure and danger, when they are only cut 
into or opened by caustic. I shall, therefore, refer 
the reader to his " Discourse,** already quoted. 

The varieties of Spilus, or mere thickening and 
discoloration of the rete mucosum, are sometimes 
removable by stimulant and restringent applications. 
A combination of lime and soap is extolled by 
several writers ; andlotions of strong spirit, with 
the Liquor Potassas, as recommended for the treat- 
ment of the Ephelides and of Pityriasis, certainly 
sometimes remove these maculae. 

With respect to those brown maculae, commonly 
called ^hleSj^ I have little to observe ; for no ad- 
vantage is obtained by any kind of treatment. It 
is scarcely safe, indeed, to interfere with them : 
for when suppuration is induced in them, it is 
always tedious and painful, the matter emitting at 
the commencement an extremely fetid odour. 
When moles are irritated by accident, or rudely 
treated, so as to produce excoriation, they are liaye, 
it is said, to becgnie^angrenous, and thus to produce 
sudden fatality. 

Moles are not always congenital. I lately saw 
an instance in a lady of remarkably fair and delicate 
skin, where a numerous crop of small moks appeared, 
in slow succession, upon the arms and neck. Con- 
genital moles, indeed, are not always stationary ; but }. 
they sometimes enlarge, gradually, for a time, and 
afterwards disappear. 

* Fab. Hild. Oper. cent. v. obs. 46. 



396 



Order IX. 

DERMAL EXCRESCENCES. 

Syn. Echphyma ( Good) : Phymatosis ( Young) : 
Hautg^wache (O.). 

Dermal Excrescences are permanent, superficial^ 
indolent productions of the cuticular membrane, thajt 
are not connected with any peculiar condition of thb 
system ; but seem to depend, either updti somfe 
peculiar local action of the capillaries that secrete the 
cuticle, or on the action of extraneous mechanical 
causes, such as pressure from tight shoes, or the action 
of hard substances upon diflPerent parts of the body. 
Although these tuberosities of the cuticle are in them- 
selves unaccompanied by any inflammatory action, yet, 
from their pressure on the neighbouring parts, they 
frequently produce pain and inflammation. 

The order comprehends three genera : — 

1. Perricca. 

2. ClaviLS. 

3. Callus. 



Genus I. VERRUCA. 

Syn. Verruca (Auct. var.): Ecphyma verruca 
( Oood) : Phyma verrucosa ( Young) : Verrue (F.) : 
Woertze (O.): Verruga (Span.): Porro (Ital.): 
ShuWxxh (Arab.) : JVart. 

Def. Small, hard, insensible tuberosities of 

THE CUTICLE, OCCURRING CHIEFLY ON THE HANDS. 



cLAvis. 397 

Warts are, undoubtedly, at first mere cuticular pro- 
ductions, most probably, depending on some peculiar 
action of the capillaries secreting the cuticle j but they 
gradually become connected with the true skin, by 
the continued morbid action of the minute vessels 
which originate them : this connection, however, is 
only with the base of the wart ; for, in the highest 
state of sensibility of that part, the apex is always hard 
and perfectly insensible. The colour of warts varies 
from a pale white to dull or obscure red ; the latter 
of which is generally the case when they cluster, and 
become attached by vascular communication with the 
true skin. 

Warts are destroyed by ligature, the knife, or 
caustic; or they are made to separate readily by 
coagulating the albumen of their centres by means of 
strong astringent decoctions, especially, that of the root 
of Tormentilla erecta. Those that occur on the penis, 
as sequelae of syphilitic affections, are rapidly destroyed 
by the decoction of Tormentilla. The recent milky 
juices of the indigenous Euphorbiaceae are advanta- 
geously used : the yellow juice of Chelidonium majus 
acts also in the same manner. One of the quickest 
and best modes of destroying them, is to cover the 
surrounding skin with common adhesive plaister, per- 
forated so as to permit the warts to be uncovered, and 
then to touch their heads twice a day with strong 
acetic acid. 



Genus II. CLAVUS. 



Syn. Clavus (Auct. var^ : Ecphyma clavus 
( Young y Oood) : Cer de pi6s (iO : Hiinerang ( G^. ) : 
Callo (/S'.) : Callo nel piede (/.) : Zekh (Pers.) : 
Corn. 

Def. A HARD, ROUNDISH, HORNY SUBSTANCE, 



39S DERMAL EXCRESCENCES. 

WITH CENTRAL NUCLEUS, SENSIBLE AT THE BASE ; 
SEATED CHIEFLY ON THE TOES. 

Corns originate in compression of the cuticle. 
They are generally solitary ; but sometimes they are 
in clusters, especially when they appear on the head. 
They have been confounded with an extensive variety 
of Icthyosis, the cornigera ; but they diflPer greatly 
both in character and origin from the elongated homy 
papillse of that curious disease. 

Their eradication is the business of the surgeon, who 
may with care take them out by the root. The pain 
they occasion is allayed by any soft substance inter- 
posed between the corn and the other toe that pressejs 
upon it. 



