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M'^
On Diseases of the Skin
Erasmus Wilson
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LIBRARY
OF
eHCSTER N. FRAZIER
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ON
DISEASES OF THE SKIN.
BY
ERASMUS WILSON, F.R.S.
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MIODLBBBX HOSPITAL SCBOOL OV MBSICIBB; BOBOBABT ABaOCIATB OV VBB TBtBBIBABf
^ MBDICAb AMOCIAnOR ; VBU.OW OF THB BOTAL MBBIOAIi ABB CBIBVBOICAIi BOOIBrT.
SECOND EDITION,
LONDON:
JOHN CHURCHILL, PRINCES STREET, SOHO.
MDCCCXLVII.
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BOSTON MEDICAL LIBRARY
IN THE
FRANCIS A. COUNTWAY
LIBRARY OF MEDICINE
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TO
SIR JAMES CLARK, BART., M.D., F.R.S.
^f^osician in ^irinarc to t(t ^ntm, $r to tl^e prince Iftttert,
THIS WORK
IS RESPECTFULLY INSCRIBED,
WITH FEELINGS OF ADMIRATION FOR UIS LIBERAL AND
INDEPENDENT PRINCIPLES,
AND OF GRATITUDE FOR UIS EXERTIONS IN THE CAUSE OF
MEDICAL SCIENCE.
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PREFACE.
The study of diseases of the skin offers a natural division into
two parts — a scientific and a practical part. The former
embraces all that belongs to structure, physiology, and patho-
logy ; the latter, the application of the results of these inyesti-
gations to the treatment and cure of disease. Conceiying that
no real improYement could be made in the practical department
of the subject in any other way than through the advancement
of the scientific portion, I have continued to bestow much atten-
tion and labour on the microscopic examination of the cutaneous
tissues. In the pages of the present edition of this work, I
have embodied a paper* on the " Development and Growth of
the Epiderma,^ in which I have put forth some original and
curious observations on the structure and formation of the
epidermal cell. I foimd the perfect cell to be composed of
secondary and tertiary cells, and the essential and primary con-
stituent of these cells to be granules of extreme minuteness.
As a contribution to structural anatomy, these observations are
important, inasmuch as they demonstrate the theory of the
development of a cell advanced by Schwann to be inapplicable
to the cells of the epiderma and epithelium. I next found
that these minute granules were the agents of coloration of the
skin, that they were in reality the pigment : the difference in
their tint giving rise to all the known diversities of shade met
* Read before the Royal Society, Jane 19, 1845.
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VIU PREFACE.
with in the rete mucosum, the nails, and the hairs. Further
examination proved that the pigment of the choroid membrane
of the eyeball and that of melanosis were composed of identical
organisms. With a view to apply these observations of normal
structure to the morbid anatomy of the skin, I made a careful
examination of the epidermal cells of the scales of lepra, and
found the primitive granules of the latter to be abnormally
formed ; they were evidently in a state of hypertrophy from im-
perfect nutrition. I have not had an opportunity of proceeding
further with this inquiry, but I intend to pursue it whenever I
shall have leisure to devote to its prosecution.
The structure of the hair has also obtained a considerable
share of my attention, and the results of my research are
reported in the following pages. It is interesting to find the
minute structure of the hair to harmonize completely with its
analogue, the epiderma ; being composed of the same primitive
granules, and differing only in their arrangement, as being sub-
servient to a different end. In the hair, these granules are dis-
posed in such regular order as to have the appearance of
parallel fibres, and their diversity of tint gives rise to the colour
of the hair. Under the influence of disease, the hair is liable
to a change, which may be compared to the alteration of the
epiderma which takes place in Lepra — ^that is, it becomes lax in
texture, brittle, twisted, and loses its natural colour. The
disease of which this morbid change is a symptom is the
common ^^ ringworm." Now, the examination of the hair in
ringworm exhibits its primitive granules morbidly enlarged like
those of the epidermal cells of Lepra; both diseases axe, in
fact, a granular degeneration of the cells of which the epidermal
product is composed. These may be regarded as first results
of the application of scientific research to practical use ; they
are humble examples, but they, nevertheless, offer a strong
encouragement to persevere.
The present edition has the advantage over its predecessor
of being illustrated with coloured delineations drawn from
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PREFACE. IX
nature, and engraved on steel. The plates are eight in number,
each representing a group of diseases. For example, if the
reader wish to place before his eyes the group of " congestive
diseases^ of the derma, he may turn to Plate 1, where he will
find displayed. Urticaria, Roseola, and Erythema ; Erysipelas
being omitted, partly because its illustration is less necessary
than that of other cutaneous diseases, and partly on account of
the large extent of surface its delineation would require. If the
reader would contrast the "congestive group" of cutaneous
diseases with others, he will find in Plate 2, the " asthenic effu-
sive group," namely, Pemphigus and Rupia; in Plate 3, the
"sthenic efiusive group/' namely, Herpes and Eczema; in
Plate 4, the "pustular group," Impetigo and Ecthyma;
in Plate 5, the " papular group," Lichen, Strophulus, and
Prurigo ; in Plate 6, the " squamous group," Lepra, Psoriasis,
and Pityriasis; Plate 7 illustrates the peculiar morbid altera-
tion of the skin termed Lupus non exedens; and Plate B,
certain diseases of the hair-follicles and hairs, namely, Acne,
Sycosis, Favus, and Trichosis furfuracea.
Another feature in the Plates which accompany this volume,
and one at which I have especially aimed, is that of bringing
together as many of the varieties of a given disease as possible.
My reasons are twofold — firstly, that the leading characters of
these varieties may be the more easily comprehended and con-
trasted ; and, secondly, that the reader may be placed in pos-
session of the largest amount of illustration admitting of being
compressed into a limited space. For example, in the upper
division of Plate 1 will be found four varieties of Urticaria, four
varieties of Roseola, and, in the lower, six varieties of Erythema;
makingin the single plate fourteen specimens of cutaneous disease,
the separate figures not being in any way stinted in dimensions,
but being, in reality, of the size of life. With the most ample
space at my command, I could have done little more than this.
I might have repeated forms, but the matter to be impressed on
the mind could not have been rendered more clear or more
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X PREFACE.
precise. Plate 2 represents, in the upper division, two varieties
of Pemphigus ; and, in the lower, three varieties of Rupia. The
upper division of Plate 3 exhibits four varieties of Herpes, and
the lower, the same number of varieties of Eczema. In Plate 4,
the number of varieties of Impetigo, in the upper division, is
four ; and in the lower division, the varieties of Ecthyma are
three. In Plate 5, there are, in the upper division, six varieties
of Lichen ; and in the lower, four varieties of Strophulus, and
one of Prurigo. Plate 6 contains, in the upper division, three
varieties of Lepra; and in the lower, three varieties of Psoriasis,
and one of Pityriasis. Plate 7 is devoted to the single subject
of Lupus non exedens ; while in Plate 8 are four varieties of
Acne^ one of Sycosis, two of Favus, and one of Trichosis. So
that, in the limited compass of eight octavo plates, no less than
sixty-one subjects are represented.
The arrangement of cutaneous diseases followed in this work
is one which takes Anatomy and Physiology for its groundwork,
and therefore becomes entitled to the designation of Natural
System of Classification.
The derma and its dependencies, its glands, and its follicles,
are the undoubted seat of all the changes which characterize
Cutaneous Pathology. These, then, constitute four Primary
Divisions of the subject — ^namely :
I. Diseases of the Derma,
II. Diseases of the Sudoriparous Glands,
III. Diseases of the Sebiparous Glands,
IV. Diseases of the Hairs and iIair-Follicles.
I. The Dermuy complex in its organization, and multiple in
its functions, naturally presents us with a much larger field of
investigation than the rest. It maybe subject to changes which
constitute the five Secondary Divisions of this Classification —
namely :
1. Inflammation of the Derma,
2. Hypertrophy of the Papillae of the Derma,
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PREFACE. XI
3. Disorders of the VasculaT tissue of the Denua^
4. Disorders of the Sensibility of the Derma^
5. Disorders of the Chromatogenous Function of the
Derma.
1. Inflammation of the Derma^ — of an organ of so much com-
plexity and importance, naturally gives rise to a variety of
effects. These effects served by their diversity as the founda-
tion of the Orders of Willan, and in the Natural Classification
they compose a series of Groups in the Secondary Division
under consideration. The Groups of Cutaneous disorders, illus-
trative of changes depending on Inflammation of the tissues of
the Derma, are six in number — ^namely :
a. Congestive Inflammation of the Derma,
h, Efiusive Inflammation of the Derma,
c. Suppurative Inflammation of the Derma,
d. Depositive Inflammation of the Derma,
e. Squamous Inflammation of the Derma,
/. Inflammation of the Derma from the presence of Acari.
The first of these groups I have deemed it advisable to divide
into two sub-groups — namely, into such as are characterized by
inflammation of the derma and mucous membranesy with constitu-
tianal symptoms of a specific kind; and such as consist simply of
ififlammatum of the derma without constitutional symptoms of a spe-
cific kindy the mucous membranes being less conspicuously dis-
ordered. It may be said that the diseases comprised in the
first sub-group, — ^viz.. Rubeola, Scarlatina, Variola, &c., — though
heretofore considered and treated of as diseases of the skin, are,
in reality, diseases of the system, of which the alteration in the
skin is a symptom of comparatively secondary importance. I
cheerfuUy assent to the validity of this argument, but I am
nevertheless unwilling to lose a group of diseases so rich and
important in their illustration of the pathological changes
wrought in and upon the skin by active inflammation.
I have styled depositive inflammation of the derma, that alte-
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Xll PREFACE.
ration which gives rise to the production of small elevations of
the skin, termed pimples and tubercles. The order Tubercula
of Willan would have formed a sub-group under this head, had I
found diseases admitting of such an arrangement But, upon
examination, afier distributing some of his genera in more ap-
propriate places, and rejecting others, either on the ground of
not being diseases primarily originating in the skin, or of not
being diseases of this climate. Lupus alone remained behind.
The last group — namely, " Inflammation of the Derma from
the presence of Acari," may appear to the eyes of some of my
readers in the light of an innovation ; but there is no part of
the Pathology of Cutaneous Disease, of the truth of which I
feel better satisfied, than of this. I have long observed the dis-
ease vrith interest and attention ; I have had ample opportunity,
from my boyhood upwards, of tracing its progress upon the skin,
and the experiments of M. Gras, recorded in the latter chapter
of this volume, I have seen exemplified in numberless instances.
I might appeal to those very experiments as a sufficient proof
of the accuracy of my view of the nature of scabies, were it not
that their author falters in his conclusions. Blinded by the
mists of prejudice that surrounded him on every side, he stands
amazed before the vision of a stimulus of the nerves of the skin,
prolonging its effects after the cause is withdrawn. Surely pa-
thology can furnish us with a thousand such instances. But in
his doubt he sinks still more deeply into the slough that a mere
physiological question had thrown in his path ; for he becomes
lost to the fact, that if a living animalcule act simply as a cause
of irritation, and give rise to certain effects, an inorganic sub-
stance may also, by exciting irritation, give rise to like effects.
I have seen instances in illustration of this, in which the erup-
tion of scabies has been prolonged for months, by a continuance
in the use of the means which destroyed the original cause —
namely, sulphur ointment But are we, therefore, to conclude,
that this sulphur irritation, so kept up for an indefinite period
after the cure of the real disorder, is an " affection psorique ?"
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PBEFACE. XIU
Is it not rather an affection sulphurique f Into this error, strange
to say, M. Gras falls in the very last page of an otherwise excel-
lent pamphlet There is, he says,
^^ An important circumstance, to which I ought to draw atten-
tion ; I mean the per^stence of vesicles after the close of an
active treatment, when dead acari only are to be found, and
when by dint of Motion and baths all the ova must have been
destroyed ; it is rare, indeed, that we discover living sarcoptes
i^r three or four days of treatment ; nevertheless, the disease
often continues for ten or fifteen days. This fact is, in truth, so
constant) that on perceiving an abundant eruption of vesicles
(psorique) covering the hands, when no cuniculus is apparent,
we may instandy conclude that the patient has been submitted
to treatment.'* ^^ In one case, I saw a young man in whom itch
had re-appeared eight days after his dismissal from the hospital,
without his having been exposed to the contagion afresh ; his
hands were covered with well-formed acuminated vesicles, but
I was unable to discover the slightest trace of a cuniculus. In
considering this fact by the side of analogous cases, in which
scabies has proved rebellious to every kind of treatment, and
where the vesicles may disappear during an acute disease, to
re-appear subsequendy, we should be tempted to believe that
the action of the acarus in the production of scabies was not
merely local and mechanical, but that it was capable of acting
on the economy in a manner that we might call vital and physi-
ohgicaL The iicarus would, consequendy, be noUiing more
than the exciting cause of the disease, without constituting it en-
tirely. In this manner we might, up to a certain point, explain
why certain kinds of transient itch may be transmitted from
animals to man, although the sarcoptes of the animal may be
wholly unable to live and propagate on the skin of man. In
adopting dus view, the treatment offers two indications — 1. To
destroy the acarus; 2. To treat the ^affection psorique^ which,
nevertheless, would get well of itself when once the sarcoptes
had been entirely removed."
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XIV 1>HEFACE.
It is to be regretted that M. Oras should have fiedled so sig-
nally in his reasoning, when the prize for excellent observations
was already in his hands. I am thoroughly convinced, and so
long as I possess that conviction, shall ever continue to main-
tain, that the Acarus is the sole and only cause of scabies, and
that every eruption, however acuminated and well-defined its
vesicles, if it be deficient in the living cause, is not scabies.
Many dermatologists, it is true, acknowledge the existence of
the acarus scabiei in itch, but they regard it as a complication,
and not as the real cause of the disease. They still treat of
scabies as a vesicular eruption, and accuse the blood and system
of taking a share in the affection. I may render this affirma-
tion more apparent, by quoting the opinions of some of the most
eminent of modem dermatologists.
Rayer, treating of the causes of scabies, remarks — *^ The
most momentary contact of the ^tdd secreted by its vesicles is
enough to communicate the infection,^ (p. 339.) Now this is
not the fact, unless the fluid of the vesicles contain the animal-
cule or its ova, which is not usually the case, and even in that
event, the contact must be such as to enable the former to take
a firm hold upon, and bury himself in the epiderma, or to afibrd
time to the latter to hatch and give exit to the livino cause of
scabies. The same author observes — ^**It is, further, rare to
discover these insects on the abdomen and on the groins, where
the eruption is nevertheless very common and very apparent ;
moreover, scabies is known to continue when no more acari are
to be discovered." It would occupy too much space to explain,
singulatim, the objections made by the opponents of the views
on this subject which I advocate in this volume ; it is sufficient
to mention, as a commentary on the last passage, that Rayer
speaks of the acarus upon the report of others ; he has never
extracted the animalcule himself; moreover, in reference to the
former part of the preceding sentence, it must be recollected,
that a single acarus is always the cause of a number of vesicles,
that number increasing with the susceptibility of the portion of
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PREFACE. XV
skiu invaded ; and in regly to the latter part, — ^the assertion is
unsupported by fact.
Cazenave and Schedel,* referring to the proximate cause of
scabies, observe — " Thfe proximate cause is wholly unknown —
an acid principle, a peculiar ferment, and lastly, the presence of
an insect, have each in its turn been advanced. This latter
hypodiesis is admitted by a considerable number of physicians ;
nevertheless, if we cannot affirm that the creature has no exist-
ence, we are at least very £ar from believing that it does.**
Gibert speaks cautiously relatively to the cause of scabies,
although he confesses to have seen the acarus several times. It
is impossible, however, from his writings, not to perceive that he
exercises considerable mental reservation on the. side of a dif-
ferent origin and cause than the animalcule in question. Thus,
speaking of the frequency of the sanguine and lymphatic tempe-
raments in France, he observes — " It would be unfair to attri-
bute the more frequent occurrence of scabies in persons of this
temperament solely to a natural predisposition to the attack of
contagious diseases, and to the more active absorption really
existing in these individuals."t And again he remarks — " The
seasons during which the skin is most permeable are those which
favour the contagion.*' In a lecture reported in the Gazette
des Hopitaux for July 31, 1841, the same author inquires — ^** Is
the acarus scabiei the cause or the product of the eruption?**
Devergie, in the Gazette des Hdpitaux for July, 1842, ob-
serves— " Since the publication of the clear and precise descrip-
tion of the acarus scabiei by Raspail, no one can doubt the
existence of the animalcule. The questions to be decided are —
Is the disease engendered by the transportation of the insect
from one person to another ? Is it Xhe fluid of the vesicles which
excites the eruption ? Is it by the ova only that the disease is
propagated ? Or, does the vesicle give origin to the animalcule ?**
The history of the itch-animalcule, which forms a curious
* Abreg^ Pratique des Maladies de la Peau, p. 16.
t Traite Pratique des Maladies de la Peao. Second edition, p. 125.
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XVI PREFACE.
narrative, I have given in the last chapter of this work. I have
many times extracted the little creature from its epidermal
haunts in cases of scabies, and I have preserved numerous
specimens of it, which are open to the examination of those
members of the profession who may feel an interest in viewing
an atom that has caused so much inkshed throughout the
civilized world, and, like another Helen, has aroused battles and
contention, that have been deemed worthy of being handed
down to future ages, in a volume dedicated especially to their
narration, the " Acaromachia."*
2. Hypertrophy of the PapiUcB of the Derma forms a well de*
fined group, being necessarily attended vdth increased formation
of epiderma. It embraces in its consideration four characteristic
examples — ^namely, Verruca, Tylosis, Clavus, and Pachulosis.
8. Disorders of the Vascular tissue of the Derma, The altera-
tions of the vascular tissue are limited to two — hypertrophy of
that structure, as in the instance of Vascular Nsevus ; and
altered relation between the containing and the contained parts,
inducing Purpura.
4. Disordered Sensibility of the Derma^ referrible to the nerv-
ous system, constitutes the distressing affection denominated
Hyperesthesia, or Pruritus.
5. Disorders of the Chromatoyenous Function of the Derma
compose a group corresponding in general expression with the
order Maculse of Willan. It admits of division into three sub-
groups— namely, into those diseases which are characterized
by Augmentation of pigment, into those which present a
Diminution of pigment, and into those which coincide in a
morbid Alteration of the pigment; each of these sub-groups
having its separate examples.
II. The Sudoriparous Glands, with their beautifully spiral
excretory ducts, are a system of organs of modem discovery,
for a knowledge of which science is indebted to the researches
* A work recently published in France.
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PREFACE. XVU
of Purkinje, Breschet, and Roussel de Vauzeme, into the minute
anatomy of the skin. The first figures of these structures,
drawn from nature, which appeared in this country, were pub-
Ushed some years since in the large work of anatomical plates,
edited conjointly by Dr. Jones Quain and by myself. The
pathology of the sudoriparous glands has not yet been sepa-
rately investigated, but sufficient observations have been made
relatively to the perspiratory secretion, to admit of an arrange-
ment of their diseases into such as give rise to
Augmentation of secretion.
Diminution of secretion.
Alteration of secretion.
III. The Sebiparods Glands, in reference to their diseases,
constitute a somewhat numerous, but highly interesting division,
under five distinct heads — ^namely,
Augmentation of secretion.
Diminution of secretion.
Alteration of secretion.
Retention of secretion.
Inflammation of the glands and adjacent tissues.
This division has been enriched by a very curious and re-
markable discovery made by Dr. Gustav Simon, of Berlin. Dr.
Simon has ascertained the existence of certain articulated ani-
malcules of goodly size, in the sebaceous substance which
collects and concretes in the hair-follicles, and which, in an ad-
vanced degree, constitutes those little accumulations termed
comedones, or grubs ; he also finds them in those still further ad-
vanced stages of the same alteration, termed acne punctata.
Directed to the haunts of this singular animal by the anatomist
above named, I have examined several hundred specimens, and
have been led to results different from those recorded by Dr.
Simon relative to the alterations which the creature undergoes
during development. With the aid of Mr. Bagg, an artist so
b
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XVIU PREFACE.
justly eminent for anatomical delineation and engraving, I have
been enabled to present my readers with a very faithful and
accurate portrait of this little animal^ in which not only the
form but much of the texture of the creature is exhibited.
With the advice of the entomologists of Berlin, Dr. Simon
named the animal, acarus folliculorum, under the presumed
belief that the specimens which he had examined were the larval
condition of an imknown acarus. My researches have con-
vinced me that this is not the case, that the animalcule is perfect
in the state in which it has been observed, and therefore, being
in structure and organization so different from an acarus, it
would be injudicious to retain that name. Under these circum-
stances, I have thought it desirable to name the little creature
Steatozoon Folliculorum, a name which conveys a more
correct signification.
To this division, also, I have transferred the molluscum con-
tagiosum of Bateman and his disciples. This disease, which is
a small tumour of the skin produced by the enlargement, from
impaction with altered sebaceous substance, of a sebiparous
gland, has been recently illustrated by two excellent papers
which appeared in the 56th volume of the Edinburgh Medical
and Surgical Journal, from the pens of Dr. Henderson and Dr.
Paterson. Both of these writers endeavour to perpetuate the
opinion, so long entertained, of the contagious nature of this
disease. Dr. Henderson and Dr. Paterson inoculated the fluid
expressed from the tumours, unsuccessfully ; had these gentle-
men made the experiment by friction of the morbid fluid into a
part of the body richly supplied with sebiparous glands, they
would have been equally unsuccessfril, for molluscum is not con-
tagious. Dr. Paterson regards the contents of the tumours as
the real disease, and he ingeniously attributes to the develop-
ment of cells from nuclear matrices, as in the instance of cancer,
the production of the disorder. By means of the same hypo-
thesis, he explains the transmission of the disease by contagion ;
for one of these cytoblasts reaching a favourable nidus for its
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PREFACE. XIX
deyelopment; — e. g., the excretory duct of a sebiparous gland —
speedily gives birth, by excentric genesis, to m}rTiads of young
cells, and a collection is produced, which constitutes the mol-
luscous tumour. But before this hypothesis can be admitted,
that must be proved which is equally hypothetical-^ namely,
the contagion of mollusoum.
Sycosis, one of the diseases included in the last group of
this division, has been recently made the subject of research by
M. Gruby, of Vienna. This gentleman has announced the dis-
covery of a cryptogamic plant developed in the root of the hair
and in the follicle around the hair, in a form of sycosis, to which
he assigns the designation, Mentagra contagiosum. I have not
yet had the opportunity of verifying M. Gruby^s discovery, and
can therefore express no opinion on its truth. M. Gruby more-
over suggests as an appropriate name for the contagious variety
of sycosis, the term Mentagrophyte.
IV. Diseases of the Hairs and Hair-follicles offer to
our examination a variety of abnormal and morbid changes
which are liable to occur in relation with these important organs.
These changes admit of consideration under the six following
heads — ^namely.
Augmented formation.
Diminished formation.
Abnormal direction of the hair.
Alteration of colour.
Diseases of the hairs.
Diseases of the hair-follicles.
Among the diseases of the hair-follicles I have placed Favus,
an affection which has been illustrated of late by the interesting
discovery by Remak, Schonlein, and Gruby, of an organic forma-
tion within its crusts, very closely resembling a vegetable growth.
The last of these authors, however, entertains an opinion rela-
tive to the nature of favus different from that which I feel bound
to advocate. He considers the crust as an independent vege-
*2
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XX PREFACE.
table formation enrooted in the follicle of the hair, and drawing
from the contiguous tissues its means of nourishment. I am far
from agreeing with him in this respect, but continue to believe,
as I have hitherto believed, previously to the discovery in ques-
tion, that the morbid condition of the follicle gives rise to the
production of the abnormal organic substance constituting the
crust. Its vegetable nature is hypotheticaL In harmony with
the view entertained by M. Gruby, this gentleman suggests that
favus should form a new order, vrith two other diseases of vege-
table origin, aphtha and sycosis contagiosum, under the desig-
nation, Nosophyta; that favus should be styled Porrigophyte ;
and aphtha, Aphthophyte, It will be time to make these altera-
tions when the observations on which they are proposed to be
based shall be proved to be incontestable.
Dr. John Hughes Bennett has made the "parasitic fungi
found growing in living animals" the subject of a paper read
before the Royal Society of Edinburgh in the month of January,
1842. This gentleman gives an excellent account of the mucedo
of favus, and has illustrated his observations by some beautiful
delineations. He remarks upon the association of parasitic vege-
tation with the matter of tubercle, and observes that the peculiar
constitution or cachexia favourable and predisposing to their
growth is the tubercular or scrofulous. " In man all the vege-
tations yet discovered have been found connected with the matter
eflused into the textures in scrofulous constitutions. The fungi
found by myself, for instance, growing in the tuberculous cavities
of the lungs, and those discovered by Schonlein, and described
by Gruby, constituting scrofulous eniptions on the skin, grew
on a finely granular amorphous mass, which presented no evi-
dence of organization. Chemical researches have shown that
this form of tubercular matter is principally composed of albu-
men, which explains the large proportion of this animal prin-
ciple present in the crust of the Porrigo or Tinea favosa, ac-
cording to the analysis given by Alibert" The succeeding
observations of Dr. Bennett harmonize exactly with the condi-
tions under which we commonly find favus first showing itself
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PREFACE. XXt
in man — namely^ in cachectic subjects, in poor-houses, public
schools, &c. ; although, on the other hand, the disease appears
to be capable of extending itself by contagion, independently of
the existence of cachexia. " The fungi found by MM. Rousseau
and Serrurier in the parroquet, grew on a species of false mem-
brane. What the nature of this membrane was, is not stated,
but it is distinctly mentioned that the animal died of laryngeal
and pulmonary phthisis. In pigeons, also, the same authors
describe it as commonly induced by exposure to cold and mois-
ture, circumstances well known to be the most common cause of
scrofula, and of tubercular depositions. According to the ob-
servations of Valentin, the parasitic confervas found growing on
fish are connected with a diseased state of the animal, and are
induced by keeping them in narrow vessels and foul water. The
gold fish was evidently unhealthy which furnished the vegeta-
tions which I have myself described, and I have shown that these
were connected with a granular, inorganic, albuminous matter,
identical with that found in the lungs of phthisical individuals,
and in the crusts of Porrigo favosa." Dr. Bennett, in the course
of his investigations, made the singular discovery of an eruption
of favus upon the face of the common mouse, and he connects
this observation with the odour of mice, so remarkable in this
disease in man. In the mouse '^ the crusts were of a more irre-
gular form, prominent in the centre, not forming distinct capsules,
or perforated by a hair. They formed a prominent whitish
friable mass on the left side of the face of the animal, about the
size of a small bean. Examined microscopicaUy, they presented
the cylindrical tubes and sporules en mussej in every respect iden-
tical to those which grow on the scalp of man."
Such is a brief sketch of the scheme, which I propose to de-
signate a Natural System of Classification of Diseases of
THE Skin, and I trust that its clearness and simplicity will be
the means of rendering a branch of medical science, which has
hitherto vnth much reason been regarded as obscure and con-
fused, more intelligible and precise. For the convenience of my
readers I have arranged the classification in a tabular form.
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XXll
PREFACE.
L DISEASES OF THE DERMA.
Inflammatioii .
Congestiye .
Effosiye.
IRabeola.
Scarlatina.
Variola.
Varicella.
Vaccinia.
/'Erysipelas.
V*, .« Urticaria.
^""-P**'*' Roseola.
\^Erythema.
{Pemphigus.
Rupia.
Herpes.
Asthenic
Sdienic
Sappuratiye
Depositive .
Squamoos .
Hypertrophy of the Papillse .
Disorders of the Vascular Tissue
Disordered Sensibility ....
Disordered Chiomatogenous
Function ......
Eczema.
Sudamina.
(Impetigo.
Ecthyma.
Strophulus.
• Lichen.
Prurigo.
Lepra.
Psoriasis.
Pityria^
From Parasitic Animalcules • Scabies.
Verruca.
Tylosis.
Clavus.
Pachulosis.
J Vascular Navi.
(Purpura.
(Hyperesthesia
Pruritus.
{Melanopathia.
PigmeBt«7N»Ti.
^. . . -«. (Albinismus.
Dmimution of Pigment . -i, ^u-
^ I^Leucopathia.
Ephelis.
Lentigo.
Chloasma.
Melasma.
Alteration of Pigment .
Chemical Coloration .
{Oxide of Silyer
Stain.
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PREFACE.
XXI 11
II. DISEASES OF THE SUDORIPAROUS GLANDS.
Angm^tatioD of Secretioo Idrosis.
Diminiitioa of Secretion Anidrosb.
i Osmidrosis.
Chromidrosis.
Hsemidrosis.
IIL DISEASES OF THE SEBIPAROUS OLANDa
Augmentation of Secretion . , Stearrhcsa simplex.
Diminution of Secretion Xeroderma.
Stearrhcea flayescens.
Alteration of Secretion
Retention of Secretion
Duct Open
iDuct Closed ,
Inflammation of Glands and adjacent Textures .
StearrbcBa nigricans.
Ichthyosis.
Comedones.
Small Sebaceoos Tomonrs.
Sebaceous Accomolations.
Comoa.
Sebaceons Miliary Tubercles.
Calcareous Miliary Tubercles.
' I Serous Cysts.
^Encysted Tumours.
(Acne.
(Sycosis.
IV. DISEASES OP THE HAIRS AND HAIR-FOLLICLES.
Augmented formation Pilous Naeyi.
Diminished formation
Abnormal Direction
(Alopecia.
Calyities.
(Trichiasis.
(Felting.
Alteration of Colour Canities.
Diseases of the Hairs
Diseases of the Hair-follicles
( Trichosis Furfhracea.
* * ' ( Trichosis Plica.
[Narcosis FoUiculorum.
Stearrhcea FoUiculorum.
Inflammatio FoUiculorum.
Favus.
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XXIV PREFACE.
Classification would appear to have been almost coeval with
the earliest observation of Diseases of the Skin. Hippocrates,
the Father of Physic, established a truly philosophical system —
namely, an Etiological Classification of these diseases, divid-
ing them into local and constitutional. The former he regarded
as of independent existence, and the latter as the consequence
of a morbid state of constitution, in which an attempt is made,
on the part of Nature, to throw out the disease. This doctrine
was subsequently adopted by Lorry, and more thoroughly ex-
plained ; and its truth has been admitted by all our most recent
and best writers. The Etiological System has been recently
revived in France by M. Baum^s, in a work entitled " Nouvelle
Dermatologie."
It failed not to engage the attention of the Ancients, that
cutaneous diseases manifest a remarkable disposition to affect
certain localities of the skin ; that some are confined to the head
alone, while others are distributed over the rest of the body. In
the fertile mind of Galen, this observation became the ground-
work of a topographical system of classification, according to
which, the diseases of the skin are divided into two classes —
those that have their seat upon the head, and those that affect
the surface of the body generally. The topographical classifi-
cation was advocated very strongly by Jerome Mercurialis, a
celebrated physician of Italy, in the sixteenth century. Mer-
curialis, moreover, subdivided the diseases affecting the body
into two secondary groups — viz., such as produce alteration of
colour, and such as produce alteration of smoothness. This
classification pays no regard either to the structures involved by
disease, or to pathological principles ; hence it is open to many
and serious objections, since, according to it, the same morbid
condition, differing simply in situation, would be regarded as
two different diseases. The Topographical System, somewhat
modified, was followed by our countryman Turner, in 1714, and
was thought not imworthy of revival by Alibert in his first clas-
sification.
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PREFACE. XXV
In the early part of the seventeenth century, it occurred to
Biolanus to arrange the diseases of the skin according to their
appearancesj and without reference to their situation. He ac-
cordingly divided them into three groups — Pustules^ Deformities^
and Tubercles. This rude scheme, at a later period, became
developed into the autificial classification of the present
day. Plenck, who published his views in 1776, divides cuta-
neous diseases into fourteen classes; but for the purpose of
establishing so many subdivisions, he falls into the serious error
of considering the different stages of the same affection as
separate diseases. The system of Plenck, considerably modified
and improved, became the groundwork of the classification of
Willan.
The fourteen classes established by Plenck are the follow-
ing:—
MaculsB, Crustae, Vulnera,
Pustulae, Squamae, Insecta,
Yesiculse, CaJlositates, Morbi unguium,
Bullae, Excrescentiae, Morbi pilorum.
Papulae, Ulcera,
The classification of Willan, published in 1798, consisted of
eight orders — viz..
Papulae, Vesiculae,
Squamae, Pustulae,
Exanthemata, Tubercula,
Bullae, Maculae.
Willis, in the latter part of the seventeenth century, arranged
Cutaneous Diseases, in accordance with their local condition,
into two groups — namely, into those attended with swelling,
and into those in which no tumefaction was present.
The only modem classification which has been attempted
since the time of Willan, is that of the distinguished derma-
tologist, Alibert, who claimed for his perfected classification the
tide of Natural System. Alibert assembled the whole of the
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XXVI PREFACE.
diseases of the skin into one large group, under the name of
Dermatosesy and this group he considered to be composed of
twelve smaller groups — ^namely,
Dermatoses Eczemateuses,
9, Exanthemateuses,
„ Teigneuses,
„ Dartreuses,
„ Cancereuses,
„ Lepreuses,
„ Veroleuses,
„ Strumeuses,
„ Scabieusesy
yy HemateuseSy
„ Dyschromateuses,
„ Heteromorphes.
These were the twelve branches of the celebrated "Arbre des
Dermatoses" of Alibert— a system gi*and in conception, but
inapplicable to the purposes for which it was intended — a
system which lives at the present only in the memory of the
past, which has ceased to exist even beneath the foliage of the
"^tZfettfo" that smiled upon its birth.
The Genera included under each of these groups are —
Dermatoses Eczemateuses, — Erythema ; erysipelas ; pemphix ;
zoster; phlyzacia; cnidosis;* epinyctide;* olophlyctide ;*
ophlyctidej* pyrophlyctide ;* anthrax; funmculus.
DermateiLses Exanthemateuses, — Variola; vaccinia; clavel6e;*
varicella; nirle;' roseola; rubeola; scarlatina; miliaria.
Dermatoses Teigneuses, — Achor;' porrigo; favus; trichoma.*
Dermateuses Dartreuses, — Herpes ;" varus ;" melitagra ;" esthio-
m6ne.**
• Urticaria.
' A Doctarnal eruption, disappearing by day, described only by Alibert
' Herpes. * Aphtlue. * Malignant pnstole.
* A yarioloid of sheep transmissible to man. * A Tarioloid.
* Crusta lactea. * Plica polonica.
** The squamous diseases, Lepra, Psoriasis, and Pityriasis.
" Acne and Sycosis. " Impetigo. " Lupus.
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PREFACE. XXTU
Dermateu^es Cancereuses. — Carcinoma; keloide.
Dermatoses Lepreuses. — ^Leuoe ;* spiloplaxie ;" elephantiasis ;
radesige.'
Dermatoses Verokuses. — Syphilis; mycosis.*
Dermatoses Strumeuses. — Scrofula; farcinoma.
Dermatoses Scabieuses, — Scabies; prurigo.
Dermateuses Hemateuses. — Peliosis ;' petechias.
Dermatoses Dyschromaietises. — Pannus ;• achrome.'
Dermatoses Heteromorphes. — Ichthyosis; tylosis; verruca; ony-
gos ;® dermatolysie ;• naevus.
The artificial classification of Willan is open to the serious
objection of assembling together, in the same class, disorders of
the most opposite kind, and of separating different phases of
the same disease. Thus the association of purpura with
rubeola and scarlatina ; erysipelas with pemphigus ; ichthyosis
with lepra ; scabies with variola and porrigo ; eczema with
varicella and vaccinia; acne with verruca; and nsevus with
ephelis, is opposed to every principle of aflfinity of disease.
While the separation of vaiiola firom varicella and vaccinia;
and rubeola and scarlatina firom variola, is equally objec-
tionable.
Another objection to the Willanean Classification is less im-
portant, but still a blemish in his system. I allude to the
imitation of the divisions and subdivisions employed in the
arrangement of zoological or botanical subjects. Thus, starting
with a ClasSy Cutaneous Disorders, Willan established eight
Orders ; eafch of these Orders has its Genera^ and the Genera
their Species. But pathological appearances do not admit of
such a gradation of subdivision, and no advantage can possibly
flow firom its adoption. The most that can be admitted is a
> The JewUh leprosy. * Malum mortuum.
* The name giyen to an elephantiasis of northern countrieSi in Norway.
« This genos inclodes Frambcesia and Molluscum. * Purpura.
• This genua includes Lentigo, Ephelis, Pityriasis Tersicolor and Pityriasis
nigra. . ' Vitiligo; Albinismus.
' Onychia. * Abnormal extensibility of the skin.
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XXVUl PREFACE.
class of Cutaneous Diseases, these divisible into orders, or
groups ; but the groups separate at once, to the exclusion of
genera, into individual diseases, or species, and varieties of
those diseases. The differences between any two varieties are
never so strongly marked as to admit of their consideration as
species, in the proper sense of employing that term.
In the Natural System of Classification, I have endeavoured
to avoid the objections which may be urged against the artificial
arrangement. I have prevented the jostling of incompatibles,
and, as far as I am able, combined affinities, and this without
disturbing a familiar momenclature. Inaeed I have scarcely
changed a single term of Willan's glossary, and in the very few
instances in which I have departed fi*om this rule, I have been
guided by weightier considerations than those of accommodating
diseases to a system of my own.
In conclusion, I may remark, that my aim has been to
simplify the diagnosis and treatment of disease in a branch
of medicine to which I have given some years of thought, and
to the mature study of which I shall continue to devote all the
leisure which the pressing engagements of medical practice
will allow.
55, upper Charlotte-street^ FUzroy square,
October, 1846.
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CONTENTS.
CHAPTER I.
ANATOMY AND PHYSIOLOGY OF THE
SKIN.
rAOK
General idea and Divisions of the
Skin I
Stnictnre of the Derma .... 2
Papillary layer of the Derma . . 3
Vessels and Nenres of the Derma . 4
Structure of the Epiderma ... 5
Development and Growth of the
Epiderma 9
Linear markings and Pores of the
Epiderma 14
^gment of the Skin 15
Analogy between the Skin and Ma- 1 5
cons Membrane 15
Sodoriparons Glands, their seat and
structure 16
Length of the Sudoriferons Tube
in the entire skin 18
Sebiparous Glands, their seat and
structure 18
Anatomy of the Hair .r .... 19
Dimensions of the Hairs .... 20
Structure of the Hiur 23
Structureof the Hair-follicle . . 26
Direction of growth of the Hair . 28
Quantity of Hair 30
Strength of Hair 31
Development of Hair 31
Chemical Analysis of Hair ... 32
Structure and mode of formation of
the Nails 32
rAOS
Chemical Analysis of Nails ... 34
Physiology of the Skin .... 34
Sensibility of the Skin 34
Absorbent powers of the Skin . . 35
The latraleptic and Endermic
methods of introducing medi-
cines into the system .... 36
Chemical composition of the Seba-
ceous secretion 37
Secretion of Perspiration .... 38
Quantity of Perspiration .... 38
Modifications of Perspiration . . 39
Effects on the body of heated Tem-
peratures, Dry and Moist ... 39
M. Fourcaulfs Experiments . . 40
Chemical composition of the Per-
spiration 41
Morbid Perspiration 42
Source of the constituents of Per-
spiration 42
CHAPTER IL
CONGESTIVE INFLAMMATION OP THE
DERMA.
Diseases incIuJed under the head
of congestive inflammation . . 44
Sub-grouping of diseases belonging
to this division 44
Genera] considerations applicable
to this division of diseases of the
skin . 45
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XXX
CONTENTS.
Seat of congestion in the Exanthe-
mata 46
Diyersity of character of congestions 46
Colour and Tamefaction of the
Exanthemata 47
Nature of Contagion and Infection 48
Forms of the Contagious principle 49
I. Inflammation of the Derma and Mh-
cotis membranes, with constitutional
symptoms of a specific kind.
Rubeola — Measles 50
Bubeola Vulgaris 51
Sequels of Measles . . 52
Rubeola sine Catarrho .... 54
sine Exanthemate . . 54
Nigra 55
Diagnosis .... 55
Causes 56
Prognosis .... 57
Treatment .... 57
Scarlatina — Scarlet Fever . 60
Scarlatina Simplex 60
Anginosa .... 62
Maligna 64
sine Exanthemate . . 65
Accidental modifications of Scar-
latina 65
Sequels of Scarlatina .... 66
Diagnosis .... 67
Causes - 69
Prognosis .... 69
Treatment .... 70
Variola — Small-Pox .... 75
Variola discreta et confluens . . 76
Inoculated Variola 81
Variola sine Variolis .... 82
Complications of Variola . . 83
Pathology of Variola ... 84
Diagnosis .... 86
Causes 86
Prognosis .... 88
Treatment .... 88
Ectrotic Methods . 91
Varicella — Modified Small-
Pox 94
Umbilicated pustular Varicella 96
Varicella Globularis .... 97
PAOB
Varicella Coniformis . . .
98
Vesicularis . . .
98
Papularis ....
99
sine Varicellis . .
99
Diagnosis . . .
100
Causes ....
100
Prognosis . . .
100
Treatment . .
100
ARioLA Vaccina — Cow-Pox .
101
Identity of Vaccinia and Variola
101
Variola Vaccina in the Cow .
107
Variola Vaccina in Man . . .
108
Casual Variola Vaccina . . .
no
Inoculated Variola Vaccina . .
112
Secondary eruptions of Vaccinia
— Vaccinella
114
Protective power of Vaccination
116
Vaccination Tests
118
Re-establishment of the protec-
tive influence of Vaccination
118
Re- Vaccination
lis
Variolation after Vaccination .
122
Retro- Vaccination
122
Variolo-Vaccination ....
123
Recurrence to the Primary
Vaccine Vesicle
126
Treatment
128
CHAPTER III.
CONGESTIVE INFLAMMATION OF THE
'^ DERBfA.
II. Inflammation of the Derma without
constitutional symptoms of a specific
kind.
General Considerations . .
Erysipelas
Erysipelas Simplex . .
Erraticum . .
Metastaticum
Miliare . . .
Phlyctenodes
(Edematodes .
of the Face .
of the Scalp .
of the Mammae
of the Umbilicus
129
130
130
132
132
133
133
133
133
134
134
134
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CONTENTS.
XXXI
FAOK
CHAPTER IV
Erysipelas Phlegmonodes .
. 134
EFFUSIVE INFLAMMATION OF THE
Diagnosis . .
. 136
DERMA.
VAOB
Causes . . .
. 136
General considerations .
. . 171
Prognosis . .
. 137
PbMPHIOUS — POMPHOLTX
. . 173
Treatment
. 137
Pemphigus Acutns .
. . . 174
. 142
Chronicus
. . 176
Urticaria Febrilis ....
. 143
Contagiosus
. . . 177
ab ingestis . . .
. 144
Diagnosis
. . . 178
Cooferta ....
. 145
Causes .
. . . 178
Eranida ....
. 145
. 145
Prognosis
Treatment
. . 178
. . 179
Subcntanea . . .
. 145
Cases illustratiye of Pem
phigus 180
Tuberosa . . .
. 146
RupiA— Atonic UiiCEiiB
. . . 181
. 148
Rupia Simplex • . .
. . . 181
Causes ....
. 148
... Prominens . .
. . . 182
Prognosis . . .
149
... Eseharotiea . .
. . . 183
Treatment . .
149
Diagnosis .
. . 184
RocEOLA — Rose-rash . . . .
151
Causes . .
. . . 184
Roseola Infantilis ....
. 152
Treatment .
. . . 185
... JEstiva
152
Cases illustratiye of Rupi
a . . 186
Autumnalis . . .
153
, . . 187
Annulata
153
'.)
Variolosa
153
Herpes Phlyctenodes .
. . . 188
Vaccina
154
Labialis . . .
. . . 189
... MUiaris
154
... Palpebralis, Nasi
ilis, et
Rheumatica et Arthri-
Auricularis .
. . . 189
tica
155
... Prsputialis .
. . . 189
... Cbolerica ....
155
... Pudendalis .
. . . 190
Disgnosis . . . .
155
Circinnate group.
)
Causes ....
156
Herpes Zoster . . . ,
. . 190
Prognosis . . .
157
Circinn^tus .
. . . 193
Treatment . . .
157
... Iris ....
. . . 193
Ebtthema
157
Diagnosis .
. . . 194
Erythema Fogax ....
158
Causes . . .
. . 195
Circinnatam . .
. 159
Prognosis .
. . 195
. 159
Treatment .
. . . 196
IrU
160
Cases illustrative of Herj
>es . 198
LflBve ....
. 161
Eczema — Humid Tetter
. . 199
Intertrigo . . .
. 161
Eczema Simplex . .
. . . 200
Papnlatnm . . .
. 162
Rubrum . .
. . 201
Tuberosum . .
. 163
..•
Mercuriale . .
. . 202
Nodosum . . •
. 168
..
Impetiginodes
. . 204
Chronicum . . .
. 164
Chronicum . ,
. . 205
Diagnosis . .
. 164
..1
Capitis . . .• .
• . 206
Causes . . .
. 165
..
Faciei . . .
. . . 207
Prognosis . .
. 165
,.
Aurium . .
. . . 207
Treatment . .
. 166
,,
Mammillamm
. . . 208
Cases illostratiye of Erythema
167
UmbiUcale .
. . 208
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XXXll
CONTENTS.
FAOB
Eczema Perioeale 208
Diagaoeis .... 209
Causes 211
Prognosis . . . *. 212
Treatment .... 812
SuDAMiNA — Miliary Vesicles . 217
Diagnosis 219
Causes 219
Treatment 219
CHAPTER V.
SUPPURATIVB INFLAMMATION OF THE
DERMA.
General considerations .... 220
Impetioo— CansTED Tetter . 222
Impetigo Figurata 222
Sparsa 225
Scabida 225
Erysipelatodes . . . 225
Capitis 226
Diagnosis .... 228
Causes 228
Prognosis. ... 229
Treatment ... 229
Ecthyma— Papuloos Scall . 231
Ecthyma Acutum seu Vulgare 232
Chronicum .... 233
Diagnosis. ... 234
Causes 234
Prognosis. ... 234
Treatment ... 234
CHAPTER VI.
DEPOsmvE inflammation of
DERMA.
General considerations . .
StROPHULOS — ToOTH-RASH
Strophulus Intertinctus
Confertus .
Volaticus .
Albidus .
Candidus .
Diagnosis
Causes .
Prognosis
Treatment
THE
236
239
240
240
241
241
241
242
242
242
242
Lichen
Lichen Simplex
Liyidus . .
Pilaris . .
Circumscriptus
Gyratus .
Urticatus .
Tropicus .
Agrius . .
Diagnosis
Causes .
Prognosis
Treatment
Cases illustratiTe of Lichen
Prurigo
Prurigo Mitis . .
Formicans
Senilis . .
Podicis .
Scroti . .
Pudendalis
Diagnosis
Causes .
Prognosis
Treatment
rAOB
. 242
. 243
. 244
. 244
. 244
. 245
. 245
. 246
. 249
. 250
. 250
. 251
. 251
. 252
. 254
. 254
. 255
. 256
. 256
. 257
. 257
. 257
. 257
. 258
. 259
CHAPTER VII.
SQUAMOUS INFLAMMATION OF
DERMA.
General considerations . . . .
Lepra
Lepra Vulgaris
... Guttata
... Nigricans
... Syphilitica
Diagnosis . . . .
Causes
Prognosis . . . .
Treatment . . . .
Cases illustrative of Lepra . .
Psoriasis
Psoriasis Vulgaris
Infantilis
Gyrata
Inveterata . . . .
Palpebrarum . . .
Labialis
THE
261
263
264
265
266
266
267
267
267
267
271
272
272
274
274
274
275
276
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CONTENTS.
XXXIU
rAOB
Psoriasis Pnepntii 276
Scrotalis et Paden-
dalis 276
Palmaris 276
Ung^am .... 277
Diagnosis .... 278
Causes 278
Prognosis. ... 279
Treatment ... 279
Case illnstratiYe of Psoriasis . 280
Pityriasis 281
Pityriasis Valgaris .... 282
Capitis 283
Palpebrarum ... 283
Labiorum .... 283
Palmaris et Plantaris 284
Prsputialis .... 284
Pudendalis .... 284
Oris 284
Diagnosis . . . 285
Causes .... 285
Prognosis . . . 285
Treatment ... 285
CHAPTER VIII.
INFLAMMATION OF THE DERMA IN.
DUCBD BT PARASITIC ANIMALCULES
INHABITINO THE EPIDERMA.
General considerations .... 287
Scabies 288
Diagnosis 291
Causes 292
Treatment 295
CHAPTER IX.
TUBERCULOUS AFFECTIONS OF THE
DERMA.
Lupus non exedens 299
Lupus exedens 301
Diagnosis 302
Causes 302
Treatment 303
CHAPTER X.
HYPERTROPHY OF THE PAPILLiE OF
THE DERMA.
rAOB
General considerations .... 304
Vbbbuca— Wabts 305
Causes 306
Treatment 306
Tylosis BT Clayus 306
Laminated Corns 307
Fibrous Corns 308
Soft Corns 310
Causes 311
Treatment 311
Pachulosis 312
Treatment 312
CHAPTER XL
DISORDERS OF THE VASCULAR TISSUE
OF THE DERMA.
General considerations . . . . 313
N^yvs^Ebectile tumoubs . . 313
Treatment 315
PUBPUBA 316
Purpura Simplex 317
Urticans 317
Hemorrhagica . . . 317
Senilis 318
Cacbectica .... 318
Febrilis 319
Diagnosis .... 319
Causes 319
Prognosis .... 320
Treatment ... 320
CHAPTER XII.
DISORDERED SENSIBILITY OF THE
DERMA.
Pbubttos— Hypebssthesta . . 321
General Pruritus 321
Pruritus Ani 322
Scroti 328
Praeputii 323
UrethrtB 323
Pudendi 323
Diagnosis .... 324
Treatment ... 324
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XXXIV
CONTENTS.
CHAPTER XIII.
DISORDERED CHROMATOGENOUS
FUNCTIONS OF THE DERMA.
MACULiE
1. Augmentation of Pigment
Melanopathia . . .
Pigmentarj Nayi — Moles
2. Diminution of Pigment .
Leucopathia ....
Albinisinas . . .
Partial Leacopathia
3. Morbid Alteration of Pigment
Ephelis — Sunburn •
Lentigo — Freckles . ,
Chloasma — Liver spot
Melasma ....
4. Chemical Coloration .
Oxide of SiWer Stain ,
PAOB
326
326
326
330
331
331
332
332
333
333
334
335
337
337
337
CHAPTER XIV.
DISEASES OF THE SUDORIPAROUS
GLANDS.
1. Augmentation of Secretion
Idbosis— Sudatoria
Idrosis Simplex
Maligna
2. Diminution of Secretion
Anidrosis . . .
3. Alteration of Secretion
Osmidrosis . . .
Chromidrosis . . .
HsDmidrosis . . .
339
339
340
341
344
344
345
345
347
347
CHAPTER XV.
DISEASES OF THE SEBIPAROUS GLANDS.
1.
Augmentation of Secretion
. 349
Stearrhoea simplex . .
. 349
2.
Diminution of Secretion .
. 350
Xeroderma ....
. 350
3.
Alteration of Secretion .
. 352
Stearrhoea flavescens .
. 352
nigricans. .
. 353
PAOB
Ichthyosis 354
squamosa . . . 355
spinosa .... 359
. Retention of Secretion . . . 362
(a.) Excretory Duct open :
Comedones — Grubs . . . 363
Small Sebaceous Tumours:
... MolInscumContagiosom 365
Treatment . . . 368
Tilesios" case of MoUuscum . . 370
Bateman*s cases 371
Dr. John Thompson and Dr.
Carsweirs cases 372
AUbert's case 373
Bietf s cases 374
Gibert's cases 375
Dr. Jacobovics's cases . . . 375
Dr. Henderson's cases . . . 376
Dr. Paterson's cases .... 377
Mr. Hale Thompson's case . . 378
Dr. Tumbull*8 case .... 378
Sebaceous accumulations . 378
Cornua— Horns .... 379
(b.) Excretory Duct closed :
Sebaceous Miliary Tu-
bercles 385
Calcareous Miliary Tu-
bercles 386
Serous Cysts .... 386
Encysted Sebaceous Tu-
mours 387
. Inflammation of the Glands and
adjacent tissues .... 388
AcNB 388
Acne Vulgaris .... 389
... Rosacea ... 391
Diagnosis . .391
Causes ... 391
Prognosis . . 392
Treatment . . 392
Sycosis 393
Sycosis Vulgaris .... 393
Contagiosum . . 394
Diagnosis . . 395
Causes . . . 395
Prognosis . . 396
Treatment . . 396
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CHAPTER XVI.
DISEASES OF THE HAIRS AND HAIIU
FOLUCLES.
1. Augmented Formation of Hair .
(A.) Abnormal Quantity . .
(b.) Abnormal Situation . .
Pilous Nayi— Moles .
Treatment .... 403
2. Diminished Formation of Hair 403
Alopecia— Baldness . . 403
Alopecia Congenita . . . 404
Accidentalis . . 404
Senilis— Calvities 406
Causes . . . 407
Treatment . . 408
3. Abnormal Direction of the Hair 410
Trichiasis 410
Felting of the Hair . .410
4. Alteration of Colour of the Hair 410
Canities— Blanching of the
Hair 412
Causes 413
5. Diseases of the Hairs . . . 416
Trichosis Furfuracea . . 416
Causes 419
Treatment 419
Trichosis Plica .... 420
6. Diseases of the Hair-FoOicUs . 422
Narcosis Folliculorum . 423
Morbus Pilaris .... 424
SrEARRH(SA Folliculorusi 424
Inflammatio Folliculorum 424
Favus 426
FaTus Dbpersus .... 427
CONTENTS.
XXXV
PAGB
FaTUS Confertus . .
. 428
AIR.
Pathology .
. . 429
rAOB
Diagnosis .
. 431
398
Causes . .
. . 432
398
Prognosis .
. . 432
399
Treatment .
. . 432
399
CHAPTER XVII.
SYPHILITIC ERUPTIONS.
General considerations .... 437
Syphilitic Urticaria 438
Roseola 438
Vesicular Syphilis 439
Rupia 439
Pustular Syphilis 440
Tubercular Pustules .... 440
Ecthymatons Pustules . . . 440
Papular and Tubercular Syphilis 442
Syphilitic Lichen 442
Syphilitic Tubercles 442
Squamous Syphilis 444
Syphilitic Lepra 445
Syphilitic Psoriasis 445
Treatment 446
Case of Syphilitic Lepra ... 447
CHAPTER XVin.
History and Description of the
Itch-Animalcule, Acarus Sea-
biei 449
History and Description of the
Steatozoon Folliculorum . . . 466
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DESCRIPTION OF PLATES.
Plate I.
CONGESTIVE INFLAMMATION OF THE DERMA.
UBTICABIA. BOSEOLA. BBTTHEBIA.
A. B. c. D. represent the typical appearances of Urticaria ; the particular cases
for illustration being selected firom the varieties— evanida, conferta, and
febrilis.
A. A. Ubticabia bvakida, (page 145.) The subject of this eruption was a
little girl, six years of age ; and, otherwise in good health. The simple
round elevations and the stripe-like wheals of urticaria are both seen in
this figure.
B. Ubticabia coirrBBTA, (page 145.) In this variety the elevations or wheals
are closely aggregated, and form thickly-set clusters.
c. Ubticabia fbbbilis, (page 143.) A single, red, hemispheroidal wheal of
this variety of the eruption.
D. A small group of the pale hemispheroidal wheals of chronic urticaria.
E. F. represent typical appearances of Roseola ; the cases for illustration being
selected from those forms of the efflorescence which are met with in adults,
namely, Roseola sestiva and Roseola autumnalis.
E. Roseola iBSTivA, or False Measles, (page 152.) The same character of
efflorescence occurring in an infant would be termed Roseola infantih's.
F. Roseolous patches ofan irregular, annular, and circular figure. These varied
appearances generally occur in a chronic form of the disease, and usually
belong to the variety *' autumnalis.'* The annulate form, if its dimensions
were increased, would represent Roseola annulata.
EBTTHEMA.
G. Ebtthem A PAPULATUM, (page 162.) The patch was developed on the con-
vexity of the elbow. The case is reported at page 167.
d
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XXXVUl DESCRIPTION OF PLATES.
u. Ebtthema tuberosum, (page 163.) The drawing was made from the leg
of a joung woman safiering under this disease. Two of the spots are at
their height, the others are fading. The case is reported at page 169.
I. Ebtthema nodosum, (page 163.) The case from which this drawing was
obtained is reported at page 168.
K. Ebtthema cibcinn atum, (page 159.) The border of the ring is broad and
smooth, and very little raised above the level of the surrounding surface.
The area is yellowish, from the subsidence of congestion.
L. Ebtthema marginatum, (page 159.) The margin is prominent and papu-
lar, the area yellow, from subsidence of congestion. The patch was situated
on the side of the neck of a young woman.
M. Ebtthema ibis, (page 160.) This is a modification of erythema mar-
ginatum, resulting from the arrest of growth of the inner rings, and the
development of a centrifugal ring from the periphery of its predecessor.
Plate 2.
effusive inflammation of the derma.
Asthenic group.
PBICPHIGUS. BUPIA.
A. Circular erythematous spots, which precede the formation of the bullae of
Pemphigus, (page 173.)
B. A bulla of pemphigus filled with a transparent fluid,
c. A bulla in which the fluid is whitish and opalescent
D. A partially collapsed bulla, out of which a drop of serum is seen issuing.
£. A partially collapsed bulla filled with sanguineous fluid,
p. The thin, corrugated, brownish scab, formed by the desiccation of the
bulla.
0. The appearance left upon the skin by the removal of the scab.
h. The stains left upon the skin some weeks after the fall of the scab.
1. A group of the smaller bullae of pemphigus, assuming a circular arrange-
ment, (page 176.)
BUPIA.
K. Erythematous spots on the skin, which precede the formation of the bullae
of Rupia, (page 181.)
li. Small bullae, distended and collapsed.
m. Eupia simplex, a small bulla converted into a scab.
N. A larger scab of rupia simplex. It is thick, hard, and corrugated,
o. Rupia pbominens, (page 182.) A well-formed and characteristic scab.
p. The unhealthy ulcer left by Rupia prominens. This figure and the large
conical crust, were drawn frx)m the same patient.
Q. A depressed mark left on the skin aft;er the fiill of the scab of Rupia
simplex.
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XXXVIU DESCRIPTION OF PLATES.
■. EBrrBBMA TrBxmoem^ (psge 163.) The dnwing wis made fiwn thcl^
of a younjT womui suflFering uDder this disetse. Two of the spots are «t
their heiKht, the others are fiMimg. The case is reported at page 169
I. EaTraKVA woDoecM, (page 163.) The case fifom which this dnwing was
obtained is reported at page 168. ,
». E«TTKaMAciBci!fHATCM, (page 159.) The border of the ring is brwd^^
smooth, and very little raised above the level of the surroundiDg sniftce.
The area is yellowish, from the subsidence of congestion.
^ Kbtthbma MAEGiKATVH, (page 159.) The margin is proniifleDt and pipn-
Ur, the area yellow, from subsidence of congestion. The patch was situated
on the side of the neck of a young woman.
M. E«ttui;ma ibis, (page 160.) This is a modification o( eirthems m^'
ginatum, resulting from the arrest of growth of the inner rings, wd the
development of a centrifugal ring from the peripheiy of its predecessor.
Plate 2.
EFFrsrVE INFLAMMATION OF THE DERMA.
Asthenic group.
A. Cirr I ^^MPBiGvs. suru.
iVri.plXr.?!?'*'"''^"* 'P***^ which precede the formation of the bulk of
8. A huul^ ' ^^"^ ^^^'^
"^^ ^ ^^tU Ut ^l^^l^'f^' ^"^ ^ith a transjiarent fluid.
^' ^ PHTtUUy II ^'"'** '^ ^'^^'^'*«h ^"^^ opalescent.
** '^ J»artiaij; ,, ^"^"^ ^"^^^ out of wfiich a drop of serum is seen issmg.
^'- '^^he thin eT ^'^ ^""^^^ ^"^ ^^ sanguineous fluid.
'>u//a. ' ^'■'■"^K hrownish scab, formed by the desiccation of the
'* ^ ^m)u;> of th "^^./^^ ^'''" some weeks after the fall of the scab.
meiit, (page jV"*'"^®'* ^"^« of pemphigus, assum^' ^ circuJar «^
BIWA.
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DESCRIPTION OF PLATES. XXXIX
B. RupiA sTPHiLiTicA. The papular and pustular origin of this form of the
disorder.
9. The appearance of the skin in a case of rupia syphilitica in which the skin
was permitted to heal previously to the removal of the crusts.
Plate 3.
effusive inflammation of the derma.
Sthenic group.
HEBPES. BCZEMA.
A. Hebpbs Z08TEB, (page 190.) A patch of this eruption on its first appear-
ance. The vesicles have not yet attained their complete size.
B. Another patch of Herpes zoster, three or four days later, when the vesicles
have attained their fuU size, some having coalesced ; and their contents have
become jellow. This cluster illustrates well, the irregular patches of
HERPES PHI^TCTENODES, (page 188.)
c. Groups of vesicles exhibiting the first stage of collapse, when a central de-
pression is formed, and the vesicle is consequently umbilicated.
D. s. In a stage further advanced, the depressed centre of the vesicle dries up
into a small scab, which is surrounded as by a rim, by the remains of the
vesicle. The eruption now acquires a purplish hue.
r. Still later, nothing renudns of the eruption but a small brown shrivelled
crust ; except in instances where ulceration takes place.
G. Hebpss cniciNifATUs, (page 193.) A small cluster of vesicles assuming
the circular or circinnate form.
H. Hebpbs ibis, (page 193.) This is a rare and curious form of herpetic
eruption.
ECZEMA.
L L Eczema simplex, (page 200.) The vesicles are minute, and raised on a
surface but little deeper in tint than the surrounding skin.
K. K. Eczema bubbum, (page 204.) The vesicles are the same as in Eczema
simplex, but the skin is red and inflamed.
L. L. Eczema impetiginodes, (page 204.) The diseased surface is covered
with broken crusts, between which the skin is seen to be highly inflamed,
while large drops of ichorous fluid are oozing from the exposed surface.
To the left of the crusts are numerous sero-pustules, and in the right-
hand comer (m) the eruption is less highly inflamed, and may be supposed
to be passing into the stage of Eczema Chbonicum, (page 205.)
As Eczema not unfrequently presents, upon the same person, and at the
same time, all the stages illustrated in this engraving, with the exception of
Eczema chronicum, the figure may be regarded as exhibiting a complete
picture of the disease.
K. A small cluster of vesicles of eczema, somewhat larger than usual, and pre-
senting a circular arrangement very like that of herpes iris. This appear-
ance is by no means uncommon.
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xl description of plates.
Plate 4.
suppurative inflammation of the derma.
IMPETIGO. ECTHYMA.
A. Impetigo figubata, (page 222.) A small patch of this eruption ; inci-
pient pustules are seen around its circumference.
B. Another patch of the same eruption, in its crusted state ; abo exhibiting in-
cipient pustules around its border.
c. Impetigo spabsa, (page 225.) The pustules dispersed irregularly over the
surface, singly and in small clusters, belong to this variety. The pustules
are seen at every stage of progress — ^namely, red points ; minute pustules ;
ripe pustules, surrounded by a halo of redness ; fading pustules, collapsed
and wrinkled ; and others further advanced, surmounted with a scab.
D. Impetigo sparsa of the scalp, (page 227.) The pustules are oval in shi^ ;
one of them being covered by a newly formed crust.
E. Another crust of this eruption, from the scalp.
F. Impetigo scabida, (page 225.) The extremity of a crust of this disease
that covered the greater part of the fore-arm of a child. Some incipient
pustules around its border indicate the nature of the eruption.
ecthyma.
EcTHYBCA, (page 231,) in its several stages of pustule, scab, ulcer, and &ding spot.
H. An incipient pustule.
1. 1. Perfect pustules.
K. K. Umbilication and incipient desiccation of the pustule.
L. A perfected scab.
M. Ulcerated state of the skin brought into view on the separation of the scab.
V. The discoloured mark which remains upon the skin after the healing of the
pustule.
o. A cluster of pustules in their scabbed or crusted state.
p. A fully distended pustule from an elderly person ; the purple hue of the
areola is characteristic of the Ecthyma lubidum of Willan, (page 233.)
Q. A crusted pustule from the same person.
B. An ecthymatous pustule from the back of the hand of a boy affected with
scabies ; the eomplication of scabies with such a pustule constitutes the
scabies pubulenta of Wilhui, (page 290.)
Plate 6.
depositive inflammation of the derma.
LICHEN. STBOPHULU8. PBUBIGO.
Lichen simplex, (page 243.) A cluster of the papulae of this eruption,
from the arm. They exhibit various degrees of inflammatory activity ;
those in the upper part and around the circumference of the cluster being
very little deeper in tint than the surrounding skin.
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IMPETIGO
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L f. P R A
PITYRIASIS
p S .' R I A 5 I S
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DESCRIPTION OF PLATES. xli
B. Lichen pilabis, (page 244.) A small cluster of the pi^ulse of lichen sim-
plex developed at the apertures of hair-follicles, so as to involve the hairs.
The figure was drawn from the leg of the same patient as a.
c. Lichen syphiliticus, (page 442.) Four clusters of the larger and duller
papulse of this eruption ; from the hreast.
D. Lichen uaticatus, (page 245.) The large papulae of this eruption ; three
of the pimples are surmounted with small crusts. This figure was drawn
irom tbs leg of the little patient reported at page 245.
B. Lichen gibctjmsckiptus, (page 244.) A patch of this eruption at an
early stage, before the centre begins to subside and the margin to extend.
F. Lichen circumscriptus, in a more advanced state.
0. Lichen agbius, (page 249.) The white specks on the sur&ce of the
patch are furfuraceous scales. These and smaU oozing points are charac-
teristic of this form of eruption.
H. h. Lichen agrius, in its crusted state ; when from the thickening of the
skin, the density of the scale-like crust, and the deep fissures, the disease
is liable to be mistaken for psoriasis. The isolated papules around the
margin of the patch are an important diagnostic sign.
strophulus.
1. Strophulus intertinctus, (page 240.) From the cheek of an infimt.
Towards the centre of the patch the eruption puts on the character of
STROPHULUS CONFBRTU8, (page 240.)
K. Strophulus volaticus, (page 241.)
L. Strophulus albidus, (page 241.)
M. Strophulus candidus, (page 241.)
prurigo.
N. Prurigo, (page 254.) The papulce of the three varieties of this disorder.
Some of the pimples are bleeding, from fresh abrasion ; while others are
covered with a snuill black crust. Intermingled with the papulae are the
brownish yellow stains which this eruption leaves behind it on the skin. I
have not attempted to give the specific appearance of the skin in this
disease, as nothing but a magnified drawing would do justice to the
subject.
Plate 6.
squamous inflammation of the derma.
LEPRA, psoriasis. PITYRIASIS.
Lepra yulgaris, (page 264,) a well-marked laminated and imbricated
scale of this eruption.
The little red pimples or tubercles by which lepra commences. The
tubercle to the right is already surmounted by a scale. These tubercles
continue to enlarge until they attain the size of a.
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Xlii DESCRIPTION OF PLATES.
c. Lepra guttata, (page 265 :) that is, spots of lepra which remain stationary
when they hare reached to about the size of the patches represented in the
figure. They are but little or not at all depressed in the centre, and hence
ha?e a whiter aspect than the larger patches of lepra vulgaris.
D. A patch of lepra vulgaris, clearing in the centre, while the scales which cover
its margin are breaking up. This is the first step towards cure.
B. Another patch, in which the centre is cleared to a greater extent, and a part
of the margin has also subsided. This is a further advance towards cure.
F. Another patch, exhibiting a more advanced stage of the curative movement.
G. Lepra vulgaris, as it affects the convexity of the elbow ; the drawing is
made from the same patient as a. In this situation the patches are gene-
rally confluent, and lose their circular form.
PSORIASIS.
H. Psoriasis vulgaris, (page 272,) with deep chaps in the morbid skin.
The drawing was made from a patch situated on the back of the hand.
I. This figure, if the patch were no larger than represented in the drawing,
would be an illustration of psoriasis vulgaris ; if, however, it extended
over a considerable portion of a limb, it would be termed psoriasis imve-
TERATA. It is intended to illustrate the latter disease.
K. Psoriasis palmaris, (page 276.) The irregular margin of thickened
epiderma and the chaps are characteristic.
PITYRIASIS.
L. A portion of a patch of Pityriasis vulgaris, (page 282,) from the nape of the
neck. The disease covered the whole of the back of the neck, the scalp,
the chest, and the shoulders.
Plate 7.
lupus non exedens.
An example of this obstinate disease which has existed for thirty-three years.
The patient has only lately come imder my care.
The tuberculated and salmon-coloured margin of the patch, its variegated area
streaked with white and cicatrix-looking lines, and the erosion of the bor-
der of the ala nasi are characteristic of this disease, (page 399.)
Plate 8.
DISEASES OF THE HAIR-FOLLICLES AND HAIRS.
ACNE. SYCOSIS. FAVU8. TRICHOSIS.
A. Acne vulgaris punctata, (page 390.) Several groups of the pimples of
this eruption, in their early state. They are characterized by the black
point which is perceived in the centre of each.
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DESCRIPTION OF PLATES. xliii
B. Acne punctata in a more advanced stage ; thej are now becoming slightly
inflamed.
ۥ CoMSDOHBS, (page 363.) These black spots on the skin, caused by
insp&Bsation of the sebaceous substance and discoloration of the external end
of the small piles so produced, generally accompany the development of
acne. They frequently precede the form a., the pimples of acne punctata
being comedones with elevation and induration of the skin, immediately
around their apertures.
0. AcNB TUixiAais, (page 389.) Conical elevations with inflamed bases, and
8U{^urating at the summit
F. A phnple of acne vulgaris, on the summit of which the pustule is in pro-
gress of desiccation into a scab.
G. AcHB vuLGABis INDUBATA, (page 390.) This is a chronic variety, and
consequently the pimples are less vividly inflamed than those of b. f.
E. Stains, pits, and scars left on the skin by acne vulgaris.
H. Acre rosacea, (page 391.) The drawing was made from a patch on the
cheek of a gentleman of middle age.
SYCOSIS.
L Sycosis, (page 393.) A patch of this eruption, from the side of the chin of
a young man of twenty-five.
TBICH08I8.
K.K. Tbiohosis fubfvbacea, or ringworm, (page 416.) Patches of common
ringworm, in its papular form : trichosis furfuracea papulosa.
L. Separate piqf^ulse of the same disease, produced by disease afifecting isolated
■ follicles.
M. Trichosis furfuracea, in its crusted form ; the crust being constituted of
flakes of epiderma and towy hairs matted together by a small quantity of
serous discharge. The crust is broken into angular compartments by the
movements of the scalp.
R. A magnified section, showing a pimple of this disease, together with two
hairs issuing from its summit ; the latter being enclosed for a short distance
by a sheath of inspissated sebaceous substance.
a A magnified hair, showing the state of disease which exists in that structure
m trichosis furfuracea, (page 418.) a. The root of the hair. h. Its shaft,
c The external or cortical layer of the hair broken from its continuity with
b^ and stripped back, so as to expose its internal surface. Several of the
granules of the diseased hair are adherent to the surface of this layer.
d. The granular layer of the hair surrounding its fibrous central part
p. The i^ypearance presented by the granules when viewed with tlie micro-
scope.
Q. A group of granules more highly magnified. Each granule is seen to
possess a nucleus.
FAVUS.
1. Faws DfBPBBsns, (page 427.) The cup-shaped, bright yellow cups of
this disease. Each crust is pierced by one or more hairs.
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Xliv DESCRIPTION OF PLATES.
8. Favus CON7EBTU8,* (page 428.) The yellow, cup-like crusts of the aggre-
gated form of the disease are clustered together so closely as to constitute
a more or less coalescent mass.
T. A diagram section of the crust of favus, which is intended to show the
insertion of the hase of the crust into the hair-follicle, and its relation to
the hairs.
* In the text, at page 428, the synonym of this disease is stated to be ** Porrigo
scutulata conferta;" the reader is requested to alter this to **Pobbioo lupinosa
COIIFBBTA."
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DISEASES OF THE SKIN.
CHAPTER I.
ANATOMY AND PHYSIOLOGY OF THE SKIN.
1. The skin is the exterior inyestment of the body, which it
serves to cover and protect It is continuous at the apertures of
the internal cavities with the lining membrane of those cavities,
— ^the internal skin, or mucous membrane; and is composed
essentially of two layers, the derma and epiderma.
2. The derma, or cutis, is chiefly composed of areolo-fibrous
tissue, besides which it has entering into its struc^e, elastic
and contractile fibrous tissue, together vnth bloodvessels, lym-
phatic vessels, and nerves. The areolo-fibrous tissue exists, in
its most characteristic form, in the deeper strata of the derma,
which are consequently dense, white, and coarse, while the super-
ficial stratum is fine in texture, reddish in colour, soft, raised into
minute papillae, and endowed vrith an abundant supply of vessels
and nerves. This peculiarity of structure of the derma has given
rise to its consideration as consisting of two layers — the super-
ficial or papillary layer, and the deep stratum or corium.
3. The epiderma, or cuticle, is a product of the derma, which
it serves to envelop and defend. That surface of the epiderma
which is exposed to the influence of the atmosphere and exterior
sources of injury, is hard and homy in texture, while that which
lies in contact with the sensitive papillary layer of the derma, is
soft and composed of cells. Hence tlus membrane, like the
derma, offers two strata for our observation, the outermost stra-
tum, commonly spoken of as the epiderma, and the innermost
stratum, or rete mucosum. The latter was considered and de-
scribed by Malpighi as a distinct membrane, and is fi-equently
referred to under the name of rete Malpighianum.
B
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2 ANATOMY OF THE SKIN.
4. Besides the derma and epiderma, the skin includes certain
important secreting organs, and certain appendages of the epi-
derma, which call for separate notice. The secreting organs
are the sudoriparous and sebiparous glands ; and the appen-
dages of the epiderma, the hairs and the nails.
5. The derma presents considerable variety in degree of
thickness in diflferent parts of the body. Upon the more ex-
posed regions, as the back, the outer sides of the limbs, and the
palms* and soles, it is remarkable for its thickness; while on
protected parts, as the inner sides of the limbs, and Ae ventral
surface of the trunk, it is comparatively thin. On the eyelids,
the penis, and the scrotum, again, it is peculiarly delicate. The
papillary layer also presents differences in extent of develop-
ment ; on the palms of the hands, the pulps of the fingers, and
the soles of the feet, this layer is thick, and the papillae nume-
rous and of great length, while in most other situations it is thin,
and the papillae are little apparent. Some contrariety is ob-
served, besides, in the relative proportion of the layers of the
derma, for on the back, where the corium is exceedingly thick,
the papillary layer is but slightly developed, while on 5ie pulps
of the fingers, where the latter is strikingly manifest, the corium
is thin.
6. The areolo-fibrous tissue of the derma is constructed of
fibres of two kinds — namely, of minute cylindrical fibres, which
are identical in their nature with the delicate wavy fibres of
common areolar, or cellular substance, and of fibres of elastic
tissue, presenting their characteristically curved ends, and
branching and anastomosing distribution. In the superficial
strata of the corium, the white fibres are collected into small
fasciculi, and form an intricate interlacement, which supports
the papUlae, and constitutes a nidus for the capillary rete of
vessels and nerves. In the middle strata, the fasciculi are
larger and flattened, and the areolar net- work coarse ; while in
the deep layer, the feisciculi are still broader — namely, about a
line in diameter, and the areolar spaces two lines. These latter
are occupied by small masses of adipose tissue, while the fas-
ciculi are continuous with the subcutaneous areolar membrane.
The yellow elastic fibres are solitary in their arrangement, they
are abundant in the superficial layers of the corium, but rare
and scarcely met with in the deeper strata. The areolae left
by the interlacement of the fasciculi of the areolo-fibrous tissue,
are the channels by which the branches of vessels and nerves
find a safe passage to the papillary layer, in which, and in the
superficial strata of the corium, they are principally distributed.
* In the palm of the hand I foand the derma to measure three-foarths of a line
in thickness.
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PAPILLARY LAYEB OF THE DEBMA. 3
7. The contractile fibrous tissue of the derma has been de-
monstrated hitherto only in certain parts of the human skin, as
in the nipples and scrotum, but it undoubtedly exists in the
corium of every part of the body. It consists of fibres of a
reddish hue, somewhat larger than those of areolar tissue, and
semi-transparent. These fibres are collected into fasciculi,
sometimes lying parallel with each other, and forming mem-
branous layers, at other times interlacing in every direction, and
constituting a firm web. They are met with in every part of
the corium, but are most abundant in the coarse network of its
under surfeLce. This tissue is easily perceived in the corium of
some animals, where it forms a web around the sebiparous glands
aad hair follicles. It probably has the same arrangement in
the skin of man ; in the former situation acting as a compressor
of the sebiparous gland, and an important auxiliary to uie cur-
rent of its secretion ; in the latter producing an erection of the
hairs analogous to the bristling wluch takes place in animals.
That appearance of the skin produced by cold or fear, (spasmus
periphericus,) that we term cutis anserinay or goose-skin, is due
to the presence of this contractile fibrous tissue.
Mr. Bowman* has indicated the presence of organic muscular
fibre in the tissue of the dartos, ^' at once known by its being
loaded with corpuscles or persistent cell-nuclei." The same
fibres probably exist in the contractile tissue of the nipple.
8. The papillary layer of the derma is raised in the form of
conical prominences or papillas. Upon the general surfitce of
the body the papilla are short, and exceedingly minute, but in
other situations, as on the palmar surface of the hands and
fingers, and on die plantar surfeice of the feet and toes, they are
long, ajid of large size. They are also difierent in their
arrangement in the situations above cited ; thus, on the general
surface, they are distributed at unequal distances, singly and in
groups, whereas, on the palms and soles, and on the corre-
spondiiig surfaces of the fingers and toes, they are collected into
little square clumps, containing firom ten to twenty papillae,
and these little clumps are disposed in parallel rows. It is
this arrangement, in rows, that gives rise to the character-
istic parallel ridges and furrows which are met with on the
hands and on t^e feet. The papillae in these little square
clumps are for the most part uniK)rm in size and length, but
every here and there one papilla may be observed which is
longer than the rest. The largest papillae of the derma are
those which produce the nail ; in the dermal follicle of the nail,
they are long and filiform, while beneath the concave surfitce of
* CyclopsBdia of Anatomy and Physiology. Article, Macoui Membnme, Note,
page 494.
B 2
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4 ANATOMY OF THE SKIN.
the nail they constitute longitudinal and parallel plications,
which extend for nearly the entire length of that organ. In
structure each papilla is composed of a more or less convoluted
capillary, and a more or less convoluted nervous loop.
9. The arteries of the derma which enter its structure through
the areolaD of the under surface of the corium, speedily divide
into innumerable intermediate vessels, which form a rich capil-
lary plexus in the texture of the superficial strata of the derma,
and in its papillary layer. In the former situation the capillary
rete is horizontal — ^that is, it corresponds with the plane of the
surface of the skin, while in the papillae it is necessarily the
reverse of this — namely, perpendicular to the plane of the sur-
face. To see the capillary plexus of the papillse, it conse-
quently becomes necessary to examine the injected skin by
means of a vertical section, but if the horizontal rete is to be
observed, no section is needed. In the papillae of some parts
of the derma, as in the longitudinal plications beneath the naU,
the capillary vessels form simple loops, but in other papillse
they are convoluted to a greater or less extent, in proportion
to the size and importance of the papillae. The capillary rete
of the horizontal strata presents, as may be inferred, a number
of circular areae, some of which appear to correspond with the
bases of the papillae, while the greater number occupy the walls
of the passages through which the sudoriferous and sebiferous
ducts make their way to the surface. After a certain extent of
course, the intermediate vessels imite to form the veins by
which the circulated blood returns to the system.
10. The lymphatic vessels probably form in the superficial
strata of the derma, a plexus, the meshes of which are inter-
woven with those of the capillary and nervous plexus. No
lymphatics have as yet been discovered in the papillae, nor,
indeed, can I imagine that they would perform any useful
oflSce in that situation. I once succeeded in injecting a minute
lymphatic plexus in the derma of a foetal lamb.
11. The nerves of the derma, after entering the areolae of the
deeper part of the corium, divide into minute fasciculi, and these
quickly separate into primitive fibres. Corresponding with the
horizontal vascular rete, the nervous fasciculi constitute a
nervous rete, from which loops of primitive fibres enter the
papillae. In the less sensitive parts of the skin, the loops are
simple, and more or less acute in their bend, in conformity with
the figure of the papilla. In the sensitive parts, however, and
especially in the tactile papillae of the pulps of the fingers, the
loop is convoluted to a greater or less extent, and acts as a
multiplier of sensation.
12. The epiderma is a membrane of defence, spread out upon
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, DEVELOPMENT OF THE EPIDERBCA. 5
the surface of the derma. As we have previously observed, this
membrane presents a difference of density according as it is
viewed from its outer or its inner surface ; the outer or free siur-
fiuje being dense and homy, the inner or attached surface being
soft and composed of cells. Moreover, the epiderma is laminated
in its structure, and the laminae present a progressively increas-
ing density, as they advance from the inner to the outer surface.
This difference in density is dependent on the mode of growth
of the epiderma, for as the external surface is constantly sub-
jected to destruction by attrition and chemical action, so the
membrane is continually reproduced on its internal surface, new
layers being successively formed upon the derma, to take the
place of the old.
The mode of development and growth of the epiderma I have
recently made the subject of special investigation, and as the
results at which I have arrived present a new view of the mode of
growth of cells, to that founded on the authority of Schwann, and
generally received, I shall make no apology for quoting entire
the paper* in which these observations are detailed : —
13. "It is the commonly received doctrine at the present day
that the cells of the epiderma and of epithelium in general, origi-
nate out of materials furnished by the liquor sanguinis or plasma
of the blood. In order that this purpose may be effected, the
liquor sanguinis is conveyed by endosmosis through the walls of
the capillary vessels, and through the peripheral boundary of the
surfjEice, the ^ basement membrane' of Bowman. Having reached
the exterior plane of the latter, the changes commence which re-
sult in the development of granules in the previously fluid liquor
sanguinis, or rather, perhaps, in the aggregation of the molecules
of ^e organizable material or blastema which was previously
held in intimate suspension or solution by the liquor sanguinis.
Out of the body, an action of this kind would be termed coagu-
lation, and where inorganic matter is concerned, crystallization ;
and the process to which I am now referring, though taking
place within the body, is analogous to these phenomena, with
the difference of being controlled and directed by the power of
life, of being, in point of fact, a vital coagulation or crystalliza-
tion. Indeed, coagulation, though occurring out of lAie body,
and sometimes afi;er the lapse of a considerable period, may be
regarded as the last act of vital existence, or as a vestige of the
atmosphere of life with which the coagulating fluid was previ-
ously charged in abundance.
" As regards the tissue under consideration, there is every
ground for belief that the organizable material or blastema of the
* This paper was read before the Royal Society, June 19, 1845.
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6 ANATOMY OF THE SKIN. #
liquor sanguinis is appropriated by the epiderma the very instant
it reaches the exterior plane of the ' basement membrane,^ some
portion of it and the greater part of the serum of the liquor san-
guinis being taken up by the newly-formed cells to be trans-
mitted in succession to more superficial ranges of cells, and the
remaining portion being converted on the spot into the primitive
granules of the tissue. This belief is supported by the fact of
die absence of any fluid stratum between ihe epiderma and the
derma, and by the close connexion known to subsist between
those two membranes. It is well known that to separate the
epiderma from the derma until the former is so thoroughly satu-
rated with fluid by maceration as to have acquired a consider-
able addition to its dimensions in all directions, or until decom-
position has commenced, is next to impossible, and in the living
state of the body separation never takes place until the mutual
connexion between the layers has been destroyed by the efiu-
sion of fluid. The microscope gives additional weight to this
evidence ; I have observed that the cells of the deep surface of the
epiderma are in immediate contact with the boundary limit of
the derma, .and that, moreover, it is frequently difficult to deter-
mine the exact line between them. I have also made the fol-
lowing experiment : I cut very thin vertical slices of the skin at
daily periods from the moment of death until decomposition had
become established, and submitted them to the action of the
compressor beneath the microscope, but in every instance, while
fresh, the two tissues yielded to the pressure in equal propor-
tion without any separation occurring. As soon, however, as
decomposition had commenced, separation was produced, and in
the early stages took place with difficulty. This experiment
proves that the firm adhesion subsisting between the epiderma
and derma is not alone due to the numerous inflexions of the
former into the latter which take place at the sudoriferous tubes,
hair tubes and sebiferous ducts, although these inflexions must
co-operate powerfully in the result.
" Being desirous of examining the under surface of the epi-
derma with the higher powers of the microscope, and failing in
all my attempts to efiect this object by taking the entire thick-
ness of the epiderma or by scraping, I awaited the first indica-
tion of its separation^ from the derma, and then removing it
carefully, made a thin slice parallel with the surface which I
vrished to examine. This plan succeeded beyond my expecta-
tions, for not only did I obtain parts so diaphanous as to enable
* It may be necessary to inform those who are unskilled in the manipnlations
required in pnrsning investigations in minute anatomy, that no decomposition had
occurred in this case; both epiderma and derma were perfectly ft'esh, and the sepa-
ration resulted chiefly from the imbibition of water by the epiderma.
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DEVELOPMENT OF THE EPIDERMA. 7
me to see the surface distinctly, but the septa between the de-
pressions for the papillae of the derma afforded natural laminae
of such transparency as permitted their structure to be Well ex-
amined.
14. " When the under surface of the epiderma was exposed to
yiew I found it to be composed of four kinds of elements, ar-
ranged in such a manner as to constitute an irregular mosaic
plane. These elements are: — 1. granules^ measuring about
aoooo of {^ ^^^^ ui diameter ; 2. aggregated granules, measuring
fi'hout toioo J 3- nucleated granules^ measuring ^^ to i^^j^ ; and,
4. cellsy measuring ^^^ to ^zins ^^ ^^ inch.
15. ^' The granules, which I may distinguish by the name of
primitive granuleSy are globular in form, homogeneous, solid,
brightly illumined by transmitted light when the centre is imder
the focus of the microscope, but dark when viewed upon the sur-
fiEtce, the darkness being increased wheneyer they are congre-
gated in clusters. These granules I conceive to be the first
organic shape of the blastema of the liquor sanguinis.
16. "The aggregated granules, measuring about towit ot an
inch in diameter, are minute masses composed of four, five or
six of the preceding, or as many as can be aggregated without
leaving an unoccupied space in the centre of die mass. With
an imperfect focus these granules have the appearance of pos-
sessing a transparent globular nucleus; but this appearance
ceases when the focus is perfect, and then the component gra-
nules are quite obvious, and the centre becomes a dark point,
namely, the shadow caused by the meeting of the primitive
granules.
17. "The nucleated granules^ measuring between ^^jVi^ and
if^ifxf of an inch in diameter, are in point of construction an
* aggregated granule' with a single layer of aggregated granules
arranged around it, so as to give the entire mass a circular or
oval form. The central * aggregated granule' has now become
a nucleus, and at the same time has undergone other changes
which in(£cate its longer existence. For example, the primitive
granules composing it are denser than they were originally, and
iiiey are separated from each other by a very distinct interstitial
spsuce filled with a transparent and homogeneous matter. Some-
times this interstitial substance presses ^e granules equally on
all sides, constituting a circular nucleus, but more frequently
two opposite granules are more widely separated than the rest,
and the nucleus receives an elongated form. The interstitial
substance is most conspicuous at the line of junction of the
nucleus willi the secondcpy tier of ^ aggregated granules,' and in
this situation gives a defined character to the nucleus. Close
observation and a perfect focus render it quite obvious that the
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8 ANATOMY OP THE SKIN.
peripheral tier of granules axe in reality aggregated. They are
lighter than the shaded granules of the nucleus, and apparently
softer in texture.
'^ The nucleated granules are more or less flattened in their
form, and present a flat surface of contact with the derma. It
is thu latter circumstance that gives the fEu^ility of determining
their mode of construction.
18. " The cells of the deep stratum of the epiderma, measur-
es W(nr to Winr ^^ ^^ ^^^ ^ their longer diameter, are the
most striking feature of this layer, and may be said to be its
chief constituent. They originate, as is evident from their struc-
ture, in the nucleated granules previously described, and consist
of a transparent layer added to the exterior of the former. Or,
if I might be permitted to describe them as they appear in their
tesselated position, they are constituted by the addition of a
transparent border to the last described nucleated granule. The
periphery of this transparent border is bounded by a dark inter-
stitial substance, which gives the border a defined outline, and in
the latter situation I imagine a cell-membrane to exist. I am
not satisfied, however, that this is the case, and the difliculty of
isolating these cells, and their roughness of outline when sepa-
rated, seem to prove that if a membrane be really present it
must be exceeoingly thin and easily torn. Assuming, there-
fore, from analogy rather than from demonstrative evidence, that
there exists a boundary membrane to the bodies I am now de-
scribing, I have termed them * cells ;' the cavity of the cell I ap-
prehend to be ^ the transparent border ;' the * nucleated granule*
is the nucleus of the cell ; the ' aggregated granule' of the latter,
the nucleolusy and Uie entire body a ^ nucleolo-nucleated cell.'
" Before quitting the structure of the * nucleolo-nucleated cell'
or primitive cell of the epiderma, there is a point of much interest
to be mentioned with regard to it, which is, that the ^ transparent
border' just described is itself a tier of * aggregated granules.'
The nucleolus, therefore, is an ^ aggregated granule,' the nucleus
a tier (taking its flat surface) of aggregated granules surroimd-
ing the former ; and the cell-chamber a tier of aggregated gra-
nides inclosing the whole.
19. ^^To return to the mosaic-like plane of the under surface
of the epiderma : the largest of the pieces composing this plane
are the nucleolo-nucleated cells. These are placed without
order ; in some parts closely pressed together, in others at short
distances apart, and here and there leaving interspaces between
them equal to the breadth of the cells. The interspaces or in-
tercellular spaces are occupied by the *nucleatea granules,'
* aggregated granules,' and * primitive granules,' irregularly set
in a homogeneous interstitial substance, which fills up all vacui-
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DEVELOPMENT OF THE EPIDERMA. 9
ties. The granules and interstitial substance modify the light
transmitted through them variously at different foci of the micro-
scope ; sometimes the granules look dark while the interstitial
substance is light, and sometimes the reverse is the case.
" Such is the structure of Ihe mosaic-like plane of the under
sur£GLce of the epiderma, and, so far, my observations having re-
ference to &cts, are demonstrable, and admit of being spoken to
positively. The interpretation of the facts I would willingly
leave to others, but feel that I am called upon to state any
opinion, founded on the above observations, that I may have
formed of the signification of these appearances. In the first
place, then, I must acknowledge myself wholly divided between
a belief in the possibility of formation of the * aggregated gra-
nule,* by the aggregation of primitive granules^ the idea which
prompted me to give it that name, and the formation of the
* aggregated granule' by the cleavage of a primitive granule. If
this question related merely to the formation of the ^ primary
aggregated granule' it would be unimportant, but it has a more
extended application. The outermost layer of the nucleus is
composed, as I have shown, of aggregated granules, and so also
is that layer which alone forms the chamber in the nucleolo-
nucleated celL To these ihe hypothesis of cleavage of a simple
granule would be most suitable, and this theory would explain,
better than any other, changes which remain to be described in
the further growth of the epidermal cell. In the second place,
the relation of cell and nucleus is a question on which I feel
considerable doubt. The process of development appears to
consist in the successive production of granules, one layer of
granules succeeding another, so that, if the organizable principle
exist in each separate granule, the organizable force may be sup-
posed to be more and more weakened in successive formations
until the moment arrives when it ceases entirely. Is that which
I have described as a * nucleolo-nucleated cell' really a cell or
still a nucleus ? The only solution to the question that occurs
to me is, determining the presence of a cell-membrane, in which
I have liot satisfactorily succeeded.
20. " Admitting the nucleolo-nucleated bodies now described
to be cells in their earliest state of formation, their size is ^^^
to T^nr of <^ uich in the long diameter, and that of their nucleus
from flo'oo ^ 45^)0 ^^ ^^ inch. In the stratum immediately above
the deepest layer I find cells measuring ^nnnr of an inch with
nuclei of 45^00' Above these, cells measuring twitj "^^ nuclei
varying firom i^^jVir ^ Wtnr? ^^^ above the latter, cells measuring
y^, with nuclei of Y^tnr. In following the layers of epiderma
upwards to the surface, cells may be observed possessing every
intermediate degree of size between the last-named cell, namely.
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10 ANATOMY OF THE SKIN.
T^9 and jf^y which is the measurement of the scales which
constitute the uppermost stratum of the epiderma. It must not
be supposed, however, that the growth of the epidermal cells
reaches its maximum only at the surfEice ; I have found cells of
that magnitude in the deeper strata, and there is every indica-
tion of die growth of these cells being completed in the stratum
immediately above the mosaic-like layer.
21. ^^ Young cells are remarkable for the large size of the
nucleus as compared with the entire bulk of the cell, and it is
quite evident also that the nuclei, up to a certain point, grow
with the cells ; their mode of growth appearing to be the sepa-
ration of the original granules by the deposition between them
of interstitial matter, and in addition, as I believe, by cleavage
and the consequent multiplication of the granules; in cells
measuring 71^ and ywisif ^^ an inch, I found the granular
character of the nucleus to be very manifest. Besides growth,
it is apparent that other changes are taking place in the nucleus ;
imbibition and assimilation of organizable material must neces-
sarily be in action in order to accomplish the formation of
interstitial matter ; but in addition to this, the central granules
undergo another change, by which they are altered in character,
and become distinguished from the rest when submitted to
chemical experiment For example, when diluted acetic acid
is added to the cells measuring ^rnnF ^^ an inch and less, the
entire nucleus is rendered transparent and less discernible than
before ; but when cells of a somewhat larger size, and conse-
quently longer growth, are submitted to the same process, the
nucleus is rendered much more distinct than it was previously.
But the body which is made so conspicuous in this latter ex-
periment is not the entire nucleus, but simply the central and
older granules of the nucleus ; the younger granules retain the
character of those of the young cells: they are made more
transparent than they were before, and have faded from sight.
I may mention, also, that the nucleus brought into view by the
acetic acid is more or less irregular in form, and has the ap-
pearance of being constituted by the fusion of the original
granules. How much of this appearance may be real, and how
much the effect of the acid, I do not pretend to say; and I set
no value on the experiment beyond die demonstration of the
mere fact which it is made to illustrate.
22. " I now turn to the growth of the cells : I have remarked,
in an earlier paragraph, that the formation of the young cell
appears to be due to the development of a stratum of * aggre-
gated granules' externally to the nucleated mass which I have
regarded as the cell-nucleus. Now, nothing is more certain
than that the growth of the cell is due to a successive repetition
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DEVELOPMENT OF THE EPIDERMA. 11
of this process, the growth of the e^ll-membrane being consen-
taneous with the development and growth of aggregated granules
within it. In cells of y^^nr to ttott of ^^ inch, iShe aggregated
granules of the periphery are not easily discernible, but in cells
measuring unnry ^^^ thence upwards to the complete size of the
epidermal cell, the fact is quite evident, and is apparent even in
the cell-scale. Indeed, a cell at the fiill period of growth is a
kind of cell microcosm, containing in its interior secondary
cells, tertiary cells, nucleolo-nucleated cells, nucleated granules,
aggregated granules, and primitive granules.
23. " It will be observed that this hypothesis of cell growth
differs from that of Schwann. The theory of Schwann always
appeared to me to be incompetent to the explanation of the
growth of the large scale of epiderma and epithelium in a tissue
manifestly subjected to considerable pressure. I sought in vain
for the watch-glass cells, elliptical cells, and globular cells in
the epiderma, and my search has been rewarded by the dis-
covery of the above-described beautiful process of formation and
growdi. It will be seen that, according to this view of the
growth of epidermal cells, they never possess anything ap-
proaching to a globular form, diat the scales are not flattened
spheres, but, on the contrary, always possessed a flattened form,
and have increased by a peripheral growth. This mode of
grovfth, again, is made manifest by the observation of a vertical
section of the epiderma. The most careful examination can
distinguish no difference between the size of the deeper and
superficial strata of cells: they have all the same average thick-
ness, all the same average length — an appearance easily ex-
plained, when we regard them as parent cells containing
secondary and tertiary cells of the same average size as the
cells of earlier formation. It is true, that the complete size of
the cell is very quickly attained, and that its growth, taking
place in the deepest stratum of the epiderma, could not be
expected to produce any difference of character in the middle
and superficial strata, but this is not mentioned, as far as I
know, by Schwann,
24. " The process of grovrth here described explains also the
fact of the disappearance of the nucleus in the scales of the
epiderma. The outermost granules of the nucleus have become
the nuclei or nucleoli of secondary cells, and have consequently
been moved away from their original position in the performance
of the office of centres of growSi to secondary cells. The ori-
ginal nucleus, therefore, is not lost, but merely robbed of some
of its component granules, which may be discovered in many
parts of the epidermal scale, instead of being concentrated in a
single mass. In these scales, and particularly in epithelial
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12 ANATOMY OF THE SKIN.
scales, the central and denser part of the original nucleus is
generally perceptible : in the latter it constitutes the scale-
nucleus, and in the epidermal scale there is always some one
little mass larger than the rest, particularly if the scale have
been for some time immersed in fluid, as when it is examined
in the serum of a blister. In an epidermal scale, measuring
f^ of an inch in long-diameter, I found several secondary cells
measuring t^, others measuring ^inny, and in the interstices,
primitive granules, aggregated granules, and nucleated cells.
25. "My observations, it will be seen, have been chiefly
directed to the epiderma, and I am prevented at present firom
carrying them further ; but I have no doubt that the epithelium
will be found to be identical in the phenomena of development
and growth with the epiderma. I have observed the same
structure in the epithelium of the mouth and fauces, and also
in that of the bladder and vagina. Incomplete epithelial cells
from the fauces, measuring ^j^ and ^7^ of an inch, presented a
very remarkable appearance ; they have a rounded lobulated
border, evidently composed of a row of secondary cells, and a
depressed centre, as though the action were subsiding in the
latter while it was progressing in the circumference.
26. " Another illustration of the structure now described, I
found in the cells of melanosis, and in the pigment cells of the
choroid membrane of the eye-ball, and I am induced to believe
that the same structure will be discovered more extensively
than at present can be anticipated. The corpuscles of
melanosis, according to my observation, are parent cells hav-
ing an average measurement of -nrinr ^^ ^^ inch, containing
secondary cells and nucleated and aggregated granules, as well
as separate primitive granules. The aggregated granules
measured from xriinr ^ yrnnr ^^ *^ inch, and the primitive gra-
nules about floooTy-
27. " There is another feature in the history of development
of the epidermal cell, which I regard as peculiarly interesting.
This relates to an organic change taking place in the assimila-
tive powers of the primitive granules, by which the latter are
altered in their colour, in short, are converted into ^ pigment
granules.' Pigment granules appear to differ in no respect from
tiie primitive granules, excepting in tint of colour and chemical
composition. They have the same globular form, the same
size, and occupy the same position in the cell, being always
accumulated around the nucleus, and dispersed less numerously
through the rest of the cell. The nucleus of the cell in the
epiderma of the negro appears to consist wholly of pigment gra-
nules ; while, in the European, there is a greater or less admix-
ture of coloured and uncoloured granules. The central granules
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DEVELOPMENT OF THE EPIDERHA. 13
are generally lighter in tint than the rest, and give the idea of
a coloorless nucleolus, while those around the circumference are
more deeply coloured. Besides a difference in the depth of
colour of the separate granules entering into the composition
of a single cell, there is also much difference in the aggregate
of the granules composing particular cells. For example, in-
termingled with. cells of a dark hue, there are others less deeply
tinted, which give the tissue in which they are found a mottled
appearance. This fact is well illustrated in the hair and also
in the nails ; in which latter, it is no uncommon thing to find
an isolated streak produced by the accumulation of a number of
cells containing coloured granules in the midst of colourless
cells.
28. " When pigment granules are examined separately, they
offer very little indication of the depth of colour which is pro-
duced by their accumulation. I have observed some to have
the hue of amber, while others scarcely exceeded the most deli-
cate fawn. The depth of colour of the deep stratum of the
epiderma in the negro is evidently due to the composition of
that layer, of these granules chiefly, while the greyness of the
superficial layers of the same tissue results not merely firom the
desiccation of these granules, but also from the fact of those
subsequently produced being less strongly coloured, and also
from the addition of a considerable mass of colourless cell
membrane. The epidermal scale of the negro has a mottled
appearance, from the numerous secondary nuclei, and their
attendant coloured granules, which are scattered through its
texture."
29. It follows, from a review of the structure of the epiderma,
that this membrane is accurately modelled on the papillary
layer, that each papilla finds its appropriate sheath in the newly-
formed epiderma or rete mucosum, and that each irregul^ty of
surfEu^e of the former has its representative in the soft tissue of
the deep layers of the latter. It is not, however, the same with
the external surface of the epiderma ; this is modified by attri-
tion and exposure to chemical and physical influence; the
minute elevations, corresponding vrith the papillae, are, as it
were, polished down, and the surface is consequently rendered
smooth and uniform. The palmar and plantar surfaces of the
hands and feet are an exception to this rule, for in these situa-
tions, in consequence of the large size of the papillae, and their
peculiar arrangement in rows, ridges corresponding vrith the
papillae are strongly marked on the superficial surface of the
epiderma. Moreover, upon the borders of the fingers, where
the linear- disposed and magnified papillae of the palmar surface
gradually pass into the irregidar and minute papillae of the
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14 ANATOMY OF THE SKIN.
dorsal surfiEtce, a transition state of the epiderma may usually
be observed.
30. Besides the form bestowed upon the epiderma by its
relation with the derma, its degree of thickness will be found
to be dependent upon the same source, and to bear an accurate
proportion to the degree of development of the papillae. Thus,
on the palms* of the hands, where the papillae are large, the
epiderma is thick ; while on the backs of those organs, or on
the scalp, where the papillae are small, it is exceedingly thin.
31. Another character presented by the epiderma is also to
be considered as the consequence of its connexion vrith and
dependence upon the derma — namely, the network of linear
fiinrows, which everywhere intersect each other, and trace out
the surface into small polygonal and lozenge-shaped areae.
These lines correspond with the folds of the derma produced
by its movements, and are most numerous where those move-
ments are the greatest, as in the flexures, and on the convexities
of joints. Some difference is perceived in the form of the areas,
when examined in these two situations ; thus in the flexures of
the joints they are narrow and long, and, for the most part,
lozenge-shaped in their figure, while on the convexities of joints,
as upon the elbow and knee, the areas are large, and more nearly
quadrangular. The furrows of the epiderma admit of a division
into two kinds — ^namely, those which correspond with joints, and
bear relation to the movements of the body and limbs, and those
which belong especially to the movements of the skin. The first
or larger kind are those which are so perceptible on the flexures
and convexities of joints, and on the palm of the hand and
sole of the foot. The latter or smaller occupy the interspaces
of the former, and those parts of the surface where the fiirrows
of articular motion have no existence. Their plan of arrange-
ment is as follows : — firom each of the hair-pores there pass off
on all sides, like rays firom a centre, firom six to ten lines, which
meet by their extremities lines proceeding firom other pores.
These lines mark out the surface into small triangular spaces or
areas, within which are other and more minute pores, probably
perspiratory pores. From the latter, a similar number of
radiating lines are given off, and abut against the coarser lines,
dividing the surface into smaller triangular areas, and giving to
the entire network the appearance of a number of nicely ad-
justed angular wheels. On the shoulder of a child of about
five years of age, I counted sixty of tl^e hair-pores vnth the
wheel-like rays within the limit of a square inch; while
between these larger pores were six hundred smaller pores,
* Id an individual not exposed to mach manual labour, I found the epiderma in
the palm of the hand to measure one-foorth of a line in thickness.
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PIGMENT 07 THE SKIN. 15
constituting so many secondary centres and secondary wheels,
and forming a very elegant mosaic pattern. On the scalp, the
fiinrows run between the hair-pores, and the included aresB are
more open than on the general sar&ce of the skin.
32. The deeper tint of colour of the skin observable among
the nations of the south, and in certain regions of the skin of
the European, is due to the presence of pigment granules in the
cells of the epiderma. The pigment bearing cells are most abun-
dant in the farrows of the derma, and in the hollows between the
papillae. The production of pigment granules is not, however,
hmited to the horizontal stratum of the derma, they are also
met with in the various inflexions of the epiderma, constituting
sudoriparous and sebiparous glands, and hair-follicles. It is in
consequence of the presence of these granules in the cells con-
stituting these inflexions that we are enabled to perceive the
organs to which they belong with greater facility ; and, for the
same reason, we discover pigment granules in die perspiratory
and sebaceous secretions.
33. The chemical composition of the pigment of the skin
may be inferred from the analysis of the pigmentum nigrum
ocidi made by Scherer.^ The principal elementary substances
composing this pigment were found in the following propor*
tions : —
Carbon 58-278
Hydrogen .... 6*973
Nitrogen .... 13768
Oxygen 21*986
The chemical composition of tiie epiderma, according to an
analysis by John, is as follows : —
Hardened albumen .... 93*0 to 95-0
Gelatinons matter ..... 5*0 „
Fat 0-5 „
Lactic acid; salts and oxides . 1-0 „
The salts are, lactate, phosphate, and sulphate of potash;
sulphate and phosphate of lune ; and ammonia ; the oxides,
those of manganese and iron.
34. The identity of structure of the external tegument or
skin, vdth the internal tegument or mucous membrane, has long
been established. In both, the same parts are found, and each
is continuous with the other. Mr. Bowman, of King's College,
whose remarks, founded on careful and persevering observation,
are always important, and deserving of attention, again directs
our noticet to this fEict, and adduces another point of similitude
between these membranes. He 6nds beneath the epithelium
* Liebig, Organic Chemistry,
t CydopeBdia of Anatomy and Physiology; Article, Mucous Membrane.
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16 ANATOMY OF THE SKIN.
of mucous membranes, on the one hand, and in contact with the
vessels of the parenchyma, on the other, ^' a simple, homoge-
neous expansion, transparent, colourless, and of extreme
tenuity f' this delicate expansion serves as a foundation on
which the epithelium rests ; and in accordance with this view he
terms it the " basement membrane.^ This is, in fact, the boun-
dary layer of all vascular membranes, and as such is met with in
serous as well as in mucous structures. The extreme tenuity of
the basement membrane may be inferred from the measurements
instituted by Mr. Bowman ; in the uriniparous tubuli, its thick-
ness does not exceed ^oooo ^^ ^^ ^<^^ ; in the seminiparous
tubuli, it is loioo ^^ ^^ ^^^^ i^ thickness ; in the lungs, it forms
almost the entire thickness of the air-cells ; and in no situation
has it been found to exceed -^^^^ of an inch. Reasoning from
analogy, Mr. Bowman infers the existence of a correspond-
ing membrane on the surface of the derma, an inference that
will be unreservedly accorded him ; but he finds it difficult to
demonstrate this membrane in the latter situation, in conse-
quence of its close adherence to the vascular rete, and deeper
seated strata. The same difficulty exists on the general surface
of the mucous membranes, and for the same reason ; but, in the
minute tubuli of the secreting glands, the connexion between
the basement membrane and the vascular rete is so slight, that
they separate on the gentlest pressure. In like manner Mr.
Bowman finds no difficulty in distinguishing this membrane in
the tubuli of the sudoriparous and sebiparous glands. Mr.
Bowman remarks, that it is the basement membrane which
gives firmness and form to the minute tubuli of secreting
glands.
35. The sudoriparous glands are situated in the middle and
deeper stratum of the corium, namely, at about half a line below
the plane of the upper surface of the epiderma. They are small,
oblong bodies, composed of one or more convoluted tubuli,* or
of a congeries of globular sacs,t ivhich open into a common
efferent duct, and t^e latter ascends through the structure of the
derma and epiderma, to terminate by a funnel-shaped and
oblique aperture or pore upon the surfiice of the latter. The
sudoriparous glands are various in size in different parts of the
body ; for example, in the palm of the hand I found them to
range between -^ and ^^ of an inch in their longest diameter;
while in the axillae they measured between ^ and ^ of an inch.
The entire length of each tubulus, comprising that which consti-
tutes the gland, as well as the excretory duct, is about one quarter
of an inch. The efferent duct presents some variety in its course
'^ MuUer. Girald^t, 1841. f Gerber.
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SUDORIPAROUS GLANDS. 17
upwards to the surface. Below the derma it is curved and
serpentine, and having pierced the derma, if the epiderma be
thin, it proceeds more or less directly to the excreting pore.
Sometimes it is spirally curved beneath the derma, and hav-
ing passed the latter, is regularly and beautifully spiral in
its passage through the epiderma, the last turn formbig an
oblique and valvidar opening on the surface. The spiral course
of the duct is especially remarkable in the thick epiderma of the
palm of the hand and sole of the foot. In those parts of the body
where the papillse of the derma are irregularly distributed, the
efferent ducts of the sudoriparous glands open on the surface also
irregularly, while on the palmar and plantar surfaces of the hands
and feet, the pores are situated at regular distances along the
ridges, at points corresponding v^ith die intervals of the small
square-shaped clumps of papillse. (§ 8.) Indeed, the apertures
of the pores seen upon the surface of the epidermal ridges give
rise to the appearance of small transverse furrows, which inter-
sect the ridges from point to point. On the palm of the hand
and palmar surface of the fingers the sudonferous pores are
situated at about one-sixth of a line apart along the ridges, and
at a little less than a quarter of a line from ridge to ridge. On
the heel there are four and a half pores in the compass of a line
along the ridge, and three and a half across the rioges.
36. The efferent duct and the component sacs and tubuli of
the sudoriparous gland are lined bv an inflection of the epiderma.
This inflection is thick and infimaibiliform in the upper stratum
of the derma, but soon becomes uniform and soft. The infim-
dibiliform projection is drawn out from the duct when the epi-
derma is removed, and may be perceived on the under surface
of the latter as a nipple-shaped cone. A good view of the sudo-
riferous ducts is obtained by gently separating the epiderma of
a portion of decomposing skin ; or they may be better seen by
scalding a piece of skin, and then withdrawing the epiderma
from the derma. In both of these cases it is the lining sheath
of epiderma which is drawn out from the duct.
TTie epidermal lining of the efferent duct and secreting sacs of
a sudoriparous gland is composed of cells of a polyhedral form,
closely packed together, and containing granular nuclei of large
size. The average diameter of the tubular epidermal lining of
a sudoriferous duct examined in the palm of the hand was -j^
of an inch, two-thirds of this diameter being constituted by the
wall of the tubule, and the remaining third by its area. The
parietes of the tubule were composed of two or three layers
of cells, of which the most external, namely, those which
corresponded with the corium, measured ^^^ of an inch in
diameter.
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18 ANATOMY OF THE SKIN.
Taken separately, the little perspiratory tube, with its ap-
pended gland, is calculated to awaken in the mind very litUe
idea of tibe importance of the system to which it belongs ; but
when the vast number of similar organs composing this system
are considered, — for it includes the sebiparous organs, which are
also agents in perspiration, — we are led to form some notion,
however imperfect, of their probable influence on the health and
comfort of die individual. I use the words " imperfect notion,"
advisedly, for the reality surpasses imagination and almost be-
lief. To arrive at something like an estimate of the value of
the perspiratory system in relation to the rest of the organism,
I counted the perspiratory pores on the palm of the hand, and
found 3528 in a square inch. Now, each of these pores being
the aperture of a Utile tube of about a quarter of an inch long,
it follows, that in a square inch of skin on the palm of the hand
there, exists a length of tube equal to 882 inches, or 73| feet
On the pulps of die fingers, where the ridges of the sensitive
layer of the true skin are somewhat finer than in the palm of the
hand, the number of pores on a square inch a little exceeded
that of the palm ; and on the heel, where the ridges are coarser,
the number of pores on the square inch was 2268, and the length
of tube 567 inches, or 47 feet. To obtain an estimate of the
length of tube of the perspiratory system of the whole surface of
the body, I think that 2800 might be taken as a fair average of
the number of pores in the square inch, and 700, consequently,
of the number of inches in length. Now, the number of square
inches of surface in a man of ordinary height and bulk is 2500 ;
the number of pores, therefore, 7,000,000, and the number of
inches of perspiratory tube 1,750,000, that is, 145,833 feet, or
48,600 yards, or nearly twenty-eight miles.
37. The sebiparous glands are small lobulated organs em-
bedded in the substance of the derma, and furnished with
excretory ducts, which open in some instances on the surface of
the epidisrma, but more frequently into the hair-follicles. They
ofier considerable variety in point of shape and size, some being
more or less globular, and others arborescent, palmated, pear-
shaped, or racemiform. The excretory duct is not less remark-
able for variety ; it is generally capacious and pouch-like, but
sometimes is slender and tortuous, like the sudoriferous ducts, and
occasionally assumes a spiral course. Like other conglomerate
secretmg organs, the sebiparous gland is composed of lobes, and
the latter of lobules. The ducts of the lobules unite to form a
single duct for each lobe, and the lobe ducts terminate in the
main excretory duct. Sometimes the ducts of two glands issue
in a single excretory tube, and occasionally three, four, and five
terminate in the same manner. On the scalp there are two
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SEBIPABOUS GLANDS. 19
(sometimes more) sebiparons glands to each hair-follicle ; they
aie small, of the racemiform^ pyriform, or palmated kind, and
are situated at about ^ of an inch below the plane of the sur-
&ce of the derma. The sebiparons glands of thenose are large
and of the arborescent type ; dieir ducts are also large, and fre-
quently distended with sebaceous^ substance, and the peculiar
animalcules (steatozoon folliculorum) of these organs. Occa«
donally, a duct may be observed which is of remarkable size
from distention, yrinle the gland is disproportionately small.
The sebiparons glands of the meatus auditoriu8,theceruminous
glands, are somewhat smaller than those of the nose; they are
arborescent, or divided into large lobes, and the entire gland is
more or less flattened upon its superficial and deep aspect, so
as to accord with the thinness of the derma in that situation.
It is the solitary sebiparons glands which attain the large size
now described ; those connected with the hair-^fbllicles are gene-
rally much smaller, and their shape is for' the most part pyri-
form or racemiform. The sebiparons glands situated around
the verge of the anus are also of considerable size, but the
largest of aU are those of the eyelids, the Meibomian glands.
The Meibomian glands consist of a central excretory duct, into
which numerous small sacculated lobules open upon all sides,
by means of short pedunculated ducts ; they have an exceed-
ingly elegant arrangement under the transparent mucous mem-
brane of the inner surface of the eyelids. The sebiferous ducts
and glands are lined by an inversion of the epiderma, which
forms a thick and fonnel-shaped cone at its commencement, but
soon becomes uniform and soft. The structure of the epidermal
Uning of the sebiferous tubes is identical with that of the sudo-
riferous ducts. (§ 36.) S^iparous glands are met with in all
parts of the body, but are most abundant in the skin of the face,
and in those situations which are tiaturally exposed to the in-
fluence of fiiction, and where at the same time the epiderma is
Ain.
38. Hairs are homy appendages of the skin, produced by the
involution and subsequent evolution of the epiderma ; the invo-
lution constituting the sheath of the follicle in which the hair is
inclosed, and the evolution, the body of the hair. A hair ad-
mits of a natural division into a central portion, or shaft, and two
extremities, — a peripheral extremity, the point, and a central ex-
tremity, the bulb, or root The shaft of a hair is rarely perfectly
cylindrical in figure, being for the most part compressed upon
its sides, and generally oval or fabiform in its section. The
celebrated Leeuwenhoeck observed this diversity of form, and
remarks, " quot orines, tot figurae." The hair also ofiers much
variety in point of size. For example : in 2000 hairs, taken from
c 2
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20 ANATOMY OF THE SKIN.
38 persons, the finest ranged between iVinr ^^^ zhf o( an inch ;
the former of these occurring in three instances, one in black,
the others in brown hair, the subjects of the observation being
adult men ; the latter, in seven persons, two men with black hair,
and five women, four with brown and one with chesnut hair.
The coarsest hairs in the same heads ranged between 7^ and
■YTu ^f *^ inch, the former being the flaxen hair of a female child,
and the latter a brown hair firom the head of a female adult. In
three South American Indians, a man, a young woman, and a
child, the finest hair occurred in the child (unnr oi an inch), next
in the man (3^), and lastly in the woman (ifhr). The coarsest
hairs of the same individuals were ^W of an inch in the man
and woman, and ^\jf in the child. The colour of the hair in the
two former was black, and that of the child red. In a New
Zealand chief, the finest of fifty hairs measured ^iir? a^d the
coarsest 7^, of an inch. The influence of a morbid habit on
the hair is shown in the instance of a scrofulous female child.
Of ninety-seven of the flaxen hairs of this child, the finest mea-
sured YTTu fl-i^d the coarsest :^ of an inch. For convenience
of reference, I have arranged these measurements in a tabular
form, as follows : —
Number of hairs m^,^ r-^—.^
examined. '^®^- Coarsest.
British 2000* ... Tir^-shs - ^^-^hs
South American Indians 155 ... -j^-^ ... li^j-^hj
New Zealander ... 50 ... ^ ... ^
Scrofulous child ... 97 ... -jV^ ... ^
39. The average thickness of the 2000 hairs above examined,
ranged between -^ of an inch, the flaxen hair of a female child,
and tJit of an inch, the brown hair of an adult woman. The
average thickness of the hairs of the three South American In-
dians was 7^ of an inch in the child, -^^ in the woman, and
■^ in the man. The average measurement of the hair of the
New Zealand chief was ^shfy ^^d that of the scrofiilous child,
^jf of an inch. In a tabular form, these measurements would
stand as follows : —
British . . . • ^ to ^
South American Indian ^ to ^
New Zealander ^
Scrofulous child ^^
The average dimension in thickness of human hair, accord-
ing to the above table, is ^^ of an inch. Leeuwenhoeck and
Rosenmiiller state it to be -^ of a Paris inch,t which is certainly
too little ; while Weber approaches more nearly to the mea-
* The measurements were in all cases made as close to the head as possible,
t A Paris inch is \^ longer than an English inch.
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DIMENSIONS OF HAIRS. 21
snrements given above, as may be seen by the following
table:—
His own hair -g^ to 71^ Paris inch.
Mulatto ^ . ^ to rb
Senegambian negro, woolly . ^ to ^ „
Nabian negress atsto^^ „
Rosenmiiller's table is as follows : —
Adult ^ to ^ Paris inch.
Lanugo from body of fcDtus . ^^ „
It is probable that these writers deduce their average from
extremes of measurement, a proceeding that must necessarily
lead to error. A correct average can only be obtained by ascer-
taining the medium range, and deducing the average from that
range. See § 41.
40. With respect to the influence of age and sex upon the
thickness of the hair, my observations are in favour of the
coarsest hair being found in the female, and the finest in the
male ; and of the hair of children being finer than that of the
adult; thus: —
Number of heads. Number of hairs. Range of thickness.
Child 6 ... 269 ... T;h5-Thu
Man 18 ... 1016 ... z^-^shs
Woman 18 ... 940 ... zhs-^jf
This is the reverse of what might have been anticipated ; I
should certainly have looked for a coarser hair in the male than
in the female, for, independently of sex, the habit of cutting the
hair closely might fairly have been expected to conduce to its
greater strength. Indeed, in one of die cases examined, the
head had been repeatedly shaven with a view to render it strong,
but the hair did not exceed the medium average of size.
41. The variety in the thickness of the hairs of the same head
is very considerable, as may be perceived in the following in-
stances, taken without selection firom a number of observations :
Number of hairs. Finest. Coarsest. Medium range. Arerage.
"' ••• nftny ••• tsts ••• TTry—imy ••• tmj
81 ... 15o0 ••• 3chy ••• TTO""?©^ ••• ToT5
79 ... TTsn ••• "tra ••• 35Ty~T6Ty ••• tstt
97 ... YTS ••• TTO ••• "Joiy^TroTy ••• TofS
"7 ... -jixF ••• TTU ••• 57Ty~TTO ••" vtu
64 ... 3^ ... ^ ... 300- aoo ... ^
The " medium range** in this table included the measurements
within which the greatest number of hairs are found, and from it
die average is deduced.
42. Variety in thickness is not, however, confined to the diflfer-
ent hairs of a single head ; it is met with even in a single hair.
Thus, a hair six inches long, and apparently of uniform dimen-
sions, ranged between ^^ and ^^ of an inch at various points
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22
ANATOMY OF THE SKIN.
of its length ; another ranged between tW ^^^ rirr 5 while a
white hair, which was obviously enlarged at short distances, pre-
sented a range of ^^ to 7^, the diameter of its point measur-
ii^g WoiF of an inch. The short hairs of the body not unfre-
quently exhibit an appearance which may be termed varicose.
In the instance of the long hairs of the head, a small share of
the diflference of diameter may be referred to overstretching in
dressing the hair, but this cause cannot apply in the case of the
varicose hairs. It has been shown by experiment that hair is
so elastic that nothing but inordinate stretching could occasion
the permanent constrictions to which my admeasurements refer.
Weber found a hair ten inches long stretch to thirteen inches,
and a hair stretched one-fifth returns to one-seventeenth of its
original length.
43. With respect to colour as a condition associated with
diversity in thickness, my observations tend to show that flaxen
is the finest and black the coarsest hair. Grey hairs commonly
represent in thickness the colour which they succeed ; but as a
general rule, the white hairs which intrude themselves as age
advances, are coarser than the hairs among which they are found,
suggesting the inference, that deficiency of the pigmentary is
compensated by excess of the albuminous principle.
The most extensive range is enjoyed by light brown hair. The
average measurements of hairs (rf different colours are as follow:
Flaxen ^i^ to ^ of an inch.
Clwsnut TirtOyiTj
5«d,- :ri7ytOTfc
Dark Brown ^^ to yfe „
Light Brown .... 3*zytOTfcT
Black :^tOyfe,
These observations aecord with those of Whithof.
44. The hairs of different regions of the body of the same in-
dividual necessarily present some degree of variety of diameter,
but the amount of variation is less than might bave been anti-
cipated, as may be seen by the foUowing table, in which the
average term is employed. The diameter of the hair of the
head is given in the first line as a standard of comparison.
MAD, obemnt.
Man,bIsok.
Man, brown. Woman, brown.
Head .
3^
vhs *•*
Tots ' ••• TsJS
Beard . .
7^
9O0 •••
Eyebrow
ths
s&o ••• ~~
Pahes . ,
soo ••
TsTT
~~ ••• loTJ
Breast .
ifc ••
400 ••• 400
Whisker
aOo ••
3o0 ••
Eyelashes
• sdo ••
— ... —
Axilla .
• Tfe *•'•
• 360 ••
• ' ••• 360
Thigh . .
ToTjy
Leg . .
ToJS
T«y ••
— ... —
VibnassBauns . j^
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STRUCTURE OF HAIR. 23
45. The entire cutaneous surfiu^e, with the exception of the
palms of the hands and soles of the feet, is organized for the
production of hairs. Upon the greater part of the body the hairs
are Tery minute, (downy hairs, lanugo,) and in many situations
are not apparent above the level of Uie skin ; in others, as upon
the outer sides of the limbs, they attain a certain length, and
upon the head, face, pubes, perinsBum, axillae, and around the
nipple, their length is considerable. When left to its full growth,
as it is in the female, the hair attains a length of from twenty
inches to a yard, the latter being regarded as unusually loiig ;
but in an instance that lately came under my notice die hair
measured six feet. The hair is known, besides, to constitute a
sexual character, appearing for the first time on certain parts of
the body at the period of puberty, and existing on regions of the
body of the male where it is generally imperceptible in the
female, as upon the sides of the face, iiie chin, the breast, the
shoulders, and the abdomen.
46. The free extremity or point of a hair is conical and more
or less sharp. When examined in one of the minute or downy
hairs which has not risen above the level of the surfeu^e, the
point appears obtuse, on account of its little difference in dia-
meter from that of the shaft. In the short hairs of thie body and
on the head, on the other hand, the point is apparently sharper,
from the greater relative size of the shaft, and actually so as a
consequence of desiccation. The pointed character of a hair is
very perceptible in the eyebrows and eyelashes, and in the
vibrissae of the nose and meatus auditorius. When the hair has
been cut, its pointed character is necessarily lost. Sometimes,
however, there is an appearance of pointing, the combined re-
sult of attrition and desiccation. But the more usual chairacter
when the hair has been long neglected, is a splitting of the end
into two or three filaments.
47. The root of a hair is somewhat larger than the shaft, and
forms the summit of an oval-shaped mass of considerable mag-
nitude, the pulp. When the hsor is cast as a process of decay,
the root is pointed, and resembles an old paint-brush worn to a
conical stump. But when it is torn out by force it presents a
variety of appearances, depending on the removal with it bf more
or less of the epidermal lining of the follicle. Sometimes this
follicular sheath is collected in a mass at the extremity of the
hair, and the latter appears, in consequence, to be bulbous.
Sometimes the epidermal sheath is drawn to a greater or less
extent beyond the root, and then, according as it is straight or
curved in direction, the root has the appearance of being'pointed
or uncinated.
48. In structure, a hair is composed of three different tissues
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24 ANATOMY OP THE SKIN.
— namely, of a loose cellulated tissue, which occupies its centre
and constitutes the medulla or pith ; a fibrous tissue, which in-
closes the preceding and forms the chief bulk of human hair ;
and a thin layer of superimposed scales, which envelopes the
fibrous structure and forms the smooth, external surface of the
hair.
49. The medulla is absent in the minute or downy hairs, and
is not unfrequently absent or small in quantity in fine hairs,
firom whatever region they are selected. In the coarser hairs of
the head and of the body, on the other hand, it is always pre-
sent, and it is especially remarkable in grey hair. It varies in
breadth from a mere line to a cylindrical body of one-third the
diameter of the hair, and is composed of large nucleated cells, of
a globular or oval figure, filled with granules and packed toge-
ther, apparently vrithout order. When newly formed, these cells
with their granules are distended with fluid, but in the shaft of
the hair the cells frequently contain air, which, from its highly
refractive powers, gives the medulla a dark appearance when
examined with the microscope. Varieties in structure of the
hair are very unusual ; I have, however, once observed the pre-
sence of two medullse ; the displacement of the medulla nearer to
one side of the periphery of the hair than to the other, in the
short and thick hairs of the body, is not uncommon.
50. The middle or fibrous layer of the hair is composed of
oval-shaped cells, closely packed together, and arranged in a
linear order. These cells are identical in structure with the
cells of the deep stratum of the epiderma, that is to say, they are
composed of granules congregated around a central granule
which constitutes the nucleus of the cell. When examined with
the microscope, it is not in all cases easy to discover the cells,
but their component granules are always obvious, and from the
plan of disposition of the cells, and their oblong shape, the gra-
nules have a linear arrangement, and assume the appearance of
fibres. The hair-fibres offer some variety of appearance, accord-
ing to the focus in which they are viewed. For example, with
a superficial focus, the peripheral granules are alone seen, and
the hair appears to be entirely composed of granules arranged
in single rows. With a deeper focus, the rows of granules ap-
pear to be associated in pairs, each pair having between them
an unconnected row of dark and apparently nuclear granules:
In this view the fibres resemble very closely a chain composed
of open links. While with a still deeper focus, the centre of the
cell, with its nucleus and granular periphery, is brought into
view. In different hairs, these three appearances are seen with
various degrees of distinctness.
51. The colour of hair appears to reside partly in the granules
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COLOUR OF HAIR. 25
and partly in an intergranular pigmentary substance which occu-
Sies the interstices of the granules and of the fibres. The most
eeply coloured granules are those which constitute the nuclei
of the cells, and in the lighter hairs these alone give colour to
the fibrous structure. In the darker hairs more or less of the
peripheral granules are also coloured, and pigment may be ob-
served in greater or less abundance in the interfibrous spaces.
With respect to the granules, the pigment appears to occupy
their periphery, sometimes surrounding them completely, and
sometimes occupying a portion only of their surface. In the
peripheral granules of the cells, the outer segment is the more
firequent seat of the pigment, while many are entirely destitute
of Aat production. This total absence of colour in many of the
granules composing even the blackest hair, gives to the fibrous
structure, when examined vdth the Horoscope, an interruptedly
streaked appearance ; and the irreguBb* intermixture of pigment
granules with colourless granules, bestows upon the tissue be-
tween the streaks a dotted character. In red hair, the granules
have a delicate golden yellow tint, while the pigmentary matter
is amber coloured. In the white hair of Albinoes and of the
aged, the pigment is entirely wanting.
52. The external layer of a hair is a thin and transparent
envelope, measuring in the hairs of the head about ^^^ of an
inch in diameter. It is composed of flattened scales, similar to
those of the epiderma, and the scales forming the surface of the
layer overlap each other from the root to the point of the hair.
The overlapping border of the scale is notched and convex, and
forms a slight projection beyond the level of the surface. Seen
with the microscope, the prominent edges of the scales have the
appearance of undulating and jagged lines, which cross at right
angles the shaft of the hair. The prominence of the edges of
the superficial scales of a hair is the cause of the sensation of
roughness which we experience in drawing a hair between the
fingers firom the point towards the root, a sensation which is not
perceived when the direction of the hair is reversed. It explains,
also, the circumstance of hairs occasionally working their way
into wounds, beneath the nails, and into the gums. In the hairs
of the axilla the external layer is generally more or less split up
into fibres, which give it a shaggy appearance. Sometimes this
appearance occurs only on one side of the hair, or more on one
side than the other, while at others it is equally conspicuous
around the entire shaft. It forms a remarkable distinctive cha-
racter of the hairs of this region, and is due, as I believe, not to
original formation, but to their saturation vnth the perspiratory
fluid.
53. llie hairs are implanted at a variable depth within the
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26 ANATOBfY OF THE SKIN.
skin, and are maintained in their position by means of their fol-
licles. The depth of implantation of the hairs of the head is
between yV «^d inr of an inch, their roots being situated in the
deep stratum of the oorium, and frequently extending into the
subcutaneous adipose tissue. The hairs of the whiskers, beard,
and pubes, are commonly prolonged beyond the corium, while
those of the general surface rarely exceed its mid-dqpth. The
depth of implantation of the hair of the pubes is the same as that
of the hairs of the head.
54. The follicle of the hair is a tubular canal excavated in
the substance of the derma and lined by a thick layer of epi-
derma. It consequently presents the same three structures that
enter into the composition of the skin, namely, an epidermal
lining or sheath, a vascular layer, and the common fibcous tissue
of the corium. Of the latter it is unnecessary to say more than
that it offers the same ofaaracters around the hair as upon the
surface of the derma, and that it sends a delicate sheath down*
wards^ upon the root of the hair when the latter extends into the
subcutaneous areolar tissue. The vascular layer corresponds
with the papillary layer of the derma, and supports a fine net-
work of capillary vessels, which supply nutrition to the epidermal
sheath and hair. The epidermal layer is composed of strata of
superimposed cells, identical in structure with those of the epi-
derma. It is nearly as thick, and often thicker than the hair
which it incloses, and lies in close contact with the latter, and
at its lower part it terminates in a slightly expanded and cellular
mass, the pulp of the hair.
55. The hair-follicle terminates inferiorly in a slightly dilated
csBcal pouch, which is filled for about the extent of xott of &n
inch with a mass of minute granules and cells. This mass of
granules and cells is the pulp of the hair, and the cells are pro-
gressively converted into the substance of the hair. The cells
produced at the middle of the fundus of the caecal pouch neces-
sarily proceed upwards in a direct line, and are the first converted
into fibres ; hence the pointed character of a hair torn up from
its root. The cells from the sides of the pouch proceed, with a
gentle curve, upwards and inwardjs, and merge into the substance
of the root of the hair, and those firom the upper part of the pulp
assume an almost vertical position, and constitute, on the one
hand, the outer layer of the hair, and, on the other, the epiderma
of the follicle* So that, at its upper part, the hair-pulp may be
said to divide into two parts, a central and isolated part, which
constitutes the shaft of the hair, and a tubular sheath, which re-
mains in connexion with the vascular part of the follicle on the
one hand, and is in apposition with the surface of the hair on
the other. The structure of the pulp and the mode of growth
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STRUCTURE OF THE HAIR-FOLLICLE. 27
of liie hair remind us forcibly of the formation and growth of
the teeth, and furnish an additional reason for regarding the
latter as dermal appendages. They explain also the well-known
fact, that if the epiderma be withdrawn from the derma when
loosened by decomposition, the hairs may frequently be removed
inclosed in their epidermal sheaths, which obviously extend un-
injured arpund the bulb, and isolate the hair from the vascular
part of the skin. I have found the vibrissse nasi the best fitted
for illustrating this point, and I may remark, that the proof of
such an organization completely sets at rest the question of the
vascularity of the bulb.
56. It is by no means uncommon to find two hairs, and
sometimes three, issuing from the aperture of one follicle ; but
at a short distance below the level of the epiderma, such a fol-
licle would be found to divide into separate tubules for each
hair. Within the nose, I have counted as many as ten hairs
issuing in this manner from a common follicle, but below the
surface there were always as many tubules as hairs.
57. In a healthy state of the skin, the space between the epi-
dermal lining of the follicle and the hair is very trifling. Indeed,
it is merely suflBcient to receive the exfoliated scales of the
former, which are to be conveyed with the growing hair to the
exterior. At a short distance (about half a line) from the epi-
derma, however, the space enlarges, in consequence of the junc-
tion with the follicle of one or two excretory ducts of sebipa-
rous glands (§ 37), and the consequent stream of sebaceous sub-
stance which is poured into it It is in this part that the entozoa
of the hair-follicles are chiefly found.
58. Mandl entertains some peculiar views with regard ta the
structure and mode of growth of hair. He describes a hair as
consisting of a cortical portion, which is cellular, and a medul-
lary portion, which is tubular. Through the latter, he conceives
that the fluids of the hair ascend, and are deposited at the free
extremity of its shaft, in successive layers, each layer becoming
gradually smaller in diameter, until the hair eventually assumes
the form of a fine point. This structure, he says, is indicated on
the tapering extremity of a hair, by a series of annular lines. The
mode of growth here described he believes to be proved by the
production of a pointed end upon hairs which have been cut,
and also by the whitening of hair which sometimes commences
at the point. The latter fact he explaiiis by the transmission of
colourless fluids to the end of the hair. Besides this mode of
increase, he admits that another takes place at the root, by appo-
sition. I have convinced myself that Mandl is in error with
regard to' his hypothesis. Growth never takes place at the
point of the hair, and consequently, the hair cannot grow white
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28 ANATOMY OP THE SKIN.
at the point. It may exhibit indications of bleaching in that
situation from external conditions sooner than in the rest of the
shaft, but the process is purely physical. Again, the annular
lines to which this author refers are simply the margins of the
overlapping scales of the cortical part of the hair, the scales
being smaller and less jagged in this situation than on the body
of the hair.
59. The hair-follicles are not situated perpendicularly but
obliquely in the skin, hence the direction of the hairs, after
their escape from the follicles, is in the same sense inclined to-
wards the surface ; and the " set" of the hair, from the root to
the point, is governed by a law as precise as that which regulates
any other of the secondary vital functions. Thus, on the head,
the hair radiates from a single point, the crown, to every part
of the circumference, making a gentle sweep behind, towards
the lefl, and in front, to the right. The direction of this sweep
is naturally indicated on the heads of children, and is that in
which the hair is turned. On the forehead, the downy hairs
proceed from the middle vertical line, with a gentle curve to the
right and left, curving downwards to the situation of the whisker^
and forming, by their lower border, the upper half of the eye-
brow. Occasionally, the line of divergence of the forehead is
oblique in its direction, running from die left of the forehead to
the root of the nose. At the inner angle of each eye is situated
another radiating centre, like that of the crown of the head ; and
a vertical line of divergence is continued downwards from this
point, by the side of Ae nose, mouth, and chin, to the under
part of the latter, where it curves inwards to the middle line^
The upper and inner rays from this centre ascend to the line
between the eyebrows, where they meet those which are proceed-
ing from the opposite centre, and those, also, which are diverg-
ing from the vertical central line of the forehead ; so that here a
lozenge is formed, which is the point of approximation of hairs
from foiu* different quarters. It is this circumstance that gives
to the hairs of the inner end of the eyebrows a direction towards
the middle line ; and occasionally we see instances in which,
from the unusual development of these hairs, the eyebrows meet
at the base of the forehead, and form a little crest, for a short
distance, along the root of the nose. The lower and inner rays
from the angle of the eye diverge from the preceding, and are
directed downwards and inwards upon the side of the nose ;
when strongly developed, they meet those of the opposite side
on the ridge of the nose, and at their point of divergence from
the ascending current necessarily form another lozenge. This
latter is a lozenge of divergence, that of the forehead being one
of convergence. The upper and outer rays from the angle of
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DIRECTION OF THE HAIR. 29
the eye curve along the upper lid, forming, by their upper mar-
gin, die lower half of the eyebrow, and at the outer angle of the
eye being lost in the converging currents of the whisker. The
lower and outer rays from the centre at the angle of the eye, to-
gether with those from the vertical line of the side of the nose,
mouth, and chin, make a gentle sweep over the cheek, side of
the face, and jaw, to be lost, the upper ones in the front of the
whisker, the middle rays, ai^r passing beneath the ear, in the
middle line of the back of the neck, and the lowest rays in the
angle of bend of the jaw, in which latter situation they come
into coalition with an ascending current from the chest The
rays from the inner margin of the vertical line of the side of the
nose, mouth, and chin, are directed inwards upon those parts.
On the upper lip, they are met by a current directed from the
apertures of the nose, outwards, and forming the sweep of the
mustachio ; a similar disposition is observed in the middle line
of the lower lip, near its free edge, while the beard is formed by
the convergence of two side currents meeting at the middle Ime.
The current from the side of the head divides at the ear, those
which pass in front of that part, and some, also, from the skin
before the ear, contributing to form the posterior border of the
whisker, and then passing backwards beneath the ear, with the
current from the face, to l£e middle line of the nape ; while those
which pass down behind the ear converge with those from the
back of the head also to the middle line of the nape.
60. On the trunk of the body, there is a centre of radiation
from each armpit, and two lines of divergence, one of the latter
proceeding from this point horizontally to the middle of the
front of the chest, the other from this horizontal line, just in
front of the axilla, vertically along the side of the trunk, across
the front of the hip, and down the inner side of the thigh to the
bend of the knee. From the axillary centre, and from Ihe upper
side of the horizontal line, a broad and curved current sweeps
upwards and inwards over the upper part of the front of the
chest, and outwards, around the neck to the middle line of the
nape, the outermost part of the current passing over the shoulder
to the middle line of the back. From the lower side of the hori-
zontal line, and from the front of the upper half of the vertical
line of the trunk, the set of the current is downwards and in-
wards, vnth a gentle undulation to the middle line, and from the
lower half of the vertical line of the trunk, the direction is up-
wards towards the middle line and umbilicus, so that the latter
is the centre of convergence of four streams from the anterior
aspect of the abdomen, two from above and two from below.
From the centre at the axilla and posterior border of the vertical
line of the trunk the current streams downwards and backwards,
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80 ANATOMY OF THE SKIN.
also with an easy undulation to die middle line of the back.
The inner extremity of the horizontal line of the chest is the
seat of a lozenge of diyergence, and that of the line of the bend
of liie lower jaw, at the front of the neck, of a second.
61. From the axillary centre just described there proceeds
another line of divergence, which encircles the arm like a brace-
let, immediately below the shoulder. From the upper margin
of this line the direction of the current is upwards over the
shoulder, and then backwards to the mid-line of the back. An-
other line commences at this ring on the front part of the arm,
and runs in a pretty straight course to the cleft between the
index finger and thumb on the back of the hand : this is the line
of divergence of the arm ; from it and from the ring the stream
sets, at first, with a sweep forwards, and then, ¥dth a sweep
backwards to the point of the elbow. In the forearm, the
diverging currents sweep downwards in front, and upwards
behind, also tending to the point of the elbow, which is thus a
centre of convergence ; whUe on the back of the hand and fingers
the sweep outwards, with a curve having the concavity upwards,
is quite obvious.
62. On the lower limb there are two vertical lines of diver-
gence : the one being the continuation of that of the side of the
trunk, proceeding around the inner side of the thigh to the bend
of the knee ; the other, an undulating line, beginning at about
the middle of the hip, running down the outer side of the thigh
to the bend of the knee, then continuing down the outer side of
the leg, reaching the front of the ankle, and terminating on the
foot at the cleft between, die great and second toe. A short
oblique line connects the two vertical lines at the bend of the
knee. On the front of the thigh, the streams from die two lines
converge, and descend towards the knee. On the back they
converge also at the middle line, but ascend towards the trunk
of the body. On the leg, where diere is but one line, the
diverging currents sweep around the limb, and meet upon the
shin, wlule on the foot they diverge with a sweep as upon the
back of the hand.
63. Quantity of hair has reference to the proximity of the fol-
licles, and also to the number of follicles which open by one
common aperture on the skin. Whithof counted the numbers
of hairs on a square inch of skin, and found of black 588 ; ches-
nut 648 ; and flaxen 728. A similar investigation was made by
Jahn in the person of an unusually hairy man, twenty -eight years
of age. In a given extent of skin in this person he found on the
Summit of the head 321 hairs.
Back of the head 242 ,,
Front of the head 238 „
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DEVELOPMENT OF HAIR. 31
Chin 52 burs.
Pabeg ^ 45 ^
Forearm 31 ,,
Outer border of hand .... 20 ^
Front of ^igh 31 „
In four years after this calculation was made, the man having
married in the meantime, liie number was diminished on all
parts of the body, with the exception of the chin and pubes,
where they had increased, on the former seven, and latter five.
64. Looking back on the structure of the hair, we cannot but
be forcibly impressed with the perfection of organization which
it exhibits, and this feeling increases when we reflect on the
elasticity and strength of so delicate and slender a thread. The
former of these properties, tested by the experiments of Weber,
has been referred to in paragraph 42. A single hair of a boy
eight years of age, says Robinson, in his Essays on natural
economy, supported a weight of 7812 grains ; one of a man aged
twenty-two, 14,285 grains ; and the hair of a man of fifty-seven,
22,222 grains. Muschenbroeck found that a human hair fifty-
seven times thicker than a silkworm's thread would support a
weight of 2069 grains, and a horse hair, seven times thicker,
7970 grains. The strength of the hair is due to its fibrous por-
tion, for hairs deficient in this structure, like those of the fallow
deer, are remarkable for their brittleness.
66. The development of hair has been made the subject of
research by Heusinger and Simon.* The latter of these gen-
tlemen has observed^ that in the embryo of the pig, at an early
period, the epiderma is inflected from point to point, so as to
form follicles somewhat enlarged at their extremity, which pass
obliquely inwards, and enter the tissue of the derma. These
follicles are rendered conspicuous from being lined in their
interior vrith cells containing pigment granules, which, in the
darker parts of the body, are deep in colour, and lighter in the
uncoloured portions. In embryos more advanced in growth,
he finds a collection of pigment granules at the bottom of the
follicle, which assume the form of the root of the future hair.
Subsequently to this formation, the pulp makes its appearance.
At a later period, the entire hair is formed, and is bent upon
itself, so that the point and root are nearly approximated. In
this bent condition, the young hair bursts through the aperture
of the follicle.
In the human embryo, the lanugo infantium begins to be ap-
parent, during the first half of the fifth month of intra-uterine
existence, upon the eyebrows, upper lip, and around the mouth ;
* Zar EDtwiekelaogsgeschichte der Haare, Von Dr. Gustav. Simon. Mailer's
Archiv., 1841.
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32 ANATOMY OF THE SKIN.
and at about the middle of the month, upon the head. By the
end of the sixth month it is pretty general over the whole body,
the last parts on which it is seen being the backs of the toes and
fingers, the pinna and the nose. At the sixth month Eble found
the hairs of the head to measure three lines, those of the eye-
brows two lines, and the eyelashes half a line. At birth, the
foetus is covered with a thick down, and it is then that we have
the best opportunity of observing the direction of the hairs
(§ 59) ; for during the first year, the greater part of these tem-
porary hairs have been shed, and they are succeeded by a more
permanent kind, which appear upon the surfetce only in certain
situations. At the period of adolescence the hairs acquire a
new impulse of growth in co-relation with the more active de-
velopment of the firame ; and when the powers of the system are
on the wane, the hair is among the first of the organs of the body
to evince an associated infirmity.
The sebiparous glands appear much later than the hair-fol-
licles, and are developed by a similar process of epidermal in-
flection from the parietes of the hair-follicles.
66. According to the analysis of Vauquelin, the chemical con-
stituents of hair are, animal matter, in considerable proportion ;
a greenish black oil ; a white, concrete oil, in small quantity ;
phosphate of lime ; carbonate of lime, a trace ; oxide of man-
ganese ; iron ; sulphur and silex. Red hair contains a reddish
oil, a large proportion of sulphur, and a small quantity of iron.
White hair, again, exhibits a white oil, with phosphate of mag-
nesia. The grey hair of old persons contains a maximiun pro-
portion of phosphate of lime.
The ultimate analysis of hair, according to Scherer,* exhibits
the principal elementary constituents in the following propor-
tions : —
Carbon 50*652
6-769
Hydrogen
Nitrogen
Oxygen
Sulphur
17-936
24-643
Fair hair contains the least carbon and hydrogen, and most
oxygen and sulphur ; black hair follows next ; while brown hair
gives the largest proportion of carbon, with somewhat less
hydrogen than black hair, and the smallest quantity of oxygen
and sulphur. The hair of the beard was found to contain more
carbon and hydrogen than the hair of the head, and less
oxygen and sulphur. The quantity of nitrogen is the same
in all.
67. The nails are homy appendages of the skin, identical in
♦ Liebig, Organic Chemistry.
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STRUCTURE OF THE NAILS, 33
(ormation with the epiderma and hair, but peculiar in their
mode of growth. A nail is convex on its external surface, con-
cave within, and implanted bj means of a root into a fold of the
derma (vallecula unguis), which is nearly two lines in depth, and
acts the part of a follicle to the nail. At the bottom of the
groove of the follicle are situated a number of filiform papillae,
which produce the margin of the root, and by the successive for-
mation of cells push the nail onwards in its growth. The con-
cave surface of the nail is in contact with die derma, and the
latter is covered with papiUse, which perform the double office
of retaining the nail in its place, and of giving it increased thick-
ness, by the addition of newly-formed cells to its under surface.
It is this constant change occurring on the under surface of the
nail, co-operating with the continual reproduction taking place
along the margin of the root, which ensures the gro^rth of the
nail in its proper direction. For it is clear tha^ if the adhesion
of the concave surface of the nail with the derma were not per-
fectly soft and yielding, the addition of successive layers of cells
to the foUicular margin would be wanting in the force necessary
to push it forward in the direction of its growth. The nail de-
rives a peculiarity of appearance from the disposition and form
of the papillae upon tiie ungual surface of the derma. Thus,
beneath the root of the nail, and for a short distance onwards
towards its middle, the derma is covered with papillae, which are
more minute, and consequently less vascular, than the papillae
somewhat further on. This patch of papillae is bounded by a
semilunar line, of which the concavity is turned towards the
root, and in consequence of appearing lighter in coloiu* than the
rest of the nail, has been termed the lunula. Beyond the lunula,
the papillae are raised into longitudinal plaits, which are exceed-
ingly vascular, and give a deeper tint of redness to the nail.
These plait-like papillae of the derma are well calculated by
their form to offer an extensive surface, both for the adhesion
and formation of the nail. The granules and cells are developed
on every part of their surface, both in the grooves between the
plaits, and on their sides, and a lamina of nail is formed between
each pair of plaits. When the under surface of a nail is ex-
amined, these longitudinal laminae, corresponding with the longi-
tudinal papillae of the ungual portion of the derma, are distincdy
apparent, and if the nail be forcibly detached, the laminae may
be seen in the act of parting from the grooves of the papillae.
This laminated structure upon the internal surface of a nail is
seen in a magnified form in many animals, for instance ; in the
perpendicular wall of the hoof of the horse. Moreover, it is this
structure that gives rise to the ribbed appearance of the nail,
both in animals and in man. The papillary structure of the
D
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34 ANATOMY AND PHYSIOLOGY OF THE SKIN.
derma, which produces the nail, is continuous around the cir-
cumference of the attached part of that organ with the derma of
the surrounding skin, and the homy structure of the nail is oon-*
sequently continuous with that of the epiderma.
That nothing may be wanting to complete the analogy be-
tween the structure of the nails and that of the epiderma and
hairs, pigment granules (§ 27) are found entering into their com-*
position. The greyness of hue which the nails of some persons
exhibit is due to the presence of this element, and upon a ^ni-
croscopic examination of a section of the nail, the granules may
be observed, in greater or less number, disseminated in streaks
among its horizontal strata.
68. In a chemical analysis of the homy tissue of nail, Scherer*
found the elementary constituents in the following proportions:
Carbon 61-089
Hvdrogen .... 6*824
Nitrogen . . . . 16 901
Oxygen . . . . ? 25186
Sulphur . . . ,p^*»6
PHYSIOLOGY OF THE SKIN.
69. In a physiological point of view, the skin is an organ of
sensation, absorption, and secretion ; in the former capacity it
affords us gratification, and warns us of the presence of in-
jurious or destructive agents ; by means of the second, it is
enabled to appropriate the fluids contained in the surrounding
medium, and perform the oflSce of a respiratory organ ; and by
means of the third, it provides for its own softness and pliancy,
it regulates the influence of temperature, both external and in-
ternal, and acts as an important depurating organ of the blood.
70. The sensibility of the skin varies normally in diflferent
parts of the body ; thus it is greatest on the pulps of the fingers,
and least in the middle of the limbs, as of the thigh and arm.
This has been proved by the curious results of the researches of
Weber, who applied the points of a pair of compasses to the
skin, in various parts of the body, in order to ascertain the
degree of sensibility of the skin in the perception of a double
impression. Thus, upon the pulp of the middle finger, the two
points were felt when only sepai'ated firom each other to the
extent of one-third of a line ; on the palmar surfiEice of the same
finger it was necessary to separate them two lines ; on the cheek,
five lines ; forehead, ten lines ; on the middle of the breast,
twenty lines ; and on the middle of the arm and thigh, thirty
lines. He observed, moreover, that the delicacy of perception
was greatest in the direction of the branches of the nerves, asy
* Liebig, Organic Chembtry.
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SENSIBILITY OP THE SKIN. 35
transversely on the feuoe and front of the neck, longitndinally on
the 6ngers, &o.* The same author has pointed ont some re-
markable instances of differences in the perception of tempera-
ture ; diuSy he has shown that if the two hands be immersed in
water of the same temperature, that in which the left is placed
will feel tlie warmest : and again, that a weak impression made
upon a large surface of skin, produces a more powerful effect
upon the nervous system than a strong impression upon a small
surface. This is practically illustrated by taking hot water, and
immersing the finger of one hand, and llie entire of the other
hand ; the single finger will suffer no inconvenience from the
heat, while to the hand it may be insupportable. In pursuing
tbe investigation of the diseases of the skin, we find hourly in-
stances in proof of tiiese facts.
The sensibility of the skin is subject to considerable modifi-
cation under the influence of disease ; the natural sensibility
may be heightened, or it may be diminished, or, again, it may
be altered. These changes obviously depend on some modifi-
cation of the nervous system, the nature of which is, for the pre-
sent at least, beyond our grasp. The more common morbid
sensations of the skin, in addition to heat and cold, are, itching,
tingling, smarting, pricking, shooting, creeping, tickUng, burning,
scalding, &c.
71. By means of its absorbing power, the skin is enabled to
act as a re^iratory organ. The importance of this function in
man is not sufficiently estimated, but in the lower animals it is
universally acknowledged. The process of absorption in the
skin is effected by an active endosmosis, which is more and more
controlled by vital influence, as it reaches the strata of the epi-
derma most nearly in contact with the derma. This function of
the skin is calculated to enact an important part in the health of
the individual, in relation to the purity or impurity of the atmo-
sphere in which he moves.
72. When the body is immersed in water of a certain tem-
perature, say at 82** of Fahrenheit,! and a few degrees below,
and allowed to remain in it for some time, it increases in weight
by absoiption of the fluid. The feet is proved by the experi-
ments of several physiologists. Westrumb J detected the fer-
roeyanate of potash in the urine of a man who had taken a bath,
which contained that salt in solution ; and D'Arcet found the
urine of another alkaline, who had badied in the Vichy waters.
Other experimentalists have even succeeded in discovering
colouring matters, such as rhubarb, in the urinary secretion
* I have repeated these experiments, and the results are truly surprising,
t Berthold, in MuUer's Archiv. for 1838.
X Journal Hebdomadaire, No. 7.
d2
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86 PHYSIOLOGY OF THE SKIN.
after bathing in water containing such substances. Opposite
results to these — namely, loss of weight by transpiration — take
place whenever the temperature of the bath nearly approaches
or exceeds that of the body. These experiments have another
important bearing on the physiology of the skin, since they
prove that the temperature of a bath which conduces to ab-
sorption has the effect of a sedative on the system, and
diminishes the rapidity of the pulse, while the converse, acting
as an excitant of exhalation, increases the frequency of the
heart's pulsations.