Genus III. CALLUS. 

Syn. Calus {F.) : SwuUe ( O.) : Nasur (Arab.) : 
Sheghe (Pers.) : Calliis. 

Def. A PERMANENT, INSENSIBLE, THICKENING OF 
THE CUTICLE. 

Many things, besides mechanical pressure, indurate 
the cuticle of the hands and the feet : thence dyers, 
brass workers, bakers, masons, smiths, and other 
artisans who employ hammers, are liable to callus : 
but, unless the callosity be so great as to affect the 
motion of the joints, or otherwise prove inconve- 
nient or cause pain, it is disregarded. In a case 
mentioned by Dr. Good, the " fingers were so rigid 
from the callosity of the cuticle, that, on a forcible 
endeavour to straighten them, blood started from every 
pore.'* 

Emollients, and suspending the use of the materials 
or the labour that have produced the callus, are all that 
are requisite for causing the exfoliation of the hard- 
ened cuticle, and perfecting the cure. 



INDEX. 



Page 



o' 



AcNB - - - 330 

simplex - - - 331 

punctata - - - 338 

— mdurata - - - 339 
rosacea - _ _ 342 



Alphos - - - - 41. 362 

Aphtha - - - - 316 

lactantium - - - 317 

adultorum - - - 321 



anginosa - - - 323 

Baras. See Elephantiasis. 

Bullae . - - - 162 

Chicken-pox - - - 258 

lenticular •. - - 261 

conoidal - - - 262 



Courap - - - - 177 

Cow-pox. See Vaccinia. 

Crusta lactea. See Porrigo larvalis. 

Crystalli. See Chicken-pox. 

DandrifT. See Pityriasis. 

Ecthyma - - - - 219 

vulgare - - - 221 

infantile - - - 222 

luridum - - - 223 

cachecticum - - - 226 

Eczema ... - 305 

solare - - - . 306 

■ impetiginodes - - - 308 

• rubrum - - - - 311 

' from mercury - - ibid» 

Elephantiasis - - - - 352 

Ephelis ... -385 



400 iNp^x. 

Page 

Erydpelas - - - 145 

— phl^gmonodes - - - 147 

— cedematodes - - 148 

gangraenosum - - - . 150 

of infants - - - 151 

• erraticum ^ - - Ufid, 

Erythema - - - - 138 

fugax - - - - 140 

laeve - . - - ibid, 

marginatum - - - 141 

• — papulatum - - _ ibid, 

tuberculatum - - - 142 

nodosum - - - 143 

— intertrigo ... ibid. 

Exanthema, what - - - - 71 

Favus ----- 173.202 
Febris ampullosa. See Pemphigus. 

bullosa. See the same. 

vesicularis. See the same. 

Fici. See Sycosis. 

Fish-skin Disease. See Ichthyosis. 

Formica. See Herpes. 

Framboesia - - - - 370 

Freckle. See Ephelis. 

Furunculus - - - - 326 

Gum, red. See Strophulus. 
Outta ros^ See Acne rosacea. 

Haemorrhoea petechialis. See Purpura. 

Heat, prickly. See Lichen tropicus. 

Herpes - . - - 276 

phlyctsenodes . - - 279 

zoster - . - - 282 

■ ■ circinatus - - - 287 

labialis - - . - 290 

— prseputialis - - - 291 

Iris - - - . 294 

Hives. See Chicken-pox. 

Hydrargyria. See Eczema rubrum. 

Ichthyosis - . - - 377 

simplex - " - - - 378 

cornea - - - 382 

Ignis sacer - - - - 158 

Sancti Anthonii - - - ibid. 

Impetigo - - - - 174 

figurata - - ' - - 176 

■ sparsa - - - - 179 

erysipelatodes - - - 200 

scabida - - - - 185 

larvalis - - - 107 

favosa - - ' - - 193 

- rodens - - - 185 



, .UWOEX, 



*0l 



Intertrigo - ^ - 

lonthos. See Acne. 

Iris. See Herpes Iris. 

I^h. See Scs&ies'. 

Itch. Baker's - - 

— Grocer's 

—^Bricklayer's - - 

Itch insect 

Ju^am. See Elephantiasis. 

Judam. See the same. 

Kriebel Krankheit 

l^actucimen. See Aphtha. 
Laryse mistaken for pediculi 
l<ent]go. See Ephelis. 
Lepra 
I - Yulsaris 
'- — alphoides 

■ nigricans 

Leprosy of the middle ages 

Leuce, probabl v the Jewish Leprosy 

differs from Ifepra 

Lichen 



T-^ 



rr 



Lupus 



simplex 

pilaris 

circimiscriptus 

agrius 

lividus 

tropicus 

urticatus 



Biaculae 

Mai des Ardens 

Measles ... 

Mercurial Rash. See Eczema. 

Miliaria 

Molluscum • - - 

Morbilli. See Rubeola. 

Mother-spots. See Naevus. 