73. The absorbent property of the skin is sometimes taken
advantage of for the purpose of introducing nutritive matters into
the system, and at others, for the exhibition of medicinal sub-
stances. Some of the latter produce their characteristic effects
when simply applied to the surface by means of a bath or poultice ;
but more frequently we find it necessary to resort to the addi-
tional aid of friction, and, moreover, we select those parts of the
skin in which the epiderma is thinnest. The substances to be
absorbed must be presented to the skin in the state of solution,
or suspension in water or oil ; but it must be admitted that the
quantity taken into the system is veiy small. The exhibition of
medicinal substances by friction on the skin, termed the latra-
leptic methody is only adapted for the more powerful medicines,
and is rarely employed at the present day, excepting in the in-
stances of mercury, croton oil, strychnine, &c. The epiderma
acts as an impediment to absorption, and as such, as an important
safeguard against the admission of injurious and poisonous sub-
stances into the system. Thus we find that it is only after long
soaking, or by long-continued friction, that we are enabled to
overcome this natural defence, and then only to a very partial
extent. But when the epidenna is removed, the case is alto-
gether altered. The derma is a highly absorbent tissue, and
medicinal substances and poisons, when brought in contact with
it, frequently act with as much rapidity and energy as when in-
troduced into the stomach. On this account, the endermic method^
as it is called, offers some advantages when medicines disagree
with the alimentary canal, or are repelled with loathing by the
patient. In the adoption of this method of administering medi-
cinal agents, it is necessary to raise a blister in the most expe-
ditious and least painftil manner, unless there be an open wound
already present, and then sprinkle the substance, in a state of
fine powder, over the surface. It follows, therefore, that such
medicines can alone be administered in this manner as produce
their effects in very small doses, such as strychnine, morphine,
digitalis, belladonna, &c. The absorbent power of the skin is
sometimes painfiilly evinced in the inflammation of the kidneys
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NATURE OF SEBACEOUS SUBSTANCE. 37
which follows the application of a blister, in the constitutional
effects resulting from the absorption of lead, or in those which
succeed the use of arsenic to ulcerated surfaces.
74. An observation made by Mr. Ceeley* would seem to ex-
plain the accidental absorption of poisonous substances by the
skin, without abrasion of the epiderma, and to prove that the
confinement of its exhalation is an important auxiliary; Thus,
he remarks, " I have often succeeded in procuring vaccine vesi-
cles without puncture, on the skins of children especially, and
young persons, by keeping lymph in contact with the skin, and
excluding it from the air by a coating of blood. Active lymph
blended with blood casually trickling down the arm, and drying
in the most dependent part, will often give rise to a vesicle."
In this case it is obvious that the lymph will become gradually
dissolved in the perspiratory secretion, an important considera-
tion in respect to the prolonged contact of poisonous substances '
with the skin.
75. The softness and pliancy of the skin are, in great measure,
dependent on the secretion of the sebaceous substance which is
poured out on every part of its surfsice. This secretion is most
abundant in situations where, from the influence of physical
action, the skin would be liable to injury were it deprived of a
similar covering. Thus we find it in large quantities on the
head and face, upon the trunk of the body, in the armpits, and
in the perineum. The sebaceous secretion is an oleaginous
fluid, containing water, stearine, oil globules, pigment granules^
and salts, together with epidermal cells thrown off by the parietes
of the glands and ducts. The secretion is modified in its qua-
lities in different parts of the body ; in some, by the presence of
an odorant principle, and in others, by a peculiarity in taste or
colour. Of the former, is the butjnic acid of the perineal region,
and the latter, the yellowish brown and bitter product of the
sebiparous glands of the meatus auditorius, the ceruminous
glands. In chemical composition, sebaceous substance consists,
according to Esenbeck,t of
Fat 24-2
Osmazome, with traces of oil . . . . 12*6
Watery extractive, (salivary matter) . 11*6
Albameu and casein 24*2
Carbonate of lime . «. 2*1
Phosphate of lime 20*0
Carbonate of ma^esia 1*6
Acetate and manate of soda and loss . 3*7
1000
* Observations on the Variola Vaccina, in the Transactions of the Provincial
Medical and Surgical Association, vol. tUi.
t Gerber*8 General Anatomy, edited by Gnlliver.
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S8 PHYSIOLOGY OF THE SKIN.
^^ The ear-wax is an emulsive compound which contains a sofit
fat, albumen, a peculiar extractive bitter matter, epithelium
scales, lactate of lime, and an alkaline lactate, but no chlorides
and no phosphates soluble in water.***
76. The function of the skin as a regulator of the temperature
of the body, and as a purifier of the blood, is efiected by means
of a peculiar secretion, the perspiration. When this secretion
is eliminated in the form of an imperceptible vapour, it is termed
insensiblej and when condensed or poured out in a fluid state,
sensibk perspiration. The insensible perspiration is partly de-
rived from tiie sudoriparous and sebiparous glands, and partly
from the natural evaporation taking place from the epiderma.
The sebiparous system has not been heretofore pointed out as a
source of the perspiratory fluid, but frequent observation has
convinced me ^at this apparatus plays an important part in the
elimination from the system of the watery elements of the blood.
Lavoisier and Seguin estimate the mean quantity of perspira-
tion, both insensible and sensible, secreted by the skin in the
course of twenty-four hours, at thirty-three ounces, while they
assign to the pulmonary exhalation, twenty-one ounces. The
experiments of Dr. Dalton frimished him vrith diflerent results,
since he attributes to the lungs an amount of exhalation five
times greater than that of the skin.
77. The quantity of perspiration is altered by a variety of
circumstances which affect the body physically, or through the
ligency of the nervous system. Of the former kind are the tem-
perature, current, and hygrometric condition of the atmosphere,
and stimulation of the skin ; and of the latter, excited or de-
pressed nervous powers. When the temperature of the atmo-
sphere is unusually elevated and the air dry, perspiration takes
place with so much activity, as to preserve the heat of the body
at its natural standard. If, instead of being still, the atmosphere
pass over the surface in a current, the quantity of perspiration
is still frirther increased, and the cooling influence is more felt.
But if, with the same temperature, the atmosphere be loaded
vrith moisture, perspiration is prevented, and the heat of the
body becomes intense. The influence of stimulation in the pro-
motion of perspiration is shown in the efiects of exercise, of the
warm bath, diaphoretics, &c. Instances of the influence of the
nervous system are exhibited in the total arrest of perspiration
during the hot stage of fever, and of its great increase under
emotions of a depressing kind, as fear and anxiety, and also in
syncope. The perspiratory secretion possesses its highest
amount of activity during digestion, while immediately after
taking food it is at its minimum.
* SimoD, Animal Chesiistry, translated by Dr. Day.
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QUANTITY OF PERSPIRATION. 89
78. The secretion of perspiration is also modified hj the
greater or less activity of the other secretions, particularly of the
lungs and kidneys, the function of these organs being frequently
vicaiioos with the skin, and vice versa. Thus, during die
summer, and in warm cUmates, the perspiratory secretion is
augmented, while the exhalation from the lungs and the quantity
of urine are diminished. In the winter and in cold climates the
reverse of this is tiie case. On quitting a warm apartment, espe-
cially after indulging in stimulants, for the cold air, a sudden
chedL is given to the cutaneous function, while that of the kid-
neys is suddenly and actively called into exercise. The same
fact is observed in certain (hseases ; thus, the excessive sweats
of phthisis may be regarded as vicarious of the diminished exha-
lation from tiie lungs, while diabetes is accompanied by a re-
markably dry state of the skin. The arrest of perspiration again,
from cutaneous disease, is often attended with serious conges-
tions of the mucous membranes.
Of some experiments made by Dr. Lining in South Carolina,
on the relative quantities of perspiration and urine during (he
wanner and colder months of the year, the results are as
follow :*
Perspiration.
Urine.
July . . .
. 86-41 .
.. 43-77
B<fay . . .
. 5811 .
.. 56-15
October . .
. 40-78 ..
.. 46-67
February
. 37-45 .
.. 77-86
79. The influence of the perspiration in regulating the heat of
tiie body is strikingly evinced in the numerous recorded instances
of exposure of the person to elevated temperatures. Sir Charles
Blagden supported a temperature of 260** for nearly ten minutes.
The furnace in which Sir Francis Chantrey dried his moulds,
and which was frequentiy entered by his workmen, is said to
have been kept heated to a temperature of 350** ; and the oven
used by Chabert during his exhibitions in London, was heated
to between 400** and 600**. On the first exposure of the body
to these high temperatures the individual is distressed by the
extreme heat ; but as soon as the perspiration flows freely, all in-
convenience ceases. The thermometer placed in tiie mouth of
a man who had been exposed to a temperature of 120** for a
quarter of an hour, stood at 105**; and the temperature of ani-
mals when the heat has been raised to a degree sufficient to
cause death, has never exceeded in elevation from nine to four-
teen degrees above the natural standard.t
* Dr. Robley DaugUson on Human Health,
f It is interesting to note, that in animals made the sabjects of these experiments,
the Mood was found in the opposite position to that which it would haye occupied
after death from cold. Instead of being collected about the heart and internal organs,
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40 PHYSIOLOGY OF THE SKIN.
80. In a damp atmosphere the cooling influence of the per-
spiration is necessarily lost, and the effects upon the system of
a prolonged exposure to a moist atmosphere at a high tempera-
ture, have been recorded by a gentleman who recently visited .
the baths of Nero, near Pozzuoli, the ancient Posidianas. To
reach the bath, he had to pass along a narrow, winding passage,
of about 120 yards in length, and seven feet high, by about three
in breadth. A little within the mouth of the passage, the tem-
perature was 104'^ in the upper strata of the atmosphere, and
91^ near the ground; farther on, the air was filled with dense
vapour, of a temperature of 118° above, and IIP below; and
over the bath it was 122% the heat of the spring being 185**.
After proceeding for about one-third the length of the passage,
he began to feel a sense of oppression and discomfort, his pulse
rising from 70 to 90 beats in the minute. A short distance fur-
ther, the oppression increased, his breathing became rapid and
panting, and he was under the necessity of stooping his head
frequently to the earth, in order to obtain a chestful of air of a
less suffocating temperature. His skin, at this time, was bathed
in a profuse perspiration, his head throbbing, and his pulse
beating 120 in the minute. Continuing his progress, the sensa-
tions of suffocation became insupportable; his head felt as
though it would burst ; his pulse was so rapid as to defy calcu-
lation ; he was exhausted, and nearly unconscious ; and it re-
quired all his remaining power to enable him to hurry back to
t^e open air. On reaching the mouth of the passage, he stag-
gered, and nearly fainted, and was very uncomfortable until re-
lieved by a bleeding from the nose. During the rest of the day,
his pulse remained at 100; he had uneasy sensations over the
surface of the body, and did not recover until after a night^s re-
pose. The same gentleman bore a temperature of 176° in dry
air without inconvenience.*
81. The recent experiments of M. Fourcaultt throw consi-
derable light on the importance to health of the secreting func-
tion of the skin. The results of the observations made by this
gentleman go to show, that if the cutaneous transpiration of an
animal be wholly prevented by means of an impermeable cover-
ing, the animal will die in a short space of time, apparently in a
as in death ensuing from Uie latter cause, the heart was empty, and the Tital fluid
dispersed towards the periphery of the body, in some instances being actually forced
out of its vessels into the surrounding tissues. The blood seemed to have been killed
by the heat, for it had lost its power of coi^n^ting, and its deep-black hue was not
altered by exposure to the atmosphere, a c^nge which takes place in living blood.
In a moist atmosphere, the animals died sooner than in dry air of a higher tempera-
ture, and without losing weight; in dry air they lost weight
* Gazette Medicale, April 27, 1844.
t Examinateur M^cale, Oct. 1841.
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ANALYSIS OF PERSPIRATION. 41
state of asphyxia. Becquerel and Brescbet, pursuing their ex-
periments on animal temperature, conceived that if they could
prevent transpiration by the skin, they should induce internal
fever ; the contrary, however, was the fetct. After the applica-
tion of a thick layer of varnish upon the skin of a rabbit, and
adjusting their thermo-electric needles, they found the tempera-
ture of t^e deep muscles, in the course of half-an-hour, to be re-
duced from lOO*' to 89** ; in another half-hour, to 76**; and in a
third half-hour, it stood at only three degrees above the tempe-
rature of the atmosphere, 6S^ ; so that, in the course of an hour
and a half, the temperature of the animal had fallen thirty-four
degrees, and the creature died.
82. The chemical constituents of perspiration are, water,
nitrogen, animal extract, fat ; carbonic acid vrith its salts, car-
bonates of soda and lime ; lactic acid with its compound, lac-
tate of ammonia ; acetic acid, butyric acid, chloride of sodium,
hydrbchlorate of ammonia, phosphates of soda and lime, sul-
phate of soda, salts of potash, and peroxide of iron. Anselmino
gives the following analysis* of the dried residue of the perspi-
ratory secretion : — •
Matters insolable in water and alcohol, chiefly calcareous salts . • 2
Animal matter soluble in water, insolable in alcohol, regarded by
Anselmino as saliTary matter (?), and sulphates 21
Matters scluble in dilute alcohol ; chloride of sodium and osmaxome 48
Matter soluble in alcohol, osmazome, and lactates ••..••• 29
100
Simon collected the perspiratory fluid from the arms and
face, and found it to be a turbid, dirty-looking fluid, which de-
posited grey floccules on standing. By the microscope these
floccules were ascertained to be epidermal cells. The specific
gravity of the fluid was, in one instance 1,003, and in another
1,004. It was slightly acid at first, but became neutral on
standing for twenty-four hours, and a rod moistened with
hydrochloric acid held over it at this period detected the vapour
of ammonia. The results of the investigations of Simon esta-
blish the existence in the normal perspiratory secretion of:
^ Substances soluble in ether : traces of fat, sometimes includ-
ing butyric acid.
^^ Substances soluble in alcohol : alcoholic extract, free lactic
or acetic acid, chloride of sodium, lactates and acetates of
potash and soda, lactate or hydrochlorate of ammonia.
<^ Substances soluble in water: water extract, phosphate of
lime, and occasionally an alkaline sulphate.
^^ Substances insoluble in water: desquamated epithelium
♦ Muller's Physiology, Translttimi, page 579.
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42 PHYSIOLOGY OF THE SKIN.
and (after the removal of the free lactic acid by alcohol) pbo^-
phate of lime, with a little peroxide of iron."*
Our information, with regard to morbid perspiration, is very
limited and unsatisfEU^tory. Simon made the analysis of this
secretion obtained from a man who had been the subject of
psoriasis vulgaris for seventeen years; but his results are incon-
clusive, from the fluid being in a state of decomposition. Its
specific gravity was 1,008 ; it smelt strongly of hydro-sulphate
of ammonia ; and gave off when evaporated a penetrating odour
of sulphuretted hydrogen, which ultimately merged into a
nauseous animal smell. *^ It yielded 9^ of solid constituents,
which, after being exposed to the influence of a red heat, were
found to consist of a large proportion of chloride of sodium,
carbonate of soda, a littie phosphate of lime, and a £air amount
of sulphuric acid.'' The perspiration of " persons with the itch
is said to have a mouldy odour.** And, " according to Stark,
the quantity of free lactic acid is increased" in certain cutaneous
affections.
83. The gases of the perspiratory secretion — namely, car-
bonic acid and nitrogen— are exhaled in largest quanti^ after
meals or violent exertion, the former being most abundant where
the food has been vegetable, and the latter where the food has
been animaLf The quantity of water excreted by tiie skin
bears reference to the circumstances above detailed — ^namely,
the comparative activity of the exhaling organs, the condition
of the atmosphere, and the state of the system. The nitrogen,
according to Liebig, originates chiefly in the decomposition of
the atmospheric air carried into the stomach vrith the saliva, or
absorbed from the exterior by means of the skin. During
digestion, the oxygen of the atmospheric air enters into com-
bination with the food, and the nitrogen is set free to make
its way by endosmosis through the stomach and diaphragm
into the lungs, or through the parietes of the body to the slun.
It follows, therefore, that the quantity of nitrogen set free in
the stomach, and, consequently, the quantity exhaled by the
skin, is proportioned to the duration of digestion. Thus, in
certain herbivorous animals in whom the process of digestion
occupies a long period, and is increased by rumination, a large
quantity of atmospheric air is conveyed into the stomach, and a
larger proportion of nitrogen is extricated from the skin, than
in camivora. The same circumstance must take place when
any cause exists which retards digestion. The quantity of
* Animal Chemistry with reference to the Physiology and Pathology of Man.
By Dr. J. Franx Simon. Translated and edited by Dr. George E. Dsy, for the
Sydenham Society, vol ii. p. 103.
f Collm de Martigny, in Migendie's Jonmal, vol. x. p. 162.
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CONSTITUENTS OF PERSPIRATION. 43
carbon also bears reference to the nature of the ingesta ; where
a large quantity of carbonic acid is generated in the stomach,
the gas makes its way directly to the lungs, as did the nitrogen,
or to the skin- Dr. Dalton estimates the proportion of carbon
eliminated by the skin, irrespective of variety in food, at one-
twentieth of the entire quantity of perspiratory secretion. To
the animal matters, the ammonia, the acetic acid, and the
lactic acid, are to be ascribed the powerful odour of the per-
spiratory fluid, while its acid re-action b determined by the
latter.
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CHAPTER II.
CONGESTIVE INFLAMMATION OF THE DERMA.
84. Under the general title of congestive inflammation of the
derma I have assembled a group of diseases, which are charac-
terizedy as a leading feature, by inflammation, and consequent
redness of the skin. This group, with some exceptions, corre-
sponds with the Exanthemata of Willan, and embraces all the
diseases included by him under that order, with the omission of
purpura. Reviewing the prominent features of this group of
diseases, it will be perceived that they admit of a natural division
into two sub-groups — namely, into such as are characterized by
Inflammation of the derma and mucous membranes^ with con-
stitutional symptoms of a specific hindy
under which head I have ranged
Rubeola,
Scarlatina,
Variola,
Varicella,
Vaccinia ;
and.
Inflammation of the dermoy without constitutional symptoms
of a specific kindy
which embraces
Erysipelas,
Urticaria,
Roseola,
Erythema.
85. The diseases contained in the first of these groups are
the exanthematous or eruptive fevers of medical practice. They
are characterized by fever of greater or less severity, which
precedes and accompanies the exanthem; by an exanUiem, or
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PHENOMENA OF CUTANEOUS INFLAMHATION^ 4$
inflammatory congestion of the derma, wbich makes its appear-
ance in the form of red points, and pursues a specific course ;
and by their mode of termination — namely^ in resolution and
desquamation of the epidenna in the two first, and by exuda-
tion and incrustation in the variolous afiections ; while all are
liable to terminate by delitescence.
86. Taking this view of the exanthematous diseases, I con-
ceive myself warranted in placing the variolous afiections in
a group with which all their analogies harmonize. They cor-
respond accurately with the definition I have given above ; the
premonitory symptoms present a close resemblance with rubeola
and scarlatina ; ^e eruption is identical at its first appearance,
and the general management required is the same. At a later
period, when variola assumes the pustular form, it must be
regarded, as far as pathology is concerned, in the light of an
advanced stage of rubeola and scarlatina, or as a severe type
of the latter diseases expending its violence on the skin,
instead of retrograding on the mucous membranes. Cer-
tainly, if we admit, with hesitation, the variolous diseases
to a place among the exanthematous fevers, we are bound to
rescue them from the unpathological position which they at
present occupy among the Pustidae and Vesiculae of Willan's
classification.
87. The severity of the febrile symptoms of exanthematous
diseases is determined primarily by the nature and activity of
the exciting cause of the disease, by the state of constitution of
the person affected, and by the greater or less freedom of evo-
lution of the morbific action upon the tegumentary textures.
Secondarily, it is modified by the extent and severity of the
exanthem, or, in other words, by the re-action of the efiects
upon the system. The constitutional symptoms are also much
modified by the extent of surface diseased. When that surface
is great, as is necessarily the case where not merely the dermal
layer, but the whole mucous membrane of the body is affected,
the peripheral and sentient parts of a considerable proportion
of the nerves of the body are involved in the inflammatory dis-
order, and, as a consequence, the spinal and cerebral symptoms
reach their highest pitch of severity and danger.
88. The congestion of the superficial capillary vessels which
accompanies the exanthemata is not limited to the dermal tissue
alone, but is distributed more or less completely over the tegu-
mentary surface of the entire body, including the mucous mem-
branes. From the great susceptibilitj' of fiie latter, they are
generally the first affected, as we perceive to be the case in the
angina of scarlatina, and the catarrh and conjunctivitis of
rubeola.. In like manner, erysipelas, urticaria, roseola, and
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46 CONGESTIVE INFLAMMATION OF THE DERMA.
erythema, have all their mucous inflammatioiis, though pre-
senting a sub-acute and less conspicuous type. TIhs differ-
ence, however, is always apparent between the inflammation of
the cutaneous siurface and that of the mucous membrane. In
the former, the inflammation either invades the entire surfisu^ at
once, or runs regularly and more or less rapidly over it ; but in
the mucous membranes, the difierent parts are affected irregu-
larly and in succession, while some escape altogether. Thus,
in scarlatina, the mucous membrane of the feuices is first in-
vaded, then possibly tfiat of the lungs, while, perhaps, at the
close of the disease, when a favourable convalescence is ex-
pected, the inflammation may be transferred to the alimentary
canal, or kidneys, and prove fatal by exciting an uncontrollable
diarrhoea or anasarca. The same remarks apply equally to
rubeola; for after the violence of. the cutaneous efflorescence
has passed away, there is yet much to be apprehended from
secondary inflammations of the mucous membranes.
89. The immediate seat of the inflammatory congestion of
the exanthemata is the vascular rete of the derma, and the dif-
ference of tint obserrable in iSiese diseases at tlieir height and
during their decline, is sufficiently explained by reference to
the structure and normal phenomena of the skin. When the
degree of excitation of the cutaneous nerves is small, and the
arterial determination but little exalted above the ordinary
standard, the vascular rete of the derma is only partially con-
gested, and the redness produced by this congestion is slight ;
such is the redness, with slight modifications, depending on
degrees of intensity of nervous excitement, which is seen in
erysipelas, roseola, and erythema. When, however, the ner-
vous activity is aroused to its highest pitch of energy, as in
scarlatina, the congestion is most intense, and the bright scarlet
of the arterial blood coursing through its vessels is litde ob-
scured by the thin veil of epiderma which binds it in its sphere.
The congestion in rubeola, scarlatina, and variola, is not con-
fined to the parallel strata of the vascular rete of the derma, as
in the second group of exanthemata, but many of the papUlse
of the derma are also distended with blood, and give rise to that
punctiform and papillar appearance of the redbess which is
characteristic of these eruptions.
90. The crescentic, or rather, the imperfectly circular, form
of the congested patches seen in rubeola, depends upon a
peculiarity in the distribution of the cutaneous nerves and ves-
sels, and corresponds with that natural appearance of the skin
which is so frequently seen in healthy children, and which is
denominated, mottled. Again, I have observed, that in inject-
ing the limb of an in&nt with size and vermilion, I can imitate
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PHENOMENA OF CUTANEOUS INFLAMMATION* 47
all the forms of redness seen in the exanthematous diseases, by
ceasing to inject from time to time, or by filling the capillaries
to their uttermost
91. The decline of congestion of the derma is accompanied
by certain alterations in the tint of redness which betokens its
presence. Thus the red patches are obserred to lose their vivid
brightness, to become duller in their hue, and to pass through
various shades of purple, until they become bluish and livid.
These changes depend upon the degree of excitement of the
cutaneous nerves at the several periods indicated by alteration
in the colour of the exanthem. When the nervous energy is at
its highest point, the capillaries contract actively upon their
contents, and maintain a rapid current of arterial blood through
their channels. But as the nervous excitement becomes gra-
dually allayed, the capillaries lose their power to contract, and
become distended by the full stream that moves more and more
tardily onwards in its course, giving time to the arterial current
to combine with the carbon of the tissues through which it flows,
and become converted into venous blood.
92. The above phenomena will explain, also, the differences
of colour which the exanthem may assume at an earlier period
than its decline, and even from the commencement of its ap-
pearance, as, for instance, in scarlatina maligna, or more strik-
ingly, in rubeola nigra. The first step or motive influence by
wMch this change is effected, is depression of nervous power ;
this depression, depriving the capillaries of their tonicity, or, in
other words, of their means of resisting the pressure of the
arterial current, they yield, they become dilated, and from
capillaries, which they were, they are converted into a venous
plexus, through which the blood moves feebly and slowly,
gathering carbon in its tardy course.
93. Congestion of the capillary rete of the derma necessarily
gives rise to tumefaction, the extent of swelling being, to a cer-
tain degree, the measure of the increased quantity of blood dis-
tributed through the part. Hence it is obvious that all exan-
thematous patches must be raised above the level of the sur-
rounding skin, even although the degree of tumefaction be really
very sUght
94. Another cause of tumefaction in an inflamed and con-
gested tissue, also follows as a natural consequence from the
over-distention of its vessels. I have already endeavoured to
show that the nervous excitation of the part must have dimi-
nished before over-distention of the capillary vessels can take
place, but so soon as that change has ensued, another pheno-
menon is immediately developed. This is transudation of the
watery part of the blood by imbibition into the surrounding
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48 CONGESTIVE INFLAMMATION OF THE DERMA.
textures, thereby physically relieving the congested vessels of
their overload of fluid. The fluid which is thus transuded
through the coats of the vessels is serum, containing in' solution
more or less of fibrine. The seat of this imbibition is for the
most part the subcutaneous areolar tissue, where it gives rise to
oedema. I may instance scarlatina in some cases, erysipelas
oedematosum, and erythema Iseve, as particular illustrations of
this kind of tumefeu^on, although it will be found, upon close
observation, to be much more extensively present among the
exanthemata. This important phenomenon is not confined to
the dermal tissue, it occurs also in the mucous membrane, and
sometimes with fatal consequences, as, for instance, in the
laryngitis of scarlatina and rubeola, where it is apt to induce
cedema of the glottis.
95. Besides the cedema resulting from serous infiltration into
the subdermal tissues, it may happen that the transudation oc-
curs also in the tissue of the derma itself, in which case the skin
J)re^ents a red, bloated, and brawn-like appearance, as in some
brms of erysipelas. Or again, not confined to the sub-dermal
and dermal tissues, the serous fluid may, after the repletion of
those textures, be efiused upon the surface of the derma, and
raise the epiderma in the form of vesicles and bullae, as we fre-
quently see to be the case in common erysipelas. This character
associates erysipelas with the third natural group of diseases of
the skin — ^namely, with inflammation of the derma, combined
with serous efiusion upon its surface, including the orders BuUse
and Vesiculae of Willan.
96. As the whole of the diseases included in the first of the
preceding groups are infectious and contagious, it may be well to
inquire the precise meaning which we attach to these terms. In
their more usual acceptation, the terms infection and contagion
relate to modes of transmission of a poisonous principle. When
the transmission is efiected by a material substance, and is
brought about by actual contact, the term contagion (immediate
contagion) is employed; but when transmission is efiected
through the agency of the winds, and at a distance, the mode of
communication is designated infection^ (mediate contagion.) In
other words, when the poisonous principle is volatile, and
capable of diffusion in the atmosphere, it is infectious ; but when
this difiusibility is absent, it is simply contagious. The differ-
ence between infection and contagion is consequently more
apparent than real, and some of our most able writers use one
or other of the terms to imply transmission without reference to
its mode. Thus, it is observed by Dr. Watson, " since in all
eases the disease is conveyed to the person of the recipient by
particles of matter proceeding from the person of the sick, and
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CONTAGION AND INFECTION. * 49
since it seems very unimportant whether those particles are in a
solid or in a gaseous form, whether they are imparted by direct
contact of the two human bodies, or by being wafted through
the air, or carried upon articles of clothing, I shall include both
and all these modes of communication under the simple term,
contagion. This, in &ct, is what is done in common discourse :
all disorders that are catching, I shall take leave to consider
contagious." *
97. In whateyer way the poisonous principle be brought to the
body of a sound person, and with whatever part of his body it
may come in contact, whether with the cutaneous surface with
or without abrasion, as in contagion, or with both the cutaneous
and mucous snrfiEice in infection, the mode of its reception by the
system is the same. In the first instance, it is dissolved in the
fluids of the body, and, in the second place, is conveyed by im-
bibition into the circulating current of the blood, thence to act
. on the nervous system, and alter its functions. Once introduced
into the system, the poisonous principle possesses the remark-
able power of exciting an action similar to that which existed in
the body whence it emanated, the intention of that action being
Ae reproduction of an identical poison. Liebig has compared
this process to fermentation ; as, when a particle of yeast is
brought in contact with a fermentable fluid, the particle of yeast
is itself lost, or is too insignificant to be traced further ; but the
action which it excites occasions the formation of an abundance
of similar yeast
98. In certain diseases regarded as contagious, another mode
of transmission occurs ; the principle of contagion exists in the
form of germs or seeds of a parasitical organism, which, wafited
to a soil fitted for their nutrition, become developed, and assume
an active growth. Of this kind are the parasitic fimgi found
upon the surface of the bodies of animals, and, according to some,
the my coderma of the crusts of favus. Langenbeck found fimgi
in the body of a man who died of typhus fever. Mr. Owen has
seen them coating the internal surface of vomicae in the lungs of
the flamingo ; and similar observations have been made by other
observers.
99. The most interesting, as it is the most important of the
phenomena of morbid poisons, is the modification which they
produce in the system of the afiected person. By virtue of this
modification, the susceptibility to be excited by a similar stimulus,
or to take on a similar action, is deteriorated, and, in many in-
stances entirely abolished. We might recur again to the simile
suggested by Liebig, for we are incapable of again exciting fer-
* Lectures on the Principlef and Practice of Physic. First edition, page 655.
£
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50 t^ONGESTIVE INFLAMMATION OF THE DERMA.
mentation in a fluid that has already fermented. It is upon this
important principle that safety from a repetition of attacks of
eruptive fever reposes.
I. INFLAMMATION OF THE DEKMA AND MUCOUS MEMBRANES,
WITH CONSTITUTIONAL SYMPTOMS OF A SPECIFIC KIND.
RUBEOLA.
Syn, MorhiUL BlactuB. Measles. — Rougeole, Fran. —
Maserriy Kindspecken, Germ.
100. Rubeola, or measles, is an accute inflammation of the
tegumentary investment of the entire body, both cutaneous and
mucous, associated with fever of an infectious and contCLgious
kind.
Upon the skin, it is characterized by a patchy redness, which,
on close examination, is found to be produced by numberless
minute red points and pimples, aggregated into small patches
of a crescentic and annular form. The efflorescence makes
its appearance on the fourth day from the commencement of
the febrile symptoms, increases for another four days, and is
succeeded at its decline by fiirfuraceous desquamation of the
epiderma.
Rubeola usually attacks children and young persons, but may
occur at any period of life ; infants and adults, however, are but
little susceptible of its influence. Its effects have been observed
in the foetus at birth, (Hildanus,) where the mother has suffered
from the disease during pregnancy. The period of incubation of
the contagion varies from seven to fourteen days, and the same
individual may be affected more than once. Its punctated and
papillated appearance depends upon congestion of isolated
papillse, and the semilimar form of the patches, upon some un-
explained peculiarity in the structure of the derma, probably
having reference to the distribution of the cutaneous nerves. The
mottled aspect of the skin of children in health, and exposed to
the cold, has the same semilunar tracery, and an analogous state
may be produced artificially by incomplete injection with size
and Vermillion.
101. The varieties of rubeola are four in number — namely :
Rubeola vulgaris.
„ sine catarrho.
„ sine exanthemate.
„ nigra.
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RUBEOLA VULGABIS — COMMON MEASLES. 51
RUBEOLA VULGARIS.
102. In rubeola YulgaiiSy the ordinary form of measles, the
disease sets in with the usual symptoms of fever — namely, with
chills, succeeded by burning heat, listlessness, languor, drowsi-
ness, pains in the head, in ^e back, and in the limbs ; frequent
pulse ; soreness of the throat, white tongue, with red edges and
tip ; diirst, anorexia, nausea, vomiting, frequent dry cough, and
high-coloured urine. These symptoms increase in violence
during the first four days. On the third, the conjunctivae look
red and inflamed, there is intolerance of lig^t, and the eyelids
are congested and swollen, while a profuse secretion of lachrymal
fluid distils from the eyes, constituting coryzcu The mucous
membrane of the nose also pours forth a large quantity of watery
secretion, and the irritation of this membrane gives rise to fre-
quent sneezing. Inflammation of the mucous membrane of the
larynx, trachea, and bronchial tubes, is indicated by hoarseness,
impeded respiration, constriction and pain in the chest, and vio-
lent cough. Moreover, children are afiected occasionally with
spasm of the muscular system and convulsions, the consequence
of reflex action of the spinal nerves ; these spasmodic attacks
are especially frequent where rubeola is complicated by denti-
tion.
The cutaneous efflorescence of rubeola makes its appearance
on the fourth day, and is attended with heat and itching ; in
children with a delicate skin it appears occasionally on the
third ; and, in some instances, from exposure to cold, or deficient
susceptibility in the skin, on the fifili or sixth. It is first per-
ceived on the forehead and front of the neck, next upon the
cheeks, and around the nose and mouth, and if the interior of the
latter cavity be inspected, it may be seen, with similar characters
to those exhibited on the surface of the body, upon the mucous
membrane of the fauces and pharynx. By the fifth day, the
efflorescence on the face reaches its height ; it then appears upon
the trunk of the body and upper extremities, and on the succeed-
ing day upon the lower extremities. On the sixth day, the
rash upon the body and limbs reaches its height The backs
of the hands are die parts last afiected, the rash appearing
on them not before the sixth day, and sometimes as late as the
seventh.
The efflorescence of rubeola, when closely examined, is seen
to consist of innumerable punctiform dots and minute pimples,
aggregated into small circular patches, which, by their increase
or coalescence, assume an irregularly crescentio form. The
patches are slightly raised above the surface, and the entire skin
is somewhat swollen. The colour of the rcish at its acme, is a
E 2
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52 CONGESTIVE INFLABfMATION OP THE DERMA.
bright raspberry red ; on the eighth day, it presents a yellowish
red tint, and then gradually fades to the normal standard of the
skin. The pimples are most frequently found mingled with the
efflorescence on the exposed parts of the body, as upon the face
and hands, and this is particularly the case in infants and adults.
Occasionally miliary vesicles are observed to complicate the
rash, and in a case recorded by WiUan, inoculation with the
lymph of these vesicles was found to produce a perfect attack
of rubeola, which W8is communicated by infection to several other
children.
The decline of the efflorescence takes place in the same order
with its invasion, fading on the sixth day, upon the face ; on the
seventh day, upon the trunk and limbs ; and on the eighth day,
upon the backs of the hands. On the ninth day, the form of the
patches is alone discoverable by the presence of a pale yellowish
discolouration, which slowly disappears. To these changes a
fiirfuraceous desquamation succeeds, which is attended with con-
siderable itching.
Of the constitutional symptoms, some are relieved on the out-
break of the efflorescence, while others are aggravated. Thus
the nausea and sickness subside on the fourth day, the restless-
ness and sense of oppression disappear on the sixth day, while
the coryza, the catarrh, the hoarseness, and the cough, with the
frequency of the pulse, decline on the seventh day. At about
the ninth or tenth day, the resolution of the congestion of the
intestinal mucous membrane is indicated by diarrhoea of some
days' continuance.
It has been already remarked, that the mucous membrane of
the eyes and of the pharynx is visibly affected with the rash.
Other symptoms which occasionally develop themselves during
the progress of rubeola, indicate an equal congestion of the in-
ternal mucous membrane. Thus, in some cases, there is haemor-
rhage from the nose ; in otliers, from the air-passages ; and in
females, not unfrequently from the uterus. Whenever the rash
is checked in its course by cold or other causes, the constitu-
tional symptoms are aggravated and dangerous, the congestion
of the mucous membranes is greatly heightened, the tongue be-
comes brown and dry, and the patient delirious.
103. Although rubeola, when it runs its course regularly, is
by no means a dangerous disease, yet, at its close, it is occa-
sionally attended by severe and alarming sequelse, which call for
the most vigilant attention on the part of the medical practi-
tioner. Thus the cough, after the subsidence of the rash, may
return with increased force and frequency, and be accompanied
by a quickened pulse, impeded respiration, and symptoms of
hectic fever, and lead to a fatal issue, by efiusion into the lungs
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RUBEOLA VULGARIS — COMMON MEASLES. 53
and chesty or by the development of scrofulous tubercles. Chil-
dren are sometimes seized with difficulty of breathing from
swelling of the mucous membrane of the air-passages and larynx,
and die, unless relieved by tracheotomy, in the course of a few
hours. The conjunctivitis which was symptomatic of the dis-
ease during its progress, may continue in a chronic form and
give rise to ulceration of the eyelids. The inflammation of the
pituitary membrane of the nose may merge into the chronic
form, and pour out a purulent secretion. The mucous mem-
brane of the mouth and fauces in infants may develop aphthae
and troublesome ulcerations ; and in children of riper years,
tumefaction of the lips and ulceration of the angles of the mouth.
The salivary glands may become enlarged by the propagation
of the inflammation along their excretory ducts. In some in-
stances, abscesses resulting in fistulous ulcers have been formed
in these glands. The diarrhoea, which usually ceases sponta-
neously after the lapse of a few days from the disappearance of
the efflorescence, may continue uncontrollable for several weeks,
and issue fatally from ulceration of the mucous membrane.
The lymphatic system may sympathize in the efiects of the cu-
taneous irritation, and occasion enlargement of the glands,
which sometimes form abscesses and ulcers, or where the mesen-
teric glands are affected, the little patient may be destroyed by
interference with the current of the chyle. In other instances,
secondar}'^ afiections of the skin are developed, in the form of
vesicles, pustules, and furuncles. When these cutaneous eruptions
appear during the violence of the mucous irritation, the visceral
disease is considerably relieved, and the recovery favourable.
Measles are most prevalent, and the accompanying catarrh
most severe during the winter, and particularly during the first
three months of the year. On the other hand, in the summer
season, and during the warm weather, the disease, when it occurs,
is mild and subdued.
^^ In measles, which are considered by Schonlein as the most
highly developed form of catarrhal disease occurring in the
northern hemisphere, the urine changes with the varying stages of
the disorder. In most cases it more or less resembles the in-
flammatory type, it is red (as in inflammatory measles), acid and
sometimes jumentous (turbid) as in gastric measles, or deposits a
mucous sediment during the course of the morning, (as in catar-
rhal measles.) Becquerel states, as the result of his observations,
that the urine is generally inflammatory at the commencement
of the febrile period. It becomes very dark and of high specific
gravity, and frequently deposits a sediment of uric acid : a small
quantity of albumen was found in a few of the cases. During
the eruptive period, the character of the urine changes ; if the
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54 CONGESTIVE INFLAMMATION OF THE DERMA.
eruption is slight and there is not much fever, it resumes tbe
normal type ; if the contrary is the case, the urine retains the
inflammatory appearance. Becquerel did not meet with any
case in which the urine was turbid or sedimentary towards the
close of the eruptive stage.
" During the period of desquamation and of convalesence the
urine either returns at once to the normal state, or continues
turbid and sedimentary for some time, or becomes pale, clear
and anaemic. In three cases, anasarca came on during convales-
oence, but the urine did not contain albumen.***
RUBEOLA SINE CATARRHO.
104. This form of measles is perfectly identical with rubeola
Tulgaris, with the exception of die catarrhal and febrile symp-
toms, which are either exceedingly slight or wholly absent. The
efflorescence is precisely similar, and follows the same stages.
Rubeola sine catarrho is usually observed during the prevalence
of an epidemic of measles, when some children will be found to
be attacked by the simpler variety, while the greater number are
seized with the disease in its ordinary form. It is not unfire-
quently met with in one member of a fGunily, when the rest of
the children have the more severe disease ; and this is especially
the case where a number of children are congregated together,
as in a public school. Rubeola without catarrh is sometimes
the immediate precursor of rubeola vulgaris, and children affected
by this form are more liable to a second attack of measles than
those who have experienced an attack of the ordinary variety.
RUBEOLA SINE EXANTHEMATE.
105. As measles may occur, divested of their mucous inflam-
mation, constituting the previous variety, so, in more rare in-
stances, the febrile symptoms and mucous inflammation may be
developed, with only a partial efflorescence, or, according to
some authors, with no cutaneous affection whatever. Rubeola
sine exanthemate, when it exists, is observed under the same
circumstances with those in which the previous variety appears
— ^namely, as isolated cases, during the progress of an epidemic,
among the members of a family affected with measles, or in a
large assemblage of children. Sydenham refers to this form of
disease under fiie name of febris morbiUosa, and Dr. Gregory
contributes additional testimony to its existence. " Guersent,"
says Rayer,t " has observed some individuals in families where
measles prevailed, exhibiting all the other symptoms of the dis-
ease, except the eruption. I have myself several times seen
* Simon's OhemUtrj, toL iL p. 269.
t Treatise on the Diseases of the Skin, translated bj Dr. Willis, p. 145.
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RUBEOLA NIGRA. 55
cases of measles, in which the eruption was incomplete, and which
might have been referred to the morbiUary fever of Sydenham ;
but I have never met with any instances like those mentioned
by De Haen, Gregory, and M. Guersent, although my attention
has been turned to this point these some years past."
RUBEOLA NIGRA.
Rubeola maligna,
106. In a debilitated state of the system, the cutaneous capil-
laries become over-distended, and the circulation through them
retarded, while some portion of their contents is efiused into the
surrounding tissues. This condition of the vessels gives to the
e£9orescence a purplish and livid appearance, with which a tint
of yellow is intermingled, and, in certain situations, a variable
number of small spots bearing a close resemblance to petechia.
This form of measles is rare, and has been described by Willan
under the designation of rubeola nigra. It commences with all
the characters of rubeola vulgaris, and runs the usual course
until about the seventh or eighth day. At this period, the pulse
becomes quickened, there is great lassitude, with prostration of
the vital powers, and the appearance of the rash alters to the
purplish and livid hue above noted. . Sometimes the constitu-
tional symptoms put on a more severe character, the respiration
is quick and impeded, the cough troublesome ; the digestive
organs much disturbed, with parched mouth and nausea ; pro-
bably delirium and efiiision into the serous cavities, with cedema
of the areolar tissue. With these aggravated symptoms, the dis-
ease is likely to terminate fatally. Rayer remarks, that he has
'^seen various examples of these livid measles in children
labouring under tubercles of the lungs and chronic csco-colitis,
and who were exhausted by diarrhoea and hectic fever."
107. Rayer has also remarked a variety of *^ black or haemor-
rhagic" measles, which are unconnected with constitutional de-
bility, and characterized by a vinous-coloured efflorescence not
disappearing under pressure with the finger. He met with this
form in strong individuals, and he finds a transition to such a
modification in the greater depth of colour, and non-disappear-
ance under pressure of some of the patches in an ordinary case
of rubeola vulgaris.
108. Diagnosis, — The diagnostic characters of rubeola are,
firstly, the affection of the mucous membrane, as indicated by
redness of conjunctivae, coryza, catarrh, sneezing, sore throat,
and cough, by which the disease may be distinguished, even
before the appearance of efflorescence ; and, secondly, by the
erescentic patches of the rcish, with intermediate unaffected por-
tions of skin.
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56 CONGESTIVE INFLAMMATION OF THE DERMA.
From scarlatina it is distinguished by the crescentic patches ;
the redness also is more intense, and uniform, or nearly so, in
this disease. Moreover, in scarlatina there is no coryza, catarrh,
or sneezing.
In roseola, although the rash is very similar, there are none
of the signs of inflammation of the mucous membrane so con-
spicuous in rubeola.
The minute spots by which the ejfflorescence of rubeola first
makes its appearance are like those of variola, especially on the
face and forehead, where they are slightly papular ; but upon
the trunk and limbs this difierence is always apparent between
them — namely, that in measles the red points are mere spots,
while in variola, they are distinctly elevated papulae.
109. The cough of rubeola is at first dry and harsh, at a later
period expectoration ensues, the expectorated mucus presenting
some peculiarities which are deserving of notice. Rayer de-
scribes these appearances as follows: — "At first mucaginous,
clear, and limpid ; at the end of three or four days the expecto-
ration becomes thick, rounded into pellets, smooth on the sur-
face, of a greenish-yellow colour, remaining perfectly distinct
firom each other, and swimming in a large quantity of ropy and
transparent mucus, similar to the matter coughed up by some
phthisical patients. By-and-bye this form of expectoration is
changed for another which adheres to the bottom of the vessel,
and seems composed of a greyish homogeneous mucus, mixed
with air and saliva, and very similar to the ordinary matter ex-
pectorated during chronic catarrhal affections. In young people
the expectoration is wanting, or not at all abundant ; and many
cases of measles occur in older subjects without being attended
with expectoration.'' Chomel remarks the following difi'erence
between the nummular expectoration of rubeola and phthisis —
namely, that in the former, the nummuli swim in a transparent
fluid, and in the latter, in one which is opaque.
The diagnosis of the varieties of rubeola needs no especial
mention.
110. Causes, — Rubeola would seem to have originated in
Arabia, the birthplace of variola and scarlatina, and to have ex-
tended with them to Europe and the rest of the world. It was
first described by Rhazes. The most remarkable epidemics of
measles which have occurred in this country, are those of London
in 1671, 1674, 1763, and 1768, having Sydenham for their his-
torian; and the epidemic of Plymouth in 1741, recorded by
Huxham.
Measles are the consequence of a special infection, or con-
tagion ; under the influence of which, conjoined with a favour-
able state of the system, rubeola is developed. In many eases
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CAUSES OF MEASLES. 57
the disease is sporadic or epidemic in its eruption, in others it
is communicated by contagion. The experiments of numerous
authors have shown that the exanthem may be transmitted by
inoculating a sound person, either with the blood, with the fluid
of the accidental yesicles which sometimes complicate the rash,
or with the secretions of those affected with the disease.
Measles may occur at any period of life, but are most fre-
quent in children. The disease is more uniyersally conta-
gious than any of the exanthematous fevers, but is only par-
tially protective of the constitution; for instances are by no
means rare, in which the same individual has been affected
more than once. The most obvious condition influencing the
attack of rubeola, is inflammation of any of the mucous mem-
branes, such as catarrh, cough, &c. This, indeed, constitutes a
morbillous constitution, and the disease is most prevalent at the
period when such a constitution is most likely to exist — namely,
during the early months of the year. Successive epidemics of
measles are usually characterized by some peculiarity either in
the intensity of the disease, or variety in the affection of espe-
cial organs.
Patients affected with measles must be secluded from
those who are sound, in order to protect the latter against con-
tagion. The period for the maintainance of seclusion is not
rightly determined, but for the sake of security should be pro-
longed to at least three weeks.
111. Prognosis. — Rubeola may generally be regarded as a
mild disease, particularly when it runs its course regularly,
when the symptoms of inflammation of the mucous membranes
are not severe, and the season temperate. The circumstances
which are calculated to render it serious are, irregularity in its
course ; its occurrence during dentition, pregnancy, after par-
turition, or in persons suffering for some time previously from
chronic disorder of an internal organ, particularly the lungs ;
retrocession of the cutaneous eruption ; acute affection of the
viscera, as of the lungs, the alimentary canal, &c., or severe
secondary disorder. Rubeola nigra is dangerous only when
complicated with excessive debility, or with any of the unfavour-
able conditions above specified.
112. Treatment. — ^When the disease is mild and regular in
its course, milk diet, subacid diluents, a moderate and equable
temperature of the sick chamber, with some simple mucilaginous
drink to quiet the cough, vnll be all the treatment required.
Indeed, the less the patient be interfered with by the employ-
ment of medicines, the better.
If the febrile symptoms run high, saline aperients and dia-
phoretics, such as the liquor ammonise acetatis with spiritus
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58 CONGESTIVE INFLAMMATION OF THE DERMA.
SBtheiis nitrici, and camphor mixture, may be employed ; but
active purgatives are calculated to be injurious, either by deter-
mining a retrocession of the eruption, or by exciting a diarrhoea
not easily to be checked. Moreover, it must be borne in mind,
that diarrhoea occurring at about the ninth or tenth day is a
natural consequence of the resolution of the fever. When from
any cause the diarrhoea is protracted beyond its proper period,
it may be admonished by a gentle purgative. An emetic at the
commencement of the attack is approved by many practitioners,
and is often useful.
When the cough is violent, the respiration frequent and diffi-
cult, witli pains in the chest denoting inflammation of the lungs,
abstraction of blood must be resorted to. In children, weakly
adults, or old persons, leeches to the chest, or cupping in this
region, will be sufficient. In persons of stronger habit, general
bleeding from the arm will be found necessary. In the country,
many patients will bear venesection with advantage, while in
crowded towns or cities this remedy must be employed with
circumspection. As an auxiliary to bleeding, or as a represen-
tative when the system may be too weakly for its use, counter-
irritation by blisters or stimulant liniments will be found bene-
ficial, and both remedies will be assisted by ipecacuanha or
tartarized antimony. Opiates are available only after the vio-
lence of the febrile symptoms has subsided, and then they may
be advantageously combined with a diaphoretic, as in Dover's
powder.
Cold affiision has been recommended in measles, but has not
gained friends, on account of the susceptibility to congestion of
the mucous membrane of the respiratory apparatus. When,
however, the skin is hot and dry, and so long as it continues so,
sponging with cold ^ater or with vinegar and water may be
adopted with safety and comfort to the patient.
Should the efflorescence recede suddenly, and some internal
organ become afiected, blood must be withdrawn from the region
of such organ, and the rash recalled by means of a mustard-
bath, and ibe application of a blister.
Rubeola nigra requires no other treatment, in addition to that
above recommended, unless especial indications present them-
selves, in which case the latter must be managed according to
the common principles of therapeutics ; thus, for debility, tonics,
mineral acids, &c., must be administered.
113. The sequelae of rubeola call for a treatment especially
directed to the nature of the secondary affection. For the
cough and pulmonary affection, counter-irritants externally ;
with diaphoretic salines and ipecacuanha internally are best
suited. Where speedy dissolution is threatened from swelling
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TBEATMENT OF MEASLES. 69
and oedema of the mucous membrane of the trachea and larjnx,
and where the local abstraction of blood by leeches has failed
to afford relief, tracheotomy must be performed. Chronic con-
junctiyitis and ulceration of the eyelias are best treated by the
application of blisters behind the ears, or upon the nape of the
necl, with a weak solution of nitrate of silver, or a collyrium of
sulphate of zinc, to the parts affected ; anointing the borders of
the lids at bed-time with simple cerate, to prevent their adhesion
during the night. The same plan of management is adapted to
the removal of unpleasant secretions from the ears, with the
addition, in chronic cases, of an injection of chloride of lime.
Aphthous vesications and ulceration of the mouth and fauces
require astringent and acid gargles, or brushing by means of a
sponge, with a weak solution of nitrate of silver. In children
too young to employ these remedies, a linctus containing the
snb-borate of soda may be found sufficient. Ulceration around
the mouth will speedily yield to nitrate of silver, or a solution
of chloride of lime. When the salivary glands are enlarged, and
threaten to suppurate, this termination may generally be pre-
vented by the application of a small blister over the tumefied
orgaji, or by blistering the surface with the nitrate of silver.
The diarrhoea may be permitted to continue, unless it be pro-
longed for too long a time, and occasion debility and constitu-
tional irritation. When such an event is anticipated, the best
treatment will be found to be, the application of a blister on the
abdomen; frictions on the legs, with a stimulating liniment;
mercury with chalk, or rhubarb and magnesia, internally, in the
first instance, succeeded by chalk mixture, and the usual means
for checking diarrhoea. When the lymphatic glandular system
is affeeted, the liniment of croton oil, rubbed on the integument
covering the enlarged glands, will be found of great service.
Indeed, any treatment for the relief of the sequelse of measles
will be inefficient, unless it be accompanied by counter-irrita-
tion. It is upon this principle that the secondary eruptive
affections of the skin are found to conduce so materially to the
cure of the internal disorder. These eruptive affections are
therefore not to be repelled, without establishing in the first
instance a more manageable form of counter-irritation, such as
an open blister, &c., in which case the eruptions will gradually
disappear.
During convalescence the patient should be protected from
pulmonary affections by warm apparel, and avoidance of a cold
and damp atmosphere.
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60 CONGESTIVE INFLAMMATION OF THE DERMA.
SCARLATINA.
Syn. Morbilli confluentes. Rubeola rossalicu Scarlet Fever. —
Scarlatine, Fran. — Sckarlachfieber, Sckarlackaufschloffy Germ.
114. Scarlatina is an acute inflammation of the tegumentary
investment of the entire body, both cutaneous and mucous, as-
sociated with fever of an infectious and contagious kind. It
commences with fever, which invades at an indefinite period
between the second and the tenth day after exposure to infec-
tion or contagion. On the second day of the fever, the eruption
is developed in the form of minute points and papulae, which
constitute patches of large size, or a general efflorescence of a
vivid scarlet colour. The rash terminates at the end of six or
seven days, leaving the skin rough and harsh, and the epiderma
peeling off in fiirfuraB and thin laminae.
115. The varieties of scarlatina, which are merely modifica-
tions in degree of one typical affection, are four in number —
namely.
Scarlatina simplex.
„ anginosa.
„ maligna.
„ sine exanthemate.
SCARLATINA SIMPLEX.
Scarlatina sine angincL*
116. Scarlatina simplex, the most benign form of scarlet
fever, commences vrith a feeling of languor and lassitude, with
pains in the head, in the back, and in the limbs ; with drowsi-
ness, nausea, and rigors, these being succeeded by heat, thirst,
and the usual symptoms of pyrexia, and increasing towards the
evening. Upon the breaking out of the efflorescence, the pulse
is quick, but feeble ; the patient is anxious, depressed in spirits,
agitated, restless, and sometimes delirious. The eyes are red
and humid, but without lachrymation ; the face is swollen ; the
tongue, covered in the middle with white mucus, is studded
with congested papillae of a vivid red colour, and red along the
edges ; the tonsils are enlarged, and the palate and pharynx red.
There is a frequent dry cough, a troublesome tingling and itching
sensation of the skin, and swelling of the hands and feet. Some-
times, however, it happens, that the eruption of scarlatina occurs
without pain or febrile symptoms.
On the second day from the commencement of these symp-
toms, the efflorescence appears upon the face, neck, and breast,
in the form of minute points, which become aggregated into
♦ Dr. Robert V^illiamg.
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SCABLATINA SIMPLEX. 61
Eatches of irregular form and size. By the third day, the rash
as extended to the trunk of the body and upper extremities,
and to the mucous membrane of the eyes, the nose, the mouth,
the pharynx, and air-passages, and by the fourth day to the
lower extremities. The patch-like distribution of the eruption
is its normal character upon the trunk of the body. On the face,
the neck, and upon the limbs, it speedily becomes continuous
and difiused. The skin is hot and itching, and fiiUy distended
by the congestion of its vessels. The scarlet surfeice is some-
times uniform and smooth, (scarlatina plana vel leviffata,) at other
times, and in some situations, it is dotted with elevated points
of a deeper tint than the adjoining surface, and is rough and
granular to the touch, (scarlatina papulosa vel milUfarmis^) and
occasionally, though rarely, it is accompanied by the develop-
ment of serous vesicles, (scarlatina vesicularisj vel phJyctcBnosay
vel pustulosa.) The efflorescence attains its most vivid redness
upon the evening of the third or fourth day from its com-
mencement. It is always brighter in the evening than in the
morning, and in certain parts of the body, as upon the loins,
the nates, and flexures of the joints, than upon the rest of the
surface.
The decline of scarlatina commences on the fifth day from the
eruption ; the redness diminishes on those parts first where it
first appeared ; islets of skin of its natural hue begin to be ap-
parent in the midst of the redness, and epidermal desquamation
occurs upon the fsLce and neck. On the sixth day, the efflores-
cence has still further decreased, and on the seventh has nearly
disappeared. On the eighth and ninth days, the desquamation
of the epiderma has become general, and, in many parts, laminae
of considerable size are thrown ofi*. The resolution of scarlatina
is sometimes accompanied by a sudden and temporary renewal
of the rash, preceded by a febrile paroxysm.
^^ In all the acute exanthemata the urine very firequently
presents, as Schonlein remarks, a peculiar character which is
due, in many cases, to an admixture of bile-pigment : it has a
dark brown colour, and resembles badly fermented beer in ap-
pearance. At the commencement of the crisis the urine becomes
clearer, and forms a pulverulent sediment consisting of uric acid
(and perhaps, urate of ammonia).
^^ In scarlatina, the urine, at the commencement while there is
considerable fever, is of a deep dark-red colour, and possesses
all the properties of inflammatory urine.
^^ In children the urine is always less coloured than in adults,
and its colour in this disease is proportionately less dark.
^* It almost always has an acid reaction, and only exhibits a
tendency to become rapidly ammoniacal, when the disease is
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62 CONGESTIVE INFLAMMATION OF THE DERMA.
associated with a nervous or septic condition of the system.
Any sediments that may be formed consist^ for the most part, of
urate of ammonia and uric acid mixed with a greater or less quan-
tity of mucus : blood-corpuscles are occasionally noticed. When
the urine is ammoniacal, viscid whitish sediments of the earthy
phosphates are deposited, and if there is much gastric disturb-
ance the urine becomes jumentous (turbid). Albumen is com-
monly but not always found in the urine during the period of
desquamation. Dropsy may even supervene without the urine
becoming albuminous : it is sometimes preceded by the occur*
rence of haematuria."*
Simon further observes in reference to the contradictory
opinions put forth with regard to the presence of albumen in Ae
urine : " We have dropsical symptoms with albuminaria, drop-
sical symptoms without albuminaria, and albuminaria without
dropsical symptoms. Solon found albumen in the urine in
twenty-two out of twenty-three cases of scarlatina. On the
other hand, Philippt observed, in Berlin, where scarlatina was
recently very prevalent and anasarca could not be warded off,
at least sixty cases in which the urine was tested both with heat
and nitric acid, and no trace of albumen could be detected."
Dr. Simon remarked that a desquamation of the mucous mem-
brane was ascertained by the presence of numerous epithelial
cells in the sediment, a condition that frequently preceded the
desquamation of the epiderma.
SCARLATINA ANGINOSA.
Scarlatina mitior^X
117. Scarlatina anginosa is a modification of simple scarlatina,
and is especially characterized by severity of the inflammation of
the mucous membrane of the fauces and pharynx, and by swell-
ing and ulceration of the soft palate and tonsils.
The primary symptoms of this variety of scarlatina are iden-
tical vrith those of the simpler form of the disease, but more
violent. The fauces from the commencement, and often before
the invasion of the symptoms, are redder than naturaL There
is a rapidly increasing sense of constriction about the throat,
and a stiffness of the muscles of the neck, and of the jaw. Upon
the second day of the febrile symptoms, the throat feels rough,
the voice is hoarse, there is a large collection of viscous mucus
in the fauces, and deglutition is painful and difficult. On the
third and fomrth days, the redness of the fauces has increased,
the mucous membrane looks turgid and swollen, and is studded
* Simon, Animal Chemistrj.
t Casper'B Wochenschrift, 1840, No. 85.
X Dr. Robert Williams.
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SCARLATINA ANGINOSA. 63
with patches of false membrane and superficial ulcerations. The
uvula and tonsils are so much enlarged as nearly to block up
the isthmus faucium, and the tongue is coated with white mucus^
and appears set with red gems, from the congestion and elonga-
tion of its papillse. While the local affection is thus rapidly
progressing, the constitutional symptoms are indicative of serious
and dangerous disturbance. There is nausea yn€i vomiting,
quickened respiration, a quick and feeble pulse, great languor
and restlessness, head-ache, delirium, and excessive heat of
skin, 104** or 105^ Heberden observed the temperature of the
sur&ice as indicated by the thermometer, to be 112 degrees of
Fahrenheit.
When ulceration of the mucous membrane of the fauces occurs,
the inflamed surface is seen to be studded on the second or third
day vnth a number of white patches, around which the congested
vessels form a zone of deep red. From the fifth to the tenth
day the whitish patch or false membrane is throvm off, and
leaves a small superficial ulcer, which quickly heals. Ulceration
takes place chiefly in irritable constitutions, and at certain sea-
sons of the year, as, for instance, during the autumnal and winter
months.
The cutaneous eruption in scarlatina anginosa is retarded by
the severity of the affection of the mucous membrane, and of
the constitutional symptoms. It fails to appear until the third
day, and is then only partial in its efl9orescence. Upon the
trunk of the body it forms scattered patches of variable size,
while upon the limbs it is developed chiefly around the joints.
It endures longer than the eruption of scarlatina simplex, and
the desquamation which ensues upon its decline is less regular
and extensive. Occasionally the rash disappears suddenly the
day after its eruption, to return in a day or two. This occur-
rence takes place more frequently in ^e autumn and vdnter
season than during the rest of the year, and is either fatal in its
consequences, or an aggravation of the constitutional severity of
the disease.
The decline of the eruption takes place on the fifth or sixth
day, and at the same time the severity of the inflammation of the
fauces subsides, the sloughs are thrown off, and the ulcerations
begin to heal. The latter process, however, and the disappear-
ance of the congestion of the mucous membrane, are not accom-
plished before die fifteenth or twentieth day. When the throat
and fauces only begin to be affected at the height of the rash, or
even at its decline, the dispersion of the inflammation is post-
poned till a later period. The constitutional symptoms follow
in the train of the affection of the throat
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64 CONGESTIVE INFLAMMATION OP THE DERMA.
SCARLATINA MALIGNA.
Scarlatina gravior,*
118. Scarlatina maligna is a highly aggravated form of scar-
latina anginosa, occurring in persons of debilitated constitution,
principally in the winter months of the year, and in damp, un-
healthy, and ill-ventilated situations. Sometimes it makes its
attack sporadically, while at other times it invades suddenly
and unexpectedly during the progress of scarlatina simplex or
anginosa.
The chief characteristics of scarlatina maligna are, the ex-
treme prostration of the powers of the system, the absence of
swelling of the tonsils, and the extensive and deep sloughing
ulcerations of the fauces. The pulse, in this affection, is irre-
gular, and scarcely perceptible ; there is great restlessness, deaf-
ness, delirium, and coma. The eyes look red and sunken, there
is an acrid secretion from the nose, which produces soreness and
excoriation around the nostrils. The cheeks are swollen and
aphthous. The lips, the teeth, and the tongue, are covered by
a dark brown or black fiir. The tongue is swollen and tender,
or even ulcerated, and the tonsils are deeply ulcerated, and
covered with dark-coloured sloughs. Respiration is impeded,
quick, and rattling ;' there is a quantity of viscous phlegm in the
pharynx ; the breath is foetid ; deglutition painful and difficult,
there is stiffness of the muscles of tibe jaws, diarrhoea, and some-
times haematuria.
The eruption in this form of scarlatina is late in appearance ;
it is pale and indistinct, with the exception of a few patches oJf
irregular size, which speedily become dark and livid, and min-
gled with petechias. " Their whole skin," writes Dr. Sims,t " in-
stead of the scarlet, assumed a very remarkable appearance,
which resembled nothing so much as that of a dead body which
has been kept several days, or as if a mixture of blood and water
were universally diffiised under it, and could be seen through
it." The duration of the rash is equally uncertain with its
period of invasion. ^^ In some instances, the rash suddenly dis-
appears a few hours after it is formed, and comes out again
after the expiration of a week, continuing two or three days ;
in one case, numerous patches of it appeared a third time, on
the seventh day from the second eruption, then remained for
two days."
Scarlatina maligna is an extremely fatal disease, as may be
inferred from the severity of its symptoms. Some patients are
cut off at an early period — namely, on the second, third, or fourth
♦ Dr. Robert Williams,
t Memoirs of the Medical Society of London.
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MODIFICATIONS OF SCARLATINA. 65
day, while others withstand its violence for a longer period.
Those who perish early, exhibit appearances of extensiye ulce-
ration in the fauces, larynx, trachea, lungs, or in the oesophagus
and alimentary canal, after death. The great fatality of ^s
disease may be inferred from the observation of Willan, that
** in 1786-7, more than two-thirds of those who were affected
with the scarlatina maligna died between the seventh and nine-
teenth day of the fever.**
SCARLATINA SINE EXANTHEMATE.
Scarlatma sine eruptione.*
119. During the progress of an epidemic of scarlatina, some
few cases have been occasionally observed, in which the fever
and angina were present, but without any, or with a scarcely
perceptible efl9orescence. Such an instance once fell imder my
own notice, in a weakly child, who slept in the same apartment
with three of his brothers and sisters, suffering from the ordinary
attack of scarlatina simplex. This form of the disease is more
frequent in a secondary attack, before the health has become
completely re-established, than as a sporadic variety, and is
more likely to occur in the adult than in children.
ACCIDENTAL MODIFICATIONS OF SCARLATINA.
120. When so extensive a surfew^e of the body is affected as
that which is the subject of disease in scarlatina, it is natural to
expect that many modifications may arise from circumstances
apparently trivial, such as those which are referrible to age, con-
stitution, season, &c. Thus while, on the one hand, cases may
occur in which all the constitutional symptoms are present with-
out the efflorescence, on the other hand, the very reverse of this
may happen. Dr. Sims remarks, ^Mn one child the scarlet
fever appeared without any angina, and having finished its
course, left the patient seemingly in perfect health ; but in a few
days tihe fever returned without any eruption, but with a very
considerable degree of sore throat, and much pain and swelling
of the tonsils and parotids, which likewise ran its course, as if
the former symptoms had never appeared.** The same author
observes, that during the periods of the year which are unfa-
vourable for scarlatina — namely, in autumn and winter, " a fre-
quent, short, hacking cough took place in several patients,**
without expectoration : that this symptom was most severe where
the cutaneous eruption and affection of the throat were the
slightest " Another circumstance in the months of November
and December was, that a few days after the apparent change
• Dr. Robert WiUiams.
F
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66 CONGESTIVE INFLAMMATION OF THE DERMA.
of the disorder, a swelling attacked the fiELce^but more frequently
the extremities, attended with the most excruciating pain.^
"Some first complained of a violent tooth-ache; after two or
three days they complained of an equally violent pain in the
back, the first one gradually subsiding. In a day or two more,
or even sooner, the pain attacked their elbows, wrists, and hands,
which were usually the parts last attacked.^
SEQUELiE OF SCARLATINA.
121. The development of the exanthema, upon certain parts
of the body, is always accompanied by more or less oedema of
the subcutaneous areolar tissue. In the majority of cases this
oedema is removed by absorption of the serous efiusion at the
decline of the eruption, but occasionally it terminates in ulcera-
tion or mortification. " Two instances of this tendency to mor-
tification occurred in two children lately admitted into St.
Thomas's Hospital. In one, the whole of the toes of the right
foot had sloughed ofi*, and the integuments of the leg had mor-
tified from the knee to the foot. In the other, mortification of
the upper lip had commenced, and continued to spread till
nearly one half of the face was eaten away. The former patient
recovered, the latter died. This tendency to mortification is
common to many parts of the body. Dr. Watson, in his account
of the fever that prevailed in the London Foundling Hospital,
gives one case that died of mortification of the rectum, and also
six others that died sphacelated in various parts of the body.
In the girls, some had the pudendal region mortified ; two had
ulcers of the mouth and cheek, which sphacelated externally ;
while one had the gums and jaw-bone so corroded, that most of
the teeth fell out before she aied. The lips and mouth of many
also that recovered, were ulcerated, and continued so fDr a
long time."*
In other cases, at the close of scarlatina, and during convales-
cence— ^namely, during the period intervening between the tenth
and twentieth day, anasarca is developed. This sequela, which
is referrible to the transfer of inflammatory action to the struc-
ture of the kidneys, is serious, and often fatal. The afiection is
indicated by languor, head-ache, restlessness, and symptoms of
general constitutional disturbance ; to these succeed oedema of
tibe fEU^e and lower extremities, and, in a short space of time, of
the entire body. Subsequently, efiUsions containing urea take
place into die serous cavities, and the patient succumbs. The
urine in this disease, as in granular kidney, is brownish in
colour, from admixture with blood, and frequently loaded with
♦ Elements of Medicine. Bj Robert V^illianw, M.D. Vol. i. page 127.
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SEQUEUB OF SCARLATINA. 67
albmnen. Anasarca is usually regarded as a consequence of
exposure to cold and damp, during the progress of scarlatina,
or at too early a period after convalescence, and it occurs, for
the most part, during the winter season.
Besides the preceding, inflammation and efiusion of senun
and pus may take place into the joints. The mucous membranes
also suffer ; the inflammation of the conjunctiva sometimes be-
comes chronic, and lasts for a considerable time. Inflammation
of the mucous lining of the tympanum and Eustachian tube may
terminate in dea&ess, and that of the meatus auditorius in
chronic suppuration. Occasionally, ulcerations are formed
around the nose or mouth ; thickening of the upper lip may
also occur ; aphthse of the tongue and mouth, or inflammation
of the salivary glands. When parotiditis ensues in the adult, it
is apt to produce considerable swelling of the gland, which con-
tinues for a long period ; in children, inflammation of this
gland, and of the submaxillary glands, may give rise to asphyxia,
or terminate in suppuration and abscess. Other sequelae of
scarlatina anginosa are, chronic enlargements of the lymphatic
glands of the neck, swelling of the testes, chronic bronchitis,
chronic diarrhoea, &c.
In scarlatina maligna the sequelae are severe and dangerous,
and often prove fatal aft^er the secondary stages of the fever
have subsided. To the tertiary affections above detailed, may
be added, as occasionally following in the train of scarla-
tina maligna, ulceration of the mucous membrane of the larynx,
trachea, and oesophagus ; ulceration of the mucous membrane
of the intestines, protracted cough, dyspnoea, suppuration of the
salivary glands, enlargement and suppuration of the lymphatic
glands of the neck, sloughing of the nates, and hectic fever.
122. Diagnosis, — The especial diagnostic characters of scarla-
tina are, Jirsth/y the decided and acute afibction of the fauces ;
^con(//y,tiie early appearance (2nd day) and rapid extension of the
efflorescence ; and tidrdly^ the bright scarlet, and diffused charac-
ter of the rash, and its frequent interspersion with red papulae.
Between scarlatina and rubeola, the closest analogy undoubt-
edly subsists, and when the natural characters of the two affec-
tions are considered, the analogy approaches almost to identity;
thus, both are inflammations of the tegumentary surface of the
body, internal and external ; both are accompanied by a cuta-
neous effloresoence, involving the vascular rete of the derma ;
both are liable to be succeeded by serious affections of the
viscera, into the structure of which mucous membrane enters as
a constituent part ; both appear during the prevalence of the
same epidemic, engendered apparently by the same infection ;
one may follow on the other as a consecutive disorder ; both
f2
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68
CONGESTIVE INFLAMMATION OF THE DERMA.
are infectious, and both are contagious. In practice alone is it
necessary to distinguish between these exanthemata. We will,
therefore, inquire what are the distinctions which we are enabled
to establish between them ?
Scariatiiuu
1. Precunorj symptoms of ooe day
duration.
2. MoooQS membrane of the eyes,
nose, and fitnces, red and inflamed,
without secretion ; pain and soreness of
throat ; no coogfa ; no expectoration.
3. Eruption on the second day of the
fever ; invades the entire sor&ce of the
body in three days ; dbappears by the
end of the seventh day.
4. The efflorescence occurs in Urge
irreguUr patches, or b more or less ge-
nenOly disused ; is of a bright scarlet,
compared by Willan to a "boiled lob-
ster's shell,** and frequentiy interspersed
with numerous snudl red papule.
5. Odour resembling old cheese.
6. Principal sequelae; anasarca; in-
flammation of the joints; gangrene;
chronic bronchitis ; ulcerations of &uces;
conjunctivitis; otitis ; abscess of salivary
glands; chronic diarrhoBa.
7. Exfoliation of the epiderma in la-
minsB.
8. Less infectious and contagious than
measles.
9. Rarely attacks the same
more than once.
person
Bubeola,
1 . Precursory symptoms of three days'
duration.
2. Mucous membrane of the eyes,
nose, and fauces, red and inflamed, with
increased secretion, coryza, sneezing,
&c; dry cough at first, subsequenUy
expectoration.
3. Eruption on the fourth day of the
fever; occupies three days in invading
the entire surficice of the body; disap-
pears by the end of the eighth day.
4. The efflorescence occurs in small
crescentic, and circular patches, with
intervening unaffected portions of the
skin ; the colour is darker than in scar-
latina, with " nearly the hue of a rasp-
berry,'* and interspersed with numerous
small red papulae, disposed in clusters.
5. Odour, sweetish, until the decline
of the eruption, then sourish.
6. Principal sequela). The same as
scarlatina, with the exception of anasarca,
inflammation of the joints, and gan-
grene.
7. Exfoliation of the epiderma, in fur-
fhraceous scales.
8. More infectious and contagious
than scarlatina.
9. Frequentiy attacks the same person
twice.
The differences above stated amount at most to one of degrree,
the infection being the same in both disorders. Thus, while
both are constituted by inflammation attacking the same tex-
tures of the body, scarlatina, during its ^rst stages^ is more
rapidly and actively determined to the cutaneous surface, the
mucous membrane, in an equal ratio, escaping the violence of
the inflammatory action. The contrary is the case vrith regard
to rubeola ; here the cutaneous determination is tardy and par-
tial, while the mucous affection is gradual, severe, and pro-
longed. During the second stages^ on the subsidence of the
cutaneous congestion, the mucous membrane may suffer more
or less in bodi, according to a variety of circumstances, such as
the greater or less exhaustion of the morbific influence in the
skin, the state of the nervous system, &c. These stages have
no natural course in either disorder, new and accidental, cr
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CAUSES OF SCARLATINA. 69
preTiously existing conditions, determining the resolution of the
inflammation, or its attack upon some weak point of the mucous
membrane.
Scarlatina sine exanthemate is distinguished from cynanche
maligna by the symptoms, which indicate the presence of an
acute disease, and one producing a powerful impression on the
yascular and nervous systems. The alimentary system is also
much disturbed, there is vomiting and diarrhoea, and the disease
is apt to run its course to a fatal termination in the lapse of a
few days, or within the first week Angina maligna, on the
other hand, is slow and gradual in its progress, extending by
degrees from the point first attacked along the trachea and
bronchial tubes, giving rise to the formation of false membranes
in its course, and attended with little constitutional disturbance,
however severe may be the local affection. In a word, the
observation of these two diseases, exhibits, in the former, fatality
in its cause ; in the latter, fatality in its effects.
123. Causes. — The cause of scarlatina is an infection, or con-
tagion, apparently identical with that of rubeola. It makes its
attack in llie form of an epidemic, and prevails mostly in the
spring and autumn seasons of the year. The atmospheric con-
ditions favourable to scarlatina are cold and moisture combined,
and the existence of this state of the weather for any time gives
rise to a medical constitution, in which scarlatina is apt to be
developed. When epidemics of scarlatina and measles occur
at successive periods, with an interval of a certain number of
years, it would appear that the fresh invasion is determined by
an increase in die numbers of the population who have not
yet suffered from the disease, and who are consequently sus-
ceptible of its influence. Scarlatina is less contagious than
rubeola, and affects children and young persons chiefly ; but
many instances occur, in which adults, and especially puerperal
patients, have suffered from this disease. Scarlatina rarely
attacks the same person more than once, and is less easily com-
municable by inoculation than measles. For protection against
the propagation of the contagion, patients recovering from scar-
latina should be secluded for three weeks or a montib.
It is worthy of remark, that an angina pseudo-membranosa,
complicated in some cases with scarlatina, not unfrequently
takes place, on the continent, in an epidemic form. In an
epidemic of this disease lately reported to the Academy of
Medicine as having occurred at Lion-d' Angers, it prevailed for
the first six mon&s of the year. During the same period,
horses suffered from a similar affection, colts from acute ente-
ritis, and cattle, sheep, and pigs, from phlyctenoid fever.
124. Prognosis. — The prognosis of scarlatina will be much
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70 CONGESTIVE INFLAMMATION OF THE DERMA.
influenced by the nature of the prevailing epidemic. It some-
times invades with such overwhehning rapidity, as to destroy
life before any pathological changes can be effected. Scar-
latina simplex is wholly divested of danger when it passes
regularly through its course. It may, however, be rendered
grave by retrocession, or by complication with disease in any of
die viscera. ^The prognosis is unfavourable if the delirium
commence, as it frequently does in children^ and sometimes
also in adults, a few hours after the seizure. In these eases the
child often dies on the third or fourth day, and the adult on the
eighth or tenth. The tongue becoming brown, or, a dean
tongue, with a rapid, fluttering pulse, are unfavourable symp-
toms. A sudden fading of the eruption, or its changing to a
livid colour, are symptoms of danger. The danger of scarla-
tina is increased by dentition. Pregnancy also adds to the
danger, as the woman frequently miscarries. The prognosis
is aJso extremely grave when it attacks women immediately
after parturition." " The fauces becoming livid under any cir-
cumstances, or an acrid discharge from the nostrils, or else the
formation of an extensive abscess in the neck, accompanied
vrith severe purging, are all unfavourable symptoms. The ap-
pearance of mortification in any part is commonly, but not uni-
versally fatal. Affection of the joints is a grave, but by no
means a fatal symptom.* The appearance of hasmorrhage from
the mucous membrane of the nose at the commencement of the
exanthema is regarded as a favourable sign.
125. Treatment, — In scarlatina simplex, the treatment should
be of the simplest kind. Sydqjiham remarks that none die of
this disorder, except from a too great ofliciousness on the part
of the practitioner — "Nimia medici diligentia." The patient
should be confined to the house, the sick apartment should be
kept cool, the bed-coverings light ; and milk diet, vrith a plen-
tiful use of diluents, enjoined. The bowels should be regulated
during the progress of the disease by gentle laxatives, and at
its decline, if indicated by debility, a nuld tonic or a little vrine
may be exhibited.
126. Scarlatina anginosa, — In scarlatina anginosa the same
general plan of management should be adopted as in the pre-
ceding form, and if the heat of the skin be excessive, great relief
will be afforded by sponging with cold or tepid water, or vine-
gar and water. The disposition to nausea which exists in
scarlatina anginosa should be met by effervescing salines,
such as the citrate of ammonia, combined with laxative doses
of neutral salts. When the tonsils are enlarged and painful,
^ * Dr. Robert Williamfi. Opus, cit, p. U5.
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TBEATMENT OP SOAiaATINA. 71
and interfere with respiration, or ave accompanied by pain in
the head, leeches should be applied in the submaxillary region,
the number being regulated by the age and strengdi ot the
patient. In moderately strong children, ten or twelve may be
employed. If there be delirium, the head should be shaved
and cold applied. Blisters to the throat are objectionable in
these cases, for by exciting inflammation of the cutaneous sur-
fjEu^e, they act as additional sources of irritation. So long as
the inflammation of the £Eiuces continues, the saline remedies
most be pursued ; but as soon as the sloughs are thrown ofl^,
and ulceration established, and the febrile s^-mptoms are on the
decline, tonic medicines, with mineral acids, and wine, are indi-
cated. Acid and astringent gargles or fumigations, or, in young
children, aspersion of the throat, with an acid and slightly
astringent solution, are often usefid in procuring the removal of
the viscid mucus and exuvisB which are apt to collect in the
£auces and excite nausea. They also serve to remove thefoetor
which accompanies the sloughii^ and ulceration.
Emetics have been recommended veiy strongly, as a means
of clearing the throat of its mucus, and, at the same time, of
lidding the stomach of its peccant contents. The violence of
the remedy feur outweighs the inconvenience which it is pro-
posed to remove, and although supported by the authority of
Withering, emetics have fallen into merited neglect. Indeed,
they are not merely negative in their efiects, but are calculated
to be injurious.
Purgatives, like emetics, have been much over-rated in the
treatment of scarlatina anginosa. Willan was an advocate for
the employment of calomel in purgative doses, with a view to
reduce the febrile excitement and heat of surface. Dr. Hamil-
ton also drew a favourable deduction from their use ; but Dr.
Robert Williams has shown that while the mortality in the
cases treated by Dr. Hamilton was twelve in ninety-five, in those
treated by moderate stimulants it was only three per cent.
Dr. Currie, of Liverpool, the celebrated advocate for the em-
ployment of cold water in fevers, pursued this practice in scar-
latina with remarkable success, washing the suiiietce whenever
the skin was " hot and dry." Dr. Bateman, and several other
eminent physicians, adopted the practice of cold afiusion, and
gave the strongest evidence in its favour. The method of using
die remedy is, to pour one or two pailfuls of cold water over the
patient, to rub him quickly dry, and place him in bed, where,
in a short space of time he falls asleep, and geners^ly breaks
out into a moderate perspiration. If the feeling of cold should
continue after the bath, a little warm wine and water is admi-
nistered to the patient. The efiect of cold afiusion is, to diminish
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72 CONGESTIVE INFLAMMATION OF THE DERMA.
the frequency of the pulse, to reduce tlie thirst and heat of skm,
and to tranquillize the nervous system. If needful, it may be
repeated for a second or a third time. When affusion is not
thought advisable, sponging the surface with cold water may be
employed as a substitute. " Cold afiusion," says Bateman,
" combines in itself all the medicinal properties which are indi-
cated in this state of disease, and which we should scarcely, k
f)riori, expect it to possess ; for it is not only the most effectual
ebrifuge, but it is, in fact, the only sudorific and anodyne which
will not disappoint the expectation of the practitioner under
these circumstances." " 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 per-
spiration has broken forth, the skin has become soft and cool,
and the eyes have brightened, and these indications of reUef
have been speedily followed by a calm and refreshing sleep."
Belladonna has obtained a high reputation among continental
practitioners for its protective and curative powers in scarlatina.
It was first suggested by Hahnemann, who had obser\'ed that all
persons to whom this medicine had been given were preserved
against the infection of scarlet fever. Whole towns and villages
have in this way been protected. The mode of administration is
in doses of a few drops of the tincture night and morning, the
dose to be regulated according to the age of the person.
Both cold affusion and belladonna appear to me to act thera-
peutically, by virtue of their sedative effects upon the nervous
system, and upon the same principle, any sedative means from
which the stimulant property were as much as possible excluded
would ensure the same desirable end. Cold afiusion has been
used with great advantage in fevers, and the sedative powers of
opium have lately been employed in France for the purpose of
checking inflammatory action.
Dr. Sims remarks, in relation to prophylactic treatment, " The
best preventive to the disease I found to be rhubarb, taken in the
quantity of a few grains every morning, so as to produce one
laxative motion in the day. I did not see one who used this
confined afterwards to bed, though several persons began it after
they were infected, but before the time of tiieir sickening."
127. Scarlatina maligna. — The vast depression of the powers
of the nervous system that exists in scarlatina maligna indicates
a tonic plan of treatment, conjoined with a proper regulation of
the digestive system bv means of gentle laxatives and attention
to the local disorder of the throat. The best tonic remedies are
quinine, with infusion of roses, and dilute sulphuric acid, gentian
with nitric and hydrochloric acids, cascarilla, hops, or canella.
The tonic and nutritive properties of wine or good beer render
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TREATMENT OF SCARLATINA. 73
them inyaluable remedies in these ea43es ; the quantity which
may be taken daily by a child amounts to one or three ounces,
and by an adult to double that quantity. The application of
leeches to the throat is contra-indicated in the malignant form
of scarlatina, and, indeed, no symptoms present themselves to
warrant their use. The same objections oppose the application
of blisters and counter-irritants. The fauces should be fumi-
gated with the steam of warm vinegar, with decoctions of con-
trayerva and bark, acidulated with acetic acid, or containing
camphorated spirit ; or gargled i^th a weak solution of chloride
of lune or capsicum pods. Dr. Watson remarks, that a great
improvement upon the old plan of capsicum gargles, is a weak
solution of common salt, either used as a gargle, or, if the dis-
ease occur ^' in a child that is not able to gargle, this solution
may be injected into the nostrils and against the fauces by means
of a syringe or elastic bottle. The effect of this application is
sometimes most encouraging. A quantity of offensive sloughy
matter is brought away ; the acrid discharge is rendered harm-
less ; the running from the nose and diarrhoea cease ; and the
disease is converted into a form which approximates to the scar-
latina anginosa.^' The surface of the body may be sponged with
warm vinegar, but the use of cold water, so agreeable and bene-
ficial in scarlatina anginosa, is painful and injurious in the malig*
nant form.
" Of late,** observes Dr. Watson, " I have been in the habit of
directing a solution of the chlorate of potash in water ^a drachm
to a pint) as a drink for patients in scarlet fever and m the ty-
phoid forms of continued fever. This practice was suggested to
me by Dr. Hunt, who tells me he has long employed it with
advantage. Under the use of a pint or pint and a half of this
solution daily, I have remarked in many mstances a speedy im-
provement of the tongue, which from being fiirred or brown
and dry, has become cleaner and moist" Dr. Watson also re-
marks that the solution of chlorine has been strongly pressed
on his attention as a praiseworthy remedy. " Two drachms of
the chlorate of potash are to be dissolved in two ounces of
hydrochloric acid previously diluted with two ounces of distilled
water. The solution must be put immediately in a stoppered
bottle and kept in a dark place. Two drachms of this solution
mixed with a pint of distilled water, constitute the chlorine mix-
ture ; of which a table-spoonful or two, according to the age of
the patient, may be given for a dose, frequently."
128. Scarlatina sine exanthemate will require the treatment
adopted for scarlatina anginosa or scarlatina maligna, according
as it may put on the characters of either of the preceding forms.
With the view of encouraging the development of the eruption^
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74 CONGESTIVE INFLAMMATION OF THE DERMA.
the skin should be stimulated by a mustard bath, by frictions
with irritating applications, and by blisters.
The retrocession of the cutaneous efflorescence in scarlatina
should be treated with mustard baths, the application of blisters,
and the friction of stimulating liniments on the skin. An erup-
tion, evincing a disposition to metastasis, may frequently be fixed
by means of a blister.
129. Complications of scarlatina, — The complications of scar-
latina call for a treatment especially directed to the organs af-
fected. Thus, when from the presence of delirium, comatose
symptoms, &c., without much inflammation of the fiEiuces, we are
led to infer congestion of the brain, leeches should be applied to
the temples or to the mucous membrane of the nose, in imitation
of the critical hsemorrhage which frequently occurs at the close
of the disorder ; and blisters should be placed behind the ears,
or upon the nape of the neck. But when these symptoms are
associated with inflammation of the fauces, the most ready, and
indeed the only method of relieving them is to apply the leeches
to the submaxillary region. When respiration is obstructed
from congestion or cedema of the mucous membrane of the
larynx or trachea, leeches should be applied over this region,
and in very severe cases it may be necessary to perform tra-
cheotomy. When the lungs or pleurae are affected, leeches to
the chest, with blisters or sinapisms, are required. When the
stomach appears to be the seat of congestion, leeches to the
epigastrium, and a blister or sinapism, will facilitate its restora-
tion. Diarrhcea is to be relieved by leeches or fomentations to
the abdomen, succeeded by sinapisms or a blister ; and the same
plan is requisite when the kidneys appear to be the organs espe-
cially disordered, the therapeutic management in the whole of
these cases being aided by mustard footbaths. The cure of
ulcerations in the fauces is best effected by means of a solution
of nitrate of silver applied with a sponge ; or by the same salt
in powder blown upon the ulcerated suifrices through a quill.
130. SeqtiekB of scarlatina. — The most important of the con-
sequences of scarlatina is anasarca : this affection calls for deple-
tion by bloodletting, if the strength of the patient warrant the
remedy; the use of the acetate of potash, as a diuretic; of pur-
gatives of calomel ; of warm baths with and without mustard ; of
dry frictions ; of heat to excite perspiration, and the application
of stimulant liniments to the skm. Dr. Robert Williams recom-
mends the supertartrate of potash, in drachm-doses, as the best
purgative ; and when the inflammatory symptoms have subsided,
salicine in five-grain doses, as combining the properties of a
tonic and diuretic ; or steel medicines, such as the tartrate of
iron.
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VABIOLA— SMALL-POX. 75
The inflammation of the joints diat so firequently succeeds to
scarlatina, is combated by means of gentle purgatiyes, some
simple sedative to relieye pain, and fomentations to the diseased
articulations. Other sequelae should be treated according to the
general principles of therapeutics.
VARIOLA.
Syii. Smallpox. Variole; Petite verokf Ftslh, —
Kinderpocken, Kinderblattem, Germ.
181. Variola is an acute inflammation of the tegiunentary in-
Testment of the entire body, botii cutaneous and mucous, asso-
ciated with fever of an infectious and contagious kind. On the
skin it is characterized by an eruption of red points, which pass
through certain stages of progressive development, becoming, in
quick succession, pimples (vari), acuminated vesicles, flattened
and umbilicated vesicles, pustules, and hard brown scabs ; the
latter fedling ofi* from the eleventh to the twenty-fifth day, and
leaving behind them small irregular pits, and permanent cica-
trices. On the mucous membranes it produces great congestion
of the surface, and in some situations pustules, particularly in the
respiratory passages. The fever of variola is of the remittent
type, preceding the eruption for two, three, or four days, ceasing
as soon as the eruption is developed, and returning when the
eruption has reached its height — namely, on the eighth day in
discreet, and on the eleventh day in confluent small-pox.
132. Small-pox admits of several divisions in relation to the
origin, distribution, and degree of severity of the disease. In
respect of origin, it may occur sporadically, or be the conse-
quence of the voluntary introduction of the variolous virus into
tiie system, constituting the two varieties termed natural small-
pox and inoculated small-pox. In reference to distribution and
degree, the eruption of small-pox may be discreet^ the pustules
being distinct and scattered over the surface of the body ; it may
be coherent^ the pustules being very numerous, and, in many
situations, placed closely side by side, but still distinct ; it may
be eonfiuenty the pustules being very numerous, and, in several
situations so closely set, as to run one into the other, and form
confluent clusters of various size ; or it may be modifiedy the
pustules being altered in their number, their size, and their
course, either by the previous invasion of small-pox, natural or
inoculated, or by vaccination. Modified small-pox is a much
milder aflTection than the parent variola, and is termed varicella,
or varioloid. Another division of variola relates to its occurrence
for the first time, or as a second attack, a distinction which is
expressed by the terms primary small-pox, and secondary small-
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76 CONGESTIVE INFLAMMATION OF THE DERMA.
pox. Besides the preceding, we sometimes have occasion to
remark, during the prevalence of an epidemic of variola, the
occurrence of the fever of small-pox, widiout its eruption ; this
variolous fever constitutes a variety which has been appropriately
termed, variola sine varioUs. These terms, expressive of dif-
ferences in the character of variola, are chiefly useful for the
purposes of communication and description. They may be
comprehended at a glance, by placing them in a tabular form ;
thus,
Natural variola —
Discreet
Coherent
Confluent
Modified.
Secondary.
Inoculated variola.
Variola sine variolis.
133. The coiurse of variola admits of consideration in five
successive periods, this division being alike convenient in the
treatment and description of the disease. The periods of variola
are those of incubation, invasion, eruption, suppuration, and
desiccation.
I. The period of incubation is of variable duration, and com-
prehends all that space of time which intervenes between the
exposure of the body to infection or contagion, and the invasion
of the disease. In very severe cases the period of incubation is
short ; in the milder forms, on the contrary, it is long. The
limits commonly assigned to this period are from five or six to
twenty days, and cases sometimes occur in which it would seem
to be still further prolonged.
II. The period of invasion is marked by symptoms which indi-
cate serious constitutional disturbance. It commences with lan-
guor and lassitude, with shivering and horripilation, pains in the
head, in the loins,* and in the Imibs ; the skin is hot, and either
dry or moist ; the pulse and respiration are quickened ; there is
thirst and loss of appetite, with a white and furred tongue,
nausea, often vomiting, constipation, pain and heat at the epi-
gastrium, restlessness, and universal prostration. To these
succeed, though various in degree in different individuals,
oppression of breathing, cough, lethargy, and sometimes coma,
llie tongue, at the commencement of Siis period usually white,
* M. Chomel regards the pain in the loins, which he refers to the kidnejs, as
pathognomonic Dr. Ueberden observed that acute pain in the loins was generally
followed by a seyere attack of the disease ; when the pain was higher in the back
the disorder was milder ; and that the most desirable indication was the absence of
pain.
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COUBSE OF VARIOLA. 77
soon becomes red at the point, and subsequently over its entire
surface. In children, convulsions not unfrequendy ensue at
this stage of the febrile symptoms. Throughout all the periods
there is exacerbation of the febrile symptoms during the night.
In confluent small-pox the symptoms of invasion attain their
highest degree of severity, there is more sickness and vomiting,
the prostration of the system is greater than in the discreet
variety ; the tongue and lips are parched, and covered with
sordes; the heat of skin is excessive; convulsions are more
frequent, and sometimes there is diarrhoea.
The period of invasion lasts from two to four days, and its
symptoms are instantly relieved by the succession of the eruptive
period.
III. The period of eruption is often ushered in by a manifest
exacerbation of the constitutional symptoms, which are at once
and immediately relieved by the outburst of the eruption ; the
oppression and languor are no longer felt, the nausea and sick-
ness cease, the pulse returns to the natural standard, and is full
and regular. The eruption first appears upon the lips and fore-
head, and then upon the rest of the face ; from the feuje it pro-
ceeds to the neck and arms ; from the latter to the trunk, and
from the trunk to the lower extremities, the entire body being
pervaded in the brief space of twenty-four hours.
The development of the eruption is indicated by the appear-
ance of small red points,* conical in their form, and hard to the
touch, which are (usseminated over the surface in numbers pro-
portionate to the subsequent pustules. Thus, in the discreet
variety, the spots are few and distinct ; in the coherent kind,
they are numerous and clustered (corymbose), like the patches
of rubeola ; while, in confluent variola, they are closely aggre-
gated, and so abundant as to difiuse a general redness over the
sur&ce. The skin is hot, tense, and shining. The red spots
soon become raised, and by the second day of eruption (fourth
or fifth of invasion) have the appearance of small conical papulas
(vari) , with red and inflamed bases, and transparent and vesicular
points. On the third, fourth, and fifth day of eruption (fifth to
ninth of invasion), the papular elevations, with meir inflamed
bases, go on progressively enlarging, the vesicles pass from a
conical into a depressed and indented or umbilicated form ;
their contents, which were at first transparent liquor sanguinis,
become whitish and milky, and a thin layer of white lymph is
formed on the derma. The umbilicated character is apparent
in many of the vesicles on the third day of the eruption, and
* By some writers these points have been compared to the spots produced by the
bite of the flea.
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78 CONGESTIVE INFLAMMATION OF THE DERMA.
by the fourth or fifth, a distinct areola begins to be formed
around each.
Similar phenomena may be observed to be taking place at the
same time in the mouth and pharynx ; the mucous membrane is
red, swollen, and congested ; there is soreness of the throat, and
painful deglutition; the respiration is somewhat impeded in
consequence of the extension of the inflammation to the larynx
and trachea ; the voice is hoarse and weak ; and there is fre-
quently a hiurd, dry, and troublesome oough. The eruption is
dcTeloped in the larynx and trachea, on tlie pharynx ana fraces,
and on the tongue, in the form of white points, which become
converted, first into vesicles, and then into pustules.
In the confluent variety, the remission of febrile symptoms is
imperfect^ the eruption appears a day earlier than in the discreet
form, the papuls are less raised, but so numerous as to give rise
to a general swelling of the skin, which is of a deep red colour,
shining and granulated. The incipient pustules constitute one
continuous vesicle over die inflamed surface, formed by the eflu*
sion of liquor sanguinis or coagulable lymph beneath the epi-
derma. This fluid, at first transparent and limpid, becomes
milky and opaque, and a thin whitish pellicle of fiitlse mem-
brane is deposited on the derma, and may be seen dirough the
raised epiderma.
The confluent and the discreet variety of small-pox frequently
occur together in the same individual, the eruption being con-
fluent on the fjEU^e,* and discreet on the rest of the body. When
the confluent form extends to the mouth and pharynx, the mu-
cous membrane is covered vrith pustules, degli^tion is rendered
exceedingly painful, and respiration is seriously impeded. In
the trachea the eruption gives rise to oough, and in the nasal
passages to sneezing and catarrh. On the eyelids the pustules
produce great tumefeiction, and severe inflammation of the con-
junctiva.
The eruptive period occupies five days ; one corresponding
with the varous stage, and the four following vnth the vesicular
stage.
IV. The period of suppuration or maturation commences on
the sixth day of eruption (ninth or tenth of invasion), by aug-
mentation of the contents of the vesicles, and conversion of their
contained lymph into pus. As a consequence of this change, the
vesicles lose their umbilicated character ; they become spheroidal
* The emptkm is alwajf most conflaent on those parts of the body where some
external source of irritation is added to that of the disease. Hence the eruption is
always most abundant on the face, the hands, the buttocks and inner sides of the
Ihiffhs in children, &c. Sydenham remarks, that if there be 10,000 pustules on the
entire body, 2000 of these will occupy the face.
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COURSE OF VARIOLA. 79
and flattened, and their whitish wpearance gives place to a tint
of yellow of increasing depth. Maturation is complete on the
eighth day of eruption. On the eighth day, also, the secondary
fever is developed, and continues until tlie eleventh, during
which time the pustules burst, and give exit to a portion of their
contents ; the period of desiccation is then established.
In the confluent variety, the inflammation, instead of being
confined to a number of distinct points, is distributed over a
large surfEice ; isolated pustules, consequently, are not formed,
but the production of pus occupies a district of considerable
extent. On the fieu^e, the raised epiderma frequently begins to
desiccate into a thin yellowish crust before the formation of
pus is completed ; the pus in this case is efiused belieath the
crust, giving to it additional thickness, and a characteristic
brownish hue.
Suppuration is first perceived on the face, whence it extends to
the rest of the body, diowing a disposition to affect those parts
first which possess the thinnest and most delicate skin. For this
reason it is that the feet and hands are the parts last observed to
undergo the suppurative change. The completion of the sup-
purative stage on the eighth day of eruption is attended vrith
considerable pain and tJbrobbing, with a vivid redness of the
skin, with great tumefaction, and a distressing sensation of ten-
sion of the integument. The swelling affects, in the first instance,
ibe head and &ce, from these it extends to the trunk and limbs,
and from the latter to the hands and feet. The eyelids are ofiien
so much swollen as completely to bury the eyes ; the nose and
lips are much enlarged ; there is swelling and congestion of the
mucous membrane of the mouth, and (in the adult) profuse
salivation ; the lining membrane of the alimentary canal sympa-
thizes in the general irritation of the mucous surfaces, as may be
inferred from the presence of diarrhcea. And the nervous sys-
tem is greatly depressed, as is shown by the listlessness and
lethargy which are conspicuous at this period.
Widi this extreme of local disorder, the secondary fever is
established, and continues unabated until the close of the
eleventh day of eruption. In mild cases this stage is accom-
panied by moderate delirium. But in more severe cases, the
tongue becomes brown, the symptoms assume the low typhoid
type, there is hard cough, with haemoptysis, and sometimes
haematuria.
In confluent small-pox, the secondary fever is not developed
until the eleventh day ; the symptoms are severe, and are onen
accompanied by restlessness, which increases towards night
This state of restlessness is a dangerous symptom.
V. The period of desiccatian is indicated by subsidence of the
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80 CONGESTIVE INFLAMMATION OF THE DERMA.
tumefEiction of the skin, bj the drying up of the pus and purulent
discharge produced during the preceding period, and by the
conversion of these fluids into scabs of various thickness. De-
siccation commences on the face much earlier (eighth day of
eruption) than on the rest of the body, and it not unfrequendy
happens that crusts are present in this region before the pustules
have attained maturity on the limbs. The crusts are formed in
two ways, either by rupture of the pustules and desiccation of
the purulent discharge which is poured out by the exposed and
ulcerated surface, or by the desiccation of the entire pustule with
its investing epiderma. The former is the more frequent method
of dieir production. When the crusts fiedl, an event that occurs
upon successive parts of the body, from the eleventh to the four-
teenth day of eruption, the skin beneath is of a bright red colour,
retaining this hue for several weeks, and the newly-formed epi-
derma is thrown off by repeated desquamation. The cicatrices
also which have been produced by the ulcerations now become
apparent
In die confluent variety, as has been already remarked, the
crust on the face commences to be formed before the completion
of the suppurative process, often as early as the eighth or ninth
day of the eruption. This extensive crust forms a complete mask
to the features, and remidns attached for ten or twelve days.
When it falls off, the skin beneath presents a vivid red colour,
and desQuamates freely, bringing into view a surfeu^e too fre-
quentiy oisfigured witii deep pits, and seamed with extensive
cicatrices. The crusts of confluent small-pox are soft and sod-
den with the fluids poured out by the inflamed skin, and their
fall is not completed tUl the twentieth or twenty-fifth day.
The desiccation of tiie pustules of small-pox is attended with
severe itching, which induces the sufferer to scratch, and often to
tear the surface with his nails. By this proceeding haemorrhage
takes place from the ulcerated surface, and the drying of this
fluid gives rise to a black discolouration of the scabs which
form over the wounded parts. The desiccation of the pus and
of the purulent discharges is attended by a nauseous and offen-
sive odour.
It is remarked by Simon, that the urinary secretion in variola,
undergoes changes having relation to the various stages of the
disease. That, in the beginning, when the fever assumes the
character of synocha, the urine is diminished in quantity, and
increased in specific gravity ; its colour is deep and red ; it is
frequently turbid, and often contains a small quantity of albu-
men. In the eruptive stage, as ascertained by Becquerel, in
five cases, in which the symptoms were severe, " the urinary
secretion was diminished, and amounted on an average to only
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INOCULATED VABIOLA. 81
23*5 ounces in twenty-four hours. The specific gravity had not,
however, increased so much as might have been supposed, being
only 1020.6. It firequently threw down uric acid precipitates,
either spontaneously, or on the addition of nitric acid, and in
one case a little albumen was observed." " According to Schon-
lein,in the first stage of variola it is of a reddish brown tint; on
the third or fourth day a sweat of a peculiar and strong odour
is observed, ajid the urine contains a turbid, apparently puru-
lent mucous sediment, of an unpleasant odour."
" During the suppurative stage of variola, Becquerel observed
that the urine retained the synochal character as long as the
symptoms continued." And in cases in which this fever per-
sisted until death, the state of the urine also remained the same.
Sediments and frequently purulent mucus occur in the urine
of this period.
'^During the period of desquamation the urine is either
normal or ansBmic.*^
In the nervous form of variola the urine is very changeable,
and often dark. ^^ In the putrid form the urine appears decom-
posed, ammoniaeal, and not unfrequentiy of a dark red colour,
from the presence of haematin."*
INOCULATED VARIOLA.
134. The intent of the operation of inoculation is to bring
some portion of the fluid contained within the small-pox pustule
into relation, either with the papillary surface of the derma, or
with the tissues situated immediately beneath the epiderma of
a sound person. When this object has been effected, the inocu-
lated particles dissolved in the fluids of the tissues are conveyed
by imbibition into the system, and communicate to the whole
mass of the blood a disposition to the production of matter of a
similar kind.
135. The local signs indicating that the inoculation has taken
effect, are first perceived on the third day from the operation,
when a slight blush of redness is seen around the puncture ; this
is accompanied by a trifling degree of itching, and the skiix feels
hard and dense when touched vnth the finger. On the fourth
and the fifth day these signs continue gradually to increase;
there is a sensation of pricking and tingling in the inoculated
spot, and a small elevation begins to be formed in the centre of
the areola. On the sixth day an incipient pustule is formed
by the efiusion of liquor sanguinis beneath the epiderma ; the
vesicle at this period begins to be depressed at its centre, and
to assume the umbilicated appearance. On the seventh day,
* SimoD, vol. iL, p. 282.
6
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82 CONGESTIVE INFLAMBfATION OP THE DERlfA.
there is tenderness of the integument around the yesicle, and
some degree of pain is felt upon moving the arm ; the vesicle
itself begins to look whitish and opaque ; the contained lymph
quickly gives way to the formation of pus, and the vesicle is
surrounded by a purplish areola. By the ninth or the tenth
day the pustule has lost its umbilicated character, and has at-
tained its perfect development. After the completion of the
pustule, the areola declines in redness, and its contents desic-
cate, the desiccation taking place during the period intervening
between the twelftti and the fifteenth day, and forming a scab of
a deep brown colour, and considerable thickness. The crust is
thrown off from the twentieth to the twenty-fiflli day, and is suc-
ceeded by a strongly marked cicatrix, which remains apparent
for the rest of life.
136. The period of invasion of the constitutional symptoms in
inoculated small-pox usually commences on the ninth day. They
resemble in character those of sporadic variola, but are mild,
and sometimes so slight as to be scarcely recognisable. In-
stances are occasionaUy met with in which the symptoms of
invasion are developed, and followed by eruption, without any
signs of inflammation in the part inocidated, and consequently
without the formation of a pustule.
137. The period of eruption in inoculated small-pox is irre-
gular in its occurrence, appearing generally on the second or
fiiird day from invasion, or on the eleventh or twelfth from in-
joculation* Occasionally it is observed at the end of a week after
inoculation, and sometimes it is protracted to a fortnight The
eruption is ordinarily very slight, sometimes failing altogether,
or being scarcely perceptible ; while, in rare instances, the erup-
tion may occur at several successive periods, or the confluent
variety of eruption be developed.
The eruptive period of inoculated small-pox is sometimes
complicated with an erythematous inflammation of the skin, con-
stituting variolous roseola.
VARIOLA SINE VARIOLIS.
138. This form of variola is rare ; it has, however, been occa-
sionally observed during the prevalence of an epidemic of variola,
iEUid is characterized by the presence of the constitutional symp-
toms and mucous inflammation of that disease without the cuta-
neous eruption. Sydenham assigned to this affection the name
of variolous fever, and the accuracy of his observations have been
confirmed by subsequent writers. Rayer remarks that he has
never seen an instance of this variety of small-pox.
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COMPLICATIONS OF VABIOLA.
COMPLICATIONS OF VARIOLA.
139. Hitherto the &yourable course only of variola has been
described, but the disease is not unfrequently attended with
complications^ which give it the character of a dangerous and,
ofiten, fatal disorder. These complications maj occur during any
one of the five periods into which the progress of -the affection
has been divided.
Instead of pursuing the milder course above indicated, the
period of invasion is occasionally marked by symptoms of ex-
cessive severity, the accompanying fever runs high, the rigor
whi(di precedes it has been long and enduring, and the pains in
the head, the chest, the prsBCordia, and the loins, are so violent
as to lead to the suspicion of inflammation of organs situated
in those regions. There is sometimes delirium and coma, at
other times convulsions ; and death may occur before the erup-
tive stage is established. In cachectic states of the system, the
period of invasion is sometimes complicated with passive haemor-
rhages from the mucous membranes, and from any trifling wound
of the skin, and by petechia in the tissues of both structures.
The period of eruption like the preceding is liable to its acci-
dents ; instead of the favourable course already noted, serious
congestions of one or more of the internal viscera may ensue.
Sometimes the congestion is directed upon the brain and spinal
cord, producing twitching of muscles, restlessness, convulsions,
or coma; sometimes on the lungs, causing bronchitis, pneu-
monia, or pleurisy ; sometimes on the mucous membrane of the
alimentary canal, giving rise to diarrhoea, dysentery, or hemor-
rhage ; and sometimes upon other of the abdominsJ organs. In
cachectic diatheses, passive heemorrhages and petechise may ac-
company this period ; and under any of the above complications,
the case may prove fatal before the completion of the eruption.
The eruptive process is liable to suffer seriously by these com-
plications ; thus, the variolous vesicles, instead of progressing,
become stationary and flaccid, or distended with a sanguinolent
and serous fluid.
The period of suppuration, as it is the most severe in its
symptoms, is also the most dangerous in its complications, and
the most frequently fatal in its results. Alarming symptoms
sometimes appear vrith astonishing rapidity, and detroy life in
a few hours, or even in a shorter period. Affections of the brain,
of the larynx, and of the trachea, are most to be apprehended
during this period. When these secondary affections are
severe, the pustules remain stationary, or become flaccid, or are
converted into sanguinolent bullae ; sometimes they are ac-
companied by petechia and passive haemorrhages, and in rare
g2
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84 CONGESTIVE INFLAMMATION OF THE DERMA.
oases disappear bj the absorption of their purulent contents.
The latter occurrence is always fatal. Other dangerous indica-
tions of this period are, the absence of the tume&ction and red-
ness of the skin, the absence of salivation, the appearance of
the brown tongue of low typhus, restlessness and anxiety, mor-
tification of any part of the skin, &c.
The termination of variola is a period of much anxiety ; for
when the disorder has run favourably through its stages, and the
danger of the disease has apparency passed away, secondary
affections are not uncommonly developed, as consequences of
the variolous inflammation. Such are, chronic inflammation of
the various mucous membranes, producing deafness, ophthalmia,
opacity of the cornea, staphyloma, oedema glottidis, haemoptysis,
pulmonary tubercles, chronic bronchitis, pneumonia, pleuritis,
empyema, chronic diarrhoea, &c., glandular enlargements, caries
of the bones of the face, subcutaneous abscesses, furuncles, ery-
sipelas, gangrene of the skin, disease of joints, monorrhagia,
miscarriage, heematuria, abscess of the kidney, and numerous
other sequelae. The cause of these various complications must
be referred to some peculiarity of constitution, and cannot be
explained by ordinary circumstances. Sometimes they would
appear to depend on the vicissitudes of season, the depth of
winter and the height of summer being most frequently attended
by adverse consequences.
Variola is occasionally complicated with rubeola and scarla-
tina, and sometimes with petechiae. The latter form of small-
pox is very severe in its affection of the mucous membranes
and viscera, but the cerebral symptoms assume a milder type.
140, Pathology. — On examination after death of those who
have fallen victims to small-pox, several of the internal organs
are found to present traces of congestion, particularly the brain,
the lungs, and the surface of the gastro-intestinal mucous mem-
brane. The tissue of the lungs is generally found congested
and infiltrated, and the serous coat of the bloodvessels is stained
of a deep red colour. Pustules are discovered upon the mucous
membrane onlv when the patient chances to perish at the com-
mencement 01 the suppurative stage. At a later period they
are usually lost, on account of the early rupture of the epithe-
lium, which, from its thinness and softness, is less resistant than
the homy epiderma. For the same reason the pustules upon
the mucous membranes never attain a size equal to those of the
cutaneous surface, and rarely contain pus. When ruptured, the
sur&ces occupied by these pustules are found to be covered with
loose laminae, and shreds of false membrane.
The situations in which pustules have been observed on
mucous surfaces are the extremities of the alimentary canal,
where the epithelium is thick — namely, in the mouth, pharynx,
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PATHOLOGf OP VARIOLA. 85
oesophagus, and rectum ; Rostan detected them throughout the
entire intestinal canal; on the respiratory mucous membrane
— namely, in the larynx, trachea, and bronchi, and in the urinary
llladder.
141. The form of the pustule of small-pox is strikingly modi-
fied in reference to the seat of its development. Thus on the
fiu5e, where the pustules advance very rapidly to maturity, they
are flat, and non-umbilicated. On the palms of the hands, and
on the palmar surface of the fingers, they rise gradually from the
surface, are but little raised above the level of the surrounding
skin, and are also non-umbilicated. On the soles of the feet, again,
they are large in extent, and still more flat than the preceding,
appearing like purplish disks with a distinct white margin, and
non-umbilicated. Usually, the umbilicated centre presents a
reddish or brownish tint, and sometimes, though rarely, it is
perforated by the shaft of a hair.
142. When a well-formed and mature pustule is examined
by dissection, it is found to be divided in its interior by a trans-
verse septum into two chambers, both containing pus. The
upper chamber is the larger of the two, and they communicate
vnth each other, to a greater or less extent, by the rupture of the
transverse septum around its marginal border. The epiderma,
forming the superficial boundary of the pustule, is the segment
of a sphere, and continuous by its circumference with the cuticle
covering the adjoining skin. The transverse septum is a layer
of false membrane, of a whitish colour, which was deposited on
the derma at an early stage of the pustule. Subsequently this
layer becomes separated from the derma, and raised by the for-
mation of pus beneath it, and at the same time it is broken
around its edges, and permits the pus of the deeper cavity to
communicate with that already contained in the superficial
chamber. In consequence of the peculiarity in the mode of its
production, this layer of false membrane generally retains per-
manently the umbilicated form of the primitive pustule, and is
thinner at the centre than towards its circumference. When
the septum is removed, the deep chamber is brought into view,
and the depressed and sometimes ulcerated base of the pock
exposed. The surface of the base is of a bright or purplish red
colour, and highly vascular.
Some diflerence of opinion subsists with regard to the cause
of the umbilicated appearance of the pustule of variola during
its early stages. Dr. Heming, many years since, attributed it
to the perforation of the pustule by the eflerent duct of a sebi-
parous gland. Velpeau, who believes that the principal seat of
small-pox is in the follicles of the derma, would, I suppose,
entertain the same opinion. Other writers believe it to be pro-
duced by the pores of the skin, and Bayer refers it to the at-
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86 CONGESTIVE INFLABfMATION OF THE DERMA.
tachment of the false membrane. I am disposed to take another
view of this depression, and believe it to depend on the close
adhesion subsisting between the epiderma and the first affected
papilla of the derma. The inflammation of this papilla has
almost completed its course before that of the surrounding
papillae has taken on the effusive stage : the central papilla
consequently occupies a different pathological position to the
rest of the papillae involved in die variolous inflammation.
This opinion seems confirmed by the muldlocular character of
the vesicle at its height, the only period when its true character
can be determined. Thus Grendrin compares its appearance,
when examined by means of a transverse section, to a spice-
box, while Bousquet likens it to a severed orange.
143. Diagnosis, — The precursory symptoms of small-pox are
liable to be mistaken for simple fever, or inflammation of such
of the viscera as may chance to be most affected. Pains in the
loins, according to Chomel, are pathognomonic; vomiting is
more frequent and the pains in the limbs are somewhat greater
than in other exanthemata, and convulsions in children are
more fi^quent. The prevalence of an epidemic of this disease,
or the previous exposure of the individual to the influence of
contagion, are alone calculated to raise suspicion in the mind
of the practitioner until the true nature of tlie symptoms is con-
fessed by the appearance of the eruption. When first developed,
the eruption presents considerable resemblance to rubeola, but
from the latter it may be distinguished, as well by the nature of
the previous symptoms, as by the more decidedly papular cha-
racter of the eruption, and the rough sensation which the papulse
communicate to the finger.
It is utterly impossible to confound the mature pustules of
small-pox with any of the pustular affections of the skin.
144. Causes. — It is affirmed by Mr. Moore in his " History
of Small-pox,** that this disease existed in China and Hindos-
tan, more than 1000 years before the birth of Christ. After a
long period it appears to have made its way into Arabia, and to
have shown itself in the Arab host at the siege of Mecca, in the
year of the birth of Mahomet, 569. Pursuing the track of armies,
we find it raging in Egypt in 640, and subsequently following the
victories of the Saracens in the eighth century, through Italy,
Spain and France. By the Saracens, the disease was commu-
nicated to the Crusaders, and the latter caused its rapid spread
throughout Europe. "There was no small-pox in the new
world before its discovery by Columbus, in 1492. In 1517, the
disease was imported into St Domingo. Three years later, in
one of the Spanish expeditions from Cuba to Mexico, a negro,
covered with the pustules of small-pox, was landed on the
Mexican coast. From him, the disease spread with such deso-
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CAUSES OF VARIOLA. 87
lation, that within a yery short time, according to Robertson,
three millions and a half of people were destroyed in that king-
dom alone. Small-pox was introduced into Iceland in 1707,
when 16,000 persons were carried off by its ravages ; more than
a fourth part of the whole population of the island. It reached
Greenland still later : appearing there, fDr the first time, in 1733,
and spreading so fatally as almost to depopulate the country.^
Small-pox occurs at all periods of life, from the foetus in the
womb to the last hours of senility. It is developed equally in
the two sexes, in all seasons, and in all climates. It may appear
as a sporadic affection, or epidemically. In the latter form, its
invasion is most frequently observed in tJie 8umi]Ser, or the
autumn season.
The cause of small-pox is a specific animal poison ;t the
period when transmission is most likely to happen being the
suppurative stage, and when developed epidemically, it is pro-
pagated in the direction of the prevailing winds. As a general
rule, small-pox attacks but once in a life-time, but against this
rule many exceptions have been recorded. Instances have been
observed, in winch tJie disease has invaded a second, a third,
and even so often as a sixth time. Sometimes the subsequent
attack is as severe as the first, but usually the secondary affec-
tions are remarkable for mildness and rapidity of course.
The protective agency of an attack of variola against subse-
quent invasions of the disease, was known at a very early period
in medical history ; thus, inoculation was practised in Constan-
tinople in 1673, and the practice was subsequently introduced
by Lady Montague into England, whence it extended to the
continent of Europe. The intention of inoculation is to pro-
duce an attack of the disorder, at a period when the physical
powers are sound, and capable of resisting its influence, by
means of inoculation. Moreover, it is found that the inoculated
disease is always more mild than the sporadic affection. Several
serious objections, however, raise themselves against inocula-
tion, and one of these so great as to have been deemed worthy
of a restrictive act of the legislature. The most obvious rea-
sons that oppose themselves are — ^firstly, that the system is
equally, perhaps more safely protected by the milder operation
of vaccination ; and, secondly, that inoctdation often produces
a severe and dangerous disease. But the most important ob-
jection to the continuance of the practice is, that the small-pox
engendered by inoculation, may be communicated to others by
contagion ; and, consequently, that one such case may become
♦ Dr. Watson's Lectures, first edition, vol. il, p. 657.
f Seyeral authors have imagined the cntaneoos eraption of small- pox to depend
npon the presence of minute animalcules ; but carefiod obserration afibrds no ground
for this supposition.
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88 CONOESTIVE INFLAMMATION OF THE DERMA.
the source of a fiGktal and deyastating epidemic. An instance of
this kind is related of Maria-Theresa of Austria, who having
inoculated a number of children, the small-pox was communi-
cated by the latter to an entire village.
145. Prognosis. — In the discreet form of variola, or when the
eruption is slight, and its course mild, the prognosis is favour-
able, usually terminating in £rom two to three weeks. In the
confluent form there is considerable danger, and the disorder
requires to be watched with care, for symptoms of a fatal nature
are apt to show themselves suddenly and unexpectedly, and the
disease is prolonged to three or four weeks. Small-pox is of
unfavourable prognosis when it presents irregularities in its
course ; when it is complicated with much cerebro-spinal or pul-
monary irritation; when the pustules contain a . sanguineous
fluid,. or are intermingled with petechiae; when the eruption is
associated with debility of system in the patient, or with signs
of violent depression, as fear, &c. ; when the pock does not pass
reg^arly through its stages, or when the persons affected are
plethoric, and unused to disease.
146. Treatment, — The uncomplicated form of small-pox re-
quires the most simple plan of treatment — namely, confinement to
bed, diluents, cooling regimen, cool and equable temperature,
frequent change of linen, and an attention to symptoms as they
arise. Meddling in variola is calculated to be as injurious as in
other eruptive diseases depending for their origin on a specific
poison ; and it must be borne in mind, that any vascular deter-
mination to the surfSeu^, whether internal or external, will be
followed by an increase in the number of pustules developed on
the irritated spot. Thus an incautious purgative at the outset
of the fever may induce so great a congestion of the mucous
membrane of the alimentary canal as may terminate seriously.
The treatment of variola in its simple form is consequently
expectant; very little is required of the practitioner during the
fever of invasion beyond the maintenance of a cooling regimen,
keeping the bowels gently open by saline purgatives, and
sponging the skin with tepid water.
At the commencement of the secondary fever, the proper
remedies are febrifiige salines, such as the liquor ammonis
acetatis, or efiervescent salines ; and at a more advanced period
a continuance of gentle laxatives or enemata, and opiates to re-
lieve restlessness, sleeplessness, and nervous symptoms. Should
the powers of the system seem to require support, this is the
period when wine and a more nourishing diet may be allowed ;
the effects of the wine being carefiilly watched.
If the cerebro-spinal system be much disturbed, leeches to the
mucous membrane of the nose or behind the ears, with mustard
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TREATMENT OF VARIOLA. 89
foot-baths ore indicated ; gargles for inflammation and dryness,
of the mucous membrane of the mouth and fauces ; leeches to
the epigastriiun for pains in that region, with violent vomiting ;
mineral acids with infusion of roses, for haemorrhages, and
emollient applications to the eyelids where the conjunctivaB are
painful and swollen. If the eruption be tardy in its appearance,
the patient may be inunersed in a warm badi, at the same time
that tartarized antimony and sudorifics are administered inter-
nally. Opiates are contra-indicated in the primary fever, on ac-
count of the extreme excitability of the nervous system ; in the
secondary fever they are frequently highly useful. Sydenham
recommended a small bleemng at the commencement of the
secondary fever, and following it up with an opiate ; but he cau-
tions us against abstracting too much blood. The safer prac-
tice is not to bleed, and in this opinion the profession are gene-
rally agreed.
These are the remedies which are applicable to small-pox in
its ordinary and uncomplicated form ; but when the disease as-
sumes any of the unfavourable characters which have been de-
scribed, other measures are indicated, such as local bleedings,
and counter-irritation. Local bleeding by leeches or cupping
may be employed at any period of the disease, when the symp-
toms indicate serious congestion of viscera ; the abstraction of
blood must, however, be conducted with caution, lest too great
debility follow its use. Counter-irritation is applicable when
the removal of blood by bleeding would be inadmissible. Under
the same circumstances, again, mild purgatives may be admi-
nistered, when symptoms of gastro-intestinal irritation are ab-
sent But purgatives, it must be recollected, are calculated to
excite and keep up irritation of the mucous membrane, and they
may frequently be very judiciously superseded by emollient in-
jections. At the close of the eruption, the employment of gentle
laxatives is indicated, and if much debility be present, tonics
should be had recourse to, and their action aided by wine and
nutritious diet. When there is pain and heat of head, with de-
lirium, which depletion from the mucous membrane of the nose
and behind the ears has been unsuccessful in removing, ice may
be applied to the head, or the cold water pillows recommended
by the late Professor Davis for hydrocephdus, or still better, the
cold cushions of Dr. James Amott*
When the nervous system is especially affected, as in that
variety termed by Dr. Gregory nervous variola, the administra-
tion of tonics is called for ; and similar means must be adopted
when there is evidence of a cachectic state of constitution, as
* See Lancet, toI. iL, 1841-2, page 441.
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90 CONGESTIVE INFLAMMATION OF THE DEBMA.
in the occurrence of petechisB, passive haemorrhages, &c. What-
ever the treatment adopted, however, these cases are too fre-
quently fatal.
Cold afiusion has, at various times, been extolled by eminent
practitioners, but the plan has been only sparingly adopted.
Some have recommended that it should be conducted in the
manner laid down for scarlatina^ while others confine themselves
to sponging the surface of the body, or the face alone. Cold
water does not appear to have the effect of causing retrocession
of the pustules, but it is thought to increase the congestion of
the mucous membranes. My brother, Mr. George Wilson, has
pursued the practice of sponging the surface for several years,
and he assures me vnth the best success.
The belladonna treatment recommended for scarlatina is also
applicable to small-pox. I have seen this remedy exhibited
widi the greatest benefit, both as a prophylactic and a curative
measure.
Vaccination has been observed to possess the power of modi-
fying variola, even when an attack of the latter has already com-
menced. Some remarkable cases are on record in which the
good effect of this remedy was apparent. It recommends itself,
moreover, by its extreme simplicity of application. Eichhom,
who was the projector of this plan, inserted the vaccine lymph
by forty or fifty incisions, immediately that the symptoms of
small-pox became apparent.
147. As regards local treatment, various plans have been
adopted and recommended for the purpose of bringing the pus-
tules to a favourable issue, and of preventing the deep ulcera-
tions, vdth their consequent cicatrices, which are apt to ensue
when the eruption is left to itself. We vrill now proceed to con-
sider these plans, but, before doing so, it may be necessary to
premise that every precaution should be taken to prevent the
rupture and laceration of the pustules by the nails of the patient,
in efforts made to relieve the itching by which the desiccating
process is accompanied. The face should be frequently and
well bathed vnth an infusion of poppies, or mallow, with weak
barley water or a weak solution of common salt, particularly in
the region of the eyes, the nose, and the lips. The secretions
from diese parts should be removed as much as possible by
means of a sponge wetted with these fluids, and whenever an
excoriation is formed, it should be anointed with a liniment
composed of equal parts of olive oil and lime water^ or dusted
with starch powder.
Great benefit is derived from pursuing the practice of the
Arabian physicians — namely, of opening the matured pustules,
gently pressing from them their contents, and removing the
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TBEATMENT OF VABIOLA. 91
latter by means of a sponge wetted with plain water, or with an
infusion of poppies. This plan accelerates very materially the
healing of the ulcerations, and prevents the formation of deep
and disfiguring cicatrices. «
148. Various ectrotic* methods of arresting the development
of the eruption of variola, and consequently, of preventing the
occurrence of cicatrices, have, firom time to time, been suggested
and employed. Nitrate of silver has been used for this purpose
by MM. Serres, Bretonneau, and Velpeau. If the apex of each
conical vesicle be removed, and the pointed extremity of a stick
of nitrate of silver be inserted into the opened vesicle, its further
progress will be instantly arrested. But this proceeding is ne-
cessarily attended with much pain, and requires a considerable
period of time for its performance. To obviate these objections,
it has been proposed to paint the entire surfEU^ with a solution
of nitrate of silver, containing fifteen or twenty grains to the
ounce. The application of this fluid to a surface of any extent
has been found to be dangerous, in consequence of giving rise
to a considerable increase of the febrile symptoms, while the
anticipated effect of checking the progress of the eruption has
only partly succeeded. The solution used in this manner forms
a mask to the part upon which it is applied, beneath which the
pustules advance unseen and unaltered. The nitrate of silver
as an ectrotic remedy is only available, therefore, for the erup-
tion situated upon the face and neck, and to this it must be used
quite at the outbreak of the disease — namely, on the first or
second day, otherwise it will be liable to failure. In summing
briefly the objections to the employment of nitrate of silver, they
may be stated as follows : — firstly, it creates pain ; secondly, it
requires more time for its application than the practitioner can
devote ; and thirdly, it augments the febrility and nervous ex-
haustion of the patient.
149. Another ectrotic remedy has been warmly eulogized by
Dr. Midivaine,t of Ghent It consists in the application of sul-
phur ointment by means of slight firiction to the entire surface
of the skin. This ointment should be composed of two drachms
of sulphur to an ounce of lard, and used three times a-day, at as
early a stage as possible of the disease. The effects of the
remedy, according to Dr. Midivaine, are, contraction and
hardening of the papulae, diminution of tumefaction of the
skin, and subsidence of the gastro-intestinal irritation. The
appetite of the patients quickly returns, and they are speedily
restored to healtn.
150. A more important ectrotic remedy than either of the pre-
♦ EcrirpfixTKciv, to render abortiye.
t Balletin de la Soc. Med. de Gaod, 1840.
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92 CONGESTIVE INFLAMMATION OF THE DERICA.
ceding, is one which has lately been made the subject of an
essay,* read before the Parisian Medical Society, by their pre-
sident. Dr. Oliffe. This remedy is mercury, applied to the ex-
ternal surface of the body, aiyi is one which is deserving our
most attentive consideration. Mercury administered internally
has long been known to possess remarkable powers in modify-
ing the influence of variola upon the system, but it was left to
modem times to prove that this agent has also the property of
neutralizing the variolous virus when applied externally. I pass
over the well-known and unmeaning experiment of Von Wenzel
— namely, the trituration of the variolous matter with calomel,
and the subsequent marvel that the virus should have lost its
inoculating power, to the more rational experiments of Serres,
afterwards so successfully pursued by M. Briquet The mer-
cury was employed by these gentlemen in the form of a plaster,
the emplastrum vigo cum mercurio, of which the formula in
the French pharmacopoeia is as follows : —
ft
Mercury 95 parts.
Balsam of storax 48
Common plaster 312
Wax, resin, turpentine, ana 16
Gum ammoniac, bdellium, olibanum, and myrrh, ana 5
Saffron 3
bpirit of layender 2
M.
In the first experiment, a strip of this plaster was placed on
the arm of a patient attacked with variola, while a similar strip
of diachylon plaster was applied to the opposite arm. Under
the mercurial plaster the development of the eruption was ar-
rested, under the other plaster no modification took place. In
a second case, the face of the patient was ^^ covered with the
plaster, a part of which he tore ofi* during the night which fol-
lowed its application. The denuded surface was the seat of
suppurating pustules, whilst on that portion of the visage which
continued subjacent to the plaster, their abortion was effected.**
In a third case — a man affected with " violent confluent variola,
the pimples were small, scarcely raised above the level of the
epiderma, and surrounded widi a brilliant red areola. The
vigo plaster was applied, and allowed to remain seven days ; on
its removal, it was found that no suppuration had been esta-
blished, with the exception of four pustules, and these were
situated near the mouth, and had not been in contact with the
plaster. This patient was radically and rapidly cured, and no
scars were manifested."
The mode of application of the mercurial ectrotic is thus
• Lancet, toI. i., 1840-41, p. 674.
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TREATMENT OF VARIOLA. 93
Stated by Dr. Oliffe : — " The whole face should be covered with
a mask of the vigo plaster, merely leaving a space for the mouth,
nostrils, and eyes. A litde mercurial ointment is applied to the
eyelids." " The plaster is allowed to remain for three days in
simple small-pox, and for four in confluent.*' In the event of
any objection to the plaster arising, mercurial ointment may be
substituted with a fisur prospect of benefit M. Serres enter-
tained the belief that the mercurial treatment would efiect the
miscarriage of the eruption, at whatever period it was used ; but
M. Briquet has satis&ctorily shown that the- eruption remains
unmodified, if it have reached its pustular stage. The proper
period for the application of the remedy is the second day, or,
at the latest, the third day of the eruption. Its effect is to pro-
duce immediate resolution of the eruption, or to arrest it at the
papular or yesicular stage ; it never becomes purulent, and the
skm between the pustules is never inflamed and swollen. But,
however powerless as a perfect ectrotic the mercurial application
may be when used in the pustular stage, it would seem from the
evidence of Dr. Oliffe, that the local inflammation is much modi-
fied and ameliorated. According to M. Briquet, " the mercury
acts as an antiphlogistic, or resolutive, in destroying or suppress-
ing the local inflammatory process ; or it exercises a specific
action on the cause, whatever it be, which produces the vario-
lous pustule.** From the researches of M. Briquet on other in-
flammations of the skin, the latter of these propositions would
appear to be the most correct.
It is interesting to learn, that in the progress of his experi-
ments, M. Briquet ascertained that mercury possessed precisely
the same influence over vaccinia as over variola — an additional
fact in evidence of the identity of these diseases.
151. An impression subsisted among the ancient physicians,
that the light of the apartment in which small-pox patients are
kept, should be either modified or excluded. In pursuance of
this view, and at the suggestion of John of Gaddesden, the
rooms were hung with scarlet cloth, and the windows carefully
blocked up. So recently as 1832, Dr. Picton,* of New Orleans,
asserts, that in his practice no instance of pitting after small-pox
occurred when the light was shut out. M. Serres placed a glass
capsule over a smaU-pox pustule, and observed the effects pro-
duced by excluding the aur and light. He found, that in pro-
portion to the exclusion of both was the development of the
pustule checked, and that when they were completely shut out,
the pustule became shrivelled and quickly dried up. Moreover,
M. Serres remarks, that he never reaped such successful results,
* American Joamal of Medical Science.
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94 CONGESTIVE INFLAMMATION OF THE DERMA.
in the cure of small-pox, as he did at La Piti6, during one year
that the patients were placed in a kind of cellax, whidb was very
dark, and ill ventilated. The same principle has been more
recently acted on by M. Legrand, who proposed to the Academy
of Medicine, in 1839, the plan of covering the siir£a.ce of the
body with gold leaf. After the experiments of M. Fourcault
(§ 81), this practice would appear somewhat hazardous.
VARICELLA.
Syn. Modified Small-pox, Varioloid, Spurious Small-pox.
VdriokepusillcB ; verrucoscB ; crystaUiruB. Variola lymphatica,
Verole volantCy Fran. — Unachten KindpockeUy Germ.
152. During the prevalence of an epidemic of small-pox, the
variolous contagion develops itself in a variety of forms, some
of which are remarkable for their severity, and others for their
exceeding mildness. A medium state between these two ex-
tremes has been denominated benignant small-pox. Upon
closer investigation, it is perceived that benignant small-pox,
and all the most serious varieties of this disease, are charac-
terized by the appearance of an eruption pursuing a given course
within a given space of time, and presenting a regular succes-
sion of alterations. On the other hand, it is likewise perceived
that there are several forms of eruption resulting from the same
variolous contagion, which are deficient in the characters needful
for their consideration with the preceding group. They are
much milder in their local, and, for the most part, in their con-
stitutional nature, and their course is limited to a shorter period.
It is to this second group that the term varicella (modified small-
pox) properly appUes, and under this head I shall proceed to
describe the difi*erent varieties which small-pox, in its modified
form, i9 capable of assuming.
153. Variola, it has just been observed, occasionally appears
in its varicellax form without any obvious cause, the modification
probably depending upon some present state of constitution of
the individual. Thus, it not unfrequently happens, that a single
member of a family may be affected by varicella, while several
others of the same family have true variola. But the individual
so afiected with varicella in this instance, may, during a future
epidemic, be attacked with genuine small-pox. At other times,
and these are the most frequent, the eruption is modified by that
state of constitution which succeeds to vaccination, inoculation,
or a sporadic attack of small-pox. Hence, after the preparation
of the system by either of these afiections, the contagion of variola
gives rise generally to varicella, and but rarely to the genuine
small-pox. If other proof were needed of the close relation
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VARICELLA — VABIOLOID. 95
sabsisting between variola and varicella, it would be found in
the fajotf &at the latter is infectious and contagious, and is capable
of communicating true variola to a sound person.
154. Varicella, in this point of view, may be regarded as an
arrest of development of variola, and the forms which it is
capable of assuming may consequently be deduced from the
observation of the natural course of small-pox. Thus, if the
variolous disorder were to expend itself in its first stages, we
should have a varicella resembling the papular eruption of small-
pox, in other words, a papular varicella ; if the variolous disorder
progress beyond this stage, we shall then have a vesicular vari-
cella ; and if it proceed still further, a pustular varicella. The
latter, however, is capable of presenting some modifications ; in
one of these, the contents of the conical vesicles are simply
transformed into a purulent fluid, without any alteration of their
form ; this constitutes the conical pustular varicella : in another,
the purulent fluid distends the vesicle to so great an extent, that
it presents a globular figure ; this is the gbAular pustular vari-
cella : while in a third, the pustules assume the characteristic
features of those of variola, being flattened and umbilicated ;
this, which is the most advanced grade of varicella, is the urn-
hiUcated pustular varicella. Moreover, it has been remarked,
that in varicella, as in variola, the constitutional affection may
be present widiout the eruption, constituting varicella sine
variceUis.
It must not be supposed, however, that any one of these forms
occurs singly ; the distinction is intended merely to apply to the
general predominance of one or the other, for each variety is
more or less commingled with the rest, and, in some instances,
all the forms appear upon the same individual in nearly equal
proportion. In describing the varieties of varicella, it will be
convenient to reverse the order of relation here laid dowij ; thus,
in a tabular plan, these varieties are —
Pustular varicella.
Umbilicated pustular varicella.
Globular pustular varicella.
Conical pustular varicella.
Vesicular varicella. Papular varicella.
Varicella sine variceUis.
155. Varicella makes its invasion with symptoms resembling
those of small-pox, but much milder in degree. In some in-
stances, they scarcely amount to more than mere indisposition,
while, on the other hand, they may be severe. The chief of
these symptoms are, feverishness, uneasiness at the epigastrium.
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96 CONGESTIVE INFLAMMATION OF THE DERMA.
nausea, yomitingy pains in the loins and in the head^ with acce-
lerated pulse. At the end of a few days, usually three or four,
the eruption makes its appearance in the form of red points and
spots, which resemble those of small-pox. The constitutional
symptoms are relieved by the eruption, and gradually decline.
The eruption, however, proceeds on its course, advancing, if it
be of the pustular kind, quickly through the papular and vesi-
cular, to the pustular stage, arriving at its height by the fourth
or fifth day, and then declining without any increase of the con-
stitutional symptoms, and without the secondary or suppurative
fever which occurs in small-pox. The pustules speedily dry up,
and form thin brownish scabs, which fall in another few days,
and leave but a slight and transient pitting of the skin, with a
few discoloured red or purplish spots. When, however, the
pustules are broken and lacerated by scratching, cicatrices of
small size occasionally result Varicella, in its progress, is ac-
companied by a broad and patchy areola of a pale red colour,
which contracts its boundaries as the pustule advances, and
ultimately forms a narrow, brownish circle around its circum-
ference.
The urine in varicella when the fever is mild, differs very
little from the normal state of that secretion. '^ Schonlein states
that in the first stage of this disease the urine is often as limpid
as in hysteria.'' While " in a case of varicella, in which the
early symptoms were extremely severe, the urine was passed in
very small quantity, of a deep red colour and a specific gravity
of 1.022..7.''*
UMBILICATED PUSTULAR VARICELLA.
Syn. Variolmd, Modified smaU-pox, Varicdla celhdoia. Crocs.
156. The precursory symptoms of this variety of modified
small-pox, usually continue for three or four days, and are suc-
ceeded by an eruption of red spots, which soon become hard and
papular in the centre. On the second day of eruption, the
papulsB are conical in form, and vesicular at their points. On
the third and fourth days, ihe vesicles increase in size, and be-
come flattened and umbiUcated, while their contents lose their
transparency, and assume an opaque and whitish hue. During
the fifth and sixth days, the suppurative stage is established, but
without secondary fever, and the pustules on the face desiccate
and form scabs. On the seventh day, desiccation occurs on
other parts of the body, and by the eighth, the whole of the
pustules are covered widi yellowish brown scabs, which, in a
few days more, are detached, and fall off. The process of de-
* Simon, yoL ii., p. 282.
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VARICELLA GLOBULARIS. 97
siccatdon commences at the centre of the pustule, and proceeds
towards the periphery, and the scabs at their fall leave a slight
pitting, and red or livid discoloration of the skin, which lasts for
a few weeks, but no cicatrices or permanent impressions remain
behind.
Umbilicated pustular varicella is generally commingled with
the conical and globular forms of the eruption, and also with the
papular and vesicular kinds. It sometimes appears in succes-
sive eruptions, and in this case it is not uncommon to find on
the skin, at the same time, papulae, conical vesicles, with their
thin scabs ; and conical, globular, and umbilicated pustules, with
their thicker and browner scabs.
VARICELLA GLOBULARIS.
SjXL Globular varioloid. Hives.
157. The globular variety of varicella is characterized by the
form and large size of the pustules, which surpass that of all
the other varicellsB. At its height, the pustule is larger than
its base, which it consequently overhangs, and the latter is not
quite circular in outline. The precursory symptoms of this
variety are usually severe. They are succeeded by the eruption
of a number of red spots, having in their centre a small, pro-
minent, and globular papula, which speedily increases in size,
and becomes vesicular at its extremity. On the second or third
day of the eruption, the contents of the vesicles assume an
opalescent and pearl-white colour, particularly towards the
centre. On the fourth and fifth days, Ae vesicles go on increas-
ing in size, the contained fluid becomes purulent, and the areola
by which their bases are surrounded, of a bright red colour.
On the sixth, the vesicles attain their greatest bulk, their con-
tents are more purulent, and the areola still fiirther increases in
redness. On the seventh and eighth days they begin to diminish,
their parietes are flaccid and wrinkled, and desiccation is esta-
blished. On the ninth day, the desiccation of the pustules is
completed on the greater part of the body, and they are con-
verted into brownish lamellated scabs, which are loosened and
thrown off* during the two or three succeeding days, leaving be-
hind them some slight impressions, and a temporary congestion
of the derma.
Globular varicella is not unfrequently mingled with the pus-
tules of the umbilicated and conical varieties. The ordinary
duration of this eruption is ten or twelve days, but if the pustules
be developed successively, it may be continued for a few days
longer.
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98 CONGESTIVE INFLAMMATION OF THE DERMA.
VARICELLA CONIFORMIS.
S3ni. Conical variaiouL Swine -pox,
158. The conical variety of varicella is recognised by the form
of its pustules ; they are developed, like the preceding, after two
or three days of constitutional symptoms, upon red spots, which
soon become papulated in the centre, and surmounted by whitish
and opaque elevations of the epiderma. During the ihird day,
the size of the vesicle is increased, its form has become more dis-
tinctly conical, and its base more highly inflamed. During the
fourth and fifth day, die vesicles stiU further augment in bulk,
their contents become purulent, and the areola which surrounds
them, more inflamed. On the sixth day, they are flaccid and
wrinkled, and begin to desiccate ; and on the seventh are covered
by prominent scabs of a yellowish, or yellowish brown colour,
which fall in the course of a few days. The pustules of conical
varicella are sometimes very numerous, and collected into closely
set clusters; they are usually attended by considerable pru-
ritus, and are not unfrequentiy intermingled with the pustules
of the umbilicated variety. The ordinary duration of the erup-
tion of varicella conifomris is eight or ten days, but when it
occurs in successive attacks, it may be continued for a few days
longer.
When the vesicles are torn and broken in attempts made by
the patient to relieve the itching, the spots become greatly
inflamed, they ulcerate, and secrete a thick pus, which concretes
into scabs of greater thickness than those of the natural pustules.
These scabs are of a dart brown, or blackish colour, they remain
longer than the thinner scabs of the pustules, and leave cica-
trices at their fall. Such accidents occur most frequently upon
the face.
VARICELLA VESICULARIS.
Syn. VariceUa ienttfinrmis, Willan. Vancdla hfwphatica, Cktchen-pox,
1 59. Vesicular varicella, or chicken-pox, is preceded by febrile
symptoms, which are very mild in the discreet form of the erup-
tion, but severe in the confluent kind. The eruption makes its
appearance in the form of small red and slighdy raised spots,
of an oval or irregular form. On the second day, a minute
transparent vesicle is developed in the centre of each of these
spots. On the third day, Ae vesicles go on progressively in-
creasing ; they are flattened on their summits, and the con-
tained fluid, transparent and limpid at first, becomes yellowish,
opaque, and lactescent. On the fourth day, they begin to
collapse and shrivel, and on the fifth and sixth, to desiccate into
thin, brownish, and lamellated scabs, which fall on the eighth
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VARICELLA PAPULARIS. 99
or ninth day, leaving behind them a slight congestion of the
derma, but no depression. While this course is being pursued
by the vesicles which first appear, others are successively de-
veloped, so that the eruption may be seen at once in all its
stages, and may be prolonged to ten or twelve days, and some-
times to two or three weeks. The eruption of chicken-pox at
first appears on the back, and thence extends to the rest of
the body ; it is attended with much itching, and many of the
vesicles retain their papular or aborted form; the perfected
vesicles are surrounded by an inflamed areola of small extent.
VARICELLA PAPULARIS.
SyD. VcnriceUa verrucosii, Horn-pox. Vdriola verninosa ; verrucotce,
160. This is the most simple, and, at the same time, the least
severe form of varicella. After the invasion of febrile symptoms
of the mildest kind, an eruption of red spots, followed by
papulsB, is developed on the surface of the skin. The papulae
are various in point of size, and hard to the touch, but they offer
no disposition to proceed to the evolution of vesicles and pus-
tules. The redness fades in the course of a few days, and the
papulae are gradually lost The eruption of papular varicella
rarely exists alone, it is usually commingled with one or other
of the more advanced varieties.
VARICELLA SINE VARICELLIS.
161. Varicellar fever occurs chiefly in those who have been
inoculated or vaccinated, or have previously suffered from
variola. It is occasionally, though rarely, observed during the
prevalence of epidemic variola.
162. Diagnosis, — Varicella differs from small-pox in several
essential particulars — ^namely, in the lesser degree of severity of
the constitutional symptoms ; in the shortness of course of the
eruption ; in the absence of secondary fever ; in the appearance
of t^e eruption at its height ; in the minor degree of inflamma-
tion surrounding the pustules ; in the thinness of its scabs ; and
in the freedom from permanent impressions and cicatrices.
At the earliest moment of eruption, it is impossible to esta-
blish a distinction, since both affections are developed in the
form of red spots with central stigmata.
168. Cattses. — Varicella originates in the variolous contagion,
and frequently precedes or follows an epidemic of small-pox.
This observation would lead to the inference that, at the com-
mencement, the variolous contagion had not yet gathered suffi-
cient power to excite true small-pox in any but the most suscep*
tible, and that, at the conclusion of the epidemic, the contagion
h2
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100 CONGESTIVE INFLAMBfATION OF THE DERMA.
had lost the strength necessary to awaken any but a modified
affection. The inference, in truth, is correct, for when in a state
of dihition, the variolous contagion is capable of producing only
varicella in persons of average susceptibility. In those who
possess the susceptibility of infection in a high degree, true
variola may be excited ; and for the same reason, the contagion
of varicella is apt to communicate variola to individuals so con-
stituted. Another condition conducive to the development of
varicella is deficient susceptibility. In some instances, this
deficiency is the result of constitutional idiosyncrasy ; in others,
and they are the most usual, it is the consequence of a modifi-
cation of the system, produced by vaccination, by inoculation,
or by a previous attack of variola.
Varicella is infectious and contagious, and transmissible by
inoculation. Its contagion may excite either varicella or true
small-pox. The result of inoculation is similar; in one instance,
varicella may be developed; in another, true variola. The
variola communicated by varicella is for the most part mild, but
the severity of the affection would appear to depend upon the
constitution of the individual, rather than upon die nature of the
contagion. Varicella may occur repeatedly in the same person,
and it possesses less preservative power against the contagion
of small-pox than vaccination.
Vesicular varicella, or chicken-pox, is stated to have occurred
as an epidemic, and independendy of variola ; Dr. Mohl* ob-
serves, that at Copenhagen the chicken-pox occurred annually
between the years 1809-1823, without any association with
small-pox. And Dr. Watson remarks, " It must, therefore, I
think, be admitted that there is a separate disease called chicken-
pox, which springs from a specific poison." Vesicular varicella
is less easily transmissible than the other forms. When inocu-
lated, varicella of the same kind is sometimes developed, at
other times the pustular form, and again, true small-pox.
164. Prognosis, — Varicella is generally a mild disease, and
one of favourable termination. Sometimes, however, it issues
fatally, and during certain variolous epidemics, is remarkable
for the severity of its concomitant symptoms, or for a fatal ten-
dency. The umbilicated pustular varicella is the most serious
of its varieties.
165. Treatment — The treatment of varicella is to be con-
ducted on the same principles vrith that of variola. If there be
congestions, they must be combated as they arise ; and if the
eruption should recede, it must be re-excited by stimulation of
the skin. In ordinary cases, the simplest antiphlogistic manage-
ment is all that is needed.
♦ De Varioloidibns et Varicellis.
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CONGESTIVE INFLAMMATION OF THE DERMA. 101
VARIOLA VACCINA.
Syn. VariolcB vacciruB. Vaccinia. Caw-pox. Cow small-pox,
166. Variola vaccina, the small-pox of cattle, is a contagious
inflammation of the skin, prevalent among cattle, and occasion-
ally communicated to man. It is characterized by tiie develop-
ment, upon inflamed bases, of multilocular and umbilicated
vesicles, which pass by degrees into the pustular form, and
terminate in hard, dark-brown scabs, the latter leaving behind
them deep and permanent cicatrices. Variola vaccina is accom-
panied by constitutional symptoms, which are mild during the
first stages of the vesicle, but become more severe, and consti-
tute a secondary fever, when the local inflammation arrives at
its height, and the suppurative process is about to be esta-
blished.
167. The existence of a disease identical with small-pox
among the inferior animals, is a theorem that might, a priori, be
predicted. It is perfectly consistent with our knowledge of the
physiological laws, and comparative structure of man and ani-
mals. It is a position well established with regard to some
other diseases, and there can be no doubt that still further ana-
logies in relation to pathology will be unveiled by future research
in that most interesting branch of medical science. The an-
nouncement of the discovery of a disease analogous to small-
pox, in the cow, in the horse, or in any other animal, at the
present day, would occasion little surprise ; it is admitted,
indeed, as a principle, in the first rudiments of our physiological
education ; but when this declaration was made in 1796 by the
immortal Jenner, it was a bold soar of genius, and too en-
lightened for the philosophy of his age. It is now, however,
well-established, that small-pox has for centuries been preva-
lent among animals in all parts of the world ; that it has made
its invasion as an epizootic, and, for the most part, in connexion
with a similar pestilence among men. Jenner was acquainted
with the fact of the occurrence of a disease in the horse, which
was communicable to the cow, and capable of engendering in
the latter animal an eruption that could not be distinguished
firom the true vaccinia. This disorder in the horse was, un-
questionably, the equine small-pox ; it was, however, from the
circumstance of its development in a situation where, from the
thinness of the skin, eniptive disease in a mild form would most
naturally occur — namely, in the heels, confounded with a more
common disease of this region, the grease. By a wrong in-
ference drawn from this observation— an inference perfectly
natural and perfectly excusable in the state of science at that
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102 CONGESTIVE INFLAMMATION OF THE DERMA.
period, an inference which its distinguished author subsequently
relinquished — namely, that the variolse yaccinae had their origin
in the horse, — Jenner created an argument which, for many
years, was industriously employed as an objection to the philo-
sophy of his views ; with how little injury to the splendour of
his discovery, we who live can telL
168. In the excellent report* of the Vaccination Section of
the Provincial Medical Association, the committee remark that
the ravages of this epizootic are not confined to one region of the
earth ; that such as it has been seen in the valleys of England,
it has likewise been observed upon the mountains of the Andes,
on the elevated ranges of the Himalayas, in the plains of Lom-
bardy, in the green pastures of Holland, and on the sunny
slopes of Asia. It is interesting, moreover, to learn, that in
Bengal the natives apply to this ddsease the self-same appella-
tion that they give to the small-pox in the human subject —
namely, btissunty mhatay or gotee. It would be so much out of
place, in a work dedicated to practical purposes, to go into the
numerous inquiries and arguments that have been raised tq>on
the question of the history and analogies of cow-pox, that I
shall content myself vrith stating the fetcts which I conceive
to be established relative to this disease, and the principal ob-
servations by which those feu^ts are supported. The mots to
which I allude are —
1. The prevalence at the same period of the cow-pox among
cattle and the small-pox among men.
2. The transmission by contagion of the small-pox to cattle,
and the consequent development of cow-pox in those animals.
3. The transmission by inoculation of die small-pox to cattle,
and the consequent development of cow-pox in those animals.
4. The transmission by contagion of the cow-pox to man, and
the consequent development of a pustule similar in character to
the vaccine pock of the cow.
5. The transmission by inoculation of the cow-pox to man,
and the consequent development of a pustule similar in charac-
ter to the vaccine pock of die cow.
6. The transmission by inoculation of the cow-pox to man,
and the consequent development of an eruption similar to, if not
identical vrith small-pox.
169. The first of these theorems appeals to history for its
proo^ and is additionally substantiated by the facts which tend
'to support the second proposition. Its accuracy has been
verified also by several practitioners, during the recent epidemic
of small-pox in England. Mr. 6ibson,t in a sketch of the pro-
* TransactionB of the Prorincial Medical Association. Vol. viiL 1840, p. i.
t Transactiona of the Medical and Phyaical Society of Bombay. VoL i.
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VARIOLA VACCINA. 103
vince of Guzerat, states that variola carries off annually many
persons^ and ^^ the same disorder is at times very fatal among
the cattle." Mr. Macpherson, writing from Murshidabad, in
1886^ observes that the disease among Uie cows has not occurred
in that province for two years ; that during the same interval
very few cases of variola have been known^ and from these cir-
cumstances he infers ^^ that the unknown causes which favour
the disease in the human subject have the same tendency in
the cattle ; in £Eict, that variola, and mhata, or gotee, owe their
origin to the same cause." Mr. Lamb, stationed at Dacca,
remarks, in 1836, that during the prevalence of variola, die
cow-pox '^ appeared in one muballa, and carried off fifteen or
twenty cows."
170. The transmission by contagion oi the small-pox to cattle,
which rests upon the assertion of numerous observers, is strik-
ingly illustrated by Mr. Ceeley,^ in the following narrative : —
" On Friday, the twenty-second of October, 1840, my friend Mr.
Knight informed me by letter, that he had on that day seen on
die hand of a patient, Mr. Pollard, aged fifiy-six, who bad never
had small-pox or vaccine, two broken vaccine vesides, which the
patient said he had caught while milking his own cows, scmie of
which he knew were affected with the same disease, and were then
very difiBcult to milk." Mr. Pollard at the same time expressed
his conviction ^^ that his cows had been infected from human
small-pox eflEluvia, to which he considered they had been ex-
posed." It appears that the small-pox had been prevalent itt
the village of Oakley, and the last three persons attacked were^
two women and one diild. ^' The two cottages in which these
three patients resided during their illness were situated on eaoh
side o^ and closely connected with, a long narrow meadow, or
close, comprising scarcely two acres. The first-named patient,
though thickly covered with pustules^ was not confined to her bed
after the frdl development of the eruption, but frequently crossed
the meadow, to visit the other patients, the woman uad child^
the former being in great danger with the confluent and malign
nant fDrm of the disease. She died on Monday, the seventh of
September, and, according to custom, was buried the same,
evening. The intercourse between the cottages across the close
was, of course, continued after this event On the following
day, the wearing apparel of the deceased, the bed-clothes, bed-
ding, &c., of both padents, were exposed for purification on the
hedges bounding the close, die chaff of the child's bed was thrown
into the ditch, and the flock of the deceased womaji^s bed was
strewed about on the grass within the close, where it was exposed
* Traniactioiis of the Provmclal Ifedioal AssooiatioD. Vol. x. 1S42, p. 211.
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104 CONGESTIVE INFLAMMATION OF THE DERMA.
and tiirued every night, and for several hours during the day,
until the thirteenth of September — eleven days. On that day,
the above-mentioned eight milch cows, and two sturks, were
turned into this meadow to graze. They entered it every morn-
ing for this purpose, and were driven from it every afternoon, to
be transferred to a distant meadow to be watered and milked,
where they remained through the night Whenever the cows
quitted the meadow in question in the afitemoon, the infected
articles above-mentioned were again exposed on the hedges, and
the flock of the bed spread out on the grass, and repeatedly
turned, where it remained till the morning, when the cows were
re-admitted. It appears, however, that the removal of the in-
fected articles was not always accomplished so punctually as
had been enjoined, for both the proprietor and the milkers affirm,
that on one occasion, at least, they observed the bed-flock on
the grass, and the cows amidst it, and licking it up. The pro-
prietor positively declares, and the milkers corroborate his state-
ment, '^ that the animals were in perfect health on their first
entering this close, but within twelve or fourteen days of that
event, five of the milch cows appeared to have heat and tender-
ness of tlie teats, upon which, imbedded in the skin, were dis-
tinctly felt small hard pimples, which daily increased in magni-
tude and tenderness, and in a week or ten days rose into blisters,
and quickly ran into brown and blackish scabs. At this period,
when the teats were thus blistered and swollen, and very tender,
the constitutional symptoms were first observed — ^viz., sudden
" sinking,'* or loss of milk, dribbling of saliva firom the mouth,
and frequent inflation and retraction of the cheeks, starring of
the coat, "tucking up of the limbs," and " sticking up** of the
back, and rapid loss of flesh : the process of milking was now
very difficult, disagreeable, and even dangerous; and on the
fourteenth of October, the middle of the third week, the detach-
ment of the crusts and loose cuticle, and the abundant discharge
of pus on attempting to milk, compelled the milkers to desist,
for the purpose of washing their hands. Soon afiter this period,
the cows became by degrees more and more tranquil, as the ten-
derness and tumefaction of the teats subsided, and, finally, milk-
ing was performed with comparative feicility, and at the period
of our visit, scarcely any trouble arose in the performance of
the operation, though here and there a teat seemed still tender.**
In his remarks upon this case, Mr. Ceeley observes, " Another
circumstance, too, requires to be particularly noticed; it is,
the fact of the occurrence of the vaccine disease on a young
sturk, which, of course, could not have been induced by those
casualties which commonly propagate it among milch cows, but
simply by the cause which originated the disease in the other
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VARIOLA VACCINA. 105
five animals, whatever that may have been. The sturk is not
considered liable to the vaccine, at least so it is inferred in this
neighbourhood, becaase no one has ever seen the animal affected
by it."