Mussels, rash produced by eating 

Naevus - - 

Nettle-rash. See Urticaria. 
.. from eating shell-fish, &c. 

Nirles. I^ee Herpes pmyctsenodes. 
Noli me tangere. See Lupus. 

Ophiasis 

Papulae - . - 

Pemphigus 

Pet^iae sine febre. See Purpura. 

D D 



Page 
^1 



59 
181 



159 



28 
?^ 

m 

41 

42 

359 

ibid. 

9 

10 

12 

13 

15 

18 
ibid* 

19 
350 

385 
159 

72 

298 
326 



108 
389 
108 



^17 

I 
153 



40S INDEX. 

Pagp 

Pfayma - - - - 325 
I^ples. See Papulae. 

PityriawB - - - - 64 

aa>itis - - - - 65 

rubra - - - 66 

— "— — verdcolw - - - «^- 



nigra 



69 



Pompholyx - - - - 166 

— — benignuf - - - 167 

— — — diutinus _ _ - Und, 

solitarius - - - 171 



Porr%o - - - - 2i02 
furfiirans - - - - 205 

— lupinosa - ... 203 

— scutulata - . _ - 209 
— — decalvans - - - 217 
Prurigo - - - - 20 
— — — Diitis - . - - 21 
— ^ formicans - - - 23 
' senilis - - - 27 

sbepapoUs - ' * a^ 

■ prseputu - - - - una, 

— ^— pubis - - - - «^« 

' urethralis - - " . ?^ 

— — — podicis - - - *^' 

scroti - - - ibid, 

' pudendi muliebris - - 31 

Psonu See Psorianis. 

— — erroneously applied to Scabies - - 240 

Psoriasis - - - - ^^ 

— ^— - guttata - - - - 53 

diflusa - - - - 54 

pyrata - - - - 56 

mveterata - - " «^' 

localis - - - 57 

— — labialis - - - ' - 58 

lotorum - - - ^*^« 

palroaria - - - - *^« 

■ ophthalmica - - " - 59 

pistoria - - - ^^« 

praeputii - - - »^* 

" scrotalis - - - ilfid. 

Psydracia - - - - 172 

Purpura - - . - 123 

simplex - - - 124 

-^— hemorrhagica - - ^ 126 

urticans ... 136 

— — senilis - - - «^* 

- contagiosa - - - 13*7 
Pustules - - ' - - 172 

four varieties of - - - «^- 

Ringworm, various - - 177. 181. 287 
of the Scalp. See Porrigo scutulata. 

Roseola - - - - H^ 

— — sestiva - - - 115 



INDEX. 403 

Page 

Roseola autumnalis - - - 117 

— — annulata - - - 118 

' infantilis - - - 119 

variolosa - - - 120 

vaccina - - - 121 

miliaris - - - 128 

Rubeola - - . - 72 
vulgaris - - - 74 

- sine catarrho - - - 80 

nigra - - - 81 

Rupia - - - - 296 

simplex - - - ibid, 

- promineQs - - - 297 
escharotica - - - - 298 

Scabies - - . . 240 

— ^ papuliformis - - - - 242 

lymphatica - - - 244 

— — purulenta - - - 245 

■ cachectica - . - 247 
Scalled head. See Porrigo favosa. 

Scaly diseases - - - 33 

Scarlatina - - - 87 

simplex - - - 89 

angmosa - - - 92 

m^igna - - - loi 

Scarlet-fever. See Scarlatina. 

Shingles. See Herpes zoster. 

Small-pox. See Variola. 

Spilus ... - 385 

Strophulus - - - 3 

intertinctus - - - 4 

albidus - - - '5 

confertus - - - 6 

volaticus - - - 7 

candidus - - - 8 

Swine-pox. See Chicken-pox. 

Sycosis - - - • 345 

menti «... 346 

' capillitii - - - - 348 

Tetter, dry or scaly. See Psoriasis. 

■ humid. See Impetigo. 
Tinea. See Ponrigo. 
Thrush. See Aphtha. 
Tooth-rash. See Strophulus. 

Tubercula - - - - 325 

Vaccinia - - - - 266 

Vari. See Acne. 

Varicella - - - - 257 

lentiformis - - - * 261 

conilbrmis - - - 262 

globularis - . - - 263 

Variola - - - - 230 



404 INDEX. 

Page 

Variola discreta - - ^ m ^^g 

■*■ coiifluens - - - 234 

Vesiculse - - - ■» 257 

Verruca - - - - , 396 

VitUigo - . . , 328 

Urticaria - . . r 106 

fdjrilis - - - - J07 

evanida - - f 110 

-^ perstans - - -» 112 

conferta ■ ~ - ^ ibid, 

'^ subcutanea - - 118 

tuberosa - - - &id» 



•r !■ 



Washerwoman's scall - - <• 58 

Water<jag8. See Chicken-pox. 

Wheals ... - 106 

Wheal-worms - -1.-337 

Yaws. See Framboesia. 

Zona. See Herpes. 
Jtoter. See the same. 



THE END. 



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