It is scarcely needful to add more evidence to that contained in
the preceding paragraph, in proof of the communicability of the
contagion of small-pox from man to cattle, but I cannot forbear
quoting one or two further illustrations ; the first is contained in
the following brief extract from a letter addressed by Dr. Water-
house, of Cambridge, Massachusetts, to the celebrated Jenner : —
" At one of our periodical inoculations," says the writer, " which
occur in New England once in eight or nine years, several people
drove their cows to a hospital near a populous village, in order
that their families might have the daily benefit of their milk.
These cows were milked by persons in all stages of small-pox ;
the consequence was, the cows had an eruptive disorder on their
teats and udders so like the small-pox pustule, that every one in
die hospital, as well as the physician who told me, declared the
cows had the small-pox."
Dr. Sonderland, of Bremen, communicated the small-pox
contagion to cows, by covering them with sheets between which
persons fatally affected with small-pox had lain. These experi-
ments were successful in a few cases, after many trials.
171. The third position — namely, the transmission of small-
pox to cattle by means of inoculation, and the consequent de-
velopment of cow-pox in those animals — is also established on
abundant evidence, for the chief of which we are again indebted
to the zealous perseverance of Mr. Ceeley, of Aylesbury. It is
stated by Dr. Macmichael, in an essay read before the College
of Physicians, in 1828, tliat "vaccine matter having failed in
Egypt, medical gentlemen were led to institute certain experi-
ments, by which it has been discovered that, by inoculating the
cow with small-pox from the human body, fine active vaccine
virus is produced." M. Viboi^, of Berlin, is reported to have '
inoculated cattle, and several other classes of domestic animals,
with success.
Mr. Ceeley instituted a series of experiments on the inocula-
tion of the cow with variolous lymph in the month of February,
1889. In his first subject, no effect was observed for nine days,
at the end of which time, one out of seven punctures inoculated
with virus of the seventh or eighth day, presented the appear-
ance of a tubercle. On the tenth day, this tubercle had all the
characters of the vaccine vesicle ; by the fifteenth day, the vesicle
reached its acme, and was "truly splendid." Decline com-
menced on the sixteenth dav, the crust was well formed on the
seventeenth, but was rubbed off prematurely. In this experi-
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106 CONGESTIVE INFLAMMATION OF THE DERMA.
ment the yesicle was retarded five days ; the usaal period of
maxifnuin development of the yariolo-vaccme pock being the
tenth day. In a second experiment, the first inoculation
failed. After re-inoculation, four out of the seven punctures
looked purplish or livid on the fifth day, and were vesicular,
with incipient central crusts on the sixth. By the tenth day
they had attained their acme. On the eleventh, decline had
commenced, and progressed gradually, till the twenty-sixth day,
when the crusts fell, leaving behind diem smooth rose-coloured
pits.
172. The foiurth proposition is one so well established as to
require no especial remark. The nature of the afiecdon resulting
from this contagion is considered in the section entitled '^ Casuid
variolsB vaccinae in man." The fifUi proposition is equally satis-
factory in its proof ; the effects of ^ primary lymph" firom the
variolas vaccinae will be stated at a future page.
178. In support of the fact announced in the sixth proposi-
tion, it has been observed, that when the epizootic disease pre-
sents characters of great severity, the symptoms produced on
man by inoculation from such cases were also severe, and ofben
serious, contrasting strongly with the mild affection engendereil
by the virus from die ordinary discreet fonn of cow-pox. Mr.
Macpherson, in experiments with this virus in Bengal, in 1837,
found that an eruption was developed, which was identical vdth
small-pox. Mr. Wood, of Gowalpara, in 1839, met vnth simihur
cases, of so great severity, diat he was led to contemplate the
substitution of inoculation with small-pox virus, as a safer ex-
pedient At Silhet, Mr. Brown removed some dark-coloured
scabs from a cow labouring under variolous disease, and tritu-
rating them in a mortar, he inoculated several children with the
pulp. These cases exhibited nothing remarkable, excepting a
somewhat greater degree of constitutional disturbance on the
eighdi day than usuaL After two mondis, children inoculated
from this stock were attacked on the eighdi day with severe
fever, " followed by an eruption, which spread over the whole
body, and, in one case, proved fatal." The eruption so pro*
duced bore all die characters of true small-pox. Thus it would
appear, that as the small-pox virus, when introduced into the
system of the cow, is so modified by the vital laws which regulate
the functions of the animal as to produce an eruption of cow-
pox ; so, on the other hand, the virus of the cow, under like
circumstances, is modified by the constitutional phenomena of
the human organism, and is made to assume the characters of
small-pox.
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CONGESTIVE INFLAMMATION OP THE DER^IA. 107
VARIOLA VACCINA IN THE COW.
174. Variola vaccina in the cow is by no means a common
affection, and when it occurs, is usually met with in milch cows,
a circumstance attributable to the transmission of the contagion
by the hands of the milkers. Occasionally the disorder appears
as an epizootic, but more frequently in the sporadic form. In
rare instances it would seem that the source of this contagion
has been a variolous eruption developed in the horse, and mis-
taken for a more common vesicular <hsease in that animal, the
grease. The vaccine disorder is modified by a variety of condi-
tions, such as the temperament of the animal, the tone of its
tissues, its state of health, the thickness of its skin, and its
colour. A slight difference is also observed in the disease, in
relation to its origin in a sporadic form, or as the result of con-
tagion communicated by the hands of milkers ; the former of
these varieties Mr. Ceeley terms naiuralj and the latter, casual.
175. Natural variola vaccina makes its invasion with heat and
tenderness of the teats and udder, unaccompanied by constitu-
tional symptoms. The inflamed surface is irregular and pimply
to the touch, and papulae of a red colour, hard, and as large as
a pea, are soon developed. In three or four days from invasion,
the papulsB have attained the size of a horse-bean ; they are ten-
der and painful, and vesicles are gradually raised upon their
summits. The vesicles, increasing in size, become acuminated,
ovoid, or globular, and are distended with an amber-tinted and
viscid fluid. When ruptured, they present depressed centres,
with an elevated and indurated margin, and when the epiderma
is rubbed off, the surface of the corium is of a vivid red colour,
with a small central slough. When uninjured, or merely rup-
tured, without the removal of the epiderma, the vesicles desiccate
into thick, dark-brown crusts, which commence in the centre,
and proceed towards the circumference, appearing at first en-
chased in the marginal elevation, and subsequendy extending
completely over it. The surface from which the epiderma is
removed becomes covered by thin, brownish scabs, which are
termed secondary,
176. Casual variola vaccina appears as an eruption on the
fifth or sixth day after contagion, in the form of small tender
papulas, which are developed upon the teats and neighbouring
surface of the udder. By the sixth and seventh days, the papulae
have attained the size of a pea ; ihej are reddish in colour, and
circular or oval in form. On the summit they become gradually
depressed, assume a yellowish- white and pearly hue, and have
a small central dot or linear impression. On the eighth or ninth
day, the central concavity increases in depth, while the margin
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108 CONGESTIVE INFLAMMATION OF THE DERMA.
becomes more elevated, tense, and shining, more pearly or silvery
in its aspect, and the central depression acquires a bluish or
slaty tint. At this period, the pock is more than half an inch
in diameter, and is surrounded by a narrow areola of a pale rose,
or light damask hue. Between the tenth and the eleventh day,
the eruption reaches its acme ; the elevations are now upwards
of three-fourths of an inch in diameter, the areola has increased
to four or five lines in breadth, and the integument beneath is
tense and indurated. The central depressions have augmented
in depth, their bluish, slaty colour has acquired greater intensity,
and the epiderma which invests them becomes distended with
an abundance of lymph, and rises into a globular or conical
vesicle. Many of these vesicles are now ruptured, others remain
whole, but, in either case, they shrivel and desiccate into brownish
or black crusts, which are first observed in the centre, and in-
crease towards the circumference, until they reach and overlap
the marginal border of the pock. The induration and enlarge-
ment of the latter diminish, and the crusts are thrown ofi"
spontaneously between the twentieth and twenty-third day,
leaving a slightly depressed and smooth cicatrix of a pale rose
or whitish colour. Such is the usual course of the cow-pock,
but it necessarily presents many diversities of appearance, de-
pendent upon aggravation of symptoms, &c. Thus, instead of
forming crusts in the manner described, ulcerated and sloughing
surfaces are sometimes produced, which remain for weeks in an
irritable state. Moreover, casual vaccine variola always presents
the eruption in every stage of its progress at the same moment,
the elevations with their central depressions are intermingled
with incipient papulse, and while the crusts are being perfected
in some, the vesicles are yielding in others to the distention of
their lymph. This succession in the eruption depends upon the
diffusion of the virus by the rupture of the vesicles, either in
consequence of the movements of the animal, or by die milker,
and the consequent re-vaccination of the neighbouring unaffected
skin. Mr. Ceeley has observed as many as sixty pocks upon the
udder and teats of a single cow.
VARIOLA VACCINA IN MAN.
177. Variola vaccina may be communicated to man, either ac-
cidentally, or by voluntary inoculation. In the former case, the
contagion is received directly firom the animal, usually firom the
cow, but sometimes, as in the case of variola equina, firom the
horse. It had long been observed, that persons who had suf-
fered firom this disease were preserved against the influence of
small-pox, and thence originated the practice, introduced by
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VARIOLA VACCINA. 109
Jenner, of transmitting the contagion artificiallj to man, hy
means of inoculation.
178. It is a principle, well established in pathological science,
that the animal system, once subjected to the influence of any
disease originating in specific contagion, is protected, to a greater
or less extent, against subsequent incursions of that disorder.
Thus we observe that the modification which the system under-
goes in the reception of rubeola and scarlatina, is protective of
the individual against that contagion for the rest of life. The
same circumstance is remarked with regard to small-pox, and
other contagious fevers. When this fact was contemplated by
the medical philosopher, in association with the fearful ravages
of that dreadful pestilence and scourge of the human race, small-
pox, such as it existed in former ages, the expedient suggested
Itself to his mind, that if the disease could be anticipated^ if the
disorder, in a mil^ form, could be communicated to man, life
would be spared, and the system equally defended against the
subsequent contagion of a more virulent and fatal disease. This
design, happy in thought, and happy in application, gave birth
to the practice of inoculation for small-pox. Inoculation for
small-pox, however, was not free from objection ; the disease
thus engendered was always serious, often fatal, and frequently
it became the source of a malignant contagion. In this state of
demi-subjugation small-pox was found by Jenner, when the
well-known fact of the protective influence of cow-pox first en-
gaged his attention, and aroused in his comprehensive mind the
philosophic thought that spread happiness and security where
gloomy anticipations and uncertainty had previously existed.
He had ibe talent to perceive in cow-pox, small-pox, in its
mildest possible form ; and he trusted, that the transmission of
this to man would ensure the same results as inoculation with
the virus of human small-pox. This trust was rewarded by the
complete success which attended the prosecution of his views.
179. In the foregoing remarks, I have endeavoured to show
that the advance of improvement to the Jennerian standard was
progressive, and that it was created by the contemplation of the
wants of the human race. Since Jenner^s discovery, nearly half
a century* has glided away, half a century, moreover, replete
with important and valuable discoveries, both in general and
medical science. A poition of that half century has seen the
attention of medical practitioners again engaged in considering
Hie imperfections of our present means of defence against small-
pox. A third aera of discovery has just dawned. It is seen,
that although, as a general rule, the principle announced in the
* Jenner's first experiment was made od the 14th of May, 1796.
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110 CONGESTIVE INFLAMMATION OF THE DERMA.
preceding paragraph — namely, that the invasion of the conta-
gious disease is protective against subsequent attacks of the
same disease is correct, yet, that exceptions to this rule do occur
so frequently, as to indicate the necessity of further investiga-
tion into the nature and history of small-pox, with a view to af-
ford additional security against its ravages. Thus it has been
observed, that secondary attacks of smidl-pox are not unusual,
and that small-pox after vaccinia very frequently occurs. In-
stances of the latter kind, indeed, are so often met with, as to
lead to the belief that vaccinia gradually loses its protective in-
fluence over the system.
180. With a view to meet the declining influence of vaccinia,
numerous propositions have been made, and modes of practice
adopted, the principal of which are, re-vaccination, retro-vacci-
nation, variolo-vaccination, and an immediate return to the
variolsB vaccinae of the cow. These variou^ modes of re-esta-
blishing the protective powers of vaccinia 1 shall examine in
their turn, after having, in the first place, traced the history of
the casual vaccinia, as observed and recorded by Mr. Ceeley,
and having described the effects of ordinary vaccination with
Jenner's lymph.
CASUAL VARIOLA VACCINA IN BIAN.
181. The transmission of the cow-pock contagion to man pre-
sents all the anomalies which are known to accompany exposure
to other sources of contagion. Milkers who have never been
vaccinated will sometimes escape altogether, while others, who
have been vaccinated or variolated, will take the disease ; and
instances not unfrequently occur, in which persons, who regard
themselves secure, in consequence of having previously suffered
from casual vaccinia, are a second time affected. In all the
three latter cases, however, and especially in the last, the dis-
order is characterized by the manifestation of a much milder type
than that of the unmodified disorder. The parts of the body
usually affected in milkers are, the backs of the hands, the
flexures of the joints and sides of the fingers, and the face.
When the eruption appears in the latter situation, the virus is
conveyed by means of the hands moistened with the lymph of
the ruptured vesicles. On the backs of the hands, and between
the fingers, the epiderma is thinner than on the palmar surface,
and consequently affords greater facility to its imbibition by the
dermal tissues. For it is satisfactorily proven, that abrasion of
the surface is by no means necessary to the inoculation of the
disease. When, however, the epiderma is abraded, and the skin
chapped, the effects of the virus are remarkable for severity, sub-
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VARIOLA VACCINA. Ill
cutaneous abscesses are liable to fbnn, and the ljiiq>faa!dc vessels
and glands frequently become inflamed.
182. The signs which indicate that die contagion has taken
effect, are the appearance of inflamed spots or papulaB, which
are hard to the touch, acuminated, and deep seated. The
papulae are of a deep rose-red, or purplish colour, and are soon
surmounted bj an ash-coloured, or livid vesicle, which assumes
the umbilicated character as it increases in size, and then be-
comes yeUowiidi in the centre. At this period the areola makes
its appearance, lymph is eflused benea4li the lunbilicated epi-
derma, and a vesicle of variable size, and of a bluish, or slate-
coloured aspect, is developed. The local inflammation is some-
times so severe as to produce sloughing of the derma and serious
constitutional disturbance.
In illustration of tins affection, Mr. Geeley* has recorded the
following interesting case : —
^^ Joseph Brooks, aged seventeen, a fine, healthy, intelligent
young man, who had not been the subject previously of variola,
or of the vaccine, stated, that he commenced milking on Friday,
the ninth of October, and that his milking was confined to four
cows, only one of which had the disease, from four to six vesi-
cles on each teat. He milked these four cows occasionally, and
continued to do so till the eighteenth of the same month, (ten
days,) having milked them in that period six times. On this
day, (the eighteenth,) he felt the cervical absorbent glands and
lymphatics stiff and tender, and on the twentieth, found a pimple
on me temporo-frontal region, which he could not resist scratch-
ing. On the day before that, he observed on his finger a red
pimple, of the size of a pin's head ; on the next day, one on the
thumb, very small. In neither situation was he aware of the
pre-existence of any visible wound or abrasion of the cuticle.
On the twenty-first he had head-ache, general uneasiness, and
pains in the back and limbs, with tenderness and pain in the
course of Ae corresponding lymphatic vessels and absorbent
glands, particularly of the axiUa, which increased till the twenty-
diird, when nausea and vomiting took place. His right eyelids
became swollen, and were closed on t^at day, but after this
period he became better, in all respects, never having been con-
fined to the house, although disabled from work. The vesicle
on the temporal region had a well-marked central depression
with a slight crust, a general glistening appearance, and was of
a bright rose or flesh colour, with a receding ateola, and there
was an inflamed, tumid, and completely closed state of the cor-
responding eyelids.
* Tnntaetion* of the Provincial Medical AssociatioD, vol. v., p. 216.
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112 CONGESTIVE INFLAMMATION OF THE DERMA.
'^ On the finger the vesicle was small and flat, with a slightly
depressed centre, containing a minute crust It had a beautiful
pearly hue, and was seated on a bright, rose-coloured, slightly-
elevated l>ase. On the thumb the vesicle was also flat and
broad, but visibly depressed towards the centre, where there ap-
peared a transverse linear shaped crust, corresponding doubt-
less with a fissure in the fold of the cuticle. The vesicle was of
a dirty yellowish hue, and visibly raised on an inflamed, circum-
scribed base ; lymph was obtained from a vesicle on the temple,
in small quantity, by carefully removing the central crusty and
patiently waiting its slow exudation. In this, as in most other
respects, it strikingly resembled the vesicle on the cow, and ap-
peared as solid and compact. The lymph was perfectly limpid,
and very adhesive. No lymph was taken from the vesicles on
the finger and thumb, with a view to avoid any interruption of
their natural course.
" On the twenty-sixth and twenty-seventh, when the redness
and elevation of the base of the vesicles had materially dimi-
nished, the vesicles themselves had become greatly enlarged.
On the thumb and finger they were loosely spread out at the
eircumference, each having a dark and deep central slough. On
the temple, the margin of the vesicle, as on the cow, was firm
and fleshy, its diameter being nearly ten lines, and its centre
filled with a dark brown firmly adherent slough. In about seven
or eight days, by the aid of poultices, the sloughs separated, and
the deep ulcers healed, leaving cicatrices, like variola, deep,
puckered, and uneven, which were seen on t^e twenty-fifth of
November."
INOCULATED VARIOLA VACCINA.
183. The inoculation of variola vaccina, or, as it is popularly
termed, vaccination^ consists in the transference of a small por-
tion of the contents of the vaccine vesicle, the vaccine lymph, or
virus, to the papillary surface, or to the tissues of the derma of a
sound person. This object is effected by means of a small
puncture, by several punctures, or by a number of superficial
scratches, with the point of a lancet or needle imbued with the
virus. Ajiother, and rarely practised mode of vaccinating, is to
make a small incision, and place within it a thread impregnated
vrith the vaccine lymph. The punctures are made obliquely
through the epiderma, in order that the papillary surface may
be attained without the eflusion of blood, or with the escape of
as little as possible. The virus which is in tMs manner intro-
duced into contact vnth the derma, is dissolved in the fluids of
the tissues, and imbibed into the system, its agency upon the
system being indicated by certain locial and constitutional effects.
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VACCINATION. 1 13
184. The local signs indicating that the vaccinalionhas taken
etkct are first apparent on the third or fourth day after the
operation, at which period there is a slight degree of elevation
and hardness of the skin (papular stage) at the seat of the punc-
ture, and a trifling blush of redness immediately surrounding it.
On the fifth and sixth day, a small quantity of liquor sanguinis
is effused beneath the epiderma, and a vesicle is formed, which
is whitish and pearly in appearance, of a roundish or oval figure,
and umbilicated at its centre. The vesicle goes on increasing
in size until the eighth or ninth day, at which period it has be-
come fiilly distended, and has attained its perfect development
On the ninth day it loses the umbilicated form, it becomes flat-
tened on the surface, and sometimes more convex than at the
circumference, and is composed of numerous small cells, which
are filled with a limpid and transparent lymph.
On the eighth day, (sometimes the ninth,) the perfect vesicle
is surrounded by an inflamed areola, of a vivid red colour, (the
pearl upon the roscy) which gradually increases in extent, from a
few lines to more than two inches in diameter. The skin in-
cluded by this areola is inflamed and tumefied, and is frequently
the seat of eruption of a crop of small transparent vesicles. On
the tenth day, the redness and heat have increased ; there is con-
siderable itching in the part, the movements of the arm are
somewhat painfiil, and the axillary glands are liable to become
tender and swollen. Tt occasionally happens, that at this period
an erythematous blush spreads from the arm^ over the surface of
the body, in irregular patches.
On the eleventh day the areola begins to diminish, the fluid
contained within the vesicle has become purulent, and desiccation
commences at its centre, and proceeds gradually towards the cir-
cumference. During the succeeding days, the areola disappears
more and more, the tumefaction subsides, and the vesicle desic-
cates into a dark brownish crust, of an irregular form. The
crust, by a continuance of desiccation, diminishes in size, and
assumes a blackish hue. It is detached at the end of seventeen
days aJiter vaccination, and leaves upon the skin a depressed
cicatrix, at tiie bottom of which are seen numerous small pits,
(foveolse,) which correspond with the separate cells of which the
vesicle was composed. The cicatrix is permanent, enduring for
the remainder of life.
To recapitulate : the two or three first days are those of incu-
batian; the fourth is papular; the fifth, sixth, seventh, and
eighth, vesicular; the vesicle presenting an umbilicated form,
and attaining perfection on the last of tiiese days ; the eighth
day, moreover, is the period of the first phasis of the areola,
when the vesicle represents the '^true pearl upon the rose;*'
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114 CONGESTIVE INFLAMMATION OF THE DERMA.
the ninth, tenth, and eleventh days are pustulaVy the lymph be-
comes purulent, the umbilicated form is lost, the areola enlarges,
and constitutional fever is established ; the twelfibh, thirteenth,
and fourteenth days are those of desiccation ; the fifteenth, six-
teenth, and seventeenth, of separationj and these latter are suc-
ceeded by the fedl of the scab.
Such is the course of the vesicle of vaccinia, which is con-
sidered necessary to the protection of the system. When its .
progress is irregular, and its development not perfectly efiected,
the constitution remains in the same state in relation to the oc-
currence of variolous contagion as before the operation. It must
be borne in mind, however, that the local afiection is neyer so
well marked in the adult as in the child, although the extension
of inflammation to the neighbouring glands and the constitu-
tional fever are often greater.
The proper time for the performance of vaccination is infancy,
between the third and the seventh month. At an earlier or a
later period, the diseases incidental to childhood may interfere
with die progress of the case. Jenner pointed out the fact that
certain diseases of the skin, particularly those of a vesicular kind,
interfered with the proper development of the vesicle, and other
influences are derived from age or idiosyncrasy.
185. The constitutional symptoms accompanying vaccination
are always slight, and often scarcely perceptible. In some in-
stances, however, a little fever is observed at about the eighth
and three following days, this febrile re-action corresponding with
the progress of the inflammation of the areola.
SECONDARY ERUPTIONS OF VACCINIA.
SjD. Vaccindla,
186. The general eflects of vaccination occasionally ofier some
peculiarities. Thus it sometimes happens, that during the course
of the vaccine pock, an eruption of vesicles appears upon the
general surface of the skin. Such an eruption lately fell under
my observation, in which vesicles and bullae* were developed
upon inflamed patches, on the greater part of the surface of the
body. The principal features of this case are the following : —
Green, a child eighteen months old, was vaccinated at the
London Small-pox Hospital, on Monday, June 7th, 1841. On
the ninth or tenth day afl^r the operation, an eruption of red
spots was perceived upon the forehead, which quickly extended
to the £EU)e, neck, trunk, and arms, and by the thirteenth day
• Mr. Ceeley reffards this eruption of a pemphigoid character as " strictly a
yaccine eraption ;" he has seen it frequently on children, and occasionally on the
cow and dog%
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EFFECTS OF VACCINATION. 115
were di^>er8ed OTer the whole of these regions, the redness
being augmented towards evening, and during the night On
the sixteenth day I first saw the patient, the vaccine crust and
areola were natural, the eruption had subsided on the face,
and was now principally confined to the arms, the chest, and
back, the legs being nearly free. In these situations it existed
in its successive stages ; there were small red spots, the earliest
form of the affection, and larger patches, of a roundish or irregu-
lar form, of about the size of a fourpenny piece, several of these
latter patches being congregated here and there, so as to form
clusters of considerable size. The margins of the patches were
of a dull red colour, and somewhat elevated, while the centres
presented a yellowish tinge, and in some situations were covered
with numerous small vesicles, containing a limpid and transpa-
rent serum. On the eighteenth day, the redness of the patches
was declining, their raised border had become lighter in tint
than the centre, and the epiderma was desquamating over their
surfeu^, particularly on those patches where vesides had existed.
On the face, the vesicles terminated in thin, brownish, and spongy
laminae. I inoculated a healthy child with lymph taken firom these
vesicles, but without any result
187. In ^ early part of the present year I had an opportu*
nity, through the politeness of my friend and neighbour. Dr.
John Hall Davis, of seeing an infemt in whom the secondary
eruption of vaccinia was so severe as to be the cause of death.
The eruption commenced upon the head and face, and thence
extended to the neck and chest. On the latter there were more
than one hundred vesicles, presenting the characteristic flattened
and umbiUcated form of i^e vaccine pock. They were for the
most part discreet, but every here and there were confluent
clusters of three, four, and five. On the neck, the vesicles were
confluent, the slight and irregular intervals of skin between the
large patches were vividly red, and the whole surface poured
out an abundant ichorous discharge. The diild had evinced a
tendency to eczematous erupticms from its birth ; a circumstance
deserving the attention of the medical practitioner.
The following case occurs in the " Ardiives de Medicine'' for
September, 1841. An iniant a week old was vaccinated July
^d ; on the IQth, several papulae appeared on various parts of the
body. On the fifteenth, there were eleven umbilicated vesicles
on the abdomen and legs, similar to those of vaccinia. Three
children inoculated with lymph from this eruption had vesicles
developed identical with those of ordinary vaccinia.
188. Dr. Greorge Gregory lately communicated to the Royal
Medical and Chirurgical Society, the case of a child in whom
peteeh^ i^peared upon the skin four days after vaccination.
I 2
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116 CONGESTIVE INFLAMMATION OF THE DERMA.
The child was to all appearance in perfect health. The areola
was occupied on the eighth day by an extensive ecchymosis, and
the body was covered by petechial spots. By the sixteenth day,
the petechias had commenced to fade. Five children of the same
family were vaccinated at the same time, and with the same lymph,
and went regularly through the disease. Dr. Gregory regarded
this case as one of petechial cow-pox, in which the influence of
the vaccine virus in the production of an hemorrhagic state of
the system was demonstrated. Petechial cow-pox is rare ; Dr.
Gregory had never before seen a similar case, and had only
heard of two of the same kind.
PROTECTIVE POWER OF VACCINATION.
189. I now come to a question of the utmost importance —
namely, the efficacy of vaccination as a protection against small-
pox. But before I engage in this discussion, it may be necessary
to define precisely the meaning which I attach to the term vacci-
nation. Vaccination I conceive to mean, —
1. That the lymph employed in the operation is pure.
2. That it has been obtained from a vesicle which has passed
regularly through the course described in the preceding section.
3. That it has been procured from the vaccine vesicle, between
the fifth and eighth day of its course.
4. That the vesicle produced by this lymph in the vaccinated
subject shall have passed regularly through the stages known as
the natural course of the vaccine pock, and described in the pre-
ceding section, (§ 184).
5. That at least one of the vesicles produced by vaccination
shall have been permitted to remain unbroken and uninjured,
until the natural vaccine crust shall have been formed, and shall
have fallen in the natural course.
6. That the cicatrix shall be well marked, and permanent ;
perhs^ps also foveolated.
When the whole of these conditions are complete, vaccination
is perfect, and the person so vaccinated may be regarded as
protected against small-pox. But if, on the other hand, any
of these conditions be incomplete, it would be monstrous to
expect that the fiill influence of the vaccine protection should
be exerted. Again, it has been observed, that the nearer the
approach of the condition to the standard above established, the
more protective will be the influence efiected by the operation,
and vice versft.
190. The purity of the vaccine lymph is a point of the first
consequence. The genuine lymph appears to undergo no change
or loss of power by indefinite transmission, provided always that
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PURPOSE OP VACCINATION. 117
due attention have been directed to the fact of its being always
obtained at the requisite period, and from a vesicle which has
passed regularly through its course, in fact, from the true " pearl
upon the rose.'* But as the attention necessary for the assur-
ance of this condition has unfortunately, in many cases, been
omitted, much spurious lymph has been mingled with that de-
rived from the original source, and, as a consequence, small-pox
after vaccination has become more frequent, and vaccination has
fallen into disrepute. It would, however, be unjust and unphi-
losophical, to attribute this apparent falling off in the influence
of the vaccine lymph to any but its true cause, the one just
mentioned.
191. The period best suited for obtaining the vaccine lymph
is that indicated by Jenner — namely, between the fifth and the
eighth day, and before the formation of the areola. After the
areola is established, the lymph becomes altered in its character
and purulent, and either loses the power of exciting a pock, or
produces one which is irregular in its appearance or course, and
IS incapable of conferring safety on the person vaccinated. It is
true, that occasionally the fallen crust is sufficiently impregnated
with the desiccated lymph to possess the power of exciting the
disease, and is sometimes used as a convenient means of trans-
porting the virus to warm climates ; but the crusts for this pur-
pose must be selected with care, and even then are liable to
£Eulure.
192. That the vaccine pock shall pass regularly through its
course, is the most important of all the conditions requisite for
the success of vaccination. Jenner especially pointed out the
necessity of this rule, for he perceived that its neglect might
lead to the most serious results. That neglect has, I fear, very
extensively existed, and many of the distressing consequences
under which we now suffer are referrible to it. The fulfilment
of this condition is in itself the best assurance of the purity of
the lymph, of the disposition of the system to receive its in-
fluence, and of the completion of the subsequent conditions.
193. When the vesicle passes regularly through its stages, the
cicatrix which it leaves behind is strikingly characteristic, and
may be depended upon as a proof of successful vaccination.
But the absence of the foveolated appearance of the cicatrix is
no proof that the preservative influence of vaccination has not
been established, provided that a permanent cicatrix of the
ordinary size be present. But when there is difficulty in dis-
covering the cicatrix, or the latter is small, it may unhesitatingly
be concluded that the pock did not complete its necessary stages,
and, consequently, that the person is still unprotected.
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118 CONGESTIVE INFLAMMATION OP THE DERMA.
VACCINATION TESTS.
194. With the view to ascertain whether vaccination has heen
eflTective, several plans have been adopted which are termed
tests. The most efficient of these is inoculating with small-pox
after vaccination ; re-vaccination is a second test ; and a third
is that described by Dr. Bryce, of Edinburgh. Bryce's test
consists in re-vaccinating a few days after the first vaccination.
In this case, if the constitution be already afiected by the
vaccine influence, the second pock hurries through its stages,
and speedily reaches an equal development with the first, ar-
riving at its acme at the same time, and desiccating and forming
its crust contemporaneously with its predecessor.
RE-ESTABLISHMENT OF THE PROTECTIVE INFLUENCE OF
VACCINU.
195. For several years past, opinion has been divided rela-
tive to the protective influence of vaccination against small-pox.
By some it is believed, that the power of vaccination as a
defence against variola diminishes gradually with the advance
of age ; and by others, it is thought that the vaccine virus intro-
duced by Jenner has degenerated during the forty-six years
that it has been transmitted through the human race, and lost a
portion of its protective quality. I shall not stop to inquire
into the merits of these two questions, both warmly contested
and supported by powerful advocates, but at once proceed to
examine the propositions that have been made and acted upon
for the purpose of supplying a remedy against the evil conse-
quences which they would imply. As a means of perpetuating
die vaccine influence, two modes of procedure have been re-
commended— namely, re-vaccination, and variolation after
vaccination. And with the view to meet the second evil, three
plans have been adopted — namely, retro-vaccination, variolo-
vaccination, and recurrence to the primary lymph firom the cow.
RE-VACCINATION.
196. The phenomena of contagion, as it afiects the human
irame, develope two important facts ; firstly j that the workings
of contagion in the animal organism destroy the susceptibility
of that organism to take on a similar action ; secondly, that, from
the moment of completion of the workings of contagion, the
organism becomes gradually and slowly restored to the condi-
tion which it possessed previously to tibe development of con-
tagion. In the abstract, these positions are incontrovertible,
but they require the modification implied in the estimate of
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RE-VACCINATION. 119
time, to render them applicable to the thousand peculiarities
that occur in daily practice. Thus, in relation to the first, we
have to inquire, — -'For what length of time the susceptibility is
destroyed? and in relation to the second, — At what period
after contagion is the restoration of the organism so far effected,
that a second attack of contagious disease may take place ? To
both of these questions the answer is — We know not All that
we can venture to affirm with regard to them is, that, in one in-
diridual, a single attack of contagious disease appears to be
protectiye of the individual for life ; while, in another individual,
a second attack may occur in a short period, the precise limits
of that period not being correctly established. The determina-
tion of the shortest period at which contagious disease may
resume its influence over the system is a point of much import-
ance, imd one of legitimate investigation. It ia in the field of
numerical medicine alone that we must look for a solution of the
questions which are now proposed.
The reasoning which is here directed to contagion in general,
applies with particular force to the protective influence of the
contagion of small-pox. A single attack of small-pox would
appear, in the majority of cases, to protect the individual for
the rest of life, but in a smaller number of instances, the vario-
lous constitution is stiU active, and a second, a third, and even
more attacks may be experienced. Now, diat which is true
with regard to variola is equally true with regard to vaccinia ;
for variola and vaccinia are, in their essential nature, one and
the same disease.^ Again, it is admitted at all hands, that
severity in the manifestation of the variolous disease affords no
security to the system greater than that to be derived from the
mDdest form ; and as vaccinia is variola in the mildest shape
in which it can be presented to the human organism, the ques-
tion of re-vaccination resolves itself into the propositions stated
above.
If we admit that vaccination, although perfectly protective of
the constitution against the recurrence of tiie small-pox conta-
gion, for an unknown, and probably variable space of time ; and
tf we, in the next place, inquire what means present themselves
of perpetuating this protective influence, the most natural and
rational method that suggests itself to oiur mind is re-vaccina-
tion. Re- vaccination, or a repetition of vaccination, is a simple
and harmless operation, producing a mild and trifling indispo-
* It is proper to mentioD, in this place, that mtinj opinions are opposed to this
belief. Dr. Kobert Williams obsenres — ^** Vaccinia is a disease sui generis,** and
fiirtber on, be remarks — ** It is likewise, by no means, proTed, that the small-pox
and the eov-pox are identically diseases of the same species.**— Vol. ii., p. 49.
** EJements of Medicine.*'
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120 CONGESTIVE INFLAMMATION OF THE DERMA.
sidon when the system is unprotected, but no effect whatsoever
when the organism is safe. Here, then, we find the operation
to be acting as a test of the safety of the individual, and no ob-
jection can possibly be raised against its use. If tiie organism
be safe, it produces no effects ; if the organism be unsafe, it pro-
duces a trifling inconvenience, but it leaves a bulwark of safety
in its train.
The only question that remains to be considered in relation
to re-vaccination, bears reference to the periods at which the
operation should be performed. This is a matter of trivial im-
port in comparison with the principle which it involves. I
would say, let vaccination be performed every five years, or
every seven years, or every ten years. But as our object is pro-
tection, let us not defer that protection too long. If the opera-
tion succeed at the end of five years, that fact affords the strongest
proof that the repetition is not too frequent If it fail at the end
of five years, let it be practised at seven ; if it fedl at seven, make
a third attempt at ten ; if the operation fail then, it may be used
at successive intervals, but the person inoculated has the satis-
£eiction of knowing himself safe, and at a most insignificant in-
convenience.
197. Numerous cases have been adduced in which an attack
of small-pox has followed vaccination.* I care not to inquire if
* It mast not be imagined that Jenner ever crntemplated an infallible remedy in
Taecination; he merely expressed his belief that vaccination would be found to pro-
tect the organism in an equal, if not in a greater degree, than variola, and with a
prodigious saving of suffering and danger. In respect of this expectation. Dr. Ro-
bert Williams remarks, that it *' has not altogether been verified, the evidence at
present accumulated showing the attacks of the latter (secondary small-pox) to be
only in the ratio of a half to one per cent, while the attacks of the former (small-
pox after vaccination) are not less than five per cent, or from five to ten times
greater. It is enough of glory, however, to the discoverer of vaccination, and of
honest pride to the profession who have adopted it, to be able to state, that by the
discontinuance of the practice of inoculation, the total number of persons attacked
by natural small-pox in this country, taking the most unfavourable calculations, is
reduced one-half, or probably from 260,000 annually, to about 130,000 annually,
while the number of deaths have been reduced in a still greater ratio, or from
60,000 to about 1 1,000 ; also, that the accidents incident to the disease, as blindness,
deafhess, lameness, and the endless catalogue of miseries that follow it, are also re-
duced almost to nothing. This result is that of England and Wales generally, and
it is still capable of being very greatly reduced, for among the better protected class
of persons, as the army, only one soldier has been attacked by small-pox in every
two thousand, annually, so that, taking the British army at 100,000 men, the mor-
tality is only four from small-pox in the whole of that large force annually. The
navy appears also to 4'xperience a similar immunity, for out of a mean strength of
7958 seamen, seven only died in seven years of small-pox in the Mediterranean
and Peninsular commands, while, in the West Indian and North and South Ameri-
can commands, none whatever. On the Coutiuent, also, where the governments
are awakened to the great truth that the health and industry of the lower orders form
the surest basis of national wealth and greatness, and where vaccination is conse-
quently made of national importance in the matter of legislation, we find that the
mortality Arom small-pox, though greater than in our army, is iufinitdy less than in
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RE-VACCINATION. 121
yaccination have been perfect in those cases, for instances are
equally numerous in which small-pox has followed inoculation,
and small-pox itself, both discreet and confluent. These facts
prove nothing unfavourable to the claims of vaccination as a pro-
tective agent against small-pox; they prove only that which
daily experience tends constantly to corroborate — namely, that
MAN HAS STILL MUCH TO LEARN. There cau be no question that
instances of variolous constitution exist, in which all preventive
means that we can suggest would be utterly futile, but these are,
happily, exceptional cases. We are, I fear, completely ignorant
of the laws which govern contagious disorders. It has been
observed, that rubeola and scarlatina, like variola, occur but once
in the lifetime ; persons having once suffered from these diseases
consider themselves secure from infection, and yet, how fre-
quently we have occasion to see the rule nullified, and secondary
attacks developed. The following table, quoted from Dr. Heim,
in the Report of the Vaccination Section of the Provincial
Medical Association, is exceedingly interesting, as showing the
relative frequency of success in vaccinating after small-pox, and
after vaccination.
Vaccinated after amalUpox with success .... 32
„ „ modified ... 26
„ „ without effect . . 42
100
Re-vaccinated with success 34
„ „ modified ... 25
„ „ without effect . .41
100
Re-vaccination is at present being performed very extensively
on the continent, which would seem to imply distrust in the
powers of the primary vaccination. The results of these opera-
tions, however, are calculated to increase our knowledge upon
this important subject.
The following are the conclusions of the Commission of vac-
cine, on vaccination performed in France, during the year 1839.
1. That the simultaneous vaccination of the mass instantly
arrests the progress of the variolous epidemic.
2. That if vaccinia be not an absolute and infaUible preserva-
tive against variola, it is at least the most certain, and the most
exempt from danger.
England and Wales generally. In Prussia, for example, according to the table
given by Hoffman, on an average of a million of deaths, only 8191 were caused by
small-pox, or one in 122. In England and Wales, however, out of 141,607 deaths,
5811 were occasioned by small-pox, or one in twenty-five, nearly; thus showing
that the country which gave birth to vaccination suffers six times more by small-
pox than that of its wiser and more considerate neighboor." — (p. 49.)
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122 CONGESTIVE INFLAMMATION OF THE DERMA.
3. That varioloid, in the majority of cases, is the only incon-
venience to which the vacciiiated are exposed.
4. That there seems no reason for the belief that the long
vaccinated are not as surely preserved at the present day as they
have hitherto been ; nor that the recently vaccinated have re-
ceived less security than those who preceded thenL
5. That the complete success of re-vaccination affords no
proof that the individual had ceased to be protected by vaccina-
tion, and that he had again become susceptible of variola.
6. That a second vaccination does not appear to possess the
power, any piore than the first, of protecting all persons indis-
criminately from the risk of a fiiture attack of variola.
7. That government ought not to command a general re- vac-
cination.
8. That the total extinction of variola is to be effected by the
universal adoption of vaccination.
VARIOLATION AFTER VAC5CINATI0N.
198. Inoculation after vaccination has been proposed as an
additional security against the contagion of small-pox. To
those who regard vaccinia and variola as different diseases, such
a suggestion is likely to be received with approbation, but if we
view Uiese disorders in their true light — namely, as one and the
same affection, inoculation after vaccination is but a repetition
of re-vaccination, and is, consequently, incapable of bestowing
any superior advantage.
RETRO-VACCINATION.
199. This operation is attended with some difficulty, in con-
sequence of the indisposition evinced by the assimilative powers
of one group of animals to the reception of virus derived from a
different order. The operation has, however, succeeded several
times in the hands of Mr. Ceeley, and its results are conclusive.
This gentleman observed a slight increase in the frequency of
the pulse of the animal as soon as the inoculation had taken
effect, and the local affection was attended with a moderate de-
gree of inflammation. The vesicles were produced late, and
good lymph was procured on the tenth day.
200. When children were vaccinated with this retro-vaccine
lymph, the development of the pock was found to be retarded,
the papular stage was not established until the sixth or seventh
day, the areola was complete on the tenth or twelfth day, and
declined during the two following days. The vesicles, in some
instances, were smaller or less firai than usual. With these ex-
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VAEIOLO-VACCINATION. 128
ceptions no difference could be detected between the retro-yac*
cine and the ordinary current lymph, and these differences were
entirely lost after three removes in the human subject. From
these experiments, I think it may justly be inferred, that for the
purpose of improving the vaccine lymph, retro-vaccination, or
passing it again through the cow, is useless.
VARIOLO-VACCINATION.
201. Inoculation with the variolo-vaccine lymph is attended
with the same difficulties of transmission as are common in the
case of unassimilated virus. Out of twenty punctures inoculated
with lymph derived from the variolo-vaccine vesicle, Mr. Ceeley
obtained only six vesicles. These, when they appeared, were
characterized by their early inflammation, and by tardiness and
irregularity in progress and development The secondary fever
which arose and subsided with the areola was severe, and if the
vesicle were ruptured, ulceration and sloughing were liable to
ensue. The effects of this lymph are illustrated in the following
successful case : — ^^ Emma Jaycock, aged fourteen, dark, swarthy
complexion, thin skin, rather florid; two points of sixth day
lymph, and four of eighth day lymph, were inserted into six
punctures ; on the fifth day, four of the papulae had ash-coloured
summits, and seemed vesicular, two were doubtfiil. On the
seventh day, there were five small, distinct, reddish grey, or ash-
coloured vesicles, one very small. On the eighth day, Ae vesi-
cles were advancing, of unequal size, and of irregular form.
Here I was forcibly struck widi the strong resemblance some of
these vesicles bore to those of the eighth day, depicted in Jenner's
work on the arm of Hannah Excell, which he thought so remark-
ably like the results of small-pox inoculation. My patient stated
that she felt slightly indisposed on the fifth and sixth day, that
the axilla was painful on the seventh day, and that she was then
giddy and sick, but felt worse on this die eighth day. On the
ninth day, the areola commenced, and she complained only of
head-ache. On the eleventh day it was fully developed, when
all her symptoms returned in an aggravated form. On the
twelfth day it declined ; but the turgid vesicles having burst the
flimsy cuticle, renewed inflammation and induration, with cir-
cumscribed sloughing and ulceration of the skin, ensued, and
rather deep scars are now visible.*'
After narrating the results of several successive removes of the
variolo-vaccine lymph, Mr. Ceeley remarks, " Nothing could be
more satisfactory or gratifying than the progress now made,
which it would be needless further to detail ; I shall therefore
abstain from the description of individual cases, after adducing
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124 CONGESTIVE INFLAMMATION OF THE DERMA.
one example from the fourteenth remove, as a type of what might
be produced in similar subjects — namely, an infant fourteen
months old, florid, plump, and healthy, with a fine, clear, thick,
smooth skin.
" In the majority of instances, in propagating from arm to
arm, distinct papulation was apparent on the second day; on the
third it was not only visible, but elevated and well defined ; on
the fifth and sixth, vesiculation was abundantly obvious, and
lymph was often taken on those days. On the seventh day,
vaccination was frequently performed, and points were often
charged ; on the eighth, the vesicle commonly exhibited a bold,
firm, and glistening aspect ; between this period and the ninth
day the areola generally commenced, (but in young infants, with
tense and sanguine skins, it appeared early on the eighth ;) by
the tenth day, the vesicle was commonly in its greatest beauty
and highest brilliancy, glistening with the lustre of silver or
pearl, having the translucency and appearance of crystal, or
shining with a pale blue tint, occasionally of a dull white, or
cream colour, bold and elevated, vrith a narrow centre and a
broad margin, or flat and broad in the centre, vrith an acute
margin, occasionally not raised above the level of the skin ; on
this and the eleventh day, an extended and generally vivid areola
existed, with more or less tension and induration on the integu-
ments. At this time the lymph was frequently pellucid, and
often perfectly efficient. From the eleventh to the thirteenth
day, gradually increasing in many individuals, both children
and adults, sometimes the entire vesicle, at other times only the
central parts, reflected a blue or slate-coloured lymph from the
congested or ecchymosed subjacent adventitious stnictures, pro-
portioned to the texture and degree of translucency yielded by
its desiccating epidermis. On the thirteenth and fourteenth day,
particularly on clear skins, moderately thick, the vesicles attained
a considerable size, measuring often in their longest diameters
six and a half, or seven lines, and acquired a light brown centre
from commencing desiccation, which was surrounded with an
outer margin of dull white, or pale dirty yellow, soft and flaccid,
and still possessing fluid contents. During this period, the
areola, of a dull red or damask hue, would revive, and decline
again and again, and even to the sixteenth or eighteenth day,
the period to which complete desiccation was frequently pro-
tracted. The crust commonly partook of the form of the vesicle,
it was often prominent and bold, varying in colour from that of
a chesnut to that of a tamarind stone. It fell generally about
the twenty-third or twenty-fifth day, often later."
" The cicatrices were of variable depth and extent. When the
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VARIOLO-VACCINATION. 125
vesicles remained unbroken on a thick sanguine skin, they were
deep, but on a thin skin, shallow ; they were not always pro-
portioned in width to that of the Tcsicle, the smallest cicatrix
often succeeding the largest vesicle, but the later the crust fell,
of course the deeper the cicatrix, which, on these occasions, was
often beautiftOly striated. I need scarcely say, that where the
yesicles were accidentally broken, or spontaneously burst, much
mischief ensued, deep sloughing of the skin, &c. Spontaneous
bursting did not often occur, except in those subjects possessing
the before-mentioned and well-known obnoxious constitutional
endermic characteristics, upon whom we must always use active
lymph with some risk.
" When the lymph in the first remove produced normal vesi-
cles, and as soon as it had passed readily from arm to arm, the
constitutional symptoms, though mild, were most commonly well
marked. In infants, restlessness, fretftdness, and inappetency
about the fifth or sixth day, were very common, sometimes as
late as the seventh day. Very few escaped feverish symptoms
on the ninth and tenth days, many had vomiting and diarrhcea.
From childhood up to puberty, the primary symptoms from the
fifth to the seventh day were unequivocally visible, and often
complained of; fever, vomiting, delirium, and diarrhoea were
not unfrequently witnessed at the commencement, or during the
progress of the secondary symptoms. In adults, of course, more
complaint was made, head-ache, chilliness, anorexia, and some-
times thirst, on the fifth or sixth day ; increased on the seventh
day, with axillary tenderness, but on the ninth and tenth days
much general febrile complaint, disinclination, and even inability
to leave the bed. But in several instances, amongst young chil-
dren, little or no complaint was made or indicated ; all the mem-
bers of the same family vaccinated from the same source might
be difierently afiected.. One, for instance, would not cease from
pastime, occupation, or meals, while another, particularly if
older, would be indisposed several days. Neither the number
nor the magnitude of the vesicles seemed to determine the
amount of the primary disturbance. If properly developed,
small vesicles often gave rise to marked constitutional symptoms,
and the most splendid vesicles were often seen with trivial, some-
times scarcely appreciable disturbance."
" The secondary symptoms are often as active with three or
four, as with six or eight vesicles ; acceleration of the pulse was
frequently noticed, when no other symptoms appeared. Both
primary and secondary symptoms very commonly showed a re-
mitting type.''
Widi respect to cutaneous eruptions, Mr. Geeley observed but
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126 CONGESTIVE INFLAMBfATION OF THE DERMA.
one in the adult, and in children nothing, approaching the
varioloid character. '^Roseola, strophulus/ lichen, were the
principal eruptions.'*
202. Dr. Basile Thiele,^ of Kasan, has succeeded several
times in inoculating the udder of cows. When children were
inoculated with matter taken from these pocks, the effects pro-
duced were more intense than those occasioned by the ordinary
vaccine lymph. In some cases. Dr. Thiele observed two febrile
attacks, the one between the third and the fourth day, the other
between the eleventh and tlie fourteenth, and these severe con-
sequences were not lost until the sixth remove. In one case, he
produced true variola, and inoculation with the matter of these
pocks gave him vaccinia.
RECURRENCE TO THE PRIMARY VACCINE VESICLE.
203. Lymph has been procured directly from the cow in
several counties of England, and numerous children have been
inoculated with this primary lymph ; indeed, the removes from
these sources have now come into almost general use. The
gentlemen to whom we are principally indebted for this supply,
are Mr. Estlin, of Gloucestershire ; Mr. Fox and Mr. Sweeting,
of Dorsetshire ; and Mr. Ceeley, of Buckinghamshire. It has
also been obtained and employed in France, by M. Saunoy.
204. Whenever an attempt is made to inoculate man with the
virus derived directly from the cow, or, on the other hand, to
inoculate the cow with humanised vaccine lymph, or with small-
pox, great difficulty is encountered. There would seem to
exist an indisposition to the assimilation of virus derived from
an animal of a different order, but when this lymph has once be-
come assimilated, all difficulty is at an end. When inoculation
is effected, a remarkable difference is perceived in the conse-
auences of the two kinds of lymph ; thus, in the transference of
le lymph of small-pox to the cow, the virus is greatly modified,
and the resulting pock is chastened and mild ; while, on the con-
trary, the lymph of the variolae vaccinae first introduced into the
tissues of man, gives rise to symptoms of greater severity than
those produced by humanised lymph. How far this difference
of effect may be dependent upon the different quality of the
fluids of an herbivorous and a carnivorous (the human infant)
or semi-camivorous animal I am unprepared to say. I think it
not improbable that the cause might be foimd in this difference
of character.
. The effects of vaccination with primary lymph are, according
* BuUetia de rAcademie Roj. de Med., Jan. 1S41.
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RECURRENT VACCINATION. 127
to Mr. Ceeley, as follows : — On the second day afker yacoination,
there is an unusual degree of redness around the puncture ; the
redness declines on icbe two following days, and becomes con-
centrated in the point where the pi^ula arises. The elevation
of the papula commences on any one of the days between the
sixth and the tenth. Desiccation of the vesicle is also protracted ;
it contains fluid until the sixteenth or eighteenth day, and the
crust remains adherent until the end of the fourth or fifth week.
The areola is completed firom the eleventh to the sixteenth day,
and is sometimes covered with small supernumerary vesicles,
and accompanied by a general eruption of papulas, vesicles, or
bullae. When the vesicle is ruptured in unfiELVourable constitu-
tions, irritable sloughing sores are sometimes formed, and the fall
of the crust is occasionally succeeded by a yellow, foul excoriation.
The vesicles produced by primary lymph are very variable in
appearance, sometimes they are " remarkably large, and finely
developed,*' at other times they are smaller, and ^ less developed
than other vesicles ;" but they " admit of a very remarkable im-
provement, by transmission of the lymph through a series of
well-selected subjects. By this process, also, in a very short time,
most of the defects and some of the evils connected with the use
of primary lymph may be dissipated, and the lymph rendered
milder, and more suited to general purposes." " Children are
the best, certainly, for the purpose, and such should be selected
as possess a thick, smooth, clear skin, and have a dark com-
plexion, and are not too florid, but still plump, active, and
healthy." " By a steady and judicious selection of these, and
similar subjects, in a few (even three or four) removes, the
severity of the local mischief becomes manifestly materially dimi-
nished, the vesicles acquire a magnitude and beauty, often
greatly superior to what is daily witnessed; and in a short time
the lymph may be transferred with safety to others, even more
sanguine and robust, where it is well known, lymph, if good for
anyldiing, will produce the finest and most perfect vesicles."
" As we advance, we find the necessity of preparing the most
objectionable subjects, and the advantage of subjecting many of
them to the same preliminary treatment, which the best and
most expert inoculators of small-pox formerly so successfully
adopted for their patients ; for it is a long time before some indi-
viduals can be safely vaccinated with this active lymph, even
though taken from the mildest vesicle."
205. Recurrence to the primary lymph from the cow appears
to me to be the only unobjectionable method of improving the
current lymph, and correcting the deterioration which has arisen
from neglect of the precepts of Jenner. Lymph from this
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128 CONGESTIVE INFLAMBfATION OF THE DERBfA.
source must necessarily be pure, and its use should therefore be
encouraged.*
206. Treatment — Any morbid conditions arising accidentally
from vaccination should be treated in accordance with the gene-
ral principles of therapeutics. Febrile symptoms may call for
the employment of antiphlogistic remedies ; and the local inflam-
mation, when it assumes a form of unusual severity, may be sub-
dued by means of a compress of linen wetted in a spirituous
lotion and covered with oiled silk. If sloughing or ulceration
occur, water-dressing should be continued until the inflamma-
tion is removed, and slightly astringent washes or a mild oint-
ment applied subsequently.
* Dr. Lichtenstein, in a iMiper, entitled '' On the sonrcf s from irhich matter pre-
servative against the small-pox has been derired," in Hufeland*s Journal for 1841,
remarks, that limpid lymph taken from the postules produced by tartarized antimony,
and inoculated in a person irbo has not been raocinated, produces resides, which
cannot be distinguished from those of yaccinia. These yesides appear to be equally
protective against small-pox with the cow-pox, and the matter may be transmitted
from person to person in the same manner. The author of the paper has inoculated
and re-inoculated thirty-one persons with the matter procured fh>m this source ;
and these persons were protected during an epidemic of small-pox, although placed
in association with patients affected with that disease.
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CHAPTER III.
CONGESTIVE INFLAMMATION OF THE DERMA.
II. INFLAMMATION OF THE DERMA WITHOUT CONSTITUTIONAL
SYMPTOMS OF A SPECIFIC KIND.
207. The diseases assembled under this head have their
general characters sufficiently marked by the definition which is
here given : they are, —
Er}'sipelas,
Urticaria,
Roseola,
Erythema.
Erysipelas serves to establish a link of transition between
eruptive fevers and the second group of cutaneous exanthemata.
In some of its characters — namely, in that of transmission by
infection and contagion, and in the presence of fever, which pre-
cedes and accompanies the local affection, it possesses a close
affinity with the former ; while in the frequent development of
the disease, without the apparent concurrence of infectious and
contagious causes, the absence of protection afforded the system
against subsequent attacks, the frequent appearance of the dis-
ease without precursory fever, and the partial affection of the
skin, it approaches nearer to tlie latter.
Urticaria seems to deserve a place next to erysipelas, from
combining considerable severity of constitutional symptoms with
a local eruption. Roseola holds a middle course between urti-
caria and erythema ; while erythema forms a transition to the
patches of cutaneous congestion on which the bullsB of the suc-
ceeding group are developed.
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ISO CONGESTIVE INFLAMMATION OF THE DERMA.
ERYSIPELAS.
Syn. Ignis Sancti AnthonzL ErysipeUy Fran. —
Rotklaufy Grerm.
208. Erysipelas^ is a difiused inflammation of the skin and
subcutaneous areolar tissue, affecting a part of the surface of the
body, and accompanied by fever which is contagious and infec-
tious. The locd inflammation has a special disposition to
spread; it is attended by swelling, a pungent, burning, and
tingling heat, and by a redness which disappears under pressure
with the finger, to return so soon as the pressure is remitted. It
is often accompanied by vesications containing a limpid amber-
coloured serum, which quickly burst, and form thin, dark-coloured
crusts. Erysipelas terminates generally in resolution with des-
quamation of the epiderma, sometimes in delitescence or sup-
puration, and more rarely in mortification.
209. Erysipelas admits of division into two principal varieties,
erysipelas simplex, and erysipelas phlegmonodes. The former
of these contains several subvarieties, and some local forms de-
serving of attention from the modifications which they present,
these modifications being a consequence of the peculiarities of
the region in which they are developed. Erysipelas phlegmo-
nodes offers but one subvariety of importance. The varieties
and subvarieties of erysipelas may be thus arranged : —
ERYSIPELAS SIMPLEX.
Subvarieties. Local subvarieties.
Erysipelas erraticum. Erysipelas faciei,
„ metastaticum, „ capitis,
miliare, „ mammse,
phlyotenodes, „ umbilicale.
oedematodes.
ERYSIPELAS PHLEGMONODES.
Subvariety,
Erysipelas gangrenosum.
ERYSIPELAS SIMPLEX.
210. The inflammation of erysipelas always extends more or
less deeply into the tegumentary textures. That which aflfects
the skin the most superficially, is the form at present under
consideration, which would seem to be limited to the derma
• Der. kpv9poct red.
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ERYSIPELAS SIMPLEX. 131
and its immediately contiguous areolar tissue. Simple erysi-
pelas occurs most frequently upon the face and heady next in
frequency upon the lunbs, ana most rarely on the tnmk of the
body. Like other cutaneous diseases, it offers for inquiry, in
the first place, its general or constitutional, and in the second,
its local symptoms.
The constitutional symptoms of idiopathic erysipelas are, chil-
liness and rigors, succeeded by flushes of heat ; dejection of
spirits, lassitude, pains in the back and limbs, pains in the
head, drowsiness ; quick and hard pulse ; thirs^ loss of appe-
tite, white and coated tongue, bitterness of mouth, nausea, vomit-
ing, pain at the epigastrium, and constipation. These symptoms
precede the local disorder tor several days, increasing with the
progress of the efflorescence, and disappearing at its decline.
During the height of the local inflammation, the affection of the
nervous system often becomes exceedingly severe ; there is low,
muttering delirium, with subsultus tendinum, an exceedingly
rapid pulse, and a brown and dry tongue. At the close of die
fever, there is commonly a critical relaxation of the bowels, a
sediment in the urine, and occasionally a slight haemorrhage
from some part of the gastro-pulmonary mucous membrane, or
from the uterus.
Simon observes that in the early stage of erysipelas the urine
puts on the inflammatory character. " It is frequently," Schon-
lein remarks, ** loaded with bile-pigment, and is of a reddish
brown or red colour. At the urinary crisis, fawn-coloured preci*
pitates are deposited, and the urine becomes clear." '< Becquerel
made two quantitative analyses of the urine of a man, thirty <-
nine years of age, who had erysipelas of the fru)e and a good
deal of fever, his pulse being 112. The urine of the first
analysis was of a deep yellowish red colour and clear ; its spe-
cific gravity was 1-021. That of the second was so deeply
coloured as to appear almost black, it threw down a redmsh
sediment of uric acid, and had a specific gravity of 1-023. The
first analysis was made on the fourth, and the second on the sixth,
dav of the fever. The analyses are as follow 3 Becquerers analysis
of healthy urine being placed for comparison in a third column : —
Anal. 1. Anal. S. HmIUi.
OoDcef of iirinei]i24hoiirf . . . 27*0 ... SOS ... 45*0
Water 965-5 ... 961*9 ... 9720
Solid constitaents 84*5 ... 38*1 ... 28*0
Urea 12*5 ... 12*7 ... 121
Uric acid 1*2 ... 1*S ... 0*4
Fixed salts ....... -- ... 8*2 ... 69
Extractive matter ..... — ... 15*9 ... 8*6
Specific grafSty 1021*0 ... 1029'! ... 1017-0
k2
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132 CONGESTIVE INFLAMMATION OF THE DERMA.
" In a woman, aged forty-five years, with erysipelas of the face,
whose pulse was 104 and full, the urine was very scanty, of a
dark brown colour, strongly acid, threw down a yellow sediment
spontaneously, and had a specific gravity of 1023-1. It con-
tained—
Water 961-7
Solid constitneots 38*3
Urea 117
Uric acid 1*3
Fixed salts 9'2
Extractive matters 15*7
^^ In five cases in which the morning urine was daily examined
with care, the characters of inflammation were present in a very
high degree; the specific gravity varied from 1021 to 1025. In
four of these cases the urine Arew down a reddish sediment,
and in two a little albumen was occasionally present"*
The local affection makes its appearance on the second or
third day from the commencement of the febrile symptoms, in
the form of a somewhat swollen and irregularly circumscribed
yellowish red patch, which is accompanied by a painful sensa-
tion of tension, and by a sharp, burning and tingling, or prick-
ing heat On the third and fourth days, the redness becomes
more vivid, the tumefaction greater, and the painful sensations
more acute. These symptoms continue without change until the
sixth or seventh day, when they begin to decline. The redness
then subsides, fading into a pale yellowish tint ; the swelling
diminishes, the epiderma is thrown into wrinkles, is dry and
friable, and speedily desquamates in thin transparent scales. The
resolution of erysipelas is the most favourable termination of the
disease.
Subvarietiet,
211. Erysipelas erraticum. — Erysipelas is remarkably and
characteristically disposed to wander from the spot where it was
first developed, to extend itself more diffusely, and to fix upon
new situations. Sometimes we find it simply spreading, and
thus increasing the extent of the inflamed surface ; at other times,
it subsides entirely upon the parts first affected, as it proceeds
in its erratic course, or it suddenly quits its original situation,
to appear as suddenly upon one more distant This erratic or
ambulant disposition of erysipelas is often seen upon the face
and head, where it is exceedingly intractable.
212. Erysipelas metastaticum, — This designation indicates a
variety of erysipelas in which the efflorescence suddenly disap-
pears on the surface of the body, and some internal organ be-
* Simon's Animal Chemistry, vol ii. page S78.
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ERYSIPELAS (EDEMATODES. IBS
comes immediately and severely affected. The metastatic form
of the disease occurs most commonly in debilitated and broken
constitutions, and is particularly observable with regard to ery-
sipelas of the head and face. The organs most liable to suffer
from the metastatic action in erj'sipelas are the brain or its
membranes, and the gastro- pulmonary mucous membrane. Me-
tastasis to the membranes of the brain is accompanied by delirium
and coma, and usually terminates fatally. Dr. Watson remarks
that the metastasis of erysipelas is rare. " I do not recollect to
have seen it But the extension of the inflammation, the super-
vention of delirium and coma, while the external inflammation
continues, is of common occurrence."
213. Erysipelas miUare. — It occasionally happens that a crop
of small vesicles, like those of eczema, make their appearance on
the inflamed surface. They contain a limpid, serous fluid, burst
in the course of a day or two from their eruption, and leave
behind them small, brownish-coloured scabs.
214. Erysipelas phlyctenodes is a common form of the disease ;
it is tiiat in which vesicles (buUse) of considerable size, and irre-
gular in their form, appear upon the inflamed skin. They
usually arise on the fourth or fifth day, burst in the course of
twenty-four hours from their development, and terminate by
forming yellowish scabs, which gradually become brown, and
afterwards black. The bulls contain a limpid serum, at first
colourless, but changing by degress to a pale straw or amber
tint. Occasionally the fluid becomes opaque, and sometimes
assumes a purplish hue ; the latter is an unfavourable sign.
215. Erysipelas cedematodes. — In persons of a lymphatic tem-
perament, and in constitutions debilitated by previous disease
or excesses, there exists a disposition to the efiusion of a serous
fluid into the tissue of the derma, and into the sub-dermal tex-
tures, constituting oedema. In this form of erysipelas the in-
flamed surface is less brightly red tiian in the preceding varieties,
the surface is smooth, tense, and shining, and a pale depression
or pit is left upon the skin by the pressure of the finger. Ery-
sipelas cedematodes occurs most frequenfly in the lower extre-
mities and external organs of generation, and terminates like the
simple form of the disease, the efiused fluid being removed sub-
sequently by absorption.
Local subvarieties.
216. Erysipelas of the face, — The face is the most frequent
seat of erysipelas. It commences usually on the side of the nose,
and spreads rapidly over the whole of one side of the face,
extending sometimes to both. The face is so much swollen by
the attack that the features are scarcely recognisable. The cheeks
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134 CONGESTIVE INFLAMMATION OF THE DERMA.
are greatly tumefied, and the eyelids turgid and infiltrated.
The constitutional symptoms accompanying the local disorder
are exceedingly severe ; there is violent head-ache, sleeplessness,
frightfol dreams, and, commonly, delirium. The disease reaches
its height on the fourth or fifth day, and terminates on the
seventh or eighth. It is firequently accompanied by inflammation
of the mucous membrane of the nose and mouth, by a swollen
and painful state of the parotid glands, and its resolution is
occasionally indicated by a critical hsemorxhage firom the pitui-
tary membrane. Erysipelas of the face is always serious, firom
the great liability to the occurrence of metastasis or extension
to the brain, and it is firequently succeeded by subcutaneous
abscesses.
When erysipelas of the head and face terminates fatally, death
is usually occasioned by effusion within the head, and coma.
Another cause of death is apnoea, fi-om infiltration of the sub-
mucous tissue of the glottis ; and a third, asthenia, or a total
prostration of the vital powers.*
217. Erysipelas of the scalp is usuaUy the consequence of a
wound or injury to the head, and occurs in about a week or ten
days fi-om the reception of the violence. The affected inte-
gument is oedematous, smooth, and shining, and very sensitive ;
but the redness is more dull than in other situations. When
left to itself, erysipelas in this region issues in suppuration
and gangrene of the areolar and fibrous tissue of the scalp. It
often terminates by metastasis or rather by extension to the
brain.
218. Erysipelas of the mammcB, — From the quantity of areolar
substance surrounding the mammary gland, erysipelas in this
region is disposed to tkke on the phlegmonous character, and to
terminate in extensive suppuration, and gangrene of the fibrous
substance. The redness accompanying the exanthem is by no
means vivid.
219. Erysipelas of the umbilical region occurs in infants, par-
ticularly in public institutions, and is referrible to irritation pro^
duced by the mismanagement of the umbilical cord, or, vnth more
likelihood, to some endemic cause. From the umbilicus, the
erysipelas extends to the integument of the abdomen, and fire-
quently to the organs of generation. It sometimes gives rise to
sphacelus of the integument and subcutaneous areolar tissue,
and terminates fatally.
ERYSIPELAS PHLEGMONODES.
220. Phlegmonous erysipelas is much more severe in its nature
than the simple varieties, and affects the deeper seated textures,
• Dt. WatKm — Lectures^
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ERYSIPELAS PHLEGMONODBS. 185
the suboQtaneons areolar tissue, the saperfioial and deep fiusci®,
and the intermuscular areolar tissue, as weU as the integument
It may occur on any part of the body, but is most frequently ob-
served in the extremities. This form of erysipelas terminates
rarely in resolution, commonly in extensive suppuration, and
gangrene of the areolar tissue and fcisci®.
The cotudtutional symptoms are identical w^ith those which ac-
company simple erysipelas, but more severe, the violence of the
symptoms being in great measure dependent upon the extent
and depth of the inflammation. When the disease spreads
widely and deeply, there is delirium, a dry and brown tongue,
frequently diarrhoea, and copious perspirations.
The heal symptoms^ when the inflammation is comparatively
superficial, are, vivid redness, which disappears on pressure, and
returns slowly on its remission, tumefaction, a smooth shming
sor&ce, and an acute burning pain, augmented by the slightest
touch. On the fifth or sixth day, if active treatment have not
been adopted, the pain diminishes and assumes a throbbing
character, the redness subsides, and an obscure fluctuation may
be felt over the surface. Suppuration has now taken place more
or less extensively, and the pus burrows beneath the skin and
friscisB in all directions, unless released by incision or ulceration.
If an incision be made, it gives exit to healthy pus, mingled
with small portions of dead areolar tissue. When the inflam-
mation is disposed to terminate in resolution, the redness, pain,
and swelling, diminish on the fifth or sixth day, the epiderma be-
comes dry and scaly, and the eflfused fluids are g^uduaUy removed.
221. If phlegmonous erysipelas attack more deeply seated
textures, or an entire member, the inflammation appears sud-
denly, the pain is more severe and distressing than in the pre-
ceding form, and the surface is vividly red, tense, and shining,
and exquisitely sensitive. On the fifth or sixth day, and some-
times earlier, suppuration takes place, accompanied by throb-
bing, and preceded by occasional chills and rigors. The redness
and pain diminish on the occurrence of suppuration, and an ob-
scure fluctuation and boggy sensation are felt on the application
of the hand. If the parts be opened at this period by a free in-
cision, a large quantity of pus will escape, mingled ydth consi-
derable flakes of areolar tissue in a state of gangrene. Should
the incision be neglected, the pus spreads completely around the
limb, burrovnng beneath the fascism, between the muscles, and
separating the integument from the parts beneath. Eventually,
the matter discharges itself by means of ulceration, but the con-
stitutional irritation is excessive ; hectic fever is induced, accom-
panied by colliquative diarrhoea, and the scene quickly closes in
death.
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186 CONGESTIVE INFLAMMATION OF THE DERMA.
222. When the pus is bound down by aponeurosis, or fasci®,
the constitutional effects are still more intense than those above
described. The integument, in a few days, becomes livid and
dark-coloured, large vesicles or phlyctens, containing a purplish
serum, rise upon the surface, gangrene ensues, attended with
entire prostration of the physical powers, and death speedily
follows. In some cases, however, when the strength of constitu-
tion of the patient enables him to resist the effects of sphacelus,
sloughs are formed, which are thrown off, and a granulating sur-
face is slowly established. The issue of phlegmonous erysipelas
in mortification, constitutes the sub-variety, termed gangrenous
erysipelas.
223. Diagnosis, — The principal diagnostic characters of ery-
sipelas are, inflammation of the skin, extending more or less
deeply into the subcutaneous areolar tissue ; tumefeu^on of the
inflamed parts ; a special disposition to spread ; and symptoms
of a dangerous fever. These signs serve to distinguish it from
erythema, in which the inflammation is superficial, being limited
to the derma ; there is scarcely any tumefaction of the inflamed
parts ; the disposition to spread is comparatively absent ; and
there is little constitutional disturbance. Erythema Isve may,
at first sight, appear to be a contradiction to these characters,
but the cedema in this affection is the cause, and not the effect,
as in erysipelas.
The uniform redness of the inflamed surface, and its partial
seat, sufficiently distinguish erysipelas firom other exanthematous
fevers. A few instances have been recorded, in which erysipelas
is stated to have been universal, but such cases must be ex-
tremely rare.
Simple erysipelas is distinguished from erysipelas phlegmo-
nodes, by the tumefaction of the latter extending more deeply,
by the greater severity both of the local and constitutional
symptoms, and by the violence of the inflammation expending
itself upon the part first attacked, without spreading to distant
regions.
224. CaiLses. — Erysipelas appears to originate in infection or
contagion, hence it is sometimes seen prevailing epidemically, or
running through the wards of an hospital. The predisposing
causes are, some inherent peculiarity of the constitution, as in
cases where it occurs hereditarily ; or some morbid state of the
system. It not unfrequendy appears in those whose nervoiis
system is debilitated by mental emotions of a depressing kind,
as anger and grief; by chronic disease ; or by excesses. Under
these conditions, the most trifling irritation may give rise to the
affection ; such as a scratch witib a pin, a leech-bite, a blister,
seton, or issue, &c. In like manner, a wound, either accidental,
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TREATMENT OF ERYSIPELAS* 137
or occasioned by a surgical operation, may be the exciting cause
of erysipelas. Persons with a thin and irritable skin, and mem-
bers of the female sex, are especially liable to erysipelas. It
makes its attacks most frequently in die summer season, and is
sometimes dependent on functional derangement, such as ame-
norrhoea, the critical period, &c. In delicate females it occa-
sionally takes place periodically.
225. Prognosis. — The prognosis of erysipelas depends upon
the various circumstances enumerated among the causes. ^Vhen
the fever is moderate, the constitution sound, and the local in-
flammation not extensive, the disease may be regarded as of
little consequence. When, however, the constitution is debili-
tated, the invasion of erysipelas is to be apprehended, not only
from the deficient power of the system, but also from the liabi-
lity which exists to inflammation of tlie superficial veins and
lymphatics, and purulent deposits in the viscera. The prognosis
is also unfavourable when it occurs either in the very young, or
in the very old ; when it is associated with a wound; when it is
complicated with vomiting, or vomiting and purging ; or when
it succeeds to anasarca. The metastatic form is always dan-
gerous, from the possibility of some vital organ being second-
arily attacked. Erysipelas erraticum occurring in the progress
of chronic disease, is also of dangerous import. Phlegmonous
erysipelas, on account of its severity, is always dangerous, and
requires the most vigilant care.
226. Treatment, — The management of erysipelas presents two
indications— ^r^tfy, to subdue the fever ; and secondly y the local
inflammation.
The first of these indications is to be eflfected by means of rest,
milk diet, gentle laxatives, salines, diluents, &c. If the patient
be young and plethoric, a bleeding from the arm may be advis-
able, followed by a brisk purgative of neutral salts or rhubarb
and magnesia. But if the subject be debilitated, depleting
measures are highly dangerous, and tonics, such as quinine,
and difiusive stimulants must be early employed. Under all
circumstances, it must be borne in mind, that erysipelas is a
disease of reduced powers, and, consequently, so soon as the
artificial excitement produced by the fever shall have passed
away, our efibrts must be directed to the restoration of the tone
of the system.
Dr. Robert Williams, whose observations on erysipelas entitle
him to the highest respect, remarks: — ^**The mode, then, in
which I am in the habit of treating idiopathic erysipelas, what-
ever may be the part affected, or with whatever symptoms it may
be accompanied, is as follows : — The patient is put on a milk
diet, the bowels gently opened^ and from four to six ounces of
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138 CONGESTIVE INFLAMMATION OF THE DERMA.
port wine, together with sago, allowed daily. This mode of
treatment it is seldom necessary to vary throughout the whole
course of the disease ; for the delirium, if present, is generally
tranquillized ; if absent, prevented ; the tongue more rarely be-
comes brown, or only continues so for a few hours ; while the
local disease seldom passes into suppuration or gangrene. In
a word, all the symptoms are mitigated, and the course of the
disease shortened. I have pursued this system for several
years, and I hardly remember a case in which it has not been
successfiil."*
Dr. Williams records several remarkable instances of the ad-
vantages of this method of treatment He does not limit the
quantity of wine to that above stated, but in more severe cases,
when the local disease still continues to extend, and the delirium
to augment, he increases the wine to eight ounces, and adds to
it the influence of quinine. " Two cases of erysipelas,** con-
tinues the author, ^^ not less instructive, were recently treated in
St. Thomas's. The patients were both stout, heedthy young
women, and nearly of the same age ; the seat of the disease also
was the same, on the head and &ce, and they suffered equally
from delirium, so that the difference between them, if any, was
scarcely distinguishable. For the one, four ounc-es of wine were
prescribed on the Saturday, and there appeared no sufficient
reason to increase the quantity on the Monday ; but between
Monday and Thursday, the day on which I next saw her, she
had so sank, that it was impossible to recover her. The other
case was admitted about three days later, and, in the first in-
stance, only four ounces of wine were prescribed for her, but,
warned by the fate of the former person, although she was highly
delirious, I immediately increased the wine to eight ounces, and
added also two grains of quinine every six hours. Under this
treatment she rapidly recovered, so much so, that in four or five
days it was thought practicable to reduce the wine to its original
quantity, or to four ounces. But on this reduction being made,
the disease immediately returned, and it was once more neces-
sary to raise it to eight ounces, and the patient now rapidly re-
covered." As a commentary on the treatment advocated by Dr.
Williams, I may mention, that the worst case of erysipelas of
the head and face I ever saw, was cured by the exhibition of
Burton ale.
Mr. Grantham, of Crajrford, in Kent, a successful practitioner
and original thinker, suggests the propriety of making early ob-
servation of the state of the urine. "I begin," he observes,
*^ with large doses of carbonate of ammonia, spirits of ammonia
and camphor mixture as an alkaline mode of treatment, which
•Page 284.
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TREATMENT OF ERYSIPELAS. 139
is generally indicated in the early stage of the inflammation, but
towards the sequel of the disease a contrary mode of treatment
is necessary, namely, small doses of sulphate of magnesia, with
fuU doses of the acidum sulphuricum aromaticum. The diet
should be liquid and nutritiye with a full proportion of common
salt ; and narcotics should be avoided unless indicated by an
alkaline state of the urine." It must be remembered that Mr.
Grantham's field of observation is a most healthful neighbour-
hood, remote from the causes of depression which exist in
towns and cities. In the latter, sedatives form as essential a
part of the treatment as stimulants.
By some practitioners, an emetic has been strongly recom-
mended in die outset of the fever, and followed up during its
progress by small doses of tartarized antimony. The excitability
which accompanies the fever is to be calmed by sedatives, such
as hyoscyamus and morphia, as circumstances may suggest, the
latter remedy being frequently necessary at night, and in the
more advanced stages of the disease. Two very valuable and
important medicines in erysipelas are aconite and belladonna ;
both of these remedies act, by reducing the excitement of the
arterial system, and procuring rest. The extract of aconite is
especially useful in checking the heart's action, and promoting
cutaneous transpiration, and for this purpose should be admi-
nistered in half-grain doses every four hours. Mr. Liston re-
marks, that after the aconite has performed its office, the extract
of belladonna, in doses of one-sixteenth of a grain, is productive
of the most beneficial effects.
In erysipelas about the head and face, the feet and legs of the
patient should be immersed in a mustard bath, and mustard
poultices or blisters applied to the calves of the legs.
227. The second indication — namely, that which relates to
local treatment, is to be fulfilled, in mflder cases, by rest, posi-
tion, evaporating lotions, warm fomentations or water-dressings,
the temperature of the applications being determined by the
feelings of the patient. On the head and face fomentations and
fluid applications are generally inconvenient, and their place
may be usefully supplied by flour dusted copiously on the sur-
face from the dredging-box. In more severe cases, the conges-
tion of the vessels of the skin is best relieved by puncturing the
surface very freely with the point of a lancet, and afterwards
using warm sedative lotions and fomentations of chamomile
and hops.
This practice was followed by Sir Richard Dobson for many
years, and always with the most favourable results. He observes,
that die punctures heal in the course of a few hours, that he
makes them on every part of the body, and that he never saw
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140 CONGESTIVE INFLAMMATION OF THE DERMA.
any ill consequences result. Sir Richard Dobson was in the
habit of making from ten to fifty punctures, about a quarter of
an inch in depth, on the inflamed surface, and repeating the
operation two or three times a day, as the case appeared to de-
maud. Mr. Liston advocates the same plan. For some time I
have pursued this method in the local treatment of erysipelas,
and always with the most gratifying eflfects. It is surprising
how quickly the tension and pain are diminished, and the tume-
faction reduced.
Great benefit is sometimes derived from the application of a
strong solution of nitrate of silver to the inflamed surface.
Mr. Higginbottom, of Nottingham, by whom this mode of treat-
ment is recommended, gives the following statement of his plan :
— " The part is first to be washed in soap and water, to remove
any oily substance from the skin, and then is to be wiped dry ;
the hiflamed and surroimding skin is next to be moistened, and a
long stick of the nitrate of sOver is to be passed over the moist-
ened surface, taking care that not only every part of the in-
flamed skin should be touched, but the surrounding healthy skin
to the extent of an inch or more beyond it, in severe cases. The
nitrate of silver may then be passed over these surfaces once,
twice, thrice or more times according to the degree of inflam*
matiou ; once in slight cases, twice or three times in common
cases, and more frequently if quick vesication be required/*
During the last eleven or twelve years Mr. Higginbottom has
found a solution of eight scruples of nitrate of silver with twelve
drops of nitric acid in an ounce of water, more convenient than
the solid salt. He regulates the application of the solution ac-
cording to the degree of severity of the local inflammation, and
prefers a dossil of lint tied on the end of a piece of stick, to a
camel's hair pencil for its difiusion over the surfetoe. " The suc-
cess of the nitrate of silver in external inflammation depends
upon its strength and its proper application. The method of
applying it by some practitioners appears to me to be quite
trifling with die remedy. Instead of covering the whole in-
flamed surface and the surrounding healthy skin with the nitrate
of silver, so as to cover the whole of the inflammation, they
simply apply it around the inflamed surface, a mode of proceed-
ing which has seldom the power of even preventing the spread-
ing of the disease or the deeper mischief when the inflammation
itself is unarrested. Sometimes, even after the most decided
application of the nitrate of silver, the inflammation may spread,
but it is then generally much feebler in character and easily
checked by the repeated application of the remedy." " I con-
sider the application of the nitrate of silver as perfectly safe. I
have seen no case of metastasis or any other bad efiects firom
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TREATMENT OF ERYSIPELAS. 141
the use of it during upwards of twenty years."* Mr. Higgin-
bottom further recommends that where erysipelas extends to the
scalp, the head should be shav^^in order that the extent of the
disease may be fully ascertained and that the solution may have
a fair chance of completely covering it. It should be applied
very freely on the scalp, where, he informs me, ** it scarcely ever
produces vesication."
The nitrate of silver is an excellent means of limiting the ex-
tension of the disease, by encircling the inflamed part by a line
drawn with a wetted stick of nitrate of silver. When an extre-
mity is attacked, the defensive cordon must extend completely
around the limb, above the afiected part, and if this simple
manoeuvre be properly performed, the inflammation will, in
many cases, be limited to the part first attacked. Nitrate of
silver appears to act, by exciting an effusion of lymph and ad-
hesive inflammation in the line of its application, which opposes
an obstacle to the propagation of the exanthema.t The erratic
form of erysipelas may frequently be fixed to the spot originally
affected, by the application of a blister ; and this is the practice
usually resorted to, for the purpose of recalling the disease,
where it has suddenly disappeared by metastasis. In erysipelas
phlyctenodes the vesicles should be opened, and the contained
fluid gently pressed out and absorbed by a soft sponge. The
epiderma of the phlyctense should be preserved as entire as pos-
sible, and replaced upon the denuded derma. This manner of
treating the vesicles of erysipelas is infinitely superior to the
ancient plan of covering them with starch powder, zinc powder,
&c. CEdematous erysipelas is especially benefited by the punc-
tures above recommended, followed, as soon as the inflamma-
tion is subdued, by compression vrith a bandage. Erysipelas of
the scalp, when it affects the deep-seated textures, as in wounds
and braises of the head, is instantly relieved, and the danger of
the disease mitigated, by a free incision carried down to the bone.
Velpeau recommends a solution of sulphate of iron, in the
proportion of an ounce to the pint of water, as a local applica-
tion in er}'sipelas. This solution, he remarks, produces a sudden
improvement in the patches, and causes their decline in one or
two days. As frequently as new patches make their appearance,
they are to be treated in the same manner, until the constitu-
tional morbific influence is expended. In situations where a
lotion would be inconvenient, this surgeon employs an oint-
ment, containing a drachm of the salt to an ounce of lard.
Mr. Grantham, to whose constitutional treatment of erysipelas
I have already referred, remarks with regard to its local manage-
* Lancet, vol. ii. 1843, p. 515.
t Ao ointmeDt of nitrate of siWer has been recommended as useful in erysipelas.
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142 CONGESTIVE INFLAMMATION OF THE DERMA.
menty ^^ My plan is to relax the skin with hot water or steam
fomentations, and after each fomentation to saturate the inflamed
surface with hot lard which is afterwards covered with wool.^
228. Phlegmonous erysipelas requires great activity of
management At the outset of the inflammatory attack, the
patient should be bled and freely purged. The afiected part
should be placed in a position to facilitate the circulation through
the limb as much as possible. A number of leeches should be
applied, and followed by fomentations and warm water dressing.
If these means fail to restrain the progress of the disease, two or
more incisions, according to the extent of the inflammation,
should be made through the afiected tissues, so as to divide
freely the superficial and deep fascia, and offer a free passage to
any pus that may have been formed. To effect this object com-
pletely, the incisions should be two or three inches in length,
and sufficiently deep. The advantages of this mode of treat*
ment are obvious, the congested vessels of the inflamed part are
relieved, and the tendency to morbid action consequently dimi-
nished. The tension, pain, and tumefaction are reduced, even
where no matter is already formed, and when suppuration is esta-
blished, a free outlet is given to the pus, and flakes of gangre-
nous areolar tissue. Whenever we are led to infer, from the
severity of the constitutional symptoms, that pus is bound down
by fascia, as in the hand and foot, a free incision is the proper
treatment, even although no swelling may be present After
the incisions, the fomentations and warm water dressing should
be continued ; and on the decline of the inflammation, a ban*-
dage appUed, to facilitate the absorption of the fluids efiused
into the surrounding tissues.
The general treatment applicable to erysipelas phlegmonodes
is the same as for simple erysipelas, and sedatives are especially
valuable* As soon, however, as the immediate inflammatory
symptoms have subsided, tonics must be employed and aided by
a more generous diet.
URTICARIA.
Syn. Uredo, Nettlerash, Fievre orti£e porcelaine, Essera^ ItaL
— Urticairej Fran. — Brennesselausschloffy Germ, — Cnidosis.
Alibert.
229. Urticaria, or nettlerash, (Plate 1,) is a transient and non-
contagious inflammation of the skin ; it is characterized by the
eruption of small elevations, having a round, oval, or wheal-like
form, of a whiter or redder tint than the healthy integument, and
surrounded by a diffused redness of greater or less intensity.
Urticaria is preceded and aocompajued by febrile symptoms,
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URTICARIA PEBRILIS. 143
and is associated with more or less irritation of the gastro-pul-
monary mucous membrane. The eruption is attended by itch-
ing, and by a burning and tingling sensation like that produced
by the sting of a nettle, and is occasionally followed by slight
desquamation of the epiderma.
280. The varieties of urticaria, distinguished by Willan, are
six in number, of which, two are referrible to the acute, and four
to the chronic form of inflammation. The six varieties are.
Acute. Chronic.
Urticaria febrilis. Urticaria evanida,
„ conferta. „ perstans,
„ subcutanea,
„ tuberosa.
URTICARIA FEBRILIS.
281. Febrile nettlerash is especially characterized by the pre-
sence of severe constitutional disorder. It commences with a
sense of weight and sickness at stomach, white furred tongue,
quick feverish pulse, pain in the head, anxiety, lassitude, faint-
ness, and drowsiness. On the second day from the invasion of
these symptoms, the patient is seized with rigors, which are fol-
lovred by the eruption upon the skin of irregular patches, of a
vivid red colour, slightly raised above the level of the surround-
ing surfeLce, and studded with whitish or reddish elevations and
wheals. The patches are dispersed in various situations upon
the surface of the body ; they appear and disappear unexpect-
edly, and without order, and they may be produced instantly on
parts apparently unaffected, by simply rubbing or scratching the
skin. They are irregular in size and form, pale and little de-
veloped during the day, but brightly red towards the evening
and during the night, at which time the febrile symptoms ex-
acerbate, and the itching and tingling become more intense and
troublesome.
On the outbreak of the eruption, the pain and sickness at
stomach are immediately relieved, but they are disposed to recur
at each temporary disappearance of the rash. The disease
usually runs its course in about a week ; at the end of that period
the febrile symptoms and the eruption decline ; the bright and
vivid red of the patches subsides into a pale and yellowish purple
and speedily disappears, leaving behind it a slight mealy des-
quamation of the epiderma, and sometimes oedema of the sub-
cutaneous areolar tissue.
282. Although febrile urticaria may be regarded as a mild
form of cutaneous exanthema, yet it is always troublesome and
distressing to the patient^ from the irritation by which it is ac-
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141 CONGESTIVE INFLAMMATION OF THE DERMA.
companied. Frequently it creates alarm by the anxiety about
the precordia and the syncope which attend its invasion ; and
instances are not wanting in which it has proved fatal. *^ I saw
it terminate fatally ,*' says Willan, '^ in the case of a man about
fifty years of age, who had impaired his constitution by hard
labour and intemperance. On the first and second day of
August, 1792, he complained of nausea, and of great pain in the
stomach, which was increased on pressure. He was very thirsty,
had a quick pulse, and a slight delirium at night. On the third
and fourth day of August, a number of elevated wheals and red
patches were difiused over the body, vrith much heat and itching
of the skin. While the rash continued vivid, his internal com-
Slaints abated, but on its sudden disappearance about the fifth
ay, the febrile symptoms and delirium became more violent
than at first. On the sixth day the eruption appeared again on
his face ; he was, notwithstanding, very hot, restless, and deli-
rious ; he remained in the same state during the following day,
and died in the evening." The same author also relates a very
distressing state of this malady which occurred in a gentlewoman,
twenty-seven years of age, and returned at intervals of a week
for a considerable length of time.
233. Febrile urticaria frequently attacks children, particularly
during teething, and in them is remarkable for its unexpected
development. Dr. Underwood observes that it " occurs in chil-
dren more generally under two years of age, and is exceedingly
troublesome to the infant, as well as matter of surprise to parents,
firom the suddenness of its appearance. Children going to bed
perfectly well, wake very uneasy, and frequently continue scream-
ing for some time before the cause is discovered. But upon
examining the body and lower limbs, they are found covered
with large wheals, similar to those produced by the sting of
nettles."
234. Urticaria ab ingestis. — The symptoms produced by
noxious alimentary substances are very remarkable and severe,
and in some instances have proved fatal, particularly when shell-
fish have been the cause. The attack comes on suddenly, as,
for instance, in the middle of the night after a hearty supper, or
a few hours after the exciting meal. The patient sufiers from
weight and an imeasy feeling in the stomach, accompanied with
nausea and giddiness, and sometimes by vomiting and diarrhoea,
a prickling sensation in the throat, and constriction in the fauces,
which produces a short, troublesome cough, and occasionally
tlireatens suffocation ; the tongue is swollen, and the voice
altered, from the extension of the swelling of the mucous mem-
brane into the larynx* The face shortly begins to swell, while
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URTICARIA EVANIDA. 145
the ears, the nose, and lips, are burning hot, and itch violently.
By degrees the eruption spreads to the trunk of the body, and
from Ae latter to the limbs, affecting the joints particularly.
When the rash reaches the extremities, the disagreeable symp-
toms pass off, and the patient recovers. This kind of attack
generally terminates at the end of two days, and sometimes
after a few hours, leaving behind it little or no trace of its
existence.
URTICARIA CONFERTA.
235. Urticaria conferta (Plate i., b.) is merely a severe de-
gree of the local affection of urticaria. The elevation of the cir-
cular prominences and wheals is not so great as in the preced-
ing variety, but they are more numerous, and frequently coalesce,
and are attended with considerable inflammation of the swTound-
ing skin. The itching and tingling are exceedingly severe, par-
ticularly at night, and the integument is tumid and swollen.
This form of the affection is apt to continue for several weeks.
URTICARIA EVANIDA.
236. Urticaria evanida (Plate i., a. a.) is a chronic variety of
nettlerash, appearing and disappearing upon the skin in the form
of white, roundish prominences and wheals, without febrile
symptoms, and with trifling redness. The eruption is not the
less attended with troublesome itching and tingling, particularly
on the removal of the dress at bedtime, and on the return of
warmth, induced by the bedclothes. It is chiefly remarkable for
its duration, lasting sometimes for months, and even for years.
urticaria perstans.
237. Urticaria perstans differs from the preceding only in the
persistent character of the eruption, which does not disappear,
as in urticaria evanida, but continues unchanged for two or three
weeks. It occurs chiefly on the limbs, and rarely on the trunk
of the body. The gastric disorder, with the itching and tingling
xmder the influence of heat, which are typical of urticaria, are
also present in the persistent variety.
urticaria subcutanea.
238. Under the above title, Willan has described a nervous
affection of the limbs, accompanied at intervals with an eruption
of urticaria. " The eruption," writes Willan, ^ occurs at distant
periods^ and continues only a few days at each return, but the
L
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146 CONGESTIVE INFLAMMATION OF THE DEBMA.
patient is harassed during the interyals, as well as during the
eruptions, with a violent and almost constant tingling in the
skin, and with other distressing symptoms. The complaint is
at first confined to one spot on the leg or arm, and commences
there with a sensation of tingling, or stinging, which is after-
wards felt more and more extensivelj along die limbs, or per-
haps over nearly the whole surface of the body. Sudden changes
of the temperature of the air, and agitation of mind, occasion in-
creased uneasiness in the skin, so diat pains are sometimes felt
as from a sharp instrument puncturing in different directions ;
at other times, as from needles piercing, or pushing the skin up-
wards. There is usually a stifihess and slight torpor in the mus-
cles of the parts most affected ; an appearance of wheals takes
place on the arms, chest, or lower extremities, from time to time,
especially during the summer. In most of the cases that I have
seen or known, die complaint was partial, affecting only the loins
and thighs, or sometimes the arms." In illustration of this dis-
ease, Willan records the case of a lady, which appears rather to
resemble a chronic affection of the spinal cord, attended occa-
sionally with the eruption of urticaria. Stinging and pricking
in the integument is a common affection in diseases of the
nervous system, but this surely affords no grounds for the
designation, subcutaneoy as applied to this variety.
URTICARIA TUBEROSA.
239. Urticaria tuberosa appears chiefly in debilitated consti-
tutions, and is a rare form of cutaneous disease. It has received
its designation from being characterized by the production of
elevations of considerable size, and extending deeply into the
subcutaneous areolar tissue. These tumours are developed, with
much itching, during the night, upon the arms and legs ; they
are painful and hot, and disappear before the morning, *^ leaving
the patient weak, languid, ana sore, as if he had been bruisec^
or had undergone much fatigue." The disease " often proves
tedious and obstinate ; I have known it continue," says Willan,
" upwards of two years, with a few short intervals. The only
causes to which it could, with probability, be attributed in the
instances presented to me were, irregularities in diet, violent
exercise, taken by persons usually sedentary, and the too free
use of spirituous liquors."
Dr. Day, in his translation of Simon's Animal Chemistry, ob-
serves : — ^^ The urine in a case of urticaria tuberculosa has been
analyzed by Scherer. The patient was a young man who like-
wise suffered from rheumatism. The urine was discharged in
very small quantity, often not more than five or six ounces in
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URINABT SECBETION IN UBTICARIA. 147
fbrtjr-eight hours. It was clear, of a brownish-red colour, very
add, and its s^cifio gravity was 1028. It contained in 1000
parts: —
Water 981*58
Solid residue 68*42
Urea 30-46
Uric acid 074
Alcoboi extract, with much lactic acid . . 21*24
Water extract 4*92
Alkaline salts 8*03
Earthy phosphates 202
The most remarkable points in the constitution of the urine
are the large amount of earthy phosphates and the excess of free
add."
In a case of urticaria, in which the urine was analyzed by Dr.
Maclagan, its composition was found to be as follows : —
Urea 6-91
Uric acid 0*05
Inorganic salts 12*03
Organic matters and water . . . . 981*01
** The chief peculiarity in the present case was a deficiency in
the ordinary characteristic ingredients of the urine, the urea and
uric acid. This could not arise from mere excess of water ;
first, because the urine was not excessive in quantity ; second,
because the inorganic salts were above the normal standard,
whereas, had the water merely been in excess, they, too, ought
to have indicated a diluted condition of the urine. Dr. Maclagan
ventured, therefore, to propose, as the pathological view of the
case, that the defect here was merely a deficiency of the urea and
mic acid ; in short, a want of what modem chemists call the pro-
ducts of transformation of the tissues, and that the retention in
this way in the system, of matters which ought to be eliminated
from it, might be the cause of this cutaneous irritation, especi-
ally occurring, as it did, after meals."*
With the view of modifying the imperfect transformation of
tissues here referred to, the patient was treated with colchicum,
upon which the specific gravity of the urine was found to have
risen to 1029*^, and its composition to be as follows : —
Urea 20*36
Uric acid . . , 0*50
Inorganic salts 12*72
Organic matters and water . . • 966*42
The conclusions deduced from this observation a^e : —
* Edinburgh Monthly JoumaL
L 2
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148 CONGESTIVB INFLAMMATION OF THE DERMA.
1. " That urticaria is intimately connected with a deficiency
of the organic salts of the urine, and their probable retention in.
the system.
2. " That colchicum has an action capable of restoring the de-
ficient salts, and thus curing the disease.
3. ^^ Rheumatism and urticaria, and purpura and urticaria, are
frequently found to be present together. They are also benefited
by the use of colchicum. It may be safely asked, do they not
depend on the same common cause — namely, the presence of
those salts in the blood ? Such an inference has been applied in
the case of rheumatism."*
240. Diagnosis, — The diagnostic characters of urticaria are —
firstly^ the appearance of Ae eruption, which resembles the
whitish elevated spots and wheals produced by nettles ; secondU/y
the itching, tingling, and pricking, which accompany the erup-
tion ; thirdly i the evanescent and fleeting habits of the eruption ;
BXid fourthly y its association with symptoms of gastric irritation.
These characters, well appreciated, sufficiently distinguish it
from every other cutaneous eruption.
The orJy afiections to which urticaria bears so close a resem-
blance as to deserve remark, are, lichen urticatus and erythema
papulatum, tuberosum and nodosum. The pimples of lichen
urticatus are, however, smaller and more persistent than the
wheals of urticaria; they appear in successive crops, and become
surmounted by a small dark-coloured crust Erythema papu-
latum resembles urticaria both in general and local symptoms,
but difiers in its course and persistency. The spots of erythema
tuberosum are quite superficial and persistent, as are diose of
erythema nodosum; characters which distinguish these eruptions
from that of the transient and quickly fading urticaria tuberosa.
Urticaria is occasionally complicated by the presence of other
diseases of the skin, as erythema, roseola, lichen, and impetigo.
It has also been observed as a complication of rubeola, variola^
and prurigo.
241. Games, — The causes of urticaria are referrible to irrita-
tion of the gastro-pulmonary and genito-urinary mucous mem-
branes. Thus it is induced by dentition, by gastric irritation,
by intestinal irritation, by uterine irritation, and, more rarely, by
pulmonary irritation. Mental excitement or anxiety, fatigue,
exposure to cold or heat, also contribute towards its develop-
ment, and occasionally it is seen in association with rheumatism.
Among the causes of urticaria, nervous debility, occasioning a
peculiar susceptibility of the cutaneous nerves, must not be
omitted. In a lady who was lately under my care, I have
* Lancet, vol. il. 1846, p. 160.
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TKEATMENT OF URTICARIA. 149
watched the red wheals appear and creep along the skin, and
disappear while I purposely engaged her in conversation on in-
difierent subjects. A word, a look, the slightest excitement^
would immediatelj bring out a copious eruption. It occurs
chiefly in the summer season, and is said to be more prevalent
in cold climates, as that of Russia, than in those of the south.
Persons who possess a thin and irritable skin, who are plethoric
and of a sanguine temperament, are most liable to the disease,
and for this reason it is more common in the female than in the
male sex. It is very frequent in children, particularly during
the period of dentition.
Tlie alimentary substances which are capable of exciting urti-
caria, act upon the system by means of the irritation which they
cause to the mucous membrane of the alimentary canal. In some
instances, this irritation is referrible to the natural susceptibility
of the individual ; while in others, the probable cause is a poison
generated by putrefactive decomposition. The substances which
have been observed to give rise to these effects in different per-
sons, are very numerous ; they are — some kinds of fish, as mus-
sels, lobsters, crabs, pravms, shrimps, oysters, dried fish, &c. ;
certain meats, such as pork, goose, &c. ; certain fruits and vege-
tables, as almonds, strawberries, raspberries, cucumbers, mush-
rooms, &c. Bayer mentions oatmeal gruel, as occasionally pro-
ducing this effect; and certain medicines, as valerian, copaiba,
&c. A member of my own family suffers, constantly, after
taking rice milk. Dr. Gregory was affected by the disease, after
eating part of a cucumber ; and he mentions two instances, of
persons attacked in a similar manner, from drinking porter. Dr.
Winterbottom was " twice violently affected, by eating the sweet
almond.^ Urticaria has been observed occasionally as a critical
eruption, and it has been stated by some authors to have oc-
curred epidemically.
Persons of great cutaneous susceptibility have the power of
exciting the eruption at any time, by merely scratching the skin.
242. Prognosis, — Urticaria is not, in itself, a dangerous dis-
ease. The acute form is easily removed by appropriate treatment.
Chronic urticaria is frequently symptomatic of nervous debiUty,
muoous irritation, or visceral Asorder, and may consequently
prove obstinate, resisting all therapeutic measures, until die dis-
ease of which it is a dependence is relieved. Retrocession of
this eruption has sometimes been followed by a serious aggra-
vation of internal disease.
243. Treatment — The treatment of febrile urticaria should be
strictly antiphlogistic ; in some cases it may be advisable to de-
plete by general bleeding ; in others, abstraction of blood from
the neighbourhood of the organs especially affected, by means
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150 CONGESTIVB INFLAMMATION OF THE DERMA.
of leeches, may suffice. The rest of the treatment should consist
in the administration of aperients, maintaining an abstemious
and cooling diet, using the warm bath and foot bath occasion-
ally, and if the seat of the visceral disorder be apparent, apply-
ing a blister over the organ affected. During convalescence, if
the powers of the system have been reduced, tonic medicines,
combined with alkalies, should be prescribed.
Where difficult dentition is the cause of the eruption, Uie
gums must be laid freely open with the lancet; the litde patient
should be immersed once or twice daily in a warm bath, and
some gentle antacid aperient administered.
When the cause of the eruption is the ingestion of noxious
and indigestible substances, no time should be lost in obtaining
the ejection of the offending matters. For this purpose, the sul-
phate of zinc, or sulphate of copper, are best suited ; or if these
be objected to, the ordinary emetic of ipecacuanha, either alone,
or combined with tartarized antimony. Willan cautions us to
avoid the latter salt, from its liabili^ to operate too violently,
and give rise to faintbigs. The employment of the emetic should
be followed by a dose of castor-oil, or some simple cathartic ; and
Plumbe recommends from twenty to forty drops of aether, to be
given every half-hour.
Chronic urticaria calls for the use of aperients, counter-irri-
tants, tonics, warm and cold baths, particvdarly the sponge bath
and shower bath, carefril attention to regimen, and the avoidance
of all indigestible substances. In one patient, sugar was excom-
municated with advantage, and in the same case great benefit
was derived from the citrate of iron, at first combined with the
hydriodate of potash, and subsequently with quinine. In an-
other case, the infusion of serpentaria with carbonate of magne-
sia and carbonate of ammonia was completely successful. Ur-
ticaria tuberosa is often so severe, as to require depletion by
venesection, and active antiphlogistic measures. Whenever
urticaria assumes an intermittent form, it must be treated with
bark or quinine, like ordinary intermittent fever.
The intense itching and tingling which frequently accompany
urticaria are best relieved by means of narcotics. Acetous and
alcoholic lotions and lemon juice are sometimes useful for a
similar purpose, and a lotion composed of carbonate of am-
monia, and acetate of lead, of each a drachm, combined with
eight ounces of rose-water, has been recommended. I have
found a lotion of chlorate of potash sometimes succeed in quell-
ing the pruritus of this and other eruptions, but that upon which
I chiefly rely is one composed of bichloride of mercury, firom
five to ten grains, spirit of rosemary and spirit of wine, of each
an ounce, and six ounces of the emulsipn of bitter almonds.
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BOSEOLA. ROSE-RASH. 151
If the eruption show a disposition to recede, or if it have
already receded, blisters should be applied to the skin ; or the
surfjELce well rubbed with some stimulating liniment, such as that
of croton-oil, in order to restore the eruption, or to set up an
equivalent action in the skin.
ROSEOLA.
Syn. Fahe MecLsks. Rose-rcLsh. Roseok, Fran.
244. Under the name of roseola, Willan has described certain
forms of cutaneous inflammation, some of which seem to occupy
a middle position between erythema, urticaria, and rubeola, with-
out being strictly referrible to either ; while others ought more
properly to be considered under one or other of the before-men-
tioned orders. The title of this affection is, perhaps, the most
objectionable in the entire nomenclature of diseases of the skin,
since colour can only be an accidental character, depending for
its existence upon a greater or less congestion or distention of
the vascular rete of the derma, and, therefore, liable to constant
change from trivial causes. The true characters of the disorder
must evidently be sought in the morbid conditions which col-
lectively constitute the real disease. With these remarks, I shall
proceed to define roseola by means of those symptoms which
appear to be characteristic of the affection.
Roseola (Plate i.) is a non-infectious and non-contagious in-
flanunation of the skin ; it is characterized by febrile symptoms
which assume the sub-acute type, and by patches of redness, of
small size, and irregular form, distributed over more or less of
the surface of the body. The exanthema is transient, and the
eruption, at first brightly red, subsides into a deep roseate hue,
which disappears by slow degrees.
245. Willan has described seven varieties of roseola, to
which three — namely, roseola rheumatica, arthritica, et chole-
rica— have been added by Bateman and Rayer. The whole of
these forms may be arranged into two groups : — idiopathic^ in
which the exciting cause is not immediately manifest; and
symptomatic^ which depend obviously upon some local source of
irritation, or are associated with some existing disease. These
Idiopathic. Symptomatic.
Roseola infantilis. Roseola variolosa,
yj sestiva, „ vaccina,
,, autumnalis, „ miliaris,
yy annulata* „ rheumatica,
„ arthritica,
„ cholerica.
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15? CONGESTIVE INFLAMMATION OF THE DERMA.
ROSEOLA INFANTILIS.
False Measles,
246. In roseola infantilis, the patches of redness are of small
size, and closely grouped together, and they resemble, in general
appearance, the eruption of rubeola. They are subject to much
variety in relation to extent, duration, and the local incon-
venience to which they give rise. Thus, in one case, they are
limited to a small district of the skin, or to the limbs, while in
others they are dispersed over the entire body. In one case,
again, they are fleeting, and disappear in the course of a day or
two, while in others they are prolonged to a week or more.
Sometimes they are productive of little inconvenience, and at
others, excite itching and tingling of the most wearying kind.
The constitutional symptoms, like the other characters of the
afiection, are marked by uncertainty in respect of degree ; in some
subjects the febrile indications are severe and active, while in
others they are transient, and speedily decline.
ROSEOLA iESTIVA.
False Meades.
247. Roseola aestiva (Plate i., e.) is the common form under
which the disease presents itself in the adult : it is developed,
as implied by its name, chiefly in the summer season, and at-
tacks persons of a weakly and irritable state of system, particu-
larly of the female sex. The disorder usually commences with
the ordinary series of febrile symptoms of the slighter kind —
namely, wilJi chills succeeded by flushes of heat, languor, pains
in the head, back, and limbs, restlessness, quickened pulse, and
thirst. These are followed, in a few days, varying in number
from three to eight, by an eruption appearing first about the face,
neck, and arms, and then extending to the body and lower ex-
tremities. In general appearance, the rash resembles rubeola,
but on closer examination, is found to consist of patches of
larger size, and more irregular form, and, at a later period, the
difierence is still more striking, in consequence of the change of
tint to a dark roseate hue. The fauces are also afiected by the
disease, presenting a deep red tint, with some degree of swell-
ing of the mucous membrane, and enlargement of the tonsils.
The eruption appears ordinarily in the evening, and arrives at
its height on the following day, being accompanied by tingling
and considerable itching. On the fourth day, the rash begins
to fade, and on the fifth, disappears, together with the constitu-
tional symptoms.
The eruption is so^letimes local in its attack, being confined
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ROSEOLA AUTUMNALIS, 153
to the fece and neck, which become tumefied, and exceedingly
painful. It is liable also to delitescence, in which case the con-
stitutional symptoms are aggravated, and relieved only by the
re-appearance of the rash«
ROSEOLA AUTUMNALIS.
248. Roseola autumnalis is evidently referrible to erythema ;
it is met with chiefly among children, but I have seen it also in
the adult, and it occurs generally during the autumnal season.
The constitutional symptoms are very slight, being limited to a
trifling indisposition. The eruption appears in roundish circum-
scribed patches, of about the size of a shilling, and of a very
dark hue, seeming, at a distance, " as if stained by the juice of
black cherries or mulberries." The patches occur the most fre-
quently upon the arms and legs, rarely on the face and body.
They continue for about a week, give rise to very little itching
or local inconvenience, and are succeeded by a slight fiirfura-
ceous desquamation.
ROSEOLA ANNULATA.
249. This form of roseola is very analogous to erythema cir-
cinnatum ; it is characterized by the figure of the eruption, ap-
pearing, in the first instance, as small red circular spots, and
increasing in a short space of time into rings of variable size,
having a central area of healthy skin. This eruption possesses
all the general characters of roseola, as described in roseola
sestiva. It appears after a slight attack of constitutional symp-
toms, which are relieved by the outbreak of the eruption, and
aggravated if it should chance to recede ; it occasions consider-
able itching and tingling of the skin during the night, so as fre-
quently to destroy rest, and afiects, more or less extensively,
the mucous membrane of the fauces. When the disease sets
in with severe symptoms, it terminates, like roseola sestiva, at
the end of a week or ten days. When, however, it assumes a
milder type, it may endure for several months, and recur at in-
tervals. Willan relates the case of a lady who sufiered from
this disease for several months together, for three successive
years. I agree with Rayer, that " the description of this variety
must be ultimately blended with that of erythema annulatum."
[E. circinnatum.]
ROSEOLA VARIOLOSA.
250. Variolous roseola is an erythematous inflammation of the
skin, which not unfrequently attends upon the eruptive fever of
inoculated small-pox, appearing on the second day from the
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154 CONGESTIVE INFLAMMATION OF THE DERMA.
oommenoement of die constitational symptoms, and upon the
nindi or tenth after inoculation. It shows itself, in Ae first in-
stance, on the breast, the face, and arms, and then extends, during
the second day of its eruption, to the trunk and lower extremities ;
on the third day, the roseate rash diminishes in yividness, and
on the fourth, subsides altogether. The proportion in which
roseola occurs in inoculated small-pox, is one in every fifteen
cases. In natural small-pox it is more rare.
Variolous roseola has been regarded as flEivourable to the pro-
gnosis of small-pox, and indicative of a mild eruption. When,
however, the colour of the rash is deep and dusky in its tint, and
the eruptive fever severe, the most dangerous form of small-pox
may be apprehended. In some instances of inoculation, the
roseola has been known to supersede the eruption of the small-
pox, and the patient is said to be equally protected against vario-
lous infection. It occurs chiefly in persons endowed with a
delicate and irritable skin.
In the management of cases of this affection, it is desirable to
guard against die retrocession of the rash. For this purpose,
the patient should be confined to his room, although children
so affected are frequently carried into the air, and exposed to the
cold without any inconvenient results.
ROSEOLA VACCINA.
251. Roseola vaccina is an efiiorescence similar to that which
accompanies variola ; it follows the development of the vaccine
vesicle, appearing on the ninth or tenth day, but much more
rarely than afker inoculation. It occurs in the form of small
erythematous patches, which seem to be propagated from the in-
flamed halo of the vaccine vesicle, and, in some instances, are
diffused over the entire surface of the body. The eruption rarely
lasts more than two days, and appears only in children possessed
of a delicate and irritable skin.
ROSEOLA MILLiRIS.
252. Under the name of roseola miliaris, Bateman describes
an erythematous inflammation of the skin, accompanied by the
development of small vesicles, which he observed towards the
close of continued and typhoid fevers. This eruption consisted
of oval-shaped and slightly raised patches, which appeared
upon the arms and breast, and were accompanied by a decided
remission of the febrile symptoms. The patches increased in
size for the space of three davs ; they were of a bright rose
colour at first, diminishing gradually in redness, and assuming
a bluish tint, and at the end of this period they disappeared
altogether.
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ROSEOLA CHOLEBICA. 155
BOSEOLA RHEUMATICA ET ARTHBITICA.
253. Rheumatic and arthritio rogeola is an eTythematoas in-
flammation of the skin, appearing in spots and patches, of va-
rious size and form, and upon different parts of the body, in
persons affected with rheumatism or gout. In some instances,
the efllorescence precedes the attack, which invades immediately
upon its decline ; in other cases, the eruption appears during
the progress or towards the close of the disease. In Wurzburg,
where rheumatism is endemic, and very severe, the exanthem
makes its attack at the commencement of the disease, and after
one or two days of suffering from gastric and febrile affection.
The eruption in this case consists of small roundish spots,
which first show themselves upon the legs, and thence extend
to the rest of the body. They present the deep rosy colour,
subsequently becoming purplish and livid, which is characteristic
of roseola.
ROSEOLA CHOLERICA.
254. This form of roseola rests upon the observation of Rayer,
who saw the variety during the prevalence of cholera, in Paris,
in 1832. "After the period of reaction," he says, "there oc-
curred in some patients, especially in women, an eruption
which, most generally, appeared on the hands and arms, and
then extended to the neck, the breast, the belly, and the
upper and lower extremities. At its commencement, it was cha-
racterized by patches, for the most part of an irregular circular
shape, of a bright red colour, elevated above the sur£Bu;e, and
but sUghdy itchy. Very numerous on the hands, arms, and
chest, tiiey were less so on various other parts ; in some places
they were crowded together, tended to confluence, and had
an appearance very aniBdogous to the efflorescence of slight
scarlet fever ; in otiier places, the aspect of the eruption was
rather like that of measles ; and in others, even more like that
of urticaria.
" I have seen this inflammation complicated witii an inflam-
matory affection of the fauces and tonsils, and its disappearance
followed by an aggravation of the general symptoms, and,
sometimes, even by death. On the chest, the spots occasionally
became confluent, and gave rise to patches as broad as the hand,
raised above the general level, and pretty well defined. The
eruption then acquired a dirty pink or rose colour. About the
sixtii or seventh day, the epiderma cracked, and was thrown off
in large flakes on almost all the places where the eruption had
existed."
255. Diagnofis, — Roseola is distinguished from other exanthe-
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156 CONGESTIVE INFLAMMATION OF THE DERMA.
mata by negative rather than by positive characters. The dis-
eases with which it is most likely to be confounded are, rubeola,
scarlatina, erythema, and urticaria.
The varieties of roseola, the most nearly allied in appearance
to rubeola, are, roseola infantilis, and roseola sestiva ; but parti-
cularly the former, which is, probably, frequently mistaken for
measles, and indeed is known by the trivial name of " false
measles.'' The diagnostic characters by which it is distinguished
from rubeola are, the absence of catarrhal symptoms, the inferior
degree of febrile affection, the larger size, more irregular form,
and deeper colour of the patches, their progress from the eltre-
mities to the trunk of the body, and, above all, the uniformity of
the redness as contrasted with the punctiform character of that
of rubeola. Moreover, the latter is contagious, and is generally
of epidemic origin, which is not the case with roseola. These
remarks apply equally to the diagnosis between roseola and
scarlatina, substituting for the catarrhal symptoms of rubeola,
the angina of scarlatina.
The degree of congestion affecting the skin in roseola is very
similar to that of erythema ; in both, the patches are irregular,
and uniform in tint, but in the former are for the most part
smaller than in the latter. Two of the varieties of roseola are
scarcely to be distinguished from erythema ; as, for instance,
roseola autumnalis, and roseola annulata* The forms originat-
ing in local irritation would more correctly be considered under
the genus erythema.
From urticaria, the distinction of roseola lies in the light
coloured and raised spots and wheals of the former, as contrasted
with die uniform redness of the patches of the latter. The local
inconvenience, also, is greater in urticaria ; for although, in both,
itching and tingling are prevailing characters, these symptoms
are more severe in urticaria, and are accompanied by pricking
and stinging.
256. Causes, — Roseola is met with in children, in persons with
a thin and delicate skin, of weakly and irritable constitution, and
particularly in females. In infants, the exciting cause is teeth-
ing, or intestinal irritation. In adults, it may be occasioned by
any causes which disturb the functions and circulation of the
skin during its periods of increased activity — namely, in the
summer season. Of this kind are, exposure to a draught of cold
air, when the body is heated by exercise ; drinking cold water
while the body is warm ; distressing the stomach with an over-
load of fruit, indigestible substances, copaiba, &c. Other causes
are, gastric and intestinal irritation, and disordered menstrua^
tion. The forms called into action by local irritation are obvious
in their causes, while those which accompany rheumatic gout or
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ERYTHEMA. INFLAMMATORY BLUSH. 167
cholera ar« referrible to some unexplained nervous sympathy
between the tissues affected and the skin.
257. Prognosis, — Roseola is a slight affection, and one of
favourable termination. When it occurs critically in connexion
^th constitutional disease, it is of good omen, and should be
encouraged.
258. Treatment — In the treatment of roseola, the cause, when
obvious, should be removed ; in the case of children suffering
from dentition, this is best effected by scarifying the gums, and
exhibiting a dose of castor-oil ; and where intestinal irritation is
in fault, by the hydrargyrum cum cret& combined with rhubarb,
or soda with rhubarb, to regulate the secretions, these measures
being assisted by a light and moderate diet. In adults, laxatives
and diluents, followed, in weakly persons, by tonics combined
with mineral acids, are the appropriate remedies. The varieties
accompanying particular diseases call for the treatment appli-
cable to those diseases ; as, for instance, colchicum in the case of
rheumatism, &c. When disordered menstrual function is the
exciting cause, recourse must be had to steel medicines, aloetic
aperients, &c. Locally, a gently stimulating lotion will be found
of service, such as one containing spirit of horseradish, mustard,
rosemary, or tincture of cantharides ; or a weakly acid lotion.
Baths are also useful, and particularly sea-bathing.
ERYTHEMA.
Syn. Iriflammatory blush. Efflorescence cutanie^ Fran. —
JSautrdtkey Germ. — Dartre erythemotde. Alibert.
259. Erythema * (Plate i., g — m.) is a superficial inflamma-
tion of the skin, which is characterized by a difiused or circum-
scribed redness occurring in one or several patches of irregular
form, and varying from a few lines to several inches in extent.
It is noncontagious, occasionally produced by local irritation,
but frequently symptomatic of constitutional disturbance or vis-
ceral disease. In the commencement of erythema the derma is
a little swollen ; the swelling, however, speedily subsides, the
redness remaining for a much longer time. Upon the disper-
sion of the redness, the skin retains for some days a purplish
and bluish tint, and the epiderma exfoliates in the form of a fur-
ftiraceous and laminated desquamation.
260. There are two degrees of erythema — acute and chronic.
Acute erythema presents for our observation eight principal
varieties — namely.
' Der. IpvBaivuv, to redden.
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158 CONGESTIVE INFLAMMATION OP THE DERMA.
Eiyihema fagax^ Eiyihema intertrigo,
,, circinnatum, ,, papulatum,
y, marginatum, ,, taberculatum,
yy Isye, ,, nodosum.
These varieties admit of arrangement into three groups, symp-
tomatic, local, and general, or idiopathic. The gymptomatic
kinds are, erythema fogax, erythema circinnatum, and erythema
marginatum. The loccd group comprehends erythema laeve, a
disease depending on the local condition of the limb, and very
appropriately designated by Good, erythema oedematosum, and
erythema intertrigo, the consequence of local irritation. The
general or idiopathic varieties are, erythema papulatum, tuber-
culatum and nodosum, which are preceded ami accompanied by
general febrile symptoms, and are very closely allied to eadk
other.
ERYTHEMA FUGAX.
261. Eiyihema fugax appears in the form of difiused patches
of redness, which are variable in depth of colour and extent, and
occur for the most part upon the upper regions of the body, as
upon the face and neck, the trunk and the arms. The redness
of this form of erythema is especially characterized by its eva-
nescent and fleeting disposition, one while vanishing suddenly,
to re-appear at successive periods, another while subsiding on one
spot, to break forth on several, and again continuing fixed for a
short period, to disperse slowly and by degrees. It is attended
by considerable heat and dryness of ^e surface, and sometimes
by swelling. At its decline, the epiderma is left rough and fiir-
fiiraceous from the disturbance to which the formative function
of the derma has been subjected.
Erythema fugax is chiefly important as a symptom of visceral
derangement, and in some instances it may be regarded as an
indication of the long continuance and danger of such disorder.
It is particularly noticed in connexion with irritation of the
mucous tissues of the body, as of the alimentary mucous mem-
brane, the respiratory membrane, the generative membrane, and
the urinary mucous membrane. In my notes for the past three
years, I find references to cases in which this form of exanthema
has appeared in conjunction with dyspepsia, diarrhoea, hepatitis,
bronchitis, hysteria, anomalous uterine irritation, pregnancy, in-
flammation of the kidneys, &c. It is also seen in some nervous
affections and fevers, and Willan records a fatal case of puer-
peral fever in which erythema fiigax was a conspicuous symptom.
This inflammation is most frequently observed in the female sex.
I had lately under my care a striking instance of this affec-
tion in the person of a young military officer, who was not aware
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ERYTHEMA CIRCINNATUM ET MARGINATUM. Id9
ci any disturbance of his general heath* The efflorescence was
attended with swelling, and would come on in the course of an
hour, and after a continuance of a few hours subside as rapidly
as it had appeared. His attention was generally drawn to the'
seat of the <£sease by some degree of itching, and upon examin-
ing the part, the redness and swelling were pereeived. Trifling
as the disorder appeared, it was to him a source of serious an-
noyance ; it sometimes made its appearance while he was en-
gaged in military duty, or dressing for a dinner party, fixing, for
example, upon die cheek, and completely closing his ^e, from
tumefEUCtion of the lids. I succeeded in curing him oS this dis-
order, by means of regular doses of the compound colocynth
pill, with tincture of gentian and the mineral acids, and tannin.
ERYTHEBiA CIRCINNATUM.
262. Erythema circinnatum (Plate i., k.) appears in the form
of small, round, and very slightly raised patches of redness,
which enlarge by their circumference, while the redness in the
centre fades and disappears. In this manner, a number of rings
with broad margins are produced, which run over the whole
surface of the affected region, and, as they increase, communi-
cate by their borders, and give rise to a number of irregular and
broken bands resembling segments of circles of various magni-
tude. The central portion of the rings, and the surface which
has been left by the erythema, has a yellowish tint, and throws
off a fnrfuraceous desquamation. The duration of erythema cir-
cinnatum is greatly dependent upon the nature of the disease
with which it is associated ; it may be stated generally at from
one to three weeks.
I have before me the notes of a case of this form of erythema,
associated with acute rheumatism, which occurred in a patient
in the Middlesex Hospital, under the care of Dr. Watson. The
spots were first developed on the abdomen, and quickly spread
from this point as from a centre, until they had occupied with
their curves the whole surface of the trunk of the body and of
the limbs. The case in other respects presented no characters
different from ordinary rheumatism ; the symptoms of the latter
were neither aggravated nor relieved by its invasion, and it
appeared to be developed in connexion with augmented per-
spiration.
ERYTHEMA MARGINATUM.
263. Erythema marginatum is an aggravated form of erythema
circinnatum, occurring for the most part in association with
chronic visceral disease, and in elderly persons. In this variety
there is a greater degree ol oongestion of the skin than in ihe
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160 CONGESTIVE INFLAMMATION OF THE DERMA.
preceding ; there is a deeper but variable tint of redness, which
nrequently approaches to a purplish hue ; the border of the circles
is more raised, and slightly papular, and the margin is abrupt
'and well-defined. Like erythema circinnatum, the present
variety presents considerable difference of appearance at different
stages of its progress ; at one time exhibiting a distinctly annular
form, at another, an assemblage of raised and inflamed bands,
having more or less of a curved direction. This diversity of
appearance of the disease at different stages of its progress
enables us to comprehend the apparent dissimilarity in the defi-
nition of erythema marginatum, as given by Willan and Bateman,
and by Rayer. The latter of these authors describes the early
stage of the exanthem, when he remarks that it consists of
" circular patches of a livid red, from half an inch to an inch in
diameter, the circumference of which is distinctly separated firom
the healthy skin, raised, prominent, and slightly papular ;" while
WUlan and Bateman, taking the latter stages as dieir type, de-
scribe the marginal ridge as existing only on one side of the
patch, the redness diffusing itself gradually in the rest of its cir-
cumference. The eruption may occur upon all parts of the
body, but is most firequently seen upon the trunk, particularly
in the loins, and on the outer sides of the limbs. Its duration
depends on the nature of the disease which it accompanies ; it
generally extends to several weeks.
264. There is a variety of erythema marginatum (Plate i., l.)
which is far firom being uncommon, and which I have generally
observed on the neck and shoulders of women and children. It
is dependent doubtless upon some slight derangement of the
nutritive functions, but fi'equently the patient is not aware of any
disturbance of health. It commences as a small red spot, which
soon becomes a circular or oval ring, strongly defined and
usually papulated. The area of the ring is yellowish and mealy,
and the ring disappears at the end of three weeks or a mondi.
From its circular form and distinctly raised edge, the subjects of
this slight disorder are generally apprehensive of its being what
they denominate the " ringworm."
265. A modification of this variety, of which I have given a figure
(Plate i., m.) I have somewhere seen denominated erythema
iris. It is distinguished by the presence of two or three rings,
the innermost ring ceasing suddenly to enlarge, and the next,
progressing from its outer margin as from a centre. I have seen
this same concentric arrangement of rings on the palm of the
hand and laying the foundation of psoriasis palmare centrifiigum.
The margin of the rings in the palm of the hand is broader than
in other situations, on account of the thickness of the epiderma,
and for the same reason the tint of colour is yellowish^
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ERYTHEMA LiEVE. ERYTHEMA INTERTRIGO. 161
ERYTHEMA L^VE.
JS, cBdematotum.
266, Erythema Isve is an inflammation of the skin associated
with oedema, and appearing for the most part in the lower extre-
mities. When, however, the vital powers of the system are re-
duced, it may be developed in any dependent part of the body.
In the lower limbs it commences around the ankles by several
small spots, which, by their increase, speedily form a patch of
considerable extent The inflamed surface is smooth, shining,
and of a bright red colour ; it is more or less swollen from dis-
tention of the subcutaneous areolar tissue with serous fluid, and
is attended with itching, and by a painful sensation of tension.
When left to itself, cedematous erythema may continue without
change for several weeks, and may terminate eventually in ulce-
ration or mortification. When it issues in resolution, the swell-
ing subsides, although the oedema may still remain for some time
longer; the brighter hue of redness merges into a purplish
and livid tint, and the skin is long before it regains its natural
appearance. Moreover, the epiderma desquamates in thin
lamellae.
In young persons, erythema laeve is an occasional result of
sedentary habits, or of fatiguing exertion in close apartments.
Those of a lymphatic temperament are most liable to its attack,
and it is not unfrequently observed in chlorosis. In adults it
sometimes appears without any more obvious cause than disorder
of the digestive system, particularly in persons of intemperate
habits. In persons of advanced life, the affection is by no means
uncommon, and occurs as a consequence of over-exertion in
standing or walking. It is also a frequent complication of the
oedema which accompanies varicose veins and anasarca. The
local afiection is usually accompanied by slight febrile s}anp-
toms, and by some degree of constitutional disorder.
ERYTHEMA INTERTRIGO.
267. Erythema intertrigo* is that form of cutaneous inflam-
mation which is induced by chafing the skin, either by the fric-
tion of one surface of the integument against another, by the
friction or pressure of dress, by the irritation of secretions and
discharges flowing over the surface, or by the presence of any
cause of irritation whatever, as over-distention of the skin, erup-
tive aflections, &c. This inflammation is attended with little or
no swelling ; but when it occupies the folds of the skin, whence
the perspiratory fluid does not easily escape, or is produced by
* Intertrigo, a chafe-gall.
M
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162 CONOESTIVE INFLAMfifATION OF THE DERITA.
contact of secretions, the abraded derma pours out a sero-puru-
lent ichor, which excites a troublesome itching. If the cause of
irritation continue for some time, the skin becomes excoriated,
and deeply chapped. The cutaneous inflammation produced by
pressure on the skin is termed erythema paratrimma.
Erythema intertrigo from the friction of adjoining surfaces is
met with between the folds of the skin of infants, as between the
buttocks, between the thighs, around the umbilicus, and in the
groins, particularly if the parts be moistened by secretions, or
unprotected by cleanliness ; in the folds of the skin of fat per-
sons, especially in warm weather ; upon the face, from the over-
flow of tears, the saliva, or the secretion of the nose ; upon thd
vulva, the prepuce, and the scrotum ; around the anus, and be-
tween the toes. A most distressing case of intertrigo in both
groins, with condylomata, and profuse, ofiensive, glairy secretion,
occasioned by the irritation of discharges from a carcinomatous
uterus, is at present (1842) under treatment in the St. Pancras
Infirmary. When the disease occurs around the anus, it gives
rise to great pain during the action of the bowels, and frequency
to spasm of tlie sphincter. In a case for which I was lately con-
sulted, where the disease afiected the prepuce, the aperture of
this part was so much contracted and hardened by the cicatrices
following upon the chaps, that not only had phymosis resulted,
but the urethra was also considerably obstructed.
ERYTHEMA PAPULATHM.
268. Erythema papulatum (Plate i., g.) is characterized by
the development of numerous small red spots, of which the
largest scarcely exceed the disk of a split pea. They are ac-
companied by considerable itching and tingling of the skin,
which is increased after meals and during the night. On their
first eruption, the spots are of a bright red colour, and slightly
raised above the surface of the surrounding skin. The swelling,
however, subsides in the course of a few days, but the redness
continues for one or two weeks, becoming purplish in its tint,
and yellowish as it fades away. In distribution, the spots are
irregular, being, in some situations, aggregated into thickly-set
patches, while in others they are scattered and dispersed. This
variety of erythema occurs most frequently on the face and neck,
the chest, the arms, and the backs of the hands and fingers. It
is met with at all periods of life, particularly in young persons
and females, is preceded by febrile symptoms of an acute kind,
and is usually associated with irritation of the gastro-pulmonary
mucous membrane, and sometimes with rheumatism.
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ERTTHEMA TUBEROSUM. ERYTHEMA NODOSUM. 163
ERYTHEMA TUBEROSUM.
269. Erythema tuberosum (Plate i., h.) consists of an erup-
tion of patches of a circular form, and of a size varying between
a fourpenny -piece and a shilling. They are frequently inter-
spersed among the s^naller spots of erythema papulatum, on the
upper parts of the body, but upon the legs, where the eruption is
most frequent, they occur without admixture. Like erythema
papulatum, the spots are preceded by itching and tingling, they
appear generally at night, are brightly red and very tender at
their first outbreak, become purplish in the course of two or three
days, and assume the yellow and greenish tint of a bruise as they
subside. The eruption is frequently ushered in with chills and
feverish symptoms, and is accompanied in its course by debility,
languor, and considerable constitutional disturbance. This
form of erythema is frequentiy met with in female servants, par-
ticularly in those who have been recently transferred from the
fresh air of the country to the confinement of London kitchens.
It is seen also in persons of debilitated constitution, and Mr.
Corfe, of the Middlesex Hospital, has observed that it is generally
associated with disordered menstrual frmction.
ERYTHEMA NODOSUM.
270. Erythema nodosum (Plate i., i.) is an inflammation of
the skin occurring in oval patches, which vary in size, from half
an inch to two or three inches in diameter, and are situated for
the most part on the upper and lower extremities. The long
diameter of the patch usually corresponds with that of the limb,
but in several instances I have seen it occupy the opposite posi-
tion, and two patches, one before and one behind, meeting by
their extremities, have surrounded the leg as with a bracelet.
The oval patches are slightiy raised above the surrounding sur-
face, the elevation increasing gradually towards the centre ; they
are hot, painfril, and tender ; of a bright red colour at their erup*
tbn, but change in the course of a few days to a purplish and
livid tint, which becomes subsequentiy yellow and greenish, and
has the appearance of an ordinary bruise. The inflammatory
activity of the patches increases for several days, during which
they are hard and painfrd ; they then become softer to the touch,
and by the eighth or tenth day have nearly subsided ; terminat-
ing by a transient discoloration of the skin, and desquamation
of the epiderma. Erythema nodosum is preceded by symptoms
of general feverishness, such as headache, languor, chills, dry
skin, quick pulse, white tongue, nausea, diminished secretions,
&c., and disturbance of the digestive organs ; these symptoms
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164 CONGESTIVE INFLAMMATION OF THE DERMA.
diminishing on the appearance of the eruption. It has also been
observed in connexion with rheumatism. This eruption attacks
chiefly young persons and females, and those of a debilitated
habit of body.
I consider erythema papulatum, tuberosum, and nodosum, so
closely allied to each other, that were it not for the fear of cre-
ating confusion, I should include them under the same name.
The two former are commonly associated in the same patient^
and I have more than once seen erythema papulatum on the face
and hands, while erythema nodosum existed on the legs.
ERYTHEMA CHRONICDM.
271. Chronic erythema may occur upon any part of the body,
as the consequence of local irritation ; and in some situations
from constitutional causes. Of the latter kind are those inflamed
patches (fiery spots) which occasionally appear upon the face,
and remain fixed for a considerable length of time — often for
years. These are generally accompanied by some irregular
state of the system that requires mecUcation.
As the efiect of local causes, chronic erythema not unfre-
quently breaks out upon the hands and feet ; upon the ears and
lips ; around the nipples of nurses ; upon the abdomen, from the
distention of the skin caused by pregnancy or ascites ; upon the
vulva, the prepuce, the scrotum, and around the anus. The
inflammation of the skin in chronic erythema generally proceeds
to the formation of chaps and fissures of various extent ; the dis-
ease is tardy in its course, and obstinate under treatment
272. Duwnom. — The diagnostic characters of erythema are,
redness andf heat of skin widi but trifling swelling, the redness
passing by degrees into a purple and livid tint, as the inflam-
matory excitement subsides. The absence of tumefaction, and
distention of the subcutaneous areolar tissue, at once distinguish
erythema from erysipelas.
Erythema fiigax is distinguished from the other varieties prin-
cipally by negative characters — namely, by the absence of those
peculiarities which mark the rest. The redness is difiused, there
is little swelling, the surface is dry and hot, and the inflamma-
tion evanescent.
Erythema circinnatum is remarkable for the annular form of
its patches ; it is distinguished from herpes circinnatus by the
absence of vesicles, and from lepra in progress of cure by its
general appearance, and by the previous history of the aflTection.
Erythema marginatum is recognised at an early stage by the
annular form of the patches, and at a later period, by its abrupt
and papulated border.
^rythema IsBve is characterized by the absence of tumefaction
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DIAGNOSIS AND CAUSES OP ERYTHEMA. 165
of the inflamed skin^ and by its association with oedema of the
subcutaneous areolar tissue.
Erythema intertrigo is distinguished from eczema by the ab-
sence of vesicles, and by the secretion from the excoriated sur-
feces being less in quantity than in the latter afiection. The
cause of intertrigo, again, is immediately obvious.
Erythema papulatum may be confounded with some forms of
roseola, and particularly with urticaria, but careful examination
enables us to distinguish several striking points of difference.
Thus, roseola is accompanied by a greater degree of febrile ex-
citement ; while urticaria is more irregular and unsteady in its
progress, and the itching is more pungent.
Erythema tuberculatum is distinguished by the circular red
patches developed on the skin, and by the constitutional symp-
toms.
Erythema nodosum is so clearly characterized, as to offer litde
room for confounding it with any other eruption. Roseola is
that which approaches it most nearly. Erythema nodosum is
distinguished from other cutaneous affections by the oval form
of the patches, and by their general erythematous characters.
It differs from roseola in the greater depth of its inflammation.
Erythema chronicum, in its various situations, may be con-
founded with chronic eczema and psoriasis, unless tiie distin-
guishing characters of these latter — namely, the vesicles and
scales — be remembered.
273. Causes, — The proximate cause of erythema is congestion
of the vascular rete of the derma, induced by local or by general
causes. The varieties coming under each of these heads have
been already specified. Erythema may also be induced by dis-
order of the digestive organs, from the use of improper food, or
from taking irritating matters into the stomach, as copaiba. The
peculiarities of colour observed in the disease under consider-
ation are explained by reference to the general principles of
inflammation. During the period of excitement, the blood is of
a bright red colour ; it courses rapidly through the part, and the
vessels become dilated. After the subsidence of the excitation,
the stream of blood flows languidly through the dilated vessels,
and assumes the venous character in its course. Hence the
bright red tint of the early periods of erythema, and its purplish
and livid hue during the subsequent stages.
The exciting causes of erythema laeve are, retarded venous
circulation through the limb, and interference with the vascular
distribution in the skin by oedematous distention of the sub-
cutaneous areolar tissue.
274. Prognosis, — Erythema is for the most part a slight affec-
tion, and derives its chief importance from the disease with
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166 CONGESTIVE INFLAMMATION OF THE DERMA.
which it may chance to be associated, or from the nature of its
cause. The duration of the acute varieties rarely extends to
more than two or three weeks. Chronic erythemata speedDy
yield when the exciting cause is removed, and erythema laeve,
the most serious of the erythematous inflammations, when it
occurs in old persons, is easily controlled by judicious treatment.
275. Treatment. — The principles of treatment of erythema
resolve themselves into three indications: — I. To restore the
altered functions of the system to healthy action. 2. To allay
the local irritation. 3. To excite the nerves of the part to
resume their normal tone, and the congested vessels their normal
dimensions and functions.
The s}anptomatic varieties of erythema require to be treated
through the disease upon which they are dependent. The
method of treatment must consequently vary in relation to cir-
cumstances. In some instances, the antiphlogistic plan may be
required, in others, the irritation of mucous tissues must be
soothed, while in others, again, it may be necessary to excite
counter-irritation at a distant part With the latter view, aloes
combined with myrrh will be found an useful remedy, particu-
larly in females.
When the system is reduced, and the powers are enfeebled,
tonic remedies are indicated ; bitters combined with acids are of
great service, together with an appropriate regimen, and the
judicious use of exercise.
Sponging the entire surface of the body with warm water and
soap every day, or every other day, with occasional warm baths,
and drying the skin thoroughly with a rough towel, will also be
found useful. To this means may frequently be added, with
great advantage, the friction on the unaffected skin of some
stimulant spirit or liniment, such as a drachm of tincture of
croton,* combined with one ounce of spirit of rosemary and three
of rose-water ; or two drachms of liquor ammonisB fortior to aqua
calcis and oleum olivs optatum, two ounces each.
The local treatment should, according to circumstances, con-
sist in evaporating lotions, water dressing, or warm fomenta^
tions. In the erydiema fugax of the face and neck, cold cream,
either alone or with the addition of liquor plumbi, will be found
a grateful application.
For erythema laeve, the general treatment must consist in the
restoration of the secretions, in establishing the regularity of the
digestive organs, and in the subsequent exhibition of tonics, vnth
attention to diet The local treatment demands rest, such a
* The tincture of croton, a most Talaable cutaneous stimulant, is made by adding
four ounces of spirit of wine to one ounce of the bruised seeds of croton. It is read/
for use at the end of a week.
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TREATMENT OF ERYTHEMA. 167
position of the limb as will assist the venous circulation as much
as possible ; evaporating lotions, or warm fomentations in the
acute stage, succeeded by the application of a well-adjusted
cotton bandage, as soon as the inflammation has somewhat sub-
sided. Gentle firictions with camphorated spirit may be employed
when the local excitement is reduced, and repeated night and
morning at each application of a fresh bandage. The erythema
accompanying anasarca is immediately relieved by position.
The excoriations of erythema intertrigo require to be kept
perfectly clean, and free from the original cause of irritation.
They should then be dusted with some absorbent powder, such
as Fuller's earth, starch powder, oxide of zinc, &c., and washed
with a lotion of chloride of lime. Er^'thema paratrimma is
relieved by astringent applications, or by soap plaster spread
upon wash leather.
Erythema papulatum, tuberosum, and nodosum, require anti-
phlogistic regimen, a brisk purgative of calomel and colocynth
at the commencement, then tonics and the mineral acids.
Chronic erythemata are to be managed according to the gene-
ral principles of treatment above detailed ; the excitement of
the afiected part is to be reduced in the first instance by sooth-
ing applications, and then astringents and gentle stimulants are
to be used. The chapping of the hands may be prevented and
relieved by the use of a small quantity of honey^ which should be
rubbed into the inflamed part each time the hands have been
washed, and then wiped ofi*, so as to remove any stickiness that
may remain. An ointment of oxide of zinc is also useful for the
same purpose.
Erythema of the nipples is best relieved by the application of
an ointment of nitrate of silver, containing from five to ten grains
to the ounce, the tinctures of kino and catechu, infusion of oak
bark or pomegranate, or lotion of chloride of lime.
It is judicious, in most cases, to wean the infant, when the
nipples are tender and chapped, but when weaning is objected
to or inconvenient, a shield and teat should be applied, without
interfering with the nitrate of sflver ointment.
For erythemata of the vulva and anus, soothing applications
in the first instance, followed by the nitrate of silver ointment, or
the astringent remedies mentioned above, constitute the most
advisable treatment. In the case of phymosis frt>m erythema,
to which I before alluded, I found it necessary to slit up the
prepuce.
Cases illustrative of Erythema.
276. Erythema papulatum. — A married lady, habitually dys-
peptic^ became overheated on the 16th of December, 1845 ; she
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168 CONGESTIVE INFLAMMATION OF THE DERBiA.
was afterwards chilled by exposure to cold in an open caniage
for some hours. At night she was feverish and restless.
Dec. 17. Next day she felt unwell, with general malaise and
lassitude, was exposed to cold as before. In the afternoon had
nausea and chills. At dinner she partook of boiled beef, at all
times an unpalatable dish to her, and suffered in the evening
from nausea and headache. In the night she was awaked with
intense nausea, but had no vomiting.
18th. Third day. Felt very unwell, nausea still continuing,
with lassitude. A punctiform rash became perceptible on the
backs of her hands and fingers ; the rash was more vivid at night,
and attended with considerable itching.
19th. Eruption increasing; affecting the elbows as well as the
hands, and slightly the neck and face.
22nd. FifUi day. Eruption at its height. On the elbows,
the papulae formed a patch of about the size of the palm of the
hand ; they were numerous on the fingers and backs of the hands,
and few and scattered on the face, neck, and head. The greater
number of the papulae were hemispheroidal, slightly raised, of a
vivid red colour, and equal in size to a split pea. Some were
clustered into circular and oval groups of the size of a sixpence,
and others were single and isolated. On the backs of the hands
were spots of a larger size than those above mentioned, as large
as a sixpence or shilling, (erythema tuberosum;) they increased
in breadth by their border, which was prominent and papular,
while the included area became pale and yellowish. The erup-
tion was very tender to the touch.
23rd. Sixth day. The symptoms of nausea and feverishness,
which were slightly diminished on the appearance of the erup-
tion, were now greatly relieved. The eruption was on the de-
cline; the tenderness subsided; the redness diminished; and
each little papula, as it gradually disappeared, formed a distinct
ring of red, with a light yellowish area. Traces of the eruption
lasted until the end of the second week.
277. Erythema papulatum et nodosum, — A widow, forty-five
years of age, regular, had been suffering for four months with
bronchitis. On the 1st of April, 1846, she had an eruption on
the fjEtce, and then on the hands, of papulae of a bright red colour,
and accompanied by severe itching and tingling. These symp-
toms were much increased on taking fluids of any kind, particu-
larly such us were warm, and they were greatly augmented by
the warmth of bed. They were very tender to the touch, parti-
cularly around the finger nails. A few days after the disappear-
ance of the eruption on the face, the large oval-shaped swelling
(delineated in Plate I.) made its appearance, attained its height
on the second day, and declined on the fourth, leaving behind
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CASES ILLUSTRATIVE OF ERYTHEMA. 169
it a purplish and yellow stain, like that of a bruise. The con-
stitutional symptoms preceding and accompanying this eruption
were nausea, feverishness, and extreme lassitude. The languor
with great depression of spirits continued until the termination
of the disease.
278. Erythema tuberosum, — A young woman, aged twenty-
two, enjoyed good health until nine months ago, when she ob-
tained service in London as housemaid. Since this period she
has suffered constant illness ; sometimes her bowels were con-
stipated, sometimes she had nausea, at other times cough ; men-
struation was disturbed, becoming scanty, and light-coloured ;
she had leucorrhcea, and copious deposits in her urine, with dif-
ficulty in passing it In fact, all the mucous membranes in her
body suffered more or less from disorder. Associated with these
symptoms, she had a constant feeling of languor, loss of appe-
tite, and indisposition to make any exertion. While in diis
state, she was seized (January 1846) with a dry, hard cough,
accompanied with headache and the usual train of febrile symp-
toms ; and a copious eruption of erythema tuberosum made its
appearance on her fore-arms, knees, and legs. The majority of
the spots were of the size of a shilling piece, they were distri-
buted irregularly over the skin, and were very tender to the
touch. On their first appearance they were vividly red, but soon
became piurplish and yellowish, and by the third or fourth day,
were on the decline. This patient recovered at the end of three
weeks ; her treatment consisting in a smart purgative at first,
followed by tonics and wine, and an occasional warm bath
during her illness. The water-dressing was used to the seat of
ihe eruption.
279. Erythema IcBve of the ankle, — A cook, forty years of age,
after a week of unusual exertion, felt languid and ill, and was
unable to walk, in consequence of pain and swelling in her right
leg. Her pulse was quick ; she had a dry, furred tongue, and
headache. The affected leg was oedematous, particularly around
the ankle. In the latter situation there was a broad and exten-
sive patch of erythema laeve. The veins of both limbs were
varicose, but she had never before suffered from any affection of
the legs. I ordered her to bed, gave her an active purgative
with salines, had the leg supported on an inclined plane, the
inflamed parts wetted widi a layer of lint dipped in a saturnine
and alcoholic lotion, and the whole of the lower leg enveloped
in oiled silk. By the next morning the redness had diminished
very considerably, and the cedema was much reduced. I then
moistened the limb with camphorated spirit, and bandaged it
firmly, from the foot upwards, to the lower part of the thigh, re-
adjusting the bandage night and morning. From the first day
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170 CONOESTiyE INFLAMMATION OF THB DERMA.
of the application of the bandage she was enabled to walk, bat
in consequence of again oTcr-exerting herself and misapplying
the bandage, which, after the first few days, I entrusted to her-
self it was found necessary to confine her again to bed, where,
in a short time, she recovered.
280. Severe erythema Imve of bath leg$, — In the autumn of
1841, 1 was called, with my firiend Mr. Coulson, to see a lady of
advanced age affected with this disease. She was corpulent, of
sedentary habits, had long suffered firom oedema, and her pre-
sent attack had lasted for several weeks, resisting the various
modes of treatment which had been pursued. The skin of the
entire surfeice of both legs was of a deep red tint, highly con-
gested, and covered with a rough and exfoliating epiderma.
Her tongue was foul, and her general health very much dis-
turbed, so much so, indeed, that she was apprehensive for her
life. For the purpose of relieving the congested state of the
skin, we recommended free scarification with the point of a
lancet, to be followed by fomentations and bandaging. To this,
however, she stoutly objected. We then ordered strict attention
to position, painting the surface with the tincture of iodine, and
carefully adjusted compression by means of strips of soap plaster
spread upon leather ; the local treatment being assisted by an
occasional aperient and tonics. In the course of a few weeks she
had entirely recovered.
281. Erythema keve, issuing in mortification and death. — ^An
aged woman complained of great pain and uneasiness in the left
foot and ankle. There was a difiused patch of redness with
slight cedema, occupying the front of the ankle, and the dorsum
of the foot. Her tongue was not much altered, but her pulse
was quick. I directed her to remain in bed, and to apply
fomentations to the limb, at the same time recommending her to
the attention of a neighbouring medical friend. In a few days
the part became discoloured, and sphacelus conmienced, which
extended rapidly up the limb as far as the groin. After death,
the whole of the arteries of the limb were found to be solidified
by calcareous depositions, and some of the smaller vessels were
completely obstructed.
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CHAPTER IV.
EFFUSIVE INFLAMMATION OF THE DERMA.
282. Under the designation ^^efiusive inflammation of the
derma,'^ I propose to consider those inflammations of that
structure which are especially characterized by efiusion of a
serous fluid upon its surface, and the consequent elevation of
the epiderma in the form of vesicles or blebs. When the his-
tory of these diseases is investigated, they are found to be
susceptible of a natural arrangement into two groups, the one
marked by diminution of the vital powers of the system — asthemc;
and the other by increased energy of the nervous and vascular
systems — sthenic. The former of these groups corresponds with
the order Bullae, the latter with the Vesiculae of Willan; and the
diseases respectively grouped under each are, —
Asthenic, Sthenic.
Pemphigus. Herpes.
Rupia. Eczema.
Sudamina.
283. The diseases composing the asthenic group agree in the
characters of presenting vesicles of large size or buUse, in the
want of tone of the cutaneous tissues, and in a greater or less
degree of debility of the vital powers. In these characters, as
well as in the existence of bull», they are allied with erysipelas,
and especially with the phlyctenoid variety. So great, indeed,
is this resemblance, that Willan was led into the error of group-
ing erysipelas with pemphigus, under the order bullss. Now,
however, it is weU known that the development of buUse is only
an occasional phenomenon of erysipelas, and that, in general
characters, that disease corresponds with the inferior class of
exanthemata.
284. Willan and his school, upon insufficient grounds, have
considered the degrees of pemphigus as difierent diseases under
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172 CONGESTIVE INFLAMMATION OP THE DERMA.
the names of pemphigus and pompholyx. Sach a sabdivision
is calculated to obscure, most unnecessarily, the characters of an
important affection, and to lead to much practical inconvenience.
The inaccuracy of this subdivision was perceived by Rayer, and
I have followed in his steps in regarding the forms of pompholyx
as varieties of pemphigus.
285. Rupia, as it is ^e last in the asthenic group, establishes,
by some of its least important characters, a link of transition to
the order vesiculss. Thus we find that the bullae of rupia are
smaller than those of pemphigus, and, in point of size, are more
nearly allied to those of herpes. In pursuance of this obser-
vation, Willan placed Rupia in his order Vesiculae immediately
after Herpes, but it was subsequently restored to its proper
position by Biett. Indeed, the correspondence of the general
characters of rupia with those of pemphigus are so intimate, that
one of its varieties occupies almost a neutral place between the
two diseases.
286. In the classification adopted in this work, I have very
considerably curtailed tiie order vesiculae of Willan. That
author had assembled seven diseases under this head, but five
of the number must necessarily be rejected in a natural classi-
fication. Of these are varicella and vaccinia, which, at the pre-
sent day, are recognised as variolous affections. Rupia, as we
have just seen, is a bullous disease ; Miliaria I have treated as
a consequence of disorder of the sudoriparous system ; and
Aphtha, his seventh genus, is a disease of the mucous membrane
oi the mouth, being very probably an eczema of that tissue.
Rayer admits six genera into the order vesiculse ; but, for similar
reasons to those which have guided me in objecting to Willan's
arrangement, I have transferred three to more appropriate places
— namely. Sudor miliaria, which originates in disorder of the
sudoriparous system ; Hydrargyria, which differs in no essential
respect, saving its exciting cause, from eczema ; and Scabies,
which is an inflammation of the derma, of various character,
excited by the presence of parasitic animalcules inhabiting the
epiderma.
287. The contents of the large vesicles of the asthenic group
of diseases comprised under the definition of this chapter differ
somewhat in composition. Both consist of an albuminous fluid,*
transparent at first, but subsequently becoming more or less
opaque and puriform. Sometimes the fluid presents a pinkish
or purplish hue, in which case the colour is derived from a
portion of the hsematosin of the blood mingled with the effused
* M. Grabj, of Yienna, who has directed his attention to the ^e^table nature
of the crosts of favos, remarks that he has discovered another plant in the bailie of
rnpia.
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PEMPHIGUS. POMPHOLYX. 173
fiuid. But in the sthenic group, the fluid of the vesicles contains
fibrine, and approaches more nearly to liquor sanguinis, while the
stratum which lies in contact with the derma becomes organized
and transformed into a false membrane. This false membrane
is especially seen in herpes zoster, and in eczema rubrum and
impetiginodes.
288. The fluid of pemphigus has been made the subject of
chemical analysis by Scherer.* It had a yellowish tint, an acid
reaction, a specific gravity of 1018, and deposited a sediment
composed of corpuscles, which Scherer states to have resembled
mucus or pus-corpuscles, but which were probably newly formed
epidermal cells (IS). On evaporation it gave forth an odour of
acetic acid, and deposited a quantity of very white albumen on
being heated. It contained no trace of urea. The analysis gave
the following results : —
Water 940*0
Solid coDstitaents 60*0
Fat containing cholesterin 2*6
Albumen, ▼ith earthy phosphates 48*0
Aloohol extract, with lactate of soda, and chlorides of
sodiam and potassium 6*5
A substance resembling ptyalin, soluble in water . . 1*9
Free acetic acid and corpuscles.
In the same patient, five years afterwards, the proportions of
water and solid constituents were 959*8, 40*2.
In certain vesicles on the abdomen, probably herpetic, from
the quantity of albumen which they contain, the fluid contents,
examined by Girardin, gave the foUowing analysis : —
Water 939*500
Solid constituents 60*500
Albumen 49*200
Cholesterin 6*475
Alcohol extract 1*075
Phosphates of soda and lime, and chloride of sodium 3*750
PEMPHIGUS.
Syn. Pompholyx. Pemphix. Fiivre bulleuscy Fran. Blasenaus-
scMag. fVassenblaseny Germ. Pemphix, Alibert.
289. Pemphigust (Plate 2) is an eruption of bullae of consi-
derable size, appearing upon circular or oval erythematous
patches, corresponding in diameter with, or a very little larger
than, the bases of the bullae. The bullae arise in the course of
* Dr. Day, in Simon's Animal Chemistry,
f Der. irtft^i^, a hobble ; xe/i0oXv(, a water bubble.
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174 EFFUSIVE INFLAMMATION OF THE DERMA.
a few hours ; they vury in balk item that of a split pea to that
of one valve of a walnut-shell, and occasionally they inorease to
Ae size of a fowl's egg. On their first appearance Ihey eontain
a transparent limpid or yellowish serum, which, in a short space
of time, becomes pinkish, sanguineous, or turbid, and is even-
tually discharged by the rupture of the bulla, or desiccates into
a thm, dark-coloured crust. When the bulla bursts, which it
generally does in one or two days, an excoriation corresponding
with its base remains behind. The disease occurs usually in
successive crops ; in rare instances, only, simultaneously upon
all parts of Ihe body. It may be partial or general, and may
be prolonged in duration from a few days to several months, and
even years.
290. The numerous varieties* of pemphigus indicated by dif-
ferent authors may all be embraced in the consideration of its
two degrees of inflammatory activity — viz., acute and chronic.
The former of these degrees includes the pemphigus vulgaris,
pompholyx benignus, and pompholyx solitarius of Willan, while
the latter corresponds with the pompholyx diutinus of that
author. The pemphigus infemtilis of Willan is more properly
referrible to rupia escharotica, and his pemphigus contagiosus
appears to be based upon insufficient data.
PEMPHIGUS ACUTUS.
291. ^Pemphigus acutus (Plate 2) is a rare form of cutaneous
disease, attacking children and young persons chiefly, attended
by a trifling or moderate degree of constitutional (Usturbance,
and lasting for a short period.f The disease may be partial or
general, disseminated or confluent, and it occurs for the most
part in successive eruptions.
The constitutional symptoms of acute pemphigus may be
slight, not exceeding a trifling degree of listlessness or languor,
or they may be severe, consisting of chilliness and rigors, flushes
of heat, pains in the head and limbs, thirst, loss of appetite,
nausea, sore throat, pain at the epigastrium, quick, frequent pulse,
and sometimes delirium. Irritation of the gastro-pulmonary, or
of the urethro-sexual mucous membrane, is a frequent compli-
cation of the constitutional symptoms.
The milder series of the above detailed symptoms belong to
the pompholyx benignus of Willan ; the same mild constitutional
* Pemphigus congenitos; p. infantilis; p. simoltaneus ; p. saccessiyos ; p. solitarioi;
p. conflaens ; p. acutas ; p. cnronicus ; p. pyreticus ; p. apyreticas.
t Rayer relates a remarkable and interesting case of this afiPection, nvhioh was
admitted into hospital on the 2 1st of August, and discharged cured on the 3rd of
September.
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PEMPHIGUS ACUTTS. 175
affection, with sickness and languor, accompany his pomphoh/x
soUtarms,
The local symptoms consist in the appearance, on the second
or third day, or at a later period from the commencement of
the constitutional disorder, of small red spots, accompanied by
itching, and a dry burning sensation. The spots speedily in-
crease in size, and constitute circular erythematous patches,
which vary in their degree of redness from a pale to a vivid
tint In die course of a few hours a vesicle rises in the middle
of each patch, becomes rapidly distended wiUi a limpid serum,
and increases to the size of a hazel nut, or of a large walnut
The buUa is of a circular or oval ibrm, and frequently somewhat
flattened at its summit. It usually corresponds very accurately
in diameter with the breadth of the erythematous patch, which it
then completely cosc^s ; at ofber times it is somewhat smaller
than the patch, and the latter shows around it as a narrow zone.
Sometimes, again, the bulla is much smaller, and appears to be
surrounded by a broad areola. The bullae generally burst at
the end of a day or two, and expose an excoriated surmce, which
secretes a serous fluid for a few days longer, and then becomes
covered by a thin, yellowish scab, which- gradually assumes a
brown, and subsequently a black colour. When the rupture of
the bullsB does not take place, the limpid and transparent fluid
which they contain assumes a yellowish and amber tint ; it then
becomes turbid and opaque, diminishes in quantity by absorp-
tion and evaporation, and at the end of about a week dries
up, forming a thin, dark-coloured scab. Occasionally the con-
tents of the buUffi become pinkish or purplish, in place of
yellowish and turbid; and when the local inflammation has been
violent, they may even be mingled with lymph or pus. The
scabs fall in the course of three weeks, leaving the skin beneath
of a dusky red hue, but perfectly sound. The period of rupture
of the buUae is dependent in a great measure upon situation, and
upon the gpreater thickness or thinness of the epiderma. The
duration of the disease is regulated by the manner of its irrup-
tion ; when the bullae appear at once, the affection terminates
in one or two weeks. When, however, they are developed,
as usually happens, at successive periods, the disease is pro-
longed in a similar ratio, and may extend to three weeks or a
month. In the progress of the cutaneous eruption, vesicles are
not unfrequendy observed upon the mucous membrane of the
mouth.
292. The urine, analyzed by Heller, in a case of severe pem-
phigus, which proved fatal, die patient being a woman forty
years of age, was acid, and its specific gravity 1017*5. It de-
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176 EFFUSIVE INFLAMMATION OF THE DERMA.
poshed a light cloudy sediment of mucus with fat-globules,
urate of ammonia and epithelium scales. His analysis is as
follows : —
Water 955*80
Solid coDstitueDts 44*20
Urea 24*63
Uric acid 0*58
Extractive matters 11*79
Fixed salts 7*20
^^ Of the fixed salts the earthy phosphates were normal, the sul-
phates much increased, and the chloride of sodium proportion-
ally diminished. The urea is considerably above the normal
average."*
293. In the exceedingly rare variety of pemphigus named by
Willan pcmpholyx soUtariuSy the bulla attains the size of an
orange, enlarging very rapidly, and containing several ounces
of serous fluid. It is preceded by a disagreeable sensation of
tingling and smarting, breaks in about forty-eight hours, and is
succeeded by a superficial ulceration. At the end of one or two
days after the disappearance of the first bulla, another rises in
its vicinity, and pursues the same course with the preceding. In
this way five or six bullae may follow each other successively,
extending the duration of the disease to eight or ten days.
Willan remarks, with regard to pompholyx solitarius, that " it is
a disease which rarely occurs, and seems only to aflfect women. I
have seen three cases of it: in one, the left arm was afiected ; in
the other two, the breasts. The excoriations occasioned pain and
irritation, vnth partial hardness in the substance of the breast**
Biett met with a chronic variety of this disease.
Pemphigus may be complicated with herpes; indeed, the
small bullae of this disease bear considerable resemblance to
the vesicles of herpes phlyctenodes, and the likeness to herpes
is still further increased by the occasional appearance of the
smaller bullae of pemphigus, in the form of rings (Plate 2, i.)
It may also be complicated with prurigo; the latter occurs
most frequently in old persons, and accompanies the chronic
variety.
PEMPHIGUS CHRONICUS.
Pompholyx diutinus, Willan.
294. The chronic form of pemphigus is identical with the
pompholyx diutinus of Willan. It is of more firequent occur-
rence than the acute variety, is tedious and painful in its course,
always successive in its appearance, and takes place in persons of
debilitated constitution, principally of the male sex, and in aged
* Dr. Day, in Simon's Animal Chemistry.
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PEMPHIGUS CHRONICUS. 177
individuals. In its irruption it is either general or partial, and
occasionallj it makes its attacks at a particular season, for several
consecutive years, appearing, for instance, in the autumn or
v?inter, and declining in the spring. Sometimes it lasts con-
tinuously for years.*
The constitutional symptoms are very slight as compared with
pemphigus acutus. There is usually some degree of sickness of
stomach, headache and lassitude, which precede for several
days the appearance of the eruption. And if the latter be severe,
the constitutional symptoms are considerably augmented. The
cutaneous disease is sometimes associated with apthae, with con-
siderable gastro-intestinal irritation, with dysuria and hsema-
turia, and in old persons it not unfirequently terminates fatally,
in consequence of its complication with pulmonary disease, or
with efiiision into the serous cavities.
The local symptoms are ushered in by pricking and smart-
ing of the skin, and by the eruption of a number of small
reddish spots, upon which buUffi speedily appear. The bull®
increase in the course of a few hours to the size of a pea or a
walnut, and sometimes they attain the magnitude of a fowl's egg.
At the end of three or four days, some of the bullsB burst, and
discharge their contents, leaving behind them an angry-looking
excoriation of the derma. In others the serous fluid becomes
reddish and turbid, and decreases in quantity until it dries up,
forming a dark-coloured scab, covered with the shrivelled epi-
derma. As one crop disappears, another is produced, so that
the disease may be observed in all its stages at the same moment,
and may be prolonged for several months, or, with intervals,
for years. Occasionally the bullae are confluent, especially
when they make their appearance, which is not frequently the
case, on the fjEu^e.
Chronic pemphigus is sometimes complicated with prurigo,
particularly in old persons ; this complication excites the most
distressing irritation, and frequently causes a fettal termination.
PEMPHIGUS CONTAGIOSUS.
295. Willan founds a contagious variety of pemphigus upon
the description of an endemic disease, accompaniea with bull®,
which raged in Switzerland in 1752, and which is recorded by
Dr. Langhans. He also alludes, in support of this variety, to
the bullae of plague, and to those which are sometimes observed
in the last stage of typhus fever. The contagious variety is tax
from being satisfactonly established.
• Dr. Dnohesne-Daparo relates that he saw, in St Lonis, a girU eighteeen yearg
of age, of weakly coostitotion, who bad never menstmated, and who had been
affected with chronic penophigas since the age of five years.
N
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178 EFFUSIVE INFLAMMATION OF THE DERMA.
296. Diagnosis. — Acute pemphigus, with its buUse raised upon
inflamed bases, bears some resemblance to erysipelas ; but the
number and small size of the erythematous patches of the former
are easily distinguished from the extepsively inflamed, the tume-
fied and painfid surfaces presented by erysipelas. From rupia
it is distinguished by the small size, the flatness, and the rarity
of the bullae, the ulceration of the skin, and the thick and pro-
minent scabs which characterize rupia.
The doration of the disease, with the exceeding mildness of
the constitutional symptoms, are the principal characteristics of
the chronic form of pemphigus.
297. Causes. — ^Acute pemphigus attacks children and young
persons chiefly; occasionally it appears as a congenital afiection,
and is sometimes of hereditary origin. The season during which
it is most prevalent is the summer. Its occasional causes are,
teething, gastric and intestinal irritation, excess in diet, deficient
innervation, irritability of system, mental afiections, amenorrhoea
and dysmenorrhoea. It sometimes results from the constitu-
tional irritation caused by the introduction of the vaccine virus
into the system. It has also been observed as a complication
of intermittent fever, and several instances are recorded of
its occurrence as an epidemic afiection. A variety named
pemphigus indicus is described by Sauvages as a symptom of
dysentery.
Chronic pemphigus affects principally aged persons, and adults
with debilitated constitutions. It is also, but less frequently,
met with in children. It appears usually in the autumn or
winter season. The most fruitful causes of chronic pemphigus
are tliose of a depressing kind, such as fatigue, anxiety, intem-
perate habits, bad food, chronic irritation of the gastro-pulmo-
nary or genito-urinary mucous membrane, amenorrhcea, resi-
dence in damp and unhealthy situations, exposure to cold, and
starvation, &o. I once saw the disease as a sequela of scarlatina.
In those most liable to this affection, there is an habitual dry-
ness of skin and deficiency of cutaneous secretion. Biett re-
marks that he has frequency found a fatty liver in persons who
have died of chronic pemphigus.
298. prognosis. — Pemphigus is dangerous in proportion to its
oomplio^itions, and to the constitutional disturbance of the sys-
tem. The acute variety is of little importance, but the chronic
affection is always obstinate, and sometimes fatal, particularly
in old persons. The disease would appear to exert sometimes
a beneficial effect upon the system ; thus Rayer narratea that he
"once saw a man who, after having had several attacks of
liaemoptysis, became subject to chronic pemphigus of the legs,
and from this period the bleeding from the lungs did not recur.
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TREATMENT OP PEMPHIGUS. 179
The cure of pemphigus has, in some cases, been obsenred to be
followed by various ill consequences."
I have seen several cases which have induced me to believe
that the eruption of pemphigus is an effort of the system to rid
itself of some morbid disposition. In this light I regard Dr.
Burners case (§ 301). This impression would lead to die adop-
tion of a different mode of treatment to that usually employed —
viz., to one of general stimulation of the surf&ce.
299. Treatment, — Wh^n the febrile symptoms are acute, it
may be advantageous to remove a few ounces of blood from the
arm, or deplete by means of leeches, following up this treatment
with purgatives and antiphlogistic regimen. Such a plan, how-
ever, must be pursued guardedly , for the natural tendency of the
disease is towards debility, and it will generally be found needful
to have early recourse to tonics. Where the febrile symptoms
are not active, piirgadves and diluents will alone be required.
In the chronic forms of the disease, tonics must be employed
at once, the best of them being acids and bark, the latter eidier
in the form of tincture or quinine. A valuable remedy in pem-
phigus is tbe hydriodate of potass. In those cases in which the
symptoms present obvious indications of diseased action in any
of the organs or viscera, such disorder should be made the espe-
cial aim of our treatment. Thus, when the alimentary canal is in
a state of irritation, that irritation must be calmed ; when the
mucous membrane of the bronchia is the seat of morbid action,
counterirritants must be applied to the chest, and such other
means adopted as will relieve those symptoms ; when the uterine
function is disordered, ferruginous remedies must be adminis-
tered, &c. Restlessness and pain will be quieted by opiates.
In an obstinate case of pemphigus, Bayer had recourse to arse-
niate of soda in small doses ; in similar cases, Fowler's solution
will be found an useful remedy.
When there is reason to believe that the eruption is an effort
on the part of nature to determine to the surface a morbid dis-
position, I should strongly recommend the employment of mus-
tard baths to the entire surface of the skin, or a stimulating
lotion or liniment of some kind, such as that of tincture of croton
(page 166). I have pursued this method with great advantage in
several general cutaneous disorders which have appeared to me
to have a similar origin, and I think that my professional brethren
will agree with me that we are warranted in having recourse to
such a mode of treatment in cases so generally fatal in their ter-
mination as chronic pemphigus, wherein our only mode of prac-
tice is to treat symptoms as they arise.
In treating the disease locally, the buUse should be punctured,
and the fluid gently pressed out so as to apply the cuticle to the
N 2
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180 EFFUSIVE INFLAMMATION OF THE DERMA.
surface of the derma. This b done with the view of preyenting
the spontaneoas rupture of the blebs, and the excoriation which
necessarily follows. Occasional warm baths will be found useful.
Where the bullae have burst, and excoriations remain, anodyne
and emollient fomentations, weakly astringent lotions, or ab-
sorbent powders, such as starch powder, may be employed with
advantage. In these excoriations, a solution of nitrate of silver,
containing two grains of the salt to an ounce of water, will be
found the best application to promote cure. Turner's cerate is
also an useful remedy, as is the unguentum zinci, recommended
by Dr. Winterbottom.
The diet requires to be regulated by the state of constitution
of the patient ; where the symptoms are febrile, milk diet is most
advisable, but when tonics are indicated, the diet should be
generous and nutritious. Wine or spirits form an admirable
adjunct to the tonic treatment
Cases illustrative of Pemphigus.
300. Acute pempkigusy^ in a man 26 years of age, a rope-mat
maker and hawker, a free drinker, under the care of Dr. Roots,
in St. Thomas's Hospital, in August, 1829. Eruption of bullae
general over body and face ; persistence by successive crops for
thirty-two days; apthous mouth; subacute gastritis induced by
the administration of five minims of liquor arsenicalis with tinc-
ture of opium, every six hours for three days ; restlessness ;
tremors ; death in thirty-two days from the commencement of
the attack. No appearances to account for death on post-
mortem examination. ^^ Dr. Roots was of opinion that it was
caused by continued irritation, arising from the exposure of so
large an excoriated surface, in the same manner as after an ex-
tensive bum."
301. Chronic pemphigus \ from deficient food, in a woman 87
years of age ; under the care of Dr. Bume, in the Westminster
Hospital, in April, 1836. Menses regular; bowels confined ;
persistence of the bulls for five weeks ; sore throat ; bulla
cured ; bronchitis ; diarrhoea ; death in ten days from the dis-
appearance of the bullae, and within seven weeks from the com-
mencement of the attack. On the post-mortem examination
" the bronchial ramifications were found fiill of muco-purulent
matter, evidently generated by the inflamed mucous membrane."
<^ In the abdomen, a large track of the mucous lining of the small
intestines, particularly the ileum, was inflamed, but no ulceration
could be detected. The large intestines were much more slightly
affected."
* Lancet, toL L 1S29, 30, p. 129. f Lancet, vol. ii. 1SS5, 36, p. 540.
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EFFUSIVE INFLAMMATION OF THE DERMA. 181
RUPIA.
Syn. Atonic ulcers, Phlyzaciay Alibert.
302. Rupia* (Plate 2) may be regarded as a modification
of pemphigus, developed in cachectic and debilitated constitu-
tions. It is characterized by the eruption of small, flattened
bullae, which are few in number and dispersed, and are sur-
rounded by a narrow zone of redness. The bullaa contain, in
the first instance, a serous fluid, which speedily becomes puru-
lent or sanguinolent, and concretes and desiccates into dark
greenish or blackish, rough crusts. These crusts are variable in
point of thickness, and Uie larger ones bear some resemblance
to the shell of the oyster ; whilst others are conical in their form,
being thicker in the middle than at the circumference, and not
unlike the shell of the limpet. When the crusts fall off*, they
leave behind them atonic ulcers of a circular form, and various
depth, which secrete an abundant ichorous and foetid fluid, and
are indisposed to heal. Rupia is tedious in its progress, and
lasts for several weeks or months.
303. The varieties of rupia are founded on the extent and
severity of the disease, and upon the thickness and form of the
crust ; they are three in number —
Rupia simplex,
„ prominens,
„ escharotica.
RUPIA simplex.
304. In rupia simplex, (Plate 2, l. m. n.) the bullae arise
without preceding inflammation. They are circular in form,
flattened on their summit, and equal in diameter to a sixpenny
or shilling piece. When first developed, they contain a transpa-
rent serous fluid, which soon becomes purulent, and gradually
concretes and dries up. As the secretion dries, the epiderma
around it shrivels, and eventually forms a brownish, wrinkled
crust, somewhat like the outside of an oyster-shell. The crust
is thickest in the middle, and is continuous at the circumference
with the epiderma of the surrounding skin. It is thrown off
after some days, and exposes a superficial ulcer, which may
either heal quickly, or continue for several days longer. In the
latter case, a new crust is formed by the desiccation of the secre-
tion upon the surface of the ulcer, and a ^succession of crusts
may in this way be produced. When the ulcer heals, its seat is
♦ Der. pvToct sorde*.
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182 SFFUSIYE INFLAMMATION OF THE DERMA.
indicated by a redness or lividity of the skin around the cicatrix,
"which endures for a coiisiderable period. The more frequent
situation of nipia simplex is the legs and lower parts of the
body.
RUPIA PROMINENS.
305. The prominent rupia (Plate 2, o.) receives its designa-
tion from the projecting and conical form of the crusts which
succeed the bullse. The bullae are of greater extent than in the
simpler variety, and are followed by a troublesome ulcer of con-
siderable depth.
Rupia prominens is preceded by several circumscribed patches
of erythema, upon which the epiderma is raised slowly, and is
distended vrith a turbid, dark-coloured fluid. The fluid soon
becomes concreted, and gradually desiccates into a thick and
wrinkled crugt of a brownish black colour. While the crust is
proceeding towards completion, the erythema slowly extends
its limits so as to form a narrow areola around the circumference
of the crust. Upon this areola the epiderma is raised, and a
fresh secretion of purulent fluid takes place beneath it, which
increases the breadth of the crust In this manner, by suc-
cessive secretions, extending each time beyond the limits of the
first formed scab, the crust is gradually enlarged at its base,
and raised more and more above the surface so as to assume the
characteristic form of the limpet shell. From its mode of grov^h,
the crust appears to be formed of concentric layers, projecting
one beyond the other like tiles upon a house-top, and when it
enlarges in breadth more than in height, it bears a close resem-
blance to the scaly shell of an oyster. The crust goes on in-
creasing for several days, sometimes for a week, and then
becomes stationary. In this state it remains for a variable
period, being at one time easily detached, and at another firmly
fixed. When detached, either spontaneously or by accident, it
is found to conceal an ulcer of considerable depth, and of variable
extent, being deep in proportion to the duration of the crust.
The ulcer, when thus exposed, sometimes secretes a new crust,
which grows thick by successive additions from beneath. At
other times — and this is the more frequent course — the ulcer
retains its open form, presenting a foid surface, thin, livid, or
pale, and excavated edges, and an inflamed areola. The ulcer
is exceedingly difficult to heal, and after the formation of a
cicatrix, leaves a livid and purplish stain, which continues for
many months.
This form of rupia occurs both on the upper and the lower
limbs, but more frequently on the latter. The bullae are two or
three in number, and successive ; usually, however, there is only
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RUPIA PROMINENS. RUPIA ESCHAROTICA. 188
one at its height, while another may be threatening to appear,
or on the decline. Sometimes the balla, instead of pursuing
the tardy course described above, is developed quickly, and is
filled with a limpid serum, which subsequently becomes opaque
and purulent. In other instances, again, the inflammatory red-
ness may be dissipated without the appearance of a bulla.
RUPIA ESCHAROTICA.
Syn. Pemphigus if\fantiliSf Willan. Pemphigus gangrenosus, Stokes.
306. Rupia escharotica, in some of its characters, bears a close
similarity to pemphigus, particularly in the absence of a thick
and rugous crust ; while in its chief feature, that of ulceration, it
evidently belongs to the present class.
The disease consists in the formation of bull® upon somewhat
prominent and purplish or livid spots. The bullae are smaller
than in the preceding varieties ; they are irregular in form, and
flattened at the summit, and they contain a sangninolent serous
fluid, which becomes turbid and dark-coloured, or almost black.
At this period, the bullae are surrounded by a purplish areola
formed by the circumference of the livid spot upon which they
are developed. At a variable period after their distention, the
bullae burst, and leave at their bases unhealthy and excavated
ulcers, which increase gradually in breadth and depth. The
ulcers are painful, they are frequently covered with sloughs, they
secrete a sanious and foetid pus, their borders are thin and in-
flamed, and they are slow and tedious in their cure. As soon
as the ulcers have formed, other bullae arise, and follow the same
course with the preceding, and the disease generally terminates
in the death of the patient from excessive and continued irrita-
tion. This disease occurs chiefly upon the lower extremities,
upon the trunk of the body, more particularly its anterior surfeu^e,
upon the neck, and upon the scrotum or labia.
Rupia escharotica is accompanied by fever, sleeplessness, rest-
lessness, and general disturbance of the nutritive functions.
307. Dr. Whitley Stokes, in a paper published in the Dublin
Medical Essays for 1807, describes this disease as it makes its
appearance in an epidemic form among children in Ireland, under
the name of pemphigus gangrenosus. It is known in difierent
counties of Ireland under the names of white blisters, eating hivej
and burnt holes. Sometimes the eruption is preceded by a livid
sufiiision of the skin, more frequently, in a state of perfect health,
one or more vesicles somewhat larger than a small-pox pustule
appear, increase for two or three days, burst, and discharge a thin
fluid having a disagreeable smeU, limpid in most cases, some-
times whitbh and sometimes yellowish. The sore left by the
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184 EFFUSIVE INFLAMMATION OF THE DERMA.
breaking of the vesicles is painful^ discharges a thin^ foetid
ichorous fluid, ulcerates and spreads quickly, the edges of the
ulcer being livid. Dr. Stokes remarks, that the unfavourable
signs of the disease are the rapidity of extension of the sores,
their abundant and highly foetid discharge, and the blackness
which commences at the edges and spreads over the entire
sore.
The parts chiefly attacked are the fold of the ears, the hands
or feet, generative organs, breast, groins, abdomen, and inside
of the- mouth and lips. " If the sores are behind the ears, they
destroy the connexion of the posterior cartilage with the cranium ;
they spread to the meatus auditorius ; to the eyes, the sight of
which seemed, in a few cases, to have been destroyed one or two
days before death ; and they sometimes extend to the vertex.
" The constitutional disturbance that accompanies this dis-
ease, seems principally the eflect of irritation. When the vesi-
cles burst, the child begins to grow peevish and fretfiil, pale,
loses its appetite, and the flesh becomes remarkably flabby. The
periods of the disorder are not very regular ; but it often happens
about the eighth day, that the pulse sinks, the lividity spreads
over the whole sore, the foetor and discharge increase greatiy.**
" Death takes place about the tenth or twelfth day, often pre-
ceded by convulsions, sometimes by extreme lividity."
308. DiagnosU, — The only cutaneous diseases with which
rupia ofiers a probability of being confounded are, pemphigus
and ecthyma. From the former, it is distinguished by the smaller
size and flatness of its bullae ; by the turbid and sanguinolent
contents of the bullae, as contrasted with the generally limpid
and transparent fluid of pemphigus ; by tbe thick, rugous, and
imbricated crusts ; and by the ulcerations of various extent and
depth.
Ecthyma diflers from rupia in being a pustular disease from
its first appearance ; by the highly inflamed areola with which
the pustules are surrounded; and by the hardness, the small size,
the embedded position, and the closer adherence, of the scabs of
ecthyma.
309. Cause, — Rupia occurs in persons of cachectic and debili-
tated constitution, in those whose strength is reduced by illness,
by want of food, want of clothing, want of cleanliness, intem-
perance, &c. Sometimes it appears as the sequela of scarlatina,
rubeola, or variola. Rayer has observed it in association with
purpura haemorrhagica ; and in the North, it is occasionally seen
as a complication of scabies. Rupia is now and then met with
in combination with ecthyma, to which it is supposed, by Bate-
man, Biett, and Plumbe, to bear considerable analogy.
Rupia escharotica is usually seen in weakly infants, and in
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TREATMENT OF RUPIA. 185
aged persons. In adults, it is sometimes found associated with
chronic rheumatism and syphilis. Dr. Whitley Stokes remarks
that the causes of this disease are obscure. It seems confined
to children, and attacks the finest in preference ; the children of
the poor more frequently than those of the affluent ; and those
who live in damp situations seem more particularly subject to it
than others. The disease is more prevalent in summer than in
winter, and appears to be infectious, though obscurely so.
310. Treatment. — The most important indication to be ful-
filled in the treatment of rupia, relates to the hygienic and die-
tetic management of the patient. The various exciting causes
enumerated as giving origin to the cachectic state of constitution
which favours the eruption, should be removed. Warm baths
should be employed once or twice a-week. The diet should be
generous and nutritious. Tonic medicines should be exhibited ;
of which wine, bark, the mineral acids, and infusion of worm-
wood, or hops, are likely to prove the most serviceable.
In treating the disease locally, it is advisable to puncture
the bullae early, and cover them with a piece of dry lint and a
light bandage, or witli the water dressing. If they exhibit no
improvement under this treatment, recourse may be had to
strapping with the isinglass plaster, or to various foims of
stimidants, such as lime water, lotions of copper, aliun, and
zinc, nitrate of silver, nitric acid, &c., rest and position being
rigidly enforced during the employment of these applications.
Bayer recommends dusting the sm-face of the ulcers with cream
of tartar. Biett speaks strongly in favour of an ointment of the
proto-ioduret or deut-iodm*et of mercury ; the former, of the
strength of a scruple to the ounce, and the latter, of twelve or
fifteen grains. In a more than usually obstinate case, which came
under my care a few years since, in the person of an under-
taker's man, I succeeded in efiecting the cure of an unhealthy
ulcer of rupia upon the arm, by injecting a strong solution of
alum beneath die edges, which were undermined to a very
considerable extent.
In the epidemic rupia escharotica. Dr. Stokes recommends
an ointment of scrophularia nodosa,^ containing as much green
vegetable matter as possible. He remarks that this is a tradi-
tional remedy, but he found it more successful than any other
plan of treatment. The ointment should be warmed until it
possesses the consistence of honey, and then laid on with a
brush, and dressed with the same spread upon lint. The
utmost gentleness should be used, and the (kessing renewed
every six hours. Where there is swelling of the surrounding
* This ointmeDt is made by stewing the small leaves of scrophularia in as small
a quantity of jmsalted batter as may be sufficient to prevent their scorching.
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186 EFFUSIVE INFLAMMATION OF THE DERMA.
parts, or when any powder has been previously used, he applies,
in the first instance, a poultice of porter and oatmeal, or a car-
rot poultice in a state of fermentation.
Cases illustrative of Rupia,
311. Rupia simplex. A young woman, twenty years of age,
brought up in the country, but latterly resident in London, was
attacked with small pox, eight years ago ; she was ill for three
weeks, and has been subject ever since to eruptions on the skin
occurring during the spring. Five years ago she suffered from
amenorrhcBa and ulcer of the leg ; and two years since, from
acute rheumatism. In the month of August, 1845, a vesicular
eruption, accompanied by symptoms of constitutional disorder,
made its appearance on her legs and thighs ; and the eruption
gradually increased until the limbs became studded all over
with dark-coloured crusts, which gave issue, whenever they were
accidentally loosened, to an ichorous discharge and blood.
Her skin was dry, shrivelled, and covered with a furfiiraceous
desquamation, and gave forth a disagreeable odour whenever
the bedclothes were raised. At the end of February, 1846, she
sank from exhaustion, and died. For a week previously to her
death she suffered an attack of bronchitis, to which she had
been subject in association with previous illness from eruptions.
There were no indications of disease of the lungs after death.
A somewhat similar case to this, but more severe in the
. cutaneous disease, a patient in the St. Pancras Infiimary, re-
covered upon being sent into the country.
312. Ruvia prominenSy* in a young woman, seventeen years
of age, of mil habit ; under the care of Mr. Bransby Cooper, in
Guy's Hospital, in April, 1828. The eruption commenced in
the beginning of March, in the form of vesicles, which became
larger in successive eruptions; the buUae are situated upon all
parts of the body, particularly the lower extremities ; tney are
each surrounded by a slightly inflamed areola, and terminate in
conical crusts. The eruption increased for ten weeks, then
subsided, and disappeared altogether at the end of thirteen
weeks. There was no reason to suspect syphilis in this case,
although the treatment consisted of mercmy and sarsaparilla.
313. Rupia prominefis^f in a woman twenty-eight years of
age, married, and the mother of several children, under the
care of Mr. Key, in Guy's Hospital, in August, 1835. Pre-
vious health bad, cough with expectoration. The eruption
appeared three weeks since, first on legs, then thighs, then arms,
then face, preceded by pains, augmented by warmth ; the trunk
* Lancet, voL iL 1827-28. -f Lanoet
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HERPES, ITS VARIETIES. 169
is firee ; bnllse flattened, containing a milky fluid, surrounded
by a slightly inflamed areola ; the bullae terminate in irregular
brown crusts, which are conical on the face ; an offiensive, thin,
bloody ichor escapes from beneath the crusts. When these
Mly foul, unhealthy ulcers are exposed. She is now labouring
under extreme debility; has no rest, from the iiTitation excited
by the disease; she is much emaciated; her pulse is small and
quick ; the catamenia are suppressed ; alimentary mucous mem-
brane easily excited, as shown by the violent action produced
by two five-grain doses of mercury with chalk, taken for two
nights. No improvement had taken place in her condition at
the end of seven weeks from the commencement of the attack.
Syphilis was suspected by Sir Astley Cooper to be the cause of
this eruption, but without any sufficient reason ; indeed, judg-
ing fr'om the circumstances of the patient, such a supposition is
highly improbable.
HERPES.
Syn. Tetter. Ohphlyctidey Alibert — Dartre^ Fran.
Fkchtey Germ.
314. Herpes* (Plate 3) is a non-contagious affection of
the skin, characterized by the eruption of clusters of globular
vesicles upon inflamed patches of an irregulai* or rounded form^
and of small extent. The eruption rarely presents any remark-
able degree of severity; it is not usually accompanied by symp-
toms of constitutional disturbance ; and it lasts for a brief period
only; rarely longer than two or three weeks. Each vesicle
runs a course of about ten days, and terminates either by
absorption of its contents, by desiccation without rupture, or
by rupture, and the formation of a thin, brownish scab, which
speedily falls.
315. The varieties of herpes derive their designation either
from the form and arrangement of the clusters, or from the
localiQr of the affection. In reference to their general charac-
ters, these varieties admit of a natural division into two groups,
a phlyctenoid group, and a circinnate group. The phlyctenoid
group is characterized by the uTegularity of form and mstribu-
lion of the clusters of which it is composed ; it is typified by
the variety herpes phlyctenodes, and embraces all the local
forms. The circinnate groupy on the other hand, is remarkable
for the circular arrangement or form of its clusters; hence, the
herpes zoster consists of irregular clusters disposed in a circular
form around the trunk of the body; herpes circinnatus is cha-
racterized by the disposition of individual vesicles in the form
♦ Der. Ipircir, to creep.
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188 EFFUSIVE INFLAMBfATION OF THE DERMA«
of a circle; and herpes iris presents the same peculiarity in the
form of concentric circles. In a tabular plan, the varieties may
thus arranged: —
1. Phlyctenoid ffraup.
2. Circinnate group.
H. phlyctenodes,
„ labialisy
H. zoster,
,, circinnatus.
,y nasalis,
„ iris.
,y palpebralis,
„ auricularis.
yy praeputialisy
„ pudendalis.
HERPES PHLYCTENODES.
Syn. Herpes miliarU, Nirlet, Olophhfctide miliare. Alihert
316. The phlyctenoid variety of herpes (Plate 3, b.) pre-
sents no regularity of form or of appearance ; it may show itself
upon any part of the cutaneous siurface, or upon several regions
at the same time, but is most commonly developed upon the
upper parts of the body, as the fEU^e, neck, and arms, and rarely
upon the lower extremities. The vesicles are globulctr ; they
vary in size from a mere point to the bulk of a pea, and are pro-
duced in dense clusters upon an irregular or rounded patch,
rarely larger than the palm of the hand. Frequently there are
two or more of these patches. The eruption usually disappears
at the end of a week ; sometimes, however, it is prolonged by
successive eruptions to two, and even to three weeks, the yel-
lowish spots which it leaves behind continuing perceptible for
as many months.
The eruption, in herpes phlyctenodes, is preceded by a sense
of heat, tingling, and smarting; upon the portion of skin so
affected, numerous minute red points are shortly perceptible.
On the following day, the redness of the patch becomes general,
and a great number of small globular vesicles, of various sizes,
and distended with a limpid transparent serum, are developed.
During the third day, the contents of the vesicles become turbid
and lactescent, with here and there one which is sanguinolent;
and on the fourth day, some few have a sero-purulent appear-
ance. On the third and fourth day, the vesicles begin to shrink,
and on the succeeding days to form, with their contained secre-
tion, thin, brownish scabs, which are thrown off by desquama-
tion by the tenth or twelfth day, leaving for some days a redness
and livor of surface which disappears only by degrees. The
purulent vesicles are not unfrequently followed by small super-
ficial ulcerations.
The local symptoms accompanying the eruption are, itching.
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HERPES LABIALIS. HERPES PRiEPUTIALIS. 189
pricking and smarting, and an intense burning heat, with fre-
quently a deep-seated pain, all of which symptoms continue for
a short time in a mitigated degree, after the subsidence of the
eruption. Constitutional symptoms are very rarely present, and,
should they exist, are limited to some degree of languor, tiiirst,
loss of appetite, and diminished secretions.
HERPES LABIALIS.
8yn. Exanthema lahiale, Hydroa febrile, J. Franck.
317. Herpes labialis resembles herpes phlyctenodes in every
respect, with the exception of situation. This eruption is pre-
ceded by itching, redness, swelling, heat, and painftil tension of
the lips, sometimes affecting the mucous membrane of the pro-
labium only, at other times the integument alone, and again,
both the one and the other conjointly. The redness extends to
a variable distance around the mouth, sometimes reaching to the
nose, and less frequently to the cheeks and chin. On the second
day from the appearance of the redness, and sometimes earlier,
several crops of small round vesicles, five or six in number, are
developed upon the inflamed surface. Some of the vesicles, by
their confluence, unite to form small cellular bullae, of the size
of a split pea. On the third and fourth days, the serous con-
tents of the vesicles become turbid and lactescent, and subse-
quently sero-purulent. On the fifith or sixth day, a brownish
crust is formed upon the affected surface, by the desiccation of
the vesicles and their contents ; and on the eighth or tenth the
crust fells. The formation of a crust may frequently be pre-
vented, by carefully opening the vesicles as soon as formed, and
by the application of a weak solution of sulphate of zinc in rose-
water. When the crust is interfered with during its formation,
and removed, a hardened scab is produced, which remains ad-
herent for a much longer period than the natural crust. Herpes
labialis is sometimes associated with apthse of the mouth.
HERPES PALPEBRALIS, NASALIS, ET AURICULARIS.
318. An eruption of globular vesicles identical with those of
herpes labialis is sometimes developed upon the upper eyelid,
along the borders of the alae of the nose, or in the concha of the
ear, in association with irritation or inflammation of the mucous
membranes of the eye, the nctres, and the external ear. The
progress of the eruption is precisely similar to that of the pre-
ceding affection.
HERPES PRiEPUTIALIS.
319. Like herpes labialis, the present variety may affect either
the mucous or cutaneous surface alone, or both conjointly. The
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190 EFFUSIVE INFLAMMATION OF THE DEBMA.
disease in this situation appears under the form of one or more
red and well-defined patches of about the size of a sixpence, upon
which the globular vesicles of herpes are developed. Qn the
cutaneous surface the vesicles pass mildly through their course^
the fluid is frequently absorbed, either in its serous or sero-puru-
lent state, or they form thin, brownish scabs, which desquamate
at the end of a week or ten days.
On the mucous membrane the inflammation accompanying the
eruption is somewhat more severe. The vesicles assume a larger
size, become speedily lactescent and sero-purulent, and termi-
nate in thin, brownish scabs. These are not unfrequently rubbed
ofi* previously to their natural desquamation, and leave behind
them small excoriated surfaces, wUch might, by inattention, be
mistaken for chancres.
The symptoms accompanyingboth of these forms of eruption
are, heat, itching, and often a pricking sensation. The dis-
ease is dependent for its cause upon friction with the dress in
persons of great susceptibility of skin ; contact with discharges
firom the vagina ; neglect of habits of cleanliness ; and irrita-
tion of the genito-urinary mucous membrane. Herpes prsepu-
tialis sometimes becomes chronic, and is then very diflicult of
cure.
In its excoriated state, as I have before remarked, this erup-
tion ofiers some risk of being mistaken for chancre. But the
superficial ulceration of herpes, the occurrence usually of several
small ulcerations in a cluster, and the uniform level of the ex-
posed surface, are characters which contrast very strongly with
the chronic progress of chancre, its thickened and raised edges,
and the whitish appearance of its surface, produced by a fidse
membrane.
HERPES PUDENDALIS.
820. This afiiection presents all the characters of the preceding
varieties, the vesicles appearing upon the integument and mucous
membrane of the labia majora, or upon the internal surface of
the vulva. In these situations, the eruption is often rendered
obstinate by the continuance of irritation kept up by the secre-
tions from ^e vagina.
2. Circinnate Group,
HERPES ZOSTER.
Sjn. Zona. Zoster, Cingulum, Ignis sacer. Zona ignea. Zona herpetica.
Shingles,
321. Herpes zoster, or shingles, (Plate 3, a. — f.) is especially
characterized by the arrangement of the inflamed patches with
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HERPES ZOSTEB. SHINGLES. 191
their clustered yesides, in the form of a half-zone,* which ex-
tends around some part of the trunk of the body, from the middle
line in front to the middle line l>el)ind. The eruption usually
occurs at about the middle of the trunk. . When it is developed
higher up, the patches take their course across the shoulder, and
are frequently prolonged along the arm ; and when it is situated
in the lumbar region, they occasionally extend to the thigh and
leg. In rare instances, the eruption is met with forming a half
collar to the neck, or a demizone around the face or head ; it
has also been obsenred upon one side of the scrotum, or penis.
Sometimes it happens that the patches assume a longitudinal
direction on the trunk, and this is their customary course on the
limbs. Bateman noticed this arrangement as a yariety, under
the name of herpes proserpens. Herpes zoster occurs indiscrimi-
nately on either side of the \K>dy ; by some authors, it is stated
that the eruption appears, for the most part, upon the right side,
while others contend that the left is the most frequently affected;
my own experience corresponds with the latter statement. It is
an acute disease, lasting from one, to three or four weeks.
fierpes zoster, in the manner and course of its eruption, is
identical with the typical form, herpes phlyctenodes, but more
seyere in its symptoms. The patches by which it appears are of
a yiyid red colour, commencing usually at both extremities of
the demizone, and proceeding outwards by successiye eruptions,
until they constitute, by their approximation, an irregular line.
The first formed patches are larger than those which succeed.
The patches are perfectly distinct from each other, being sepa-
rated, to a greater or less extent, by interstices of sound integu-
ment. Shortly after the appearance of each patch, a number of
small white and glistening prominences are seen upon its surfeu^e,
which speedily assume the form of yesicles, and dbe latter go on
increasing in size, until, at the end of three or four days, they
attain the magnitude of small peas. The yesides are deyeloped
in groups, consisting of considerable numbers upon each patch,
and in some situations they become confluent, and resemble
small bullae. On their first eruption they are filled with trans-
parent serum, which becomes turbid on the second and third
day, and subsequently sero-purulent, or purulent in some, and
of a dark brown colour, or blackish tint, in others. On the fourth
or fifth day, the yesicles begin to collapse and fade ; they look
wrinkled, and, during the two following days, dry up, with their
contents, into small scabs, of a dark brown colour, which fall on
the tenth or twelfth day, leaving behind them a redness of the
* An unfounded notion was prevalent amongst the older physicians, that if the
zone encircled the entire body, the case would terminate fatally. Pliny, amongst
others, refers to this prejudice.
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192 EFFUSIVE INFLAMMATION OF THE DEBMA.
skin, which slowly disappears. The vesicles are not unfrequently
intermingled with true pustules.
This disease is greatly modified, as regards its termination,
by the state of health and vigour of the patient. In young and
healthy persons the contents of many of the vesicles are ab-
sorbed on the fifth or sixth day, and the affection terminates by
desquamation. In weakly and old persons, on the contrary, the
sero-pustules burst, and produce painful excoriations, or ulcera-
tions, which are often long in healing. These unpleasant con-
sequences are most frequent on the dorsal region of the trunk,
from the friction and pressure to which the vesicles are subject
in this situation during decubitus. Sometimes, also, in old per-
sons, the disease terminates in gangrene of the integument.
The symptoms accompanying herpes zoster are, a pungent
and burning heat at the commencement of the vesicular erup-
tion, and a continuance of the pain, to a greater or less extent,
throughout the course of the disease. Its invasion is not unfre-
quently indicated by acute pains, which seem to shoot through
the chest and epigastrium; and by tumultuous action of the
heart. The cclse of the affection is sometimes marked by severe
nervous pains, which continue for several weeks, or even months.
The constitutional symptoms are for the most part slight, con-
sisting of some degree of feverishness, quickened piSse, and
gastro-intestinal irritation. In some cases, the latter symptom
is remarkable for its severity, and, in rare instances, the eruption
is preceded by a rigor.
The urinary secretion in herpes zoster has been made the sub-
ject of chemical examination by Heller.* In one case, that of
a boy eight years of age, the urine was abundant, faindy alka-
line, pale yellow, rather turbid, rapidly became putrid, and de-
posited crystals of ammoniaco-magnesian phosphate. Its spe-
cific gravity was 1014-1015. In a young man, aged nineteen,
the urine was clear, became turbid in the course of twelve hours,
and deposited crystals of ammoniaco-magnesian phosphate ;
specific gravity 1018. In a man, thirty-one years of age, in
whom there was slight fever, the urinary secretion was sup-
pressed, that which was examined being the first that had passed
for twenty-four hours. It was strongly alkaline, and deposited
a sediment of ammoniaco-magnesian phosphate and urate of
ammonia. Its specific gravity was 1028.
The deductions resulting from the analyses of the three cases
are, that there is : — " 1. A marked increase of the chlorides and
phosphates, and a corresponding diminution of the sulphates ;
2. An excess of hydrochlorate of ammonia; 3. A large amount
• Dr. Day, io Simon's Animal Chemistry.
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HEBPES CIBCINNATU8. HEBPES IBIS. 193
of fkt ; 4. A diminution in the amount of urio acid ;^ an in-
crease only occurring when the disease is accompanied with
fever. The presen<^ of oxalate of lime may always be sus-
pected in these cases.
HEBPES CIBCINNATUS.
Syn. Vesicular ringworm.
322. Herpes circinnatus (Plate 3, o.) is an eruption of vesi-
cles, of small size and globular shape, upon patches of inflamed
sldn, which assume the form of a circular ring. The circles sxe
of various size and breadth, rarely exceeding in diameter the
palm of the hand, and they inclose an area of unaffected skin.
They are of a vivid red colour, and the vesicles by which they
are covered are exceedingly numerous and sometimes confluent.
The patches run through dieir course in eight or ten days, but
when the disease assumes a chronic character, and the circles
are successive in their eruption, it may be prolonged for several
weeks. This eruption appears upon all parts of the body, but
is most frequently developed on the face, the neck, the breast,
and the upper extremities.
Herpes circinnatus commences in the form of small circular
or oval patches of vivid redness, which become paJe in the centre
while they increase in size by the circumference. The vesicles
are developed near the outer margin of the patch ; they are small,
and globular, and they run through the usual course of herpetic
vesicles, becoming, at first, turbid and milky, and then desiccat-
ing into small thin scabs, which fall off in eight or ten davs, the
denuded surface of the skin retaining a red colour, which gra-
dually subsides. The symptoms accompanying the eruption
are, a slight pricking and smarting sensation, with some degree
of itching.
When the attack* is particularly slight, the vesicles are very
small, and their contents are disposed of by absorption, the erup-
tion in this case terminating by furfiiraceous desquamation. In
other cases, the central area is not wholly free from the influ-
ence of the inflammatory action, but desquamates with the cir-
cumferential ring.
HEBPES IBIS.
SyD. Bainbow ringworm.
323. Herpes iris (Plate 3, h.) is a very remarkable and rare
variety of cutaneous affection. It is characterized by the erup-
tion of vesicles, either singly or in small aggregated clusters,
which are encircled by four or five rings, differing in shade of
red, and supporting vesicles of great minuteness. The first ring
from the centre is of a reddish brown colour ; the second is
lighter in tint, elevated, and somewhat yellowish; the third is of
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194 EFFUSIVE INFLAMMATION OF THE DEBMA.
a vivid red colour, and the fourth of a pinkish hue, subsiding gra-
dually into the tint of the surrounding skin. When there are
other circles, they present each a different shade of red, and
the entire disk is about equal in size to the circumference of a
shilling.* The smaller vesicles are usually found only on the
second and third rings ; the first ring being the areola of the
central vesicle. The eruption may appear upon all parts of the
body, but is most frequent on the face and hands, and around
the joints. Its duration extends to ten or twelve days.
Herpes iris commences in the form of small patches of general
redness, which speedily assume the appearance of concentric
circles. In the course of the second day, a vesicle is developed
in the centre of each patch, and around this other vesicles some-
times become clustered. On the third and fourth days, vesicles
begin to be developed on the circular rings. The fluid con-
tained in the central vesicle is at first transparent; on the third
and fourth days it becomes turbid, the same change taking place
at the same time in the other vesicles. The eruption usually
terminates by the absorption of the fluid contained in the vesicles,
and the formation of a slight desquamation. Sometimes the
vesicles burst, and give rise to the production of small, thin,
brownish scabs, which fall at the end of ten or twelve days.
This affection gives rise to but little constitutional disturbance,
and not much local inconvenience. It is ordinarily limited to a
few disks, but sometimes these are so numerous as to be distri-
buted more or less closely over the entire body.
324. Diagnosis. — The globular form of the vesicles, their size,
their number, their pearl-like lustre, their clustered arrange-
ment, and the redness and isolation of the patches, are the chief
pathognomonic characters of herpes, and serve to distinguish it
from every other affection. The vesicles are too small to be
mistaken for the bullae of pemphigus, and they are larger and
more prominent than the vesicles of eczema.
Herpes phlyctenodes and zoster are distinguished only by the
arrangement of the inflamed patches. In the former they are
distributed upon various parts of the body at the same time,
while in the latter they are limited to a region. The vesicles of
herpes zoster are larger than those of the other varieties of this
genus, they are also more serious in their consequences.
Herpes circinnattiSy from the peculiarity of its form, is liable to
be confounded with erythema circinnatum, or with lepra in its
* Dr. Marshall Hall has given an excellent description of this disease in the
Edinhorgh Medical and Surgical Journal. He remarks that some of the patches
attain the diameter of ao inch, and that the central vesicle sometimes hecomes deve-
loped to the sice of a bulla, and obscures the concentric rings.
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DIAGNOSIS AND CAUSES OF HERPES. 195
decline. From the first it is not easily distinguished, unless one
or more of its vesicles remain ; from the second, the absence of
a hard and an elevated border, the absence of similctr patches on
other parts of the body, the presence of, at least, one or two her-
petic vesicles, and the speedy decline of the redness, serve to
establish a difference.
Herpes iris bears resemblance to a variety of roseola with con-
centric rings, and to erythema iris (§ 265). The diagnosis be-
tween these diseases is, however, at once rendered evident by the
total absence of vesicles or their traces on the two latter.
325. Causes. — Herpes occurs, for the most part, in young per-
sons and females, and particularly in those who possess a delicate
and irritable skin. The seasons in which the disease is most
prevalent are, the spring, the summer, and the autumn. Herpes
is very commonly dependent upon some disturbance of the diges-
tive fiinctions, or upon irritation of the respiratory mucous mem-
brane, and may frequently be regarded as an efibrt of the system
to eliminate some disposition to visceral disease. The ordinary
exciting causes of the afiection are, irregularities in diet, ex-
posure to cold while the body is heated, coldness and dampness
of the atmosphere, contact of local irritants, fatigue, moral emo-
tions of a depressing kind, &c.
Herpes labmlis not unfrequendy results from the influence of
cold, as in the transition frt)m a warm atmosphere to a cold
sharp wind. It is also associated with gastro-pulmonary irri-
tation, and frequently appears as a critical sequela of fevers,
catarrhs, and some affections of the viscera.
Herpes zoster frequently attacks adults and old persons, and in
the latter is often a painful and distressing disease. In adults
it has been observed to be more common in the male than in the
female sex. The seasons most favourable to its appearance are
the summer and autumn. Sometimes the affection would appear
to be hereditary, and in certain seasons it has attacked so many
persons as to give rise to the suspicion of its being an epidemic
disorder. In rare instances, it has been observed as a critical
eruption.
Herpes drdnnaius is sometimes seen to attack several mem-
bers of the same family at the same time, or consecutively. This
observation, however, merely points to a similarity of exciting
cause, since various experiments have shown the impossibility
of propagating the eruption by inoculation.
326. Prognosis, — Herpes, in young persons and in the adult,
is a mild disease, and is important only in relation to the visceral
affections with which it is concomitant, and of which it is fre-
quently symptomatic; in old persons, however, it is serious,
from the disposition to gangrene in the inflamed skin. As an
o2
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196 EFFUSIVE INFLAMMATION OF THE DERMA.
illustration of the occurrence of this affection in a symptomatic
form, I have preserved the notes of a case of partial herpes
zoster, in which the eruption appeared upon the left shoulder, over
the infiraspinata fossa, in a young lady, sixteen years of age, in
the spring of 1840. Upon examining her chest I found it to be
small and contracted, and her respiration weakly, but she had
no cough. I explained to her mother that the eruption was of
little consequence, otherwise than as indication of susceptible
lungs ; that she must use the greatest precaution in protecting
her from the influence of cold ; and I gave her such hygienic in-
structions as I deemed best for the purpose of carrying out that
object, ordering the- frequent application of a counter-irritant to
the chest and trunk, and the use of flannels next the skin. I
heard no more of this young lady until the January following,
when I visited her on her death-bed, at her particular request
She had fallen a victim to phthisis, and died a few days after
my visit.
327. Treatment. — The treatment of herpes should be mildly
antiphlogistic, and should consist of gentle laxatives, diaphore-
tics, and diluents, unless some visceral disorder be suspected,
and call for especial attention. If the febrile symptoms run
high, bleeding, either generally or locally, may be practised with
advantage, more particularly in herpes zoster, in which this more
active treatment is most likely to be demanded. The local
management requires the aid of fomentations and emollients to
relieve the local pain, unless contra-indicated by position or
other circumstances. In most instances, a simple ointment will
be found preferable to fomentations, especially when the vesicles
are seated on parts of the body liable to friction or pressure. In
the latter case, where some of the vesicles have burst, and the
surface is bedewed with moisture, it may be dusted with starch
powder with considerable advantage. When the eruption is
evidently symptomatic, the indication ofiered by nature of the
advantage of a counter-irritant should be carefully followed up.
Herpes, on its subsidence, sometimes leaves behind it intense
pains, which can alone be combated by sedatives. These after-
pains are particularly characteristic of herpes zoster.
Herpes labialis is too slight to require remedial treatment ; i^
however, the heat, tension, and itclung, are productive of much
uneasiness, they may be relieved by a weak lotion of acetate of
lead, or sulphate of zinc, or by the following application : —
R
Ungaenti flor. Sambuci, ^j.
Liqaoris plambi, 5J.
M. bene.
The course of these vesicles, at an early stage, may frequently
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TREATMENT OF HERPES. 197
be arrested by the above lotions ; when, however, the vesicles
have formed, thej may still be checked by puncturing them with
a needle, and by inserting, for an instant, a fine point of nitrate
of silver into the puncture.
The other local forms of herpes, including herpes praDputialis,
may be treated upon the principle recommended for herpes
labialis.
In herpes zoster^ when the patient is weakly or aged, tonic
remedies and a generous diet will be required. He should be
careful not to lie on the affected side, lest the vesicles be rup-
tured, and troublesome ulcerations or gangrenous sores pro-
duced.
When the vesicles are succeeded by excoriations or ulcera-
tions, the ointment recommended for herpes labialis, spread
upon lint, will be found an useful application. If the excoria-
tions exhibit a tendency to gangrene, an ointment of nitrate of
silver, containing ten grains of the salt to an ounce of simple
cerate, should be used. And if the disease be accompanied by
much pain, an ointment of opium, in the proportion of half a
drachm of the watery extract to an ounce of simple cerate, will
be found an advantageous remedy. My friend Mr. Lay, who
suffered severely from the itching attendant upon this disorder,
while engaged in Beechey's expedition, had recourse to a moist
doth, which he found of great service in quelling that symptom
when augmented so as to become unbearable by the warmth of
bed. Lotions of sulphate of zinc, of super-sulphate of alumina,
and sub-borate of soda, are recommended by Bateman for the
same purpose.
The ectrotic treatment is applicable to herpes zoster, as well
as to herpes labialis, and the other varieties of the eruption.
The vesicles should be carefully punctured with a needle, and
the sharp point of a pencil of nitrate of silver introduced, for
an instant, into the opening. By this means the progress of
the vesicles may be checked, and die cure brought more speedily
about than by leaving the eruption to its course. In pursuing
this plan, the possibility of some visceral disease should not be
lost sight of; and as the cutaneous irritation will be diminished
by the remedy, an artificial counter-irritant should be adopted
in its place.
If any tardiness be apparent in the development of the erup-
tion, the treatment suggested by Mr. Plumbe should be adopted
— namely, the application of a strip of blistering plaster on the
sound skin, in the situation where the vesicles are likely to ap-
pear, or immediately adjoining those which are already pro-
duced. This application has not only the effect of checking the
extension of the disease, " but of producing a shrivelling of the
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198 EFFUSIVE INFLAMMATION OF THE DERMA.
vesicles already formed, and cutting short its progress altogether;
avoiding at once its tediousness and all the pain attending it."
Care must be taken not to apply the blister over the vesicles, for
this is liable to give rise to sloughing of the derma occupied by
the vesicles. Moreover, Mr. Plumbe has remarked that blisters
do not rise upon the inflamed patch of herpes.
Herpes circinnatus and iris require no especial remedies ; they
should be treated upon the general principles above indicated.
When the circinnate variety becomes chronic, Gibert recom-
mends the following ointment : —
Salpharet of lime, 5L
Camphor in powder, gr. xv.
Aznngiffi, ^.
M«
If this ointment should fail, a blister will often succeed in
putting a stop to the eruption.
Cases illustrative of Herpes.
328. Herpes phlyctenodes, — A boy, fifteen years of age, sat
for some time on the grass, on Good Friday, April 10th, 1846.
The next day he had severe pain over the whole of the front
part of the right thigh, which was attributed to rheumatism. On
the evening of Saturday, a blush of redness, in patches, was
apparent on the surface. On Sunday, minute vesicles in clus-
ters were perceived here and there upon the red patches.
These vesicles soon became distended with a transparent and
colourless fluid, and reached their full size, looking towards
evening like so many pearls. On Monday, some of the vesicles
were already becoming shrivelled, and had a purplish hue,
while others fully distended possessed a rich grape-yellow tint.
On Tuesday, aU the vesicles were on the decline, with the ex-
ception of a few tardy clusters, which were now attaining
maturity. On Wednesday, the fourth day of the eruption, the
greater part of the vesicles had dried up into reddish-yellow
wrinkled scabs. On succeeding days the scabs became gra-
dually darker and harder, and were closely embedded in the
skin. By Saturday, a few only of these scabs remained ; and
on Sunday, the completion of the week, traces only of the exist-
ence of the eruption remained.
329. Herpes zoster^ congenital.* — A lad, nine years of age, had
a severe attack, occupying the right half of the trunk, in April,
1827. The boy's grandfather had sufiered from the afiection
several times. One of his uncles had the disease when a boy.
* Medical Gazette, vol ii. p. 683.
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ECZEMA. HUMID TETTER. 109
330. Herpes prfBputidlis tmth irritation of the mucous membrane
of the bladder and urethra, — ^Mr. B., a gentleman of about thirty
years of age, who had resided for the greater part of his life in
India, applied to me, during the summer of 1841, in consequence
of a suspicion that hie was affected with stricture. I foimd, how-
ever, that this was not the case, but that the mucous membrane
of the urethra was exceedingly irritable. At one of his visits he
showed me an eruption of vesicles of herpes upon the prepuce,
at the same time telling me that he was liable to such attacks
occasionally, but that ^ey subsided in a few days, and were
productive of temporary inconvenience only. He was in the
habit of applying to them, when they appeared, a simple un-
guent, consisting of elder flower ointment, and oxide of zinc,
prescribed for him by Mr. Vincent.
ECZEMA.
Syn. Humid tetter^ or scalL Dartre squameuse humide^ Alibert.
331. Eczema^ (Plate 3) is a non-contagious affection of the
skin, characterized by the eruption of minute vesicles in great
numbers, and frequently confluent, upon a surface of irregular
form, and usually of considerable extent. The vesicles are so
closely aggregated in some situations, as to give rise to one
continuous vesicle of great breadth. These larger vesicles,
when laid open, appear to be cellular in their structure ; the
cellular disposition obviously depending upon the juxtaposition
of the numerous small vesicles of which they are composed.
The vesicles of eczema terminate by absorption of the fluid
which they contain, or by rapture and moist excoriations, suc-
ceeded by thin crusts, and furfiiraceous desquamation. The
eruption is generally successive, and variable in its period of
duration. It is not limited to the skin only, but frequently ex-
tends to the neighbouring mucous membrane. It is often
developed on the scalp, and upon the hair-bearing parts of
the body.
332. The varieties assumed by eczema, in its development
upon the cutaneous surface, are (Uvisible into two groups, acute
and chrome. In the former are arranged four principal varieties,
and in the latter one typical form. Besides diese, several local
forms of the disease, either from their severity, or from certain
peculiarities which they present, desei*ve distinct consideration,
and may be assembled into a third group, the members of that
group being susceptible of assuming, as circumstances may
* Der. k^€iV, to boil oat.
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200 EFFUSIVE INFLAMBfATION OF THE DERMA.
direct, either the aciite or the chronio type. The varieties of
eczema, therefore, are, —
1. Acute, 2. Chronic.
E. simplex. E. chrouicum.
„ Tubrum.
„ mercuriale.
„ impetiginodes.
3. Local forms.
E. capitis.
„ faciei.
auriculare.
mamillare.
umbilicale.
perineale.
ECZEMA SIMPLEX.
333. In this, the most simple form of eczema, (Plate 3. i. i )
the vesicles, about the size of the head of a small pin, exceed-
ingly numerous, and clustered into confluent patches of various
extent, are accompanied by very trifling redness and inflam-
mation of the skin.
The eruption makes its appearance suddenly, without pre-
monitory symptoms, and the vesicles are distended with a trans-
parent limpid serum, which gradually becomes turbid, and then
milky. The fluid is then by degrees absorbed, and the epiderma
shrivels into a thin pellicle, which is thrown off" by desquama-
tion. When, however, the vesicles are broken, as frequently
occurs, the scale which follows is thicker and more adherent,
and remains attached to the surface for a longer period. The
afiection is generally prolonged by successive eruptions for two
or three, and sometimes for a greater number of weeks, but is
so slight as to leave behind it no trace of the previous existence
of morbid action. It is accompanied by itching, which is some-
times considerable and troublesome, but presents no constitu-
tional symptoms. Rayer remarks that the vesicles ^'usually
correspond with the minute projections whence the hairs issue,
and which may be very distinctly seen by examining the insides
of the arms and thighs with attention.'' This does not agree
with my experience ; they appear to me to occupy the inter-
linear compartments (§ 31) of the skin.
Eczema is sometimes general, but more frequently local, in its
eruption. The parts of the body most liable to its attack are
the arms and forearms, and particularly the hands, and between
the fingers. Rayer alludes to a variety of eczema simplex de-
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ECZEMA SIMPLEX. ECZEMA EUBBUM. 201
scribed by his pupil, Dr. Levam. This variety is " distinguished
by clustered patches of vesicles, the dimensions of which vary
from those of a sovereign to those of a two-sovereign piece."
" The clusters are scattered over the ski a, which only appears
red in the places affected. On the red patches, covered with
vesicles, the cuticle may sometimes be raised and removed in a
single piece.'' From ihis description, it would seem that the
eruption bears the same relation to eczema simplex that herpes
phlyctenodes does to the local forms of that eruption.
I have observed another variety, in which the vesicles were
conical in form, and resembled diose of scabies. They were
dispersed singly and in small number over the hands and arms,
and were each succeeded by ia. thin scale. Their elected seat
was the thinly covered skin between the fingers, on the flexures
of the wrists, and the anterior surface of the forearm and elbow-
joint.
ECZEMA RUBBUM.
834. Eczema rubrum, or inflammatoryeczema, (Plate 3, k. k.)
is distinguished from the preceding variety by the development
of the vesicles upon a surface which is tense, swollen, and of a
vivid red colour. The eruption appears, in the first instance,
in the form of minute white points, dispersed in great numbers
over the inflamed surface. These speedily increase in size, and
become small, transparent vesicles, filled with limpid serum,
and surrounded by an areola of still deeper redness. When
the disease is disposed to terminate favourably, the redness
subsides at the end of a few days or of a week, the fluid con-
tained within the vesicles i§ absorbed, and their epidermal
parietes shrivel and dry up, forming thin scales, which are
thrown ofi* by desquamation, and leaving behind them a redness
of the skin, which continues for a considerable time.
When, however, the affection is more severe, the inflammation
augments instead of diminishing, and the vesicles are produced
in so great number as to become confluent. Their contents, at
first limpid, become turbid and milky ; they burst almost as soon
as formed, and leave behind them inflamed and excoriated sur-
faces, which pour out an abundant secretion. The ichor from
the inflamed surfaces is profrise and irritating, and serves to in-
crease the extent of the excoriations. The exposed derma is of
a bright crimson colour, and is covered here and there with
flakes of a whitish membraneous film. Some of these crimson
excoriations are bordered by an abrupt margin of thick and soft-
ened epiderma. When the discharge diminishes in quantity, it
concretes into the form of softish lamellae, which harden by expo-
sure to the atmosphere, and constitute scabs of various extent
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202 EFFUSIYE INFLAHICATION OF THE DERMA.
and thickness. The more severe degrees of eczema nilmim
endure for two or three weeks, and if the causes continue which
gave rise to the disease in the first instance, or if any source of
irritation still remain, it may assume the chronic form.
ECZEMA MERCURIALE.
Syn. Hydrargyria, Erythema mercuriale. Erythema ichorosum, Marcet.
Mercurial lepra, Moriartj.
335. Eczema mercuriale offers some points of dissimilarity
from eczema rubrum, but not sufficient, in my opinion, to warrant
its consideration as a separate genus of vesicular disease, under
the name assigned to it by J5r. Alley — hydrargyria. At the
present day the eruption is rare, but formerly, when mercury
was a fashionable remedy, its occurrence was more fi'equent.
Dr. Alley describes three varieties, or rather degrees, of the
affection — namely, hydrargyria mitis, febrilis, and maligna.
Eczema mercuriale is characterized by a red efflorescence
occurring in patches of variable size, and surmounted by trans-
parent vesicles of extreme minuteness. In the mild form of the
affection, the vesicles are not perceived until the surface is ex-
amined with care, but in the more severe degrees the vesicles
increase in size, and their transparent contents become opaque
and purulent. In some instances, particularly where febrile
symptoms are present, the efflorescence occupies a large extent
of surface, sometimes the entire body, and assumes the appear-
ance of rubeola ; at a later period, the small semilunar spots
coalesce, and form patches of larger size. The more usual seat
of the eruption is the trunk of the. body, or the thin skin of the
pudendal region ; sometimes it appears first on the backs of the
hands, and more rarely on the face. The eruption is preceded
by heat and smarting of the skin, and its progress is remarkable
for excessive heat, with smarting and pruritus. When the vesi-
cles are very minute, they dry up without giving rise to secon-
dary inconvenience ; but when they occiu: in folds of the skin,
or are larger in size, they are usually broken, and the abraded
derma pours out an acrid and offensive* ichor in considerable
quantity. When the eruption declines— an event that usually
happens at about the tenth or twelfth day in the mild form of
the disease, and at a variable period later in the severe forms —
the epiderma is thrown off by repeated desquamation, leaving
the skin of a deeply red colour for some time. Sometimes at
the close of the eruption the disease concentrates itself on a
particular spot, and remains obstinately fixed for weeks, or even
months. Of tliis kind is a case lately under my care, in which
* Spens compares it to putrid fish.
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ECZEMA MEBCURIALE. 208
the congestion and epidennal exfoliation were limited to the
palms of the hands.
Mercurial eczema, in its mildest form, may appear without
constitutional symptoms, or with but trifling gastro-intestinal
disturbance and feverishness. But in a more advanced degree, —
in that, for instance, naxned febriUs by Dr. Alley, — the invasion is
marked by rigors, nausea, pains in the head, diminished secre-
tions, and other symptoms of severe constitutional disturbance.
The fauces are always more or less inflamed in these cases, and
the inflammation of the mucous membrane often extends to the
bronchial tubes. In the most severe form of the affection —
namely, in that produced by a continuance in the use of mercury
after die eruption has appeared — ^the hydrargyria maligna of
Dr. Alley — the fiuje is enormously swollen, the eyelids closed,
the throat tumefied and painftil, the colour of the efflorescence
of a deep purple colour, and all the symptoms aggravated.
The epidermal exfoliation continues for a greater length of time,
it is thrown ofi* in large flakes, and the naUs are sometimes cast
with the epiderma.
Persons who have once sufiered from eczema mercuriale are
subject to subsequent attacks.
The mercurial eruption is sometimes the consequence of a
long continued use of mercury, but occasionally it would seem
to depend on a peculiar idiosyncrasy of the individual, unless
we suppose the ey^s of the observers to have become so obscured
by a mvourite hypothesis, as to see nothing but hydrargyria in
every inflammatory eczema, developed after taking a dose of
medicine containing a particle of mercury. This idea is naturally
excited when we read of eczema mercuriale following the exhi-
bition of a single blue pill, although I am quite ready to admit
that mercury upon some constitutions possesses remarkable
powers, and I have seen a man salivated from stopping his tooth
with the metaUic alloy commonly used for that purpose. At
other times, mercurial inunction, or a mercurial atmosphere,
is the cause of the eczematous eruption. Dr. Alley conceives
that in his cases the efiect of the mercurial ointment may have
been much heightened by its admixture with camphor, the
formula consisting of two scruples of the latter to an ounce of
the unguent. Dr. Moriarty* assigns opium as a cause of this
eruption. Indeed, the susceptibility of the skin after an attack
is so great, that in Hewson Bigger's case it recurred several
times under the use of opium. In Dr. Crawford's case,t the
eruption was reproduced by one grain of opium. Cold, also,
has had the efiect of re-exciting it.
* Edinburgh Medical and Sargical Joornal, toL xyL p. 37. f Idem.
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204 EFFUSIVE INFLAMMATION OF THE DERMA.
The treatment of eczema mercuriale consists in the removal
of the cause, and the pursuance of the general plan laid down
for the management of the mUder forms of eczema simplex. Dr.
Crawford found the liniment of oil and lime-water the best local
application. Internally he gave tonics. Dr. Marcet's* case,
wluch appears to have been simply eczema rubrum, following
gonorrhoea, was treated with the warm bath, poultices moistened
with liquor plumbi, and diaphoretic laxatives.t
ECZEMA IMPETIOINODES.
336. Eczema impetiginodes (Plate 3, l. l.) is a severe de-
gree of eczema rubrum ; in some instances it presents all the
characters of the latter at the outset, and subsequently assumes
appearances peculiar to itself. At other times the disease breaks
foith in all its severity on its first invasion. M. Devergie re-
marks that eczema takes on the impetiginous character in the
proportion of thirty-five per cent.
In eczema impetiginodes the skin is highly inflamed and
swollen, the vesicles, which are in many places aggregated into
confluent clusters, often communicate with each otiber, and form
a continuous vesicle of some extent. The contents of the
vesicles, which are at first limpid, speedily become turbid and
puriform, and in a short space of time are efiiised upon the sur-
face by the rupture of the epiderma. The purulent secretion,
after its efiusion, concretes upon the broken surface, and pro-
duces yellowish, lamellated crusts, often of considerable extent.
When the crusts are rubbed ofi*, or removed, the exposed sur-
face of the derma presents a vivid crimson colour, partly con-
cealed here and there by films of whitish lymph, and secreting an
abundant ichorous fluid, having a reddish tinge. This secretion
hardens, if the inflamed surfieu^ be exposed to the influence of
the atmosphere, into a thin, dark-coloured scab, which remains,
unless disturbed by accident or design, until the excoriated
surface is healed.
The eruption of eczema impetiginodes, as of the milder forms
of eczema, is successive; fresh crops of pustular vesicles are
produced as the first decline, and in this way the disease is pro-
longed for two, three, or more weeks, especially if irritated by
the employment of injudicious remedies. In the latter case the
afiection often lapses into the chronic form of eczema.
Eczema impetiginodes is for the most part local in its attack,
confining itself to a single region of the body, and that of limited
* Medico- Chirargical TranstctionB, yoI. iL
t The Edinbarffh Medical and Surgical Journal contains other cases by Dr. Spens,
ToL I; Dr. MacMullin, vol iL ; Dr. Ratter, vol. y. ; and Dr. Ramsay, vol. yii.
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ECZEMA IMPETIGINODES. ECZElfA CHBONICUM. 205
extent The forearms and hands are the frequent seat of the
disease, and the feu^e is not unconnnonly affected. In these
cases, there are no constitutional symptoms. But when the
disease is general in its eruption, or when children are the sub-
jects of the partial affection in any degree of severity, the ordi-
nary constitutional symptoms accompanying inflammation are
developed— viz., quick circulation, excited nervous system,
disordered digestive system, and diminished secretions. The
local symptoms correspond in degree with the violence of the
affection, consisting in burning and distressing heat, and in
excessive smarting and throbbing, which are greatly augmented
by the warmth of bed, and entirely banish sleep.
ECZEMA CHBONICUM.
337. Whenever, from the continuance of any of the preceding
forms of eczema for a lengtiiened period, either as a result of
the severity of the original disease, or of mismanagement in its
treatment, the surrounding skin is irritated by the ichorous dis-
charge secreted by the excoriations, the deeper textures of the
integument become more or less involved in the morbid action.
The skin is inflamed and swollen, the subcutaneous areolar
tissue becomes dense and infiltrated, new excoriations, with
deep and extensive chaps and fissures, are produced, and a pro-
fuse ichorous secretion is poured out by the diseased structures.
The chronic form^of eczema is most frequently met with in
the flexures of joints, more rarely it extends over a consider-
able surfEUse, and occasionally involves an entire limb. It is
obstinate and troublesome under treatment, and frequentiy, in
defiance of the best directed management, endures for several
months.
Sometimes the secretion diminishes in quantity, and con-
cretes into thin, yellowish, lamellated scabs, which fall off from
time to time, and are replaced by successive deposits of thinner
scabs. The surface upon which they rest becomes less red and
hot, and the diseased skin appears to be graduaUy progressing
towards cure, when suddenly tiie redness and tumefaction return,
a fresh crop of vesicles is produced, which burst and go through
the usual course, but in a shorter space of time than the fii^
In this manner fresh and fresh crops are at intervals developed,
and the morbid action is kept up for months, and even for years.
Chronic eczema is always attended with severe itching, which
only increases with the attempts made by the patient to relieve
himself by scratching. In. certain situations, the pruritus is
wholly unbearable, and excites tiie wildest paroxysms, as, for in-
stance, when it occurs in the vulva, upon the scrotum, or around
the anus.
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206 EFFUSIVE INFLAMMATION OF THE DERMA.
ECZEMA CAPITIS.
Vesicular scaU,
338. Eczema of the scalp is a frequent affection in in£saits at
the breast, in children during dentition, and in those who are
unhealthj and scrofulous, at a later period. I have had occa-
sion to observe this disease, on numerous occasions, among the
ill-fed and poorly-clad children of workhouses. The disease
may be limited to a part, or it may attack the whole of the scalp,
from which it is liable to extend to the face, the ears, and the
neck. The scalp is red, swollen, and painfdl, the vesicles are
produced in great numbers, and speedily burst, pouring forth
an abundance of ichorous secretion, which collects around the
hairs, and involves them in a thick, lamellated, yellovnsh crust
The disease is attended vnth intense pruritus, it difiuses an
offensive odour around the patient, and if neglected, engenders
pediculi in great numbers. It has been remarked by several
authors, that the health of children affected vnth this disease is
good ; indeed, they affirm that it acts as a prophylactic against
more serious disorders, and recommend that the discharge
should be checked with caution. Rayer observes, that ^^ those
children who labour under eczema of the face and hairy scalp,
whilst they are teething, rarely suffer from convulsions or obsti^
nate diarrhoeas.'*
If the disease be neglected, — and indeed sometimes when great
watchfrilness has been used in the treatment of the patient, — ^it is
liable to fall into a chronic state. The scalp becomes thickened,
and sometimes fissured ; the lymphatic glands frequently become
enlarged ; subcutaneous abscesses occasionally form ; die quan-
tity of secretion is diminished, and the pruritus is not so great
The incrustations are lamellated in form, and dispersed among
the hair in great abundance, assuming the characters which have
been described by Alibert under the name of teyne Jurfaracee,
At other times, the secretion collects the hair into smtdl bundles,
and forms around them thin, shining, and silvery pellicles.
Rayer compares these sheaths very aptly to the " pellicles that
envelope the sprouting feathers of young birds." To the imagi-
native eye, the hairs, 3ius surrounded by thin, silvery pellicles,
bear some resemblance to asbestos ; hence the designation ap-
plied to this variety by Alibert, teigru amiantacie. Chronic
eczema of the scalp not unfrequendy extends to the follicles and
pulps of the hair, and destroys their function, producing partial
alopecia. The destruction of the hair also takes place occa-
sionally upon the eyebrows and eyelids.
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EFFUSIVE INFLAMMATION OF THE DERMA. 207
ECZEMA FACIEI.
389. Eczema of the face is an affection of frequent occurrence
in inffiuits at the breast (hence it is sometimes confounded with
orusta lactea) and young children, and is more rarely developed
in the adult It is sometimes an extension of eczema capitis,
but at other times appears primarily on the fetce, and especially
upon the cheeks, the chin, ^e upper lip, and the forehead. The
eruption invades, as in eczema rubrum, with a numerous cluster
of minute and scarcely raised vesicles, which burst in a few
days, and pour forth their serous or sero-purulent contents
upon the inflamed surface. The eruption not unfrequently
assumes the appearance of eczema impetiginodes, or partakes
in some parts of the characters of this disease, while in others
it retains the form of eczema rubrum. The efiused secretion
desiccates into thin, lamellated, yellowish and greenish scabs,
which become more and more thickened by fresh additions of
secretions from beneath, while the eruption extends by its cir-
cumference. In this manner the entire face may be covered by
a thick, lamellated crust, which forms a complete mask to the
features, not unlike that of the porrigo larvdUs of Willan. The
inflammation sometimes extends to the neighbouring mucous
membranes, as to the conjunctiva, the Schneiderian membrane,
or the membrane of the mouth. The affection is attended with
considerable itching and smarting, and the skin becomes fissured
with cracks induced by the movements of the face. The blood
which escapes from these chaps, and frt)m accidental scratches,
mingles with the secretion from the excoriated surfaces, and
tinges the crusts of a deep brown colour. When the disease
declines, no trace of the affection remains ; but if the face be
scratched, as frequently occurs, in consequence of the intensity
of the pruritus, unsightly scars are left behind. The affection
occasionally spreads from the face to the rest of the body, and
if improperly treated; may endure for many months, or even years.
Eczema of the face sometimes merges into a chronic form ;
the vesicles cease to be produced, the secretion diminishes, the
sur&ce becomes dry and less red, a number of thin, greyish
lamellae usurp the place of the fallen crusts, and are succeeded
in their turn by a turfuraceous desquamation. At a later period
the skin may be left sound, but somewhat thickened, and of a
deeper tint than natural, and the accustomed pale hue is regained
only in the course of time.
ECZEMA AURIUM.
340. Eczema makes its attack upon the ears at all periods of
life, and in both sexes, and is not unfrequently met with in chil-
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208 EFFUSIVE INFLAMMATION OF THE DERMA.
dren during deDtition. The ears affected by this disease are
red, swollen, and tender, and are covered by vesicles and chaps,
which pour out a provision of ichorous sero-purulent fluid.
The discharge spreading upon the inflamed surface desiccates
into a yellowish and brownish lamellated crust, which is con-
stantly augmented by fresh secretion. Prom the pinna, the in-
flammation often extends into the meatus, and gives rise to great
pain. Small subcutaneous abscesses form in the integument
around the ears, and the neighbouring lymphatic glands fre-
quently enlarge.
In children this affection generally terminates favourably, but
in persons of more advanced life it is very apt to assume the
chronic form. In the latter case vesicles cease to be produced, the
incrustations become thinner, and are diminished ; the tissues of
the ear are swollen and infiltrated; the meatus is constricted,
the skin is fissured by painftd chaps, and the disease is exceed-
ingly obstinate, often resisting every method of treatment, and
enduring for years.
ECZEMA MAMMILARUM.
341. Eczema of the nipples is a somewhat rare variety of
eczematous affection, and usually assumes a chronic form. It
has been occasionally observed in women during suckling, but
is more frequently met with in girls at puberty, in women who
have never been mothers, at the critical period of life, and in old
persons. It is characterized by an eruption of small- vesicles,
succeeded by chaps, both the one and the other exuding a con-
siderable quantity of secretion, which desiccates into lamellar
scabs and scales. The affection is attended with much itching,
and the nipple is tender, and frequently bleeds on being rubbed
or scratched. In the chronic form, the disease is exceedingly
obstinate and diflicult of cure. Should it occur during lactation,
it is desirable that the infant should be weaned.
ECZEMA UMBILICALE.
342. In infants an eczematous eruption followed by excoriation
and considerable discharge takes place around the umbilicus.
The affection is of little importance, and soon yields to appro-
priate treatment
ECZEMA PERINEALE.
343. In this affection, the eczematous eruption is developed
upon the scrotum in the first instance, and thence extends to the
neighbouring parts of the thighs, and to the anus ; or it may
commence in the latter situation, and spread to the scrotum.
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DIAGNOSIS OF ECZEMA. 209
commence in the latter situation, and spread to the scrotum.
The disease, whatever its mode of origin, is exceedingly dis-
tressing, being accompanied by a most unbearable pruritus,
which is increased, radier than mitigated, by the efforts of the
patient to relieve himself by scratching. The vesicles burst or
are ruptured as soon as formed, a large quantity of ichorous se-
cretion is poured out, fissures and excoriations are formed, and
life becomes a burden to the sufferer. Eczema in this region
generally assumes tlie chronic form, and continues with tempo-
rary remission in the severity of the symptoms, for months and
even years. It is generally met with in persons of the middle
period of life.
In the female, eczema perineale is, if possible, more painful
and distressing than in the male, and is much heightened by
the extension of the eruption to the mucous membrane of the
vulva. The irritation is moreover augmented by the frequent
efiusion of morbid secretions from the vagina. All the functions
of the region are rendered painful, the smarting is excessive, and
the pruritus unbearable. Adults are most frequently attacked
with this disease, and children rarely. I have, however, seen
one instance in a little girl eight years of age.
344. Dioffnosis. — The different varieties of eczema present
differences of character which are peculiar to themselves, and
must be borne in mind in our endeavours to establish the dia-
gnostic signs of the disease. Thus in eczema simplex, we find
clusters of minute vesicles in great numbers, and without accom-
panying redness ; in eczema rubrum, the vesicles are surrounded
by inflamed areolae of considerable extent, and mingled with
moist excoriations ; in eczema impetiginodes, many of the vesi-
cles contain a sero-purulent fluid, others are serous, and others
again are supplanted by excoriated patches ; in the latter stages
of all the above varieties, we find lamellated scabs and incrus-
tations of variable thickness ; and in eczema chronicum we have
chaps and fissures pouring out an abundance of ichorous fluid,
and, at a later period, copious desquamation. Moreover, eczema
is frequently seen as a complication of scabies, and is itself com-
plicated by the pustules of impetigo and ecthyma.
Eczema simplex is not unfrequently confounded with scabies,
and from the similarity of some of their characters, this mistake
is very likely to occur. In both, vesicles are present ; in both,
the eruptions are developed without redness of the skin ; both
are situated in the flexures of joints, between the fingers, &c.,
and both are accompanied with pruritus. But, upon careful ex-
amination, considerable differences will be detected between the
two diseases.
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210 EFFUSIVE INFLAMMATION OF THE DERMA.
Simple eczema is likely to be confounded witli sudamina, with
which its vesicles bear considerable analogy. The characters
by which it may be distinguished are, that in the latter the vesi-
cles are of larger size than those of eczema, being equal in bulk
to a millet seed, while those of eczema rarely surpass the bead
of a small pin. The vesicles of sudamina are scattered and dis-
creet, those of eczema, confluent, and very closely aggregated.
The former, again, are associated with profuse perspiration,
which is not the case with eczema. Moreover, sudamina occur
without preceding irritation of the skin, and their presence giTCS
rise to no abnormal sensations.
Eczema impetiffinodes is liable to be mistaken for scabies and
impetigo. Scabies complicated vdth pustules, as it sometimes
occurs, presents several points of resemblance with eczema im-
petiginodes, but the other characteristic signs and the presence
of a parasitic animalcule are absent. The pustules of scabies,
again, contain pus from their first appearance. In impetigo, the
pustules never contain senim ; they are larger than the eczema-
tous sero-pustules, uncomplicated with vesicles, which are always
present in association with eczema impetiginodes, and confined
to a small extent of surface. Again, the hardened coverings of
the excoriations of eczema are thin scabs, while those of im-
petigo are dense and thick greenish-yellow or brownish crusts.
Eczema chronicum presents many points of resemblance with
lichen agrius ; for instance, the chaps and fissures, and the icho-
rous secretion from the excoriated surfaces. But the incrusta-
tions produced by the desiccation of the secretion are somewhat
different in the two diseases; in the former, they are thin,
lamellar, and of considerable extent; in the latter, they are
smaller in breadth, thicker, and more yellow. But the prin-
cipal difference is rendered apparent when the incrustations fall ;
for in eczema the surface is smooth, and somewhat tumid and
shining, while in lichen it is rough and papular, the pimples
being easily distinguished by the touch, if not at once detected
by the eye. Moreover, the elementary characters of the two
diseases are generally present in the neighbourhood of the erup-
tion ; in lichen, some few papulae may always be discovered,
and in eczema, a few scattered vesicles may for the most part be
found.
Chronic eczema may also be confounded with psoriasis, when
the former ceases to exude any secretion, but upon careful in-
rtion, a certain difference wiD always be observed between
lamellated scales which are produced by both affections.
Those of psoriasis retain more of the characters of the epidenna
than the incrustations of eczema. In other cases, however, it
will be difficult to establish a positive diagnosis between the two
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CAUSES OP ECZEMA. 211
diseases, unless a few elementary vesicles be found to confirm
our decision.
Eczema capitis is sufficiently distinguished from other diseases
of the scalp by the characters which have been already indicated
in the description of this affection.
Eczema aurium is distinguished from erythema intertrigo by
the absence of all trace of vesicles in the latter, and by its ap-
pearance in the cleft behind the ears. It is attended with chap-
ping, and by the effusion of serous discharge. The same cha-
racters serve to establish the diagnosis between eczema mam-
millamm, umbilicale, and perineale, and erythema of those
regions.
S45. Causes, — Eczema is apt to occur either symptomatically,
as a consequence of some constitutional disturbance, or as an
effect of the application of local irritants to the surface of the
skin. Of the former kind are the changes which take place in
the system under hygienic influences, as during the spring and
summer season of the year, particularly when accompanied by
atmospheric vicissitudes ; affections of the digestive system, as
dentition ; the irritation produced by unsound milk in infants at
the breast ; and stimulating and improper food and drinks in
persons of all ages ; affections of the uterine system, as amenor-
rhoea, dysmenorrhoea, utero-gestation, and the critical period
of life ; the cessation of lactation ; affections of the nutritive
system, as scrofula ; and affections of the nervous system, as
mental emotions, particularly of the depressing kind. The local
causes of the disease are heat and cold, together with friction,
and irritation of the skin produced by whatever cause. Thus,
occasionally, we find eczema resulting from exposure to the
sun's rays, a variety which has, by Willan, been denominated
eczema solare. It not unfrequently attends the inflammation
produced upon the skin by the irritation of a blister, or by the
application of the compound sulphur ointment, or of a burgundy
pitch plaster. A variety is also met with affecting the hands of
persons, who are called upon, in the ordinary occupation of life,
to manipulate dry and powdery, or stimulating substances. Of
this kind is the eruption on the backs of the hands sometimes
observed in grocers, and termed the grocer's itch. In the same
category must be enumerated the transmission of eczema, by
contact, from one person to another, the discharge from the vesi-
cles in this case not effecting any specific action, but merely
acting the part of a local irritant Eczema is developed in
females more frequently than in males, an observation which
must be referred for its explanation to the greater cutaneous
susceptibility of the former than of the latter sex. Again, dif-
ferent parts of the body exhibit a greater or less disposition to
p2
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212 EFFUSIVE INFLAMMATION OF THE DERMA.
the invasion of the disease at different periods of life ; hence it
is well remarked by Rayer, that in " infancy and youth, eczema
appears more particularly on the head ; in riper years, on the
breast and belly, but especially on the genital organs ; and in
advanced life, on the lower extremities, and about the margin of
the anus." In some instances, the eruption has been observed
to be hereditary in its origin, being developed in the infant soon
after birth, and after the previous occurrence of the disorder in
the parent
346. Prognosis. — Eczema acts verj' commonly as a safety valve
to the health of the system, and the discharge by which it is
accompanied must be checked very guardedly, and not before a
counter-action, either on the skin, or on die alimentary mucous
membrane, has been established by art. In most instances, the
eruption is difficult of cure, not so much from any pathological
peculiarities which it presents, as from the circumstance of its
being often symptomatic of constitutional disturbance or visceral
disease, which must be removed before the local affection can
be conquered ; indeed, it usuaUy happens, that the cure of the
constitutional disorder is followed by a spontaneous disappear-
ance of the eczema.
347. Treatment. — The treatment of eczema must be regulated
by the severity of the symptoms, and by the particular causes of
the affection. When the eruption is of idiopathic origin, the
requisite treatment will be antiphlogistic ; active when die dis-
ease is acute, as in eczema rubnim and eczema impetiginodes ;
moderate when the disease is mild, as in eczema simplex. In
all the three varieties, and also in eczema chronicum, water-
dressing, warm baths, and vapour baths, will be found useful,
and the regimen should be cooling and moderate. In the milder
degrees of eczematous eruption, saline laxatives, vrith diluents
and acidulated drinks, will generally suffice. In the more severe
degrees, the abstraction of a small quantity of blood, with a
more energetic aperient and diluent course, will be requisite.
Whenever the disease is symptomatic in its origin, the treat-
ment must be directed against the cause ; for instance, in the
case of disorder of the alimentary system, the remedies must be
adapted to relieve irritation existing in the organs of that system ;
while the affection which originates in disordered uterine func-
tions will demand the especial management of the uterine organs.
When the constitutional powers are reduced, a tonic course and
more geperous regimen will be pursued with benefit. In the
chronic form of eczema, when the disease is obstinate, and re-
sists our common methods of treatment, it becomes necessary to
modify the state of the constitution by various means ; as, for
instance, by a course of hydriodate of potash, of mercury, of
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TREATMENT OP ECZEMA. 213
Donovan's solution, of liquor arsenicalis, or of tincture of can-
tharide8>
In treating the disease local] j, if there be considerable redness
and inflammation, blood may be abstracted from the part by
leeches or puncture; the bleeding being subsequently en-
couraged by the water-dressings or by a poultice. The local
warm bath and vapoiur bath will also be found of great service.
When the severity of the inflammatory action is somewhat
diminished by these means, the alkaline bath or warm sea- water
bath may be employed, and a lotion of nitrate of silver, contain-
ing from two to ten grains to the ounce, applied twice or thrice
in the day. In the interim of the employment of the baths, I
have used the tincture of iodine pencilled on the part ; or when
this excited too much irritation, a liniment of lime-water and oU,
either simple or with liquor plumbi, or the nitrate of silver.
The remeoies available in chronic eczema are, sulphuret of pot-
ash in lotion or ointment, lime-water, bichloride of mercury in
weak solution, calamine ointment, zinc ointment, sulphate of
copper ointment, tannin ointment, white precipitate ointment,
red precipitate ointment, calomel ointment with watery extract
of opium, carbonate of lead ointment, tar ointment, sulphur oint-
ment, and mercurial ointment.
To relieve the pain and pruritus which accompany the erup-
tion, the following remedies as local applications may be tried —
viz., acidulated lotions, alkaline lotions, lotion of super-acetate of
lead, emulsion of bitter almonds, or of hydrocyanic acid, lotions
of opium or hyoscyamus, camphor mixture^ infosion of dulca-
mara, &c.
When the eruption is of long standing, and there exists any
reason for the belief that the arrest of the secretion would be
attended with injury to the health, counter-irritation should be
established either upon the trunk or limbs, or even on both. The
best counter-irritants in these cases are the croton liniment
* Id employing arsenic and cantharides as therapeatic agents, it will be neces-
sary to watch their effects with care, and bear in mind the serious symptoms which
may resolt from ibeir abose. Should any of these symptoms be apparent — ^namely,
nenrons disorder, and disorder of the alimentary canal, in the case of arsenic, or of
the arinary system, in the case of cantharides, the medicines most be immediately
liud aside, either permanently, or to be resumed after a few days, according to the
judgment of the practitioner. Wheneyer we put a stop to the exhibition of arsenic,
and return to it again, it is necessary to begin with a smaller dose than that at
which we left o£ Arsenic, when it acts upon the nenrons system, performs the part
of an alterative, but when its effects are directed upon the digestive system, it appears
to me to act, like cantharides, upon the mucous membrane of the kidney — ^riz., by
counter-irritation, by exciting inflammatory action in the interior, and thus deter-
mining from the surface.
The best formula for the exhibition of cantharides is one in which it is combined
with equal parts of compound tincture of camphor, and taken in tincture of cin-
chona.
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214 EFFUSIVE INFLAMMATION OF THE DERMA.
(§ 275.), or spirituousor acetous infusions of horse-radish, or mus-
tard. Rayer recommends issues and open blisters. In weakly
constitutions, stimulating remedies are required ; and in eczema
of old standing, these applications must be powerful, in order to
set up a new action in the part affected. With this view, I am
in the constant habit of using a saturated solution of bichloride
of mercury in proof spirit, applied upon the diseased part
by means of a camel's hair pencil, or, whiat is preferable, the un-
diluted tincture of croton. Under certain circumstances, it is
judicious not to attempt the cure of old-standing eczemas.
Two new medicines have lately been introduced in the treat-
ment of chronic disorders of the skin, and particularly of chronic
eczema ; these are, Anthrakokali and Fuligokali.
348. Anthrakokali was introduced by Dr. Polya, of Pesth,
about six years back, as a specific in certain diseases of the sldn,
and was made the subject of a short treatise by Dr. Jacobovics.
It was administered by Dr. Polya as an internal medicine, and
was especially employed against tettery affections, which this
gentleman conceived to originate in a peculiar constitutional dis-
order. Anthrakokali, in the hands of Dr. Polya, produced the
same specific effects, in relation to the tettery principle, that
mercury effects in the case of syphilis, sulphiu: in the instance
of scabies, and iodine in that of scrofula.
According to Dr. Polya, anthrakokali acts upon the entire
system, producing a temporary increase of the local affection. It
gives rise also to violent perspirations, and produces a general
state of feverishness, under which the disease is cured. Thus it
would appear, that by exciting a disease greater than that which
it is employed to cure, it works its beneficial effects.
On the reputation which this substance obtained in the hands
of Dr. Polya, Gibert made trial of it in St. Louis. Adminis-
tered internally, he obtained none of the marked results de-
scribed by its proposer; and after a fruitless experiment of
several months' duration, gave it up as useless. Gibert next
used anthrakokali as a local application, in the form of oint-
ment; he found it less stimulant than the ordinary alkaline oint-
ment, but yet sufficiently resolutive. As a general principle, he
remarks, " the anthrakokali is a stimulant well suited to those
cases in which we commonly employ sulphur and alkalies. It
can only be used in the second stage of tettery affections —
namely, in that in which the acute period has yielded to the
chronic state, the latter being, nevertheless, subject every now
and then to re-excitement." For this reason, we find him laud-
ing the effects of the anthrakokali, in a case of psoriasis invete-
rata, which had assumed an inflammatory activity under the use
of an ointment of ioduret of ammonia. Thus, it would appear,
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TREATMENT OF ECZEMA. 215
that the anthrakokali deserves a place only among our more
common stimulating applications, and is to be resorted to in
cases where moderate stimulation is required, or where the
morbid surfEice has become habituated to other forms of stimu-
lant.
My own practice is a complete corroboration of the results
obtained by Gibert I have not ventured to use the remedy in-
ternally, after perusing the account given of its effects by Dr.
Jacobovics, but I have found it an ordinary stimulant as a local
application. An additional stimulant is, however, often of con-
siderable value in our treatment, after we have employed with-
out success the forms which we are most accustomed to pre-
scribe. I have frequently observed a morbid siurface, which has
remained unchanged for weeks under the use of a given reso-
lutive, suddenly assume a favourable aspect when treated by
another with which the tissues are less familiar.
349. The mode of preparation of Anthrakokali is as fol-
lows : —
Carbonate of potass . . . . 180 parts
Boiling water 2500 „
After the solution of the alkaline salt, add hydrate of lime, in
sufficient proportion to leave the potass free. Filter the fluids,
and evaporate in an iron vessel until the surface assumes the
appearance of oil. Then add 150 parts of coal in fine powder,
stirring it with the liquid until it be well mixed. Tlie iron
vessel is then to be removed from the fire, and the stirring is to
be continued until the contents are converted into a black ho-
mogeneous powder. The anthrakokali should then be placed
in well-stoppered bottles, in a dry place, in order to exclude
moisture.
Dr. Polya also prepares a sulphuretted anthrakokali, by add-
ing with the coal fifteen parts of sulphur, also in fine powder.
This latter preparation is more active than the simple anthra-
kokali.
Anthrakokali is delitescent, and very soluble in water. Its
solution is of a deep brown coloiur, throwing down a black flaky
precipitate with a mineral acid. The coloiu: of the solution of
the sulphuretted anthrakokali is blackish-green.
Dr. Polya asserts, that the anthrakokali is a chemical com-
pound of potass and coal, and that in the form of solution the
latter is actually dissolved in the water. The test of this solution
is the continuance of the fluid of its brown hue, vrithout the oc-
currence of any precipitate. Gibert, however, denies this
chemical combination, and regards it as a simple mechanical
admixture. The coal, he says, separates from the fluid by pre-
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216 EFFUSIVE INFLAMMATION OF THE DERMA.
cipitation, until the latter loses the whole of its colour, and none
of the former remains behind.
Dr. Polya prescribes two grains of the powder, three or four
times a day, in liquorice powder, or carbonate of magnesia. The
ointment prepared by Gibert consists of
Antbrakokali, gr. zvj.
AxungisB, ^j.
M.
To be applied with or without friction, as the case may demand,
twice in flie day.
850. Soot has long enjoyed a reputation as a stimulant re-
medy in chronic diseases of the skin ; it has for many years
been used as a popular application in diseases of the scalp, and
very recently has been recommended with much praise in the
treatment of favus.
Fuligokali is a compound of soot and potass, in imitation of
anthrakokali. It was first prepared by M. Deschamps, a chemist
of Avallon, and has been made the subject of experiments,
attended with considerable success, by M. Gibert, in Saint
Louis. M. Gibert has employed the fiiligokali both internally
and externally, and finds it superior to anthrakokali. As an
external application, in the form of ointment, it is resolutive,
detersive, and stimulant.
The mode of preparation of the compound is the following: —
Caostic potass .... 20 parts
Soot 100 „
Water q. s.
Boil the mixture for an hour ; cool, filter, evaporate, and dry.
The fuligokali is obtained in the form of scales or powder, and
must be kept in well-stoppered bottles, in a dry place.
A sulphuretted fuligokali is obtained by the following pro-
cess ; —
Soot 60 parts
Caustic potass .... 14 „
Salphnr 4 „
Heat the sulphur and potass with a little water, and after their
solution, add the soot Evaporate, dry, and close the resulting
compound in well-stoppered bottles, and keep it in a dry place.
The ointment used by M. Gibert is composed of a scruple to
half a drachm of the salt to an ounce of lard. In larger pro-
portion it is highly irritating.
Soot is a substance which is variable in its composition, and
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SUBAMINA. MILIABIA. 217
must differ according to the circomstance of being procured
from the combustion of wood or coal. Its principal constituents
are: —
Acetate, sulphate, and carbonate of lime,
Hydrochlorate of ammonia,
Chloride of sodium,
A brown, bitter, extractive matter.
An empyreumatic tar,
A bitter, volatile oil, possessing a strong odour of soot,
A fatty matter, containing oleic and stearic acid.
Carbon.
The potass solution dissolves the volatile principle of the soot,
together vrith its aqueous extract. It contains, consequently, its
active principles.
It is probable that both the anthrakokali and the fuligokali
owe much of their therapeutic value to the alkali which forms
their basis. I have employed the fuligokali in several cases,
but place no confidence in it as a remedy.
SUDAMINA.
Syn. MUiary vesicles. Miliaria, Miliary eruption^ Ifydroa.
351. Sudamina are small prominent vesicles, of a rounded
form, and about equal in size to millet seeds. They are trans-
parent at first, and have a pinkish hue (miliaria rubra), but at
the end of twelve or twenty-four hours, they become opaque and
milky (miliaria alba), and resemble small pearls scattered on the
skin. Their period of duration is three or four days ; they then
shrivel and dry up, and form thin scabs, which are thrown off
by desquamation. By successive attacks, the eruption may be
continued for several weeks.
Sudamina may be situated on any part of the body ; the most
frequent seat is the trunk, where they usually occupy a district
of considerable extent They are always discreet, though some-
times very numerous, are preceded by no signs, or by very
little indication of cutaneous irritation, and by trifling redness
of the skin.
Sudamina have received their name from being always asso-
ciated with excessive heat of the skin, and often vnth profuse
perspiration. Hence they are occasionally met with in eruptive
fevers — namely, in rubeola, scarlatina, and variola. They also
accompany simple, remittent, and typhoid fevers, and most in-
flammatory affections accompanied by profuse perspirations, as
acute rheumatism. From the size whicn they usually present —
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218 EFFUSIVE INFLAMMATION OF THE DERMA.
namely, that of a millet seed, they have been termed miliary
vesicles; hence the specific designation attached to certain dis-
eases, as erythema miliare, implies a complication by these
vesicles. Sudamina are most frequently observed in persons
possessing a thin and irritable skin, and during the summ^
season.
352. Since the days of Sydenham, who advocated bo power-
fully the adoption of a cool temperature and cooling regimen in
fevers, sudamina have become rare ; but previously to his time
they were exceedingly frequent, and from their connexion with
fever were regarded as a specific disorder, preceded and accom-
panied by severe and dangerous fever. This fever was termed
miliaria, and for many years was regarded as a dangerous and
fittal disease, spreading like an epidemic, and destroying mul-
titudes of lives. But, as I before remarked, since a more rational
method of treatment has been employed in medicine, miliary
fever has ceased to exist. Bateman remarks, '^ It is scarcely
necessary now to enter into any detail 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
effect 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 evi-
dence of its origin." " Hippocrates, whose mode of treatment in
febrile diseases was not calculated to produce excitement, has
once or twice but casually mentioned the miliary eruption. And
again, at the latter part of the seventeenth century, when, in the
practice of the majority of physicians, the miliary fever was a
frequent and fatal occurrence, Sydeidiam witnessed no such
fever ; but mentions the occasional appearance only of miliary
vesicles, which he ascribes to their proper cause."*
'^ Among the various circumstances," continues Bateman,
" 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 puer-
peral women. This is sufficiently accounted for by the treat-
ment which was unhappily pursued during the confinement after
childbirth, and of which an impressive description is given by
Mr. White. For not only was the mother immediately loaded
with bedclothes, 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, all access of air was denied, even through a keyhole.
From these causes fever was almost necessarily induced, with the
* Synopsis, edited by Dr. Thomson, p. 348.
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DIAGNOSIS OF MILIARIA. 219
most profuse sweats, oppression, anxiety, and fainting; and
these again were aggravated by spicy caudles, spirits, opiates,
and ammoniacal medicines. That numbers should perish under
such man^ement, with every symptom of malignity, and that
many who survived it should escape with broken constitutions,
will surprise no person who is acquainted vrith the baneful influ-
ence of over-excitement in febrile complaints.***
353. Diagnosis, — The diagnosis of miliary vesicles is not diffi-
cult ; their being discreet, though numerous ; their form and
size ; their occurrence chiefly on the trunk of the body ; the
absence of inflammatory redness of the skin ; and their associa-
tion with constitutional disease, and generally vrith a clinical
state of the patient, sufficiently distinguish them from the smaller,
itching and tingling, clustered, vesicles of eczema. The seat of
eczema, again, is so different, and the inflammation of the skin
which generally surrounds the vesicles. The vesicles of herpes
are too large, and the inflammation at their base too conspicuous
to be confounded with sudamina.
The causes of sudamina have been sufficiently indicated in the
preceding description, and the prognods must depend upon the
disease with which they are associated, and of which £hey are
simply symptomatic.
The treatmenty again, applies to the fever which they accom-
pany. The vesicles are too insignificant to call for the use of
therapeutic measures.
* Opus cit, p. 35a
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CHAPTER V.
SUPPURATIVE INFLAMMATION OF THE DEBMA.
354. Under the influence of a degree of inflammation of the
derma, for the most part greater, at least at its commencement,
than that which exists in the effusive group of diseases, the in-
flamed derma gives rise to the formation of pus ; the pus oc-
cupying the surface of the derma, and producing an elevation
of the epiderma to a limited extent. This irregularity of the
surfGLce of the skin — ^namely, an elevation of the epiderma con-
sequent on the presence of pus, is termed Apustiikf and this is
the only accurate sense in v^hich that term can be employed.
There is a vdde distinction between a vesicle and a pustule, when
these two pathological forms present their typical characters ;
but it not unfrequently happens, that in consequence of a repa-
rative action set up in the vesicle, pus is produced upon its
dermal base, and mingling vnth the serum, constitutes a sero-
purulent, and, subsequently, a purulent or pustular vesicle. In
such a case it is necessary to remember that a true pustule con-
tains pus from the first moment of its formation, and by this
circumstance is essentially distinguished from a vesicle.
355. It is requisite, at the onset of our study of cutaneous
diseases, to be most precise in our definitions, and to draw as
broad a line as possible between the various pathological forms
which we are desirous of characterizing. Scarcely any word
in medical nomenclature has been used more loosely than the
term pustule. At one time it was employed to signify a papula,
at another a vesicle, and it was not until the time of the Lin-
naeus of cutaneous pathology, that the proper application of the
term was truly made. WiUan employed it, with the characters
above stated, as the type of his fifth order — pusttdcB ; and in this
sense it has been subsequently adopted by successive dermato-
logists.
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CHAAACTERS OF PUSTULAR DISEASES. 221
366. The diseases which I propose to consider under the
definition above given, are two in number — namely.
Impetigo,
Ecthyma.
357. The order pustulsB of Willan embraces five diseases,
two of which, had he lived at the present time, would, I am con-
vinced, have been excluded by himself — namely, porrigo, and
scabies. The genus porrigo of Willan contains diseases of the
most opposite Und, and has been the source of much confusion,
so much, indeed, that it would be well that the term should, for
the future, become obsolete and forgotten. Scabies, again, is a
disease possessing several elementary forms, of which both
vesicles and pustules are accidental, and only occasionally
present ; the pustules, when they exist, belonging to ecthyma.
Variola, as placed by Willan in the order pustulse, is forcibly
torn from all its natural affinities, and for this reason I have
thought it correct to transfer the genus to the group of eruptive
fevers. Rayer admits no less than ten genera of pustular in-
flammations, for four of which he is indebted to variola — namely,
variola, varicella, vaccinia, and vaccineUa. There could have
been no objection to thus establishing a distinct group of
variolous afiections, indeed, some benefit might have flowed
from such an arrangement, but the possible advantages are imme-
diately destroyed by the companionship with which he has
leagued them. Thus, from the highly inflammatory and conta-
gious fever of variola, we pass on immediately to three forms of
disease of the sebiparous glands — namely, rosacea, acne, and
sycosis ; next in order follows impetigo, then favus, a peculiar
disease of the hair follicles, and lastly, ecthyma.
358. The genera impetigo and ecthyma constitute the two
essential forms of pustules indicated by Willan — namely, psy-
dracia and phlyzacia, the former being a psydracious (v^t^Cf ^9
vipcutioLj frigidaB guttulse) pustule — ^that is, '^ a small pustule, often
irregularly circumscribed, producing but a slight elevation of
the cuticle, and terminating in a laminated scab. Many of the
psydracia usually appear together, and become confluent ; and,
after the discharge of pus, they pour out a thin, watery humour,
which frequently forms an irregular incrustation.'* The latter,
a phlyzacious (^Xi/^eiv, to be hot) pustule — that is, one, " com-
monly of a large size, raised on a hard, circular base, of a vivid
red colour, and succeeded by a thick, hard, dark-coloured scab."
The achor and the favus of Willan are no longer considered as
pustules.
359. The transition, which I have already had occasion to
remark, from erythema to pemphigus, and from rupia to herpes,
may also be extended to pustulous afiections. Eczema, in cer-
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222 SUPPURATIVE INFLAMMATION OF TBM DBRMA.
tain of its forms — as in the impetiginous varietjr — is seen
gradually merging into impetigo^ while ecthyma is feathest re*^
moved, both in position and characters, from the vesicular
group.
IMPETIGO.
Syn. Psydracia. Crusted tetter, or icall. Dartre cmstade, Fran.
KleienausatZy Germ. — MeUtoffraj Alibert
360. Impetigo* (Plate 4, a.— p.) is a non-contagious in-
flammation of ihe skin, assuming usually a subacute type, and
characterized by the eruption of small, hemispheroidal, or flat-
tened pustules, with but little inflammation at their base. The
pustules are for the most part arranged in thickly-set clusters,
which occupy a small extent of sur£EU)e ; at other times they are
distributed, more or less generally, over the surfSeu^e of the body.
Each pustule attains its full development, and bursts in the
course of two or three days, terminating in rough, yellowish,
and transparent crusts, of considerable thickness. The disease
occurs frequently in successive crops, is attended with trifling
or no constitutional symptoms, and endures from three or four
weeks, to as many months, and even years.
361. The mode of distribution of tiie pustules has given rise
to the division of the disease into two principal varieties —
namely.
Impetigo figurata,
„ sparsa.
To these have been added, by Willan, other varieties, respective
of degree of severity or locality, which it would be more desir-
able to consider as subvarieties under the above heads ; one of
these, impetigo rodens, I omit altogether from consideration,
since the disease described by Bateman under this name is
evidendy a cancerous ulceration of the skin, and not an impe-
tigo. The remaining varieties are —
Impetigo scabida,
„ erysipelatodes,
„ capitis.
IMPETIGO FIGURATA.
Syn, Dartre cnutacie flavetcente, Alibert
362. This variety (Plate 4, a. b.) is characterized by the
occurrence of the eruption upon a distinctly circumscribed and
defined spot, which is usually circular on the face and upper
parts of the body, and oval on the lower extremities. The
* Impetigo, <A hnpetUy aecordiog to Pliny.
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IMPETIGO FIOUBATA. 223
disease oommenees bj the appearance of one or several small
patches of redness^, which remain distinct throughout the pro-
gress of the eruption, or subsequently unite with each oUier^
and constitute a single patch, or it may appear at once as an
inflamed patch of considerable size. Upon this inflamed patch
a numerous crop of small yellow pustules are developed, which
rise but slightly above the surfeu^e of the skin, and are collected
into thickly set, and sometimes confluent clusters. At the end
of one, two, or three days, the pustules burst and discharge
their contents, and the efiused fluid desiccates into thick, brittle,
greenish-yeUow coloured crusts, resembling a pateh of dried
honey. Beneath the crust the surfeice is red, inflamed, and
excoriated, and pours out an abundant sero-purulent viscous
secretion, which contributes still more to the thickness of the
crust. Unless prolonged by successive eruptions, the crust falls
ofi* in from two to four weeks, leaving the surface beneath of a
vivid red colour, somewhat swollen, exceedingly tender, and
covered by a thin and shining epiderma. The surface is oc-
casionally fissured by the movements of the part, and a secre-
tion is poured out, which hardens into a thin secondary crust,
and is followed by successive laminse, formed in the same way.
When the whole of the original patch is concealed by the kind
of incrustation above described, the character of the disease may
still be distinguished by a few scattered pustules, which always
appear around the circumference of the crust As the disease
progresses towards cure, the sero-purulent secretion diminishes
by degrees, and ultimately ceases; the crusts are no longer
augmented in thickness ; the secondary crusts, which have be-
come progressively thinner, cease to be formed, and the skin,
which is left red and congested, returns, after a certain space of
time, to its original colour and pliancy.
Constitutional symptoms are either very slight in impetigo,
being limited to some degree of lassitude and headache, or they
are absent altogether. The local symptoms consist of heat and
itching, which are much increased, and accompanied by a feel-
ing of tension and smarting during the pustular stage. After
the formation of the crusts these symptoms gradually subside,
but the skin remains tender for some time after their fall, and
very susceptible of a return of the eruption if exposed to ft^sh
irritation.
Impetigo figurata presents various modifications in relation to
the extent of surface afiected, and the course of the disease.
Sometimes it is confined to a very limited space, as to the middle
of one cheek, the upper lip, the nose, or one or both eyelids,
while, at other times, it fixes at once upon the entire face.
Sometimes the eruption occupies a patch of small size in the
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224 SUPPURATIVE INFLAMBfATION OF THE DEBMA.
fif St instance, while the disease spreads by its circumference,
(impetiffifums ringwormj) so as eventually to cover a large sur-
lace, whereof the centre presents the crusted stage of the affec-
tion, and the periphery its erythematous and pustular stages.
The crusts again occasionally offer a peculiarity of appearance,
being conical in their shape, and compared by Alibert to stalac-
tites. This variety in form he terms dflr/reer2«^flM»e5tefac^i/brwie;
it is most frequently seen upon the eyelids, borders of the eye-
brows, nose, &c.; in brief, in any situation where the effused
secretion has an inclination favourable to the gravitation of the
fluid from the surface of the skin.
Instead of running through its course, and terminating by the
restoration of the skin to soundness, within a moderate period,
impetigo figurata is sometimes prolonged indefinitely by succes-
sive eruptions of pustules, each eruption pursuing the natural
course of the typical affection. These successive attacks are
occasioned either by a continuance of the original cause of the
disorder, or by the employment of stimulating and irritating
substances for its cure. In such cases the morbid action extends
to the deeper tissues of the skin, producing thickening and con-
densation of the integument Again, the eruption may occur
periodically, appearing in the spring or autumn season, for
several successive years.
The most frequent seat of impetigo figurata is the £Eice, and
more particularly the cheeks, but it may also occur upon the
trunk of the body and extremities. The fore-arms I have re-
marked to be a very usual position of the eruption. It very
commonly appears upon several regions at the same time, and
there exists some little difference in regard to the form of the
patch, according as it may be developed upon the upper or the
lower extremities ; thus, on the former it approaches nearer to
the circular, and on the latter to the oval shape.
863. Impetigo figurata sometimes assumes a chronic form;
fresh crops of pustules are no longer produced, but the integu-
ment takes on a morbid action, it becomes thickened and infil-
trated, and the excoriated surfaces pour out an abundance of
viscous sero-purulent secretion, which continually desiccates into
fresh incrustations, the incnistations being reproduced as often
as they are rubbed or thrown off. Occasionally, the incrusta-
tions, instead of being thrown off, form a thick case upon the
part affected, or around the limb, and constitute that variety
which has been denominated by Willan, impetigo scabida. A
limb, surrounded by a case of incrustation of mis kind, has been
compared, very aptly, to the trunk of a tree covered with a rough
and cracked bark.
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IMPETIGO SPARSA. IMPETIGO SCABIOA. 225
IMPETIGO SPARSA.
SjTD. Scattered scall, or tetter,
364. Impetigo sporsa (Plate 4, c.) differs from impetigo figu-
rata only in the more disseminated arrangement of the pustules.
Instead of being confined, as in the latter, to a single spot or
region, they are, in the sprinkled form, distributed over a consi-
derable surface ; for instance, over an entire limb, and sometimes
over the whole body. The eruptive process pursues precisely
the same course with that described as the .typical form of the
preceding variety ; it is attended with considerable pruritus, and
the pustules are successive, numbers being freshly developed in
the midst of fiilly formed crusts. Impetigo sparsa usually ap-
pears on the limbs, especially upon the lower extremities, and
about the ankles, and is frequently seen in the neighbourhood
of joints. On the legs it is not unfrequently associated with
oedema, and is exceedingly troublesome.
Impetigo sparsa is more apt to degenerate into the chronic
form than the preceding variety. The surface beneath the crusts
often presents superficial ulcerations, the integument becomes
thickened and infiltrated, and the large collections of crusts con-
stituting impetigo scabida are more frequently produced.
IMPETIGO SCABIOA.
365. Impetigo scabida (Plate 4, p.) is merely that state of
the two preceding varieties, in which the surface is covered by
a thick incrustation, resembling the rough bark of a tree. This
crust is broken and fissured from point to point by the move-
ments of the part, and through the apertures a quantity of sero-
purulent secretion oozes to the suifrice, and desiccates upon the
exterior of the crust. Sometimes impetigo scabida occurs upon
the face, forming a complete mask to the features, but generally
it is seen only on the limbs, and accompanies the chronic form
of the eruption. It is attended with much pain in moving the
limb, and by troublesome pruritus. When the crust is removed,
the surface beneath is observed to be excoriated by superficial
ulcerations, and fresh incrustations are speedily formed. Im-
petigo scabida is for the most part met with in old persons, and
in those of debilitated constitution, and is not unfrequently as-
sociated with oedema.
IMPETIGO ERYSIPELATODES.
366. The ordinary forms of impetigo are characterized by the
absence of constitutional symptoms, and by the moderate degree
of inflammation which accompanies the local disease. Some-
Q
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226 SUPPURATIVE INFLAMMATION OF THE DERMA.
times, however, the eruption is preceded by burning heat of sur-
face, tension, great redness, tumefaction, in short, by the usual
signs of erysipelas. To these are added fever and considerable
constitutional disturbance, the eruption appearing as usual, and
running the same course. It is upon this combination of symp*
toms tibat Willan has bestowed the designation of impetigo
erysipelatodes.
IMPETIGO CAPITIS.
Syn. Crusta lactea. Tinea lactea, Porrigo larvalis, Porrigo favosa* Teiffne muqueuse.
Teigne granule, Alibert Milchgrind, MUchschorf, Germ.
867. That affection of the face and head of young childreu
termed milk-crust, or crusta lactea, and by Willan, porrigo lar-
valis, is an impetigo figurata, identical with the typical form of
this disease, or if it be in any kind different, modified merely by
the age of the patient, or by its more or less extensive occupa-
tion of the scalp and face. Crusta lactea presents several varie-
ties in relation to degree of inflammation and thickness of crust ;
it may exist upon all parts of the head and face at the same time,
or be located separately upon the face, the scalp, the ears, the
temples, the alse nasi, or the lips.
The pustules of crusta lactea, from exposure to the influence
of the air, are somewhat whiter than those of impetigo developed
on more protected parts of the body. They are accompanied by
much itching, and are frequently broken by the action of the
nails ; the escape of pus and of the viscous sero-purulent fluid
which succeeds giving rise to the characteristic greenish-yellow
crusts of impetigo ; and when, as frequently happens, the blood
flows from the wounds caused by the nails, those parts of the
crusts stained by the sanguinolent fluid assume a deep brown
colour. When Ac wounds inflicted by the nails are deep, cica-
trices are apt to remain after the subsidence of the disease, but,
under ordinary circumstances, the skin is left perfectly free from
any trace of morbid action. On the fall of the crust, the skin is
red and congested, and covered by a thin and glossy epidenna;
by degrees, the natural hue of the integument is restored, and
the epiderma, after repeated exfoliations, regains its normal
appearance.
368. Impetigo figurata of the scalp (crusta lactea of the scalp)
is modified in its characters by its development upon the seat of
the hair. The hairs are matted together by the sero-purulent
discharge, and a thick yellow crust is formed, to which the
matted hairs act the part of a felt. If this crust be allowed to
remain, the morbid secretions collect beneath, and give forth a
most offensive odour; the scalp is irritated and inflamed by its
presence ; pediculi are sometimes engendered in great numbers,
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IMPETIGO OF THE SCALP. 227
and occasionally the hair falls with the crusty leaving the skin
bald and thickened. Sometimes, as a consequence of this irri^
tation, purulent collections are formed beneath the sldn, and the
lymphatic glands of the neck become enlarged.
The alopecia produced by impetigo differs materially from
that occasioned by trichosis and favus ; in the former, the eject-
ment of the hair is only temporary, the formative structure is not
organically injured, and the hair is subsequently reproduced, of
the same colour and with the same characters as the rest. Again,
the patches are not regularly circumscribed nor perfectly de-
nuded, as in trichosis and favus ; on the contrary, they are un-
certain in form, and some hairs still remain on various points of
ihe alopeciated surfsbce.
Impetigo of the scalp will last for months, and even for years,
unless the crust be entirely removed, and the causes of irritation
above alluded to prevented. When the inflamed skin is exposed
at an early period, some few superficial ulcerations, from which
an abundant secretion is poured out, are all that appears ; at a
later stage, however, the ulcers become larger, ana the deeper
textures of the scalp are more or less involved.
The local symptoms accompanying impetigo capitis are, heat,
pruritus, and more or less tension and pain. The constitutional
symptoms are scarcely apparent, or very trifling, and when they
exist, are frequently attributable to other causes, such as teeth-
ing, &C., the period of dentition being that at which crusta lactea
mostly appears. The eruption is occasionally vicarious of vis-
ceral disorder, and in this case requires to be watched with care
during the progress of treatment The pustules are sometimes
intermingled with vesicles of eczema.
869. Impetigo sparsa of the scalpj (Plate 4, d. e.) — In certain
instances, although these are rare as compared with the occur-
rence of ihe preceding affection, the pustules of impetigo assume
upon the scdip the dispersed form of impetigo sparsa. The se-
cretion from these pustules produces the agglutination of several
hairs, and forms hard and irregular crusts of a brownish or
greyish colour, which have been compared to small fragments of
mortar imbedded among the hair. From these crusts, small
particles or granules are frequently broken off, and are found
mter8}>ersed between the hairs ; hence the disease has been de-
signated by Willan, porrigo granulata, and by Alibert, teiffne
granuUe. Impetigo sparsa of the scalp, when neglected, gives
rise to most of the inconveniences described under the head of
impetigo figurata of the same region. The secretion becomes
highly offensive ; it acts as an additional cause of irritation to the
cutaneous textures, and is the source of attraction to innumeraUe
epizoa.
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228 SUPPURATIVE INFLAMMATION OF THE DERMA.
This disease occurs in young persons, and particularly in
children ; it is usually situated on die back part of the scalp, but
sometimes affects the entire head. It is met with only in those
whose constitution is enfeebled, and who are exposed to hygienic
influences of an unhealthy kind.
370. Diagnosis. — The pathognomonic characters of impetigo
are, the small size and little elevation of its psydracious pustules ;
the subsequent abundant viscous and yellowish secretion which
the exposed surfaces pour out ; and the thick yeUowish green,
or brownish and greyish, semi-transparent crusts. I have seen
eczema impetiginodes mistaken for impetigo, but with the cha-
racters of the latter in the memory, it is scarcely possible to con-
found this disease with eczema. In eczema, the typical vesicles
are always present on some part of the morbid surface, while its
scabs are thin and lamellated.
When impetigo affects the chin only, it may be mistaken for
sycosis, unless we recollect that in the latter eruption the pus-
tules are larger, more prominent, discreet, less yeUow in colour,
and succeeded by less secretion. Moreover, the crusts of sycosis
are darker in colour, less moistened by secretion, not renewed
when they fall off, and accompanied by tubercles and indu-
rations.
Impetigo of the scalp is distinguished from favus by the ab-
sence of the bright yeUow cups, in addition to which, the loss of
hair which accompanies the latter form of disease constitutes an
important distinction.
The pustular forms of sj-philitic disease may simulate impetigo,
but in these cases, the livid or purplish stain of the skin, the dark
colour of the crusts, and the deep and obstinate idcers which
follow, are peculiar to syphilis.
371. Causes, — Impetigo occurs in both sexes, at every age,
and in all seasons ; it is, however, more common in children
than in the adult, and in women and persons having a thin and
delicate skin, than in the male sex, and those whose skin is less
susceptible. Impetigo figurata is most frequently met with in
the spring season, while impetigo sparsa appears usually in the
autumn, and in persons of adult and advanced age.
The disease is sometimes referrible to constitutional causes,
as in those instances where it is foimd associated with the general
disturbance produced by dentition, amenorrhoea, or by Ae ces-
sation of the menstrual period. Its appearance seems influ-
enced also by mental excitement, excess in diet, or stimulating
drinks, violent exercise, &c. It is very commonly met with in
workhouses, where a number of children of unhealthy constitu-
tion, poorly fed, and insufficiently clothed, are assembled toge-
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TREATMENT OF IMPETIGO. 229
ther ; and particularly where care is not bestowed upon the three
great hygienic principles — ventilation, cleanliness, and exercise.
Local irritation of the skin is a frequent occasional cause, as
in that produced by lichen, the application of stimulating sub-
stances to the cutaneous sinrface, such as dry powders, metallic
dust, sugar, lime, &c., and the heat of the sun in the spring and
summer season.
The impetigo capitis of infants, or the crusta lactea, is espe-
cially referrible to the irritation caused by teething, the disease
occurring both at the first and second dentition. It is developed
at this period in strong and healthy children, as well as in those
who are weakly and scrofulous.
372. Prognosis. — Impetigo is an extremely troublesome and
offensive disease, but by no means dangerous to life. It is fre-
quently tedious of cure, especially when injudiciously treated,
and by the improper use of remedial means may be prolonged
indefinitely, or be made to assume the chronic form, which latter
is always obstinate and rebellious.
373. Treatment. — In impetigo, unaccompanied by severe or
extensive inflammation, emollient and sedative fomentations, the
vapour bath and water-dressing are the proper applications. If
the inflammatory action be greater, a few leeches may be applied
with benefit, and if the inflammation be extensive as well as
severe, general bleeding may be employed. If the above simple
treatment fail in restoring the skin to its healthful condition,
alkaline or sulphuro-alkaline or astringent lotions may be used,
or any one of the following ointments — namely, oxide of zinc,
calamine, acetate of lead, white precipitate, or dilute nitrate of
mercury. Hydrocyanic acid, in the formula recommended by
Dr. Thomson, is also a valuable remedy : —
Hydrocyanic acid, 3 iv.
Acetate of lead, gr. xt.
Alcohol, 5 iy.
Water, Jvij.
M. ^
In the chronic form of impetigo, the vapour douche and bath
will be found invaluable remedies ; they soften and remove the
crusts without exciting pain, and calm the irritation of the skin.
After the entire separation of the crusts, the inflamed surface
should be bathed with a weak alkaline or astringent lotion and
enveloped in oilskin, the vapour douche being repeated once or
twice daily. Should the disease resist these measures, recourse
may then be had, in turn, to lotions containing sulphuret of
potash, nitric acid, and nitrate of silver. The ointment of the
nitrate of mercury may in some cases be found useful. Creosote
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280 SUPPURATIVE INFLAMMATION OF THE DERMA.
ointment, and zinc ointment, T have employed successfully after
the local action has been reduced, and the system regulated. In
very obstinate cases, arsepic, both as a general and local measure,
has been recommended.
The constitutional treatment should consist in the restoration
of any of the organic functions that may be disturbed. For this
purpose, laxative medicines, antacids, emmenagogues, and tonics,
may, according to the indications of the ease, be employed.
In the treatment of crustalactea, warm bathing and the vapour
bath, with weakly alkaline fomentations, are the chief remedies.
The other applications above recommended may also be used in
a diluted form ; and in strong and robust children it is often
desirable to diminish the congestion of the skin by means of one
or two leeches. The internal exhibition of laxative remedies,
such as mercury with chalk and rhubarb, or rhubarb and mag-
nesia, will also be found useful; and in most instances, when the
infant is suckling, it will be proper to change the nurse, or wean
the child. Rayer judiciously recommends, that where this dis-
ease depends obviously on dentition, and where the constita-
tional symptoms accompanying that state are relieved by its
presence, we should be cautious in repressing the disorder, and
confine our treatment to simple cleanliness.
In impetigo of the scalp, &e hair should be cropped over the
diseased parts, and the crusts completely removed by means of
the vapour douche and water-dressing. The parts should be
kept ftee from the irritation of fresh incrustations by frequent
washing, and the same remedial means pursued as above recom-
mended for impetigo in other parts of the body.
374. An incident which recently fell under my notice, speaks
volumes with regard to the treatment of this disease. I had
often occasion to observe with regret the utter uselessness of all
medicinal applications in the treatment of these cases in the
St. Pancras Infirmary, where numerous children are annually
affected, and several are constantly in the sick wards. Thw
want of success originated in the absence of proper nurses to
carry out the directions of the surgeon. It was in vain that the
necessity of cleanliness was urged upon them ; they received
little for their labours, and were not disposed to engage in a
most disagreeable duty on philanthropic grounds alone. Under
such circumstances, the pharmacopoeia was exhausted of its
specifics, but no advantages resulted. Things were in this state,
and I had little hope of change, when, to my surprise and
delight, I perceived the number of patients suddenly diminish,
and those who remained looked cheerfiil and better in health.
I inquired into the cause of this change, when I learned that a
new nurse had been appointed to the charge of the children,
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ECTHYMA. PAPULOUS SCALL. 231
and that she had set her shoulder yigorously to the wheel of
these obstinate eruptions, and had turned out several cures.
Upon asking her how she proceeded, she of course looked mys-
terious ; but I quieted her fears of my perquisitions, by telling
her that it was not her secret that I sought ; that my object was
simply to approve of her proceeding, and to urge her to its con-
tinuance. She said, in reply, that her treatment consisted in the
application of a remedy derived from a " subscription" given to
her mother by Sir Astley Cooper ; that this legendary specific
was a coarse admixture of " butter and pepper." For sound
philosophy, this remedy,* in its modus operandi, is worthy of the
celebrated name with which the female asclepiad had associated
it, and I applauded its effects ; it was an apt illustration of the
sympathetic treatment of wounds by anointing the weapon with
salves, and swathing it in bandages. But I reserved for myself
that which my female colabourer could not have comprehended
— the perception of the benefit derivable from the thorough
ablutions and rigid cleanliness with which the specific was ac-
companied.
ECTHYMA.
Syn. Phlyzacia, Papulous scaU.
375. Ecthymat (Plate 4, h. — q.^ is an acute inflammation of
the skin, characterized by the eruption of prominent pustules, of
a rounded form and considerable size, upon any part of the sur-
face of the body. The pustules are usually discreet, they are
developed on a hard and inflamed base, and terminate in dark-
coloured crusts, which leave a deeply congested surface on their
fall, and sometimes a superficial ulcer, followed by a cicatrix.
The eruption is for the most part partial and successive ; in rare
instances it is general ; in the former case it may endure for one
or two weeks ; in the latter, for several months. It is not con-
tagious.
3764 Ecthyma is endowed by Willan with four varieties, hav-
ing relation to the constitution and age of the patient ; these are,
ecth}ana vulgare, ecthyma infantile, ecthyma luridum, and
ecthyma cachecticum. I prefer, however, with Rayer, to con-
sider the disease as presenting an acute and a chronic type ; the
former of these divisions corresponding with the ecthyma vul-
gare, and the latter embracing the three remaining varieties. In
a tabular form, the varieties of ecthyma are,
* A hamble imitation of the ungaeotum piperis nigri, of the Dablin Pharma-
copceia, formerly recommended for tinea and fayas.
t Der. UOvuvt to burst forth.
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282 SUPPURATIVE INFLAMMATION OF THE DERMA.
Ecthyma acutum seu vulgare.
[ E. infantile,
EcthTina chronicuin, - E. luridum,
[ E. cachecticum.
ECTHYMA ACUTUM SEU VULGARE.
377. This eraption (Plate 4, h. — n.) is most frequently seen
upon the extremities, often on the shoulders and neck, but
rarely on the scalp. Its development is indicated by the ap-
pearance of small, red, and circumscribed spots, which gradually
rise above tiie surface, are hard and painful to the touch, and
increase to a variable size. Upon the summit of each of these
conical elevations a small quantity of puriform fluid is effused
beneath the epiderma, and the matter continues to be augmented
by additional secretion, until a pustule is formed. The size of
the pustule is various ; usuaUy it is as large as the half of a pea,
and surrounded by a hardened base of vivid redness, while at
other times it covers the whole extent of the hardened base,
and resembles a bulla distended with pus. The development
and growth of the pustule is accompanied by severe pain, which
is frequentiy of the lancinating kind. In the course of three
or four days after the completion of the pustule, the contained
fluid dries up into a dark-coloured scab of various thickness,
which falls off in a few days, leaving behind a congested circular
spot, of a deep red colour. Sometimes the purulent fluid is
removed by absorption, and tiie surface of the skin is restored
to its natural state, after repeated desquamation. At other
times a superficial ulcer is formed, particularly on the Jower
extremities, and terminates with a slight cicatrix. Wheti the
eruption of pustules has been numerous, the congested spots
left by the fall of the crusts present a remarkable appearance.
Rayer gives so excellent an account of the structure of the
pustules, during their progressive development, that I am
tempted to quote his words. " We find," vnrites tiiis author,*
" 1. that in their first stage (red elevations) there is merely
sanguineous injection with conical tumefaction of the corion ;
2. that in the apex, more rarely over the whole surface of the
elevations, and under the cuticle, there is an effusion of a certain
quantity of purulent serum; 3. that in the third stage, which
follows immediately after, there is a kind of pseudo-membranous
matter deposited in the centre of the elevation, which is now
evidently perforated ; 4. that after the voidance of this matter,
and the removal of the cuticle, the pustule appears under the
form of a cup-shaped cavity, surrounded by a hard, thick, puffed
* Translation by Willis, second edition, p. 530.
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ECTHYMA CHRONICUM. 233
edge ; 5. lastly, that oh the following days this thickened mar-
gin subsides, at the same time that a slight cicatrix is formed
under the crust, the centre of which is fixed within the point
where the perforation has been observed.
ECTHYMA CHRONICUM.
378. Chronic ecthyma (Plate 4, h. — q.) is a more common
form of disease than the acute variety ; it occurs in successive
eruptions, generally in persons of debilitated and cachectic
habit, and is prolonged for several months.
When it appears in ill-fed, ill-clad, and weakly children, or
in those who are debilitated from preceding disease, it consti-
tutes that variety which has been designated by Willan, ecthyma
infantile. This eruption is not unfrequently associated with
irritation, or disease of the alimentary mucous membrane. The
pustules are very dissimilar in point of size, some being small,
and some large ; they are circular in form, surroimded by an
areola, more or less inflamed, and terminate by absorption of
the purulent fluid, and epidermal desquamation, or by ulcera-
tion. The ulcers in this disease are unhealthy, and difficult of
cure.
In old persons, and in those who have injured their consti-
tution by excess, the congested areolae often present a purplish
red and livid colour ; the pustules are of large size, and filled
vnth a sanguinolent, puriform fluid, and they are remarkable
for the tardiness of their course. This character of the eruption
constitutes the ecthyma luridnm (p. Q.) of Willan and Bateman.
In persons of unsound and cachectic constitution, of all ages,
the cachectic form of eruption is developed. The pustules occur
upon all parts of the body, but most firequently on the legs.
The inflammation preceding the eruption is more extensive than
in ecthyma acutum, and variable in degree. At the end of six
or eight days, the epiderma is raised by the efiiision of a small
quantity of dark, sanguinolent pus, which forms by its increase
an unhealthy and discoloured pustule. When the pustule is
fuUy developed, the epiderma bursts, and the denuded surface
becomes covered by a thick, dark-coloured crust, which appears
enchased within the skin, and remains adherent for several
weeks. If the crust be removed by accident or design, an ill-
favoured ulcer with inflamed edges is exposed, which is tedious
and difficult of cure.
The pustules of ecthyma are not unfirequently associated with
scabies, lichen, prurigo, and some other chronic afiections of
the skin.
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fid4 SUPPURATIVB INFLAMMATION OF TH£ DERMA.
379. Dioffnosis. — The large size and prominence of the pus-
tules, their inflamed bases, and the mode of their development,
seire to distinguish ecthyma from all other pustular affections.
When the pustules of acne and sycosis attain a large size, they
bear some resemblance to ecthyma, but are easily distinguished
by the broad and inflamed areola of the latter, and the hard,
tubercle-like elevations without areolae of both the former.
Syphilitic ecthyma is distinguished from the form at present
under consideration, by the more chronic character of the erup-
tion, the limited extent of the areola, its coppery hue, the black-
ness and concentric marking of the crust, and the presence of
other signs of constitutional syphilis.
380. Causes. — Ecthyma maj^ be developed at all periods of
life, and at all seasons, but is principally observed in young
persons and in the adult, and most frequently in the spring and
autumn.
It may be excited by various stimuli applied to the surface of
the skin, such as sugar, lime, salt, sulphur, &c. Grocers are
liable to this eruption, from the irritation produced by the first
of these substances, and bric^ayers of the second. The mani-
pulation of pulverulent substances of all kinds is apt to act as
an exciting cause, and simple friction may give rise to the same
consequences. The pustules following the irritation of tartarized
antimony are ecthymatous; they are umbilicated, contain in
their interior a false membrane, are very numerous, and suc-
ceeded by dark-coloured crusts.
Ecthyma is frequently excited by the irritation caused by
other cutaneous diseases, as by variola, rubeola, scarlatina,
herpes, prurigo, scabies, &c.
This eruption is often symptomatic of a disordered state of
the system, as of some chronic affections of the viscera, or irrita-
tion of the gastro-intestinal, or uterine mucous membrane. It
may also be induced by excess of mental or physical exertion,
by bad and deficient food, want of proper clothing, residence in
damp and unhealthy situations, want of cleanliness, debilitating
causes of various kinds, excesses, and exposure to vicissitudes.
381. Prognosis. — The prognosis of ecdiyma depends on the
state of constitution of the patient rather than upon the eruption,
which is in most cases an effect of disordered health. When
the cause is external, and the form of the disease acute, the
eruption seldom continues longer than two or three weeks ; but
the chronic affection may be prolonged for several months.
382. Treatment. — In the acute variety of ecthyma, after the
removal of the cause, some gentle laxative and alterative medi-
cine with diluents and abstemious regimen is all that will be
required. The best local application is the superacetate of
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TBEATMENT OF ECTHYMA. 235
lead, or oxide of zinc ointment, or if the inflammation be severe,
sedative and emollient fomentations and water-dressing.
When the disease is symptomaticof visceral disturbance, the
treatment must be directed to ^e organ afiected ; the abstrac-
tion of blood is sometimes useful ; tonic medicines, preparations
of iron ; abstinence from stimulating food or drinks ; the cold
or tepid bath, succeeded by friction on the sound integument,
&c. I have employed the iodide of potassium with great
benefit, in the bad state of health which accompanies ecthyma
cachecticum. The iU-fEivoured ulcers sometimes left by the
latter variety of the disease maybe brought into good condition
by water-dressing, and mild stimulants, such as a solution of
the nitrate of silver, sulphate of zinc, supersulphate of alumina,
chloride of lime, &c., or the weak nitric acid lotion, either with
or without opium.
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CHAPTER VI.
DEPOSITIVE INFLAMMATION OF THE DERMA.
383. By the term " depositive," which I have selected only in
the absence of a more suitable word, I mean to express that con-
dition of the inflamed membrane in which plastic lymph is
exuded by the capillary rete into the tissue of the derma, so as
to give rise to the production of small hard elevations of the skin,
or pimples. In the preceding groups of diseases we have seen
simple congestion of the papillse of the derma, efiusion of the
serous portion of the blood on the surface of the derma, forma-
tion of pus on the surface of the derma ; but the alteration now
under consideration is different from the whole of these ; there
is no inordinate congestion, there is no serous effusion, and no
generation of pus. As far as my observation of the pathological
characters of the present disease enables me to determine, there
is effusion of plastic l}anph into the tissue of the derma, consti-
tuting a pimple of small size.
384. The pathognomonic symptoms accompanying pimples
correspond, moreover, with the supposition of such a pathologi-
cal structure ; they are accompanied by incessant itching, a sen-
sation which may easily be explained by reference to the mode-
rate degree of pressure produced upon the nervous plexus of the
papillary layer by the effused lymph, or, probably, by the dis-
tention of the neurilemma of the nerves by the more fluid parts
of the l3anph, so as to affect the nutrition of the nervous sub-
stance. Pruritus is unquestionably a degree of pain, but it is
one of a mild kind, and such as we see for the most part in
papular eruptions of the skin, or when the derma is returning
to its natural state afiter inflammatory congestion of its tissue,
or, again, when foreign substances, such as scabs and crusts,
effused fluids, parasitic animalcules, &c., lie in contact with the
skin.
385. The diseases which are here characterized by the desig-
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GENERAL CHARACTERS OP PAPULiE. 237
nation " Depositive inflammation of the derma,*' correspond with
the order Papulae, of Willan ; and in this instance no difference
of opinion exists among dermatologists as to the morbid affec-
tions admitted into the group. They are three in number —
namely,
Strophulus.
Lichen.
Prurigo.
Rayer and Gibert remark that the above number might very
properly be reduced to two ; for that strophulus is nothing more
than the lichen of young children and infants, while Alibert con-
siders the whole under the single genus. Prurigo.
386. The definition given by Willan of the elementary form
of papular affections admits of no improvement. A papula or
pimple is " a very small and acuminated elevation of the cuticle
(derma) with an inflamed base, very seldom containing a fluid,
or suppurating, and commonly terminating in scur£'' Papulse
terminate by resolution, generally with furfuraceous desquama-
tion of the epiderma. The papulae of strophulus have usually a
greater elevation than those of lichen and prurigo. Some diffe-
rences are perceived also in relation to colour ; thus the pimples
of strophulus may be either red or white, those of lichen are
always more or less red and inflamed, while the papulae of prurigo
scarcely differ in tint from the surrounding skin.
387. In the preceding edition of this work, I stated my belief
that the precise element of the dermal system affected in the
papular diseases was the papillae of the slan. More recent and
careful examinations have proved to me that this is not the case,
but that the real seat of morbid change is the vascular boundary
of the various excretory tubides of the skin : for example, the
sudoriferous and sebiferous ducts, and hair-follicles. This fact
being determined, we have an explanation of various of the phe-
nomena which accompany the eruption : for example, the fre-
quent perforation of the pimples by a hair, the formation of a
lliin scale upon the summit of the papule, the occasional appear-
ance of a minute aperture in this situation, and the oozing of a
transparent and colourless fluid from the same point. We can
also better understand the provoking itching wnich is a symp-
tom of the eruption, the obstruction which is offered to the
escape of secretions, and the obstinacy of these disorders. The
papulae of prurigo are perfectly identical with die papulae of
lichen, the difference between them being, that the latter are
generally acute in their course, while the former are always
chronic. But there is an appearance of the skin in prurigo that
must be familiar to all who are conversant with cutaneous dis-
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238 DEPOSITIVB INFLAMMATION OF THE DERlfA.
eases ; an uneyenness of surfisu^e, prodaoed by numbeiless slight
but broad elevations, separated n*om each other by the linear
markings of the skin. Now these are the eleradons which have
been described by all dermatologists, not excluding myself,
under the name of the broad and flat papulae of prurigo. " Soft
and smooth papulsB, somewhat larger and less acuminated than
those of lichen, and seldom appearing red or inflamed, except
from violent friction. Hence an inattentiye observer may over-
look the papulae altogether."* Rayer speaks of them as being
" soft to die touch, and broader than lliose of lichen, from which
ihey also difler in preserving the natural colour of the skin."
" They occasionally project in so slight a degree, that they ap-
pear to be situated rather in the substance than on the surface
of the skin." Now there is an evident obscurity about these
descriptions, a contradiction in fttct, which must have involved
many in perplexity with regard to the real meaning of the
authors. Fapulae precisely defined, broad, soft;, smooth, and
large, and yet not distinguishable in colour from the adjacent
skin, easily overlooked, and suggesting to the practised eye some
uncertainty as to whether they were in or upon the skin. I will
endeavour to explain the mystery.
388. Prurigo, I believe to be, in its origin, a disease of the
nervous system, and specially of the cutaneous nerves. As a
consequence of the altered innervation of the skin, the dermal
tissues become changed in structure — ^namely, condensed and
thickened. The most careless examination is sufficient to esta-
blish these two points ; the skin feels hard, it moves like a piece
of thick leather ; the areae included between the lines of motion
are large ; its natural suppleness is gone ; its very colour is
changed ; it looks yellowish and dirty. • But it is. smooth ; there
are no such projections as we should call pimples, or if there
be, they are few and scattered. Arrived at this point, there re-
mains but one conclusion for the student There are no papulae,
therefore the disorder cannot be prurigo. And yet the disease
is so characteristically prurigo, that, setting aside the symptom
of pruritus, the dermatologist is enabled to decide at once upon
its name.
What, then, are the signs by which prurigo is so immediately
distinguished ? They are, the thickening and condensation of
the slan, and the consequences of this condition. Upon close
examination, the angular areae included by the linear markings
of the skin (§31) are seen to be elevated above their natural
level, the elevation being occasioned by the thickening of the
derma. That this is the case is evident from the position of the
* Bateman, Synopsis, third edition, page 15.
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STBOPHULUS. TOOTH-RASH. 239
pores — ^namely, in the ftirrows which constitute the linear mark-
ings, and at the point of divergence of several of these. The
elevations, theretore, are simply the effect of a swollen state of
the derma, the areae being magnified by hjrpertrophy, and the
linear markings being magnified in depth by the same canse.
These swollen areas are die so-called papulae, the broad and flat
and smooth papulae. It is not, then, to be wondered at, that they
should be with difiiculty discerned, tiiat they should be " over-
looked," seeing, as I have shown, that they are not papulae
at all.
But we do meet with papulae in prurigo, altiiough not a ne-
cessary feature of that disease. These papulae are not the areae
of the linear markings of the skin ; they occupy the grooves of the
linear markings. They are, in fact, the pores raised into pimples,
and are identical with the pimples of lichen. It is these latter
which generally suffer abrasion of their tips from scratching, and
then become surmounted by a small dark-coloured scab.
389. The papular group of diseases of the skin offer no tran-
sitional characters to the pustular affections which preceded
them, unless we consider as manifesting that relation the large
papulae with pustular heads, which are j^equently found in asso-
ciation with syphilitic lichen. Their alliance with the succeed-
ing group — namely, of squamous diseases — is hardly more direct,
consisting only in their elevation above the surface, and in the
production of a thin furfuraceous scale, by which they are sur-
mounted at their decline.
STROPHULUS.
Syn. Tooth-rash, Gown. Gum.
890. Strophulus (Plate 6) is a disease of early infancy, con-
sisting in the eruption of small pimples upon part, or upon the
whole surface of the body. The pimples are usually red, but
sometimes whiter than the surrounding skin ; they are attended
by itching, which is increased by warmth ; but they give rise to
litde constitutional disturbance, and terminate by resolution and
epidermal desquamation.
The appearance, distribution, and colour of the pimples of
strophulus have given rise to its division into five varieties —
namely.
Strophulus intertinctus. Strophulus albidus.
„ confertus. „ candidus.
„ volaticus.
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240 DEPOSITIVE INFLAMMATION OF THE DERMA.
STROPHULUS INTERTINCTUS.
891. Strophulus intertmctus (Plate 5, i.), the red gum, or red
gown of popular language, is an eruption of prominent pimples,
of a vivid red colour, upon one or several regions of the body,
or generally dispersed over the entire surface, the eruption being
intermingled with minute red points and erythematous patches
of variable extent The pimples remain upon the skin for some
time, some disappearing while fresh crops break forth, and the
disease terminates, at the end of one or two weeks, by desqua-
mation of the epiderma. Occasionally the strophulus appears
at successive periods, being alternated by intervals of freedom
from the attacks. This eruption was observed by Willan to be
developed principally on the cheeks, the backs of the hands, and
the fore-arms. It is unaccompanied by symptoms of constitu-
tional disturbance, and as frequently affects the strongest and
healthiest as weakly children. Strophulus is sometimes coinci-
dent with acidity of stomach and intestinal disorder, both of
which may depend, with the eruption itself, upon the irritation
of teething. When the eruption has been repelled by exposure
to cold or mismanagement, serious effects have been produced
on the nervous system and alimentary mucous membrane.
STROPHULUS CONFERTUS.
392. Strophulus confertus, or tooth-rash (Plate 5, i.), is a
more severe variety than the preceding. The pimples are more
numerous, and smaller in size ; they are aggregated into consi-
derable patches, and are often confluent Sometimes they are
distributed generally over the surface of the body, but more fre-
quently are confined to a single spot, or to several regions, as the
face, die breast, or the arms. The redness of the eruption is
less vivid, but more lasting, than strophulus intertinctus. The
disease usually attains its height in twelve or fourteen days, and
then subsides, leaving a copious furfuraceous desquamation of the
epiderma. Frequently on its decline a fresh eruption succeeds.
Strophulus confertus, according to Willan, occurs in most infants
at about the fourth or fifth mondi.
393. Another form of this disease is described by the same
author as taking place in infants of seven or eight months. The
pimples in this modification are collected into one, two, or three
large and irregular clusters, which appear upon some one point,
as upon the fore-arm, and thence extend, upwards and down-
wards, along the arm. The patches as well as the intermediate
skin are of a deep red colour, and are succeeded by an extensive
epidermal exfoliation ; the skin remains, for some time after, dry
and harsh, and of a dull red colour.
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STROPHULUS VOLATICUS. STROPHULUS ALBIDUS. 241
This form of strophulus sometimes occurs upon the legs, and
assumes a very painful and obstinate form. The eniption ex-
tends upwards along the thighs to the loins and abdomen, and
produces a redness which is nearly continuous. The epiderma
becomes dry, and cracks and separates in large flakes, leaving
the integument beneath inflamed and rough. These symptoms,
with considerable heat, pruritus, and irritation, may be prolonged
for several months, or, as Willan remarks, they may continue
until the infant completes its first year.
The constitutional symptoms of strophulus confertus, as of
the preceding variety, are very slight, but the local pruritus is
troublesome, and often severe. The disease is referrible for its
cause to the irritation of teething, as is implied in its popular
designation of tooth-rash,
STROPHULUS VOLATICUS.
394. This variety (Plate 5, k.) is characterized by the erup-
tion of papulae of a vivid red colour, in small circular clusters,
which are scattered over the surface of the body. Each cluster
contains from three to twelve papulae, which are hot, and attended
with much itching. In a few days the inflammatory condition
subsides, the pimples assume a brownish tint, and the eruption
terminates by epidermal desquamation. More frequently, how-
ever, new patches appear as the older ones decline, and die dis-
ease may be prolonged for several weeks. The patches of stro-
phulus volaticus are particularly observed on the cheeks and on
the arms.
Strophulus volaticus is accompanied with general uneasi-
ness and fretfulness, quick pulse, white tongue, and disordered
bowels.
STROPHULUS ALBIDUS.
395. In strophulus albidus (Plate 6, l.) the pimples are white,
and minute in size, each being surrounded by an areola of
slight redness. They appear for the most part on the face, neck,
and breast, and continue for a considerable time. They are not
unfrequently intermingled with the red papulae of the preceding
varieties.
STROPHULUS CANDIDUS.
396. In this variety (Plate 5, m.) the papulae are of larger
size, and broader than in any of the preceding forms ; they are
hard, smooth, and tense, and without accompanying redness.
The pimples are scattered irregularly over the body, but are
most strongly developed on the arms, the shoulders, and the
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242 DEPOSITIYE INFLAMMATION OP THE DEBMA.
loins. They subside at the end of a week, and then graduallj
disappear. This eruption occurs most commonly in die latter
periods of dentition, and is sometimes observed during conva-
lescence from inflammatory disorders.
397. Diagnosis. — Strophulus is distinguished from other
papular affections chiefly by its occurrence at the infantile
period of life. The papulae so closely resemble those of lichen
as to appear identical with that disease. They are indeed
modified only by the age of the subject in whom they are
developed.
398. Causes. — Strophulus is generally due to gastric and
intestinal irritation, and is frequently associated with the con-
stitutional disturbance induced by dentition. It occasionally
arises from local causes, as from deficient, irritating, or coarse
clothing, want of cleanliness, excess of or improper food, heat,
&c., and is usually developed in children possessing a delicate
and irritable skin. The eruption often alternates with attacks
of gastro-intestinal irritation.
399. Prognosis. — This eruption is wholly unattended with
danger, and rarely presents any features of severity.
400. Treatment. — When the eruption obviously originates in
local irritation, the acting cause should be removed, and fre-
quent ablutions adopted. The tepid bath should be used fre-
quently, together with emollient and sedative fomentations.
The pruritus, which is so annoying a symptom in this eruption,
may be relieved by a lotion of acetate of lead, or sulphate of
zinc, by one containing acetic acid alone, lemon juice, salt
and water, or almond emulsion. When the disease is associated
with gastro-intestinal irritation, it is desirable to avoid the pos-
sibility of repelling the cutaneous determination by cold appli-
cations, and where this has unfortimately been done, recourse
must be immediately had to ihe warm bath, either simple or
medicated with a handfiid of mustard.
When difficult dentition is the exciting cause, relief may be
obtained by incising the gums. And if gastro-intestinal irrita-
tion be present, antacid and laxative remedies should be admi-
nistered. Mercury with chalk, and rhubarb, are valuable
medicines in this state of the alimentary canal.
LICHEN.
401. Lichen (Plate 5) is an eruption of minute conical
papulsB occurring in the adult, and distributed upon a single
region, or over the entire surface of the body. The pimples are
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LICHEN SIMPLEX. 243
comparable in size to millet seeds ; thej are reddish in colour,
or scarcely different firom the natural hue of the skin, and are
attended with much itching and tingling. They are usually de-
veloped in clusters, and appear in single or successive eruptions.
They are non-contagious, and terminate in resolution and fiir-
furaceous desquamation, sometimes in superficial ulceration.
402. The appearance, situation, form, and severity of the
disease, have given rise to its division into seven principal varie-
ties— viz..
Lichen simplex. Lichen gyratus.
„ lividus. „ urticatus.
„ pilaris. „ tropicus.
„ circumscriptus. „ agrius.
LICHEN SIMPLEX.
403. In the simple form of lichen, (Plate 5, a.) the pimples
are distributed irregularly over the surface affected, forming litde
patches from point to point, in which the papulae are more
numerously assembled than in neighbouring parts. Simple
lichen is usually a chronic disorder, but occasionally presents
itself in an acute form. The acute variety is preceded and accom-
panied by febrile symptoms, but these are very slight, and are
referrible to the disordered state of the system, rather than to
the cutaneous disease.
Li the acute form of lichen, the eruption is ushered in by
some degree of smarting and pruritus, which are increased
towards night ; the papulae are red and inflamed, and they con-
tinue hot and itchy for several days. In the course of three or
four days the redness begins to subside, the pruritus diminishes,
and the papulae decline ; vanishing altogether at the end of a
week or ten days, and being succeeded by furfuraceous desqua-
mation of the epiderma.
In the chronic form of the disorder, the papulae are less red
and inflamed. Individually, they run the same course of about
a week or ten days, but being followed by successive crops, the
eruption is prolonged for several months, and even years. By
the continuance of irritation, the skin becomes thickened, and
throws off a copious furfuraceous desquamation, which is espe-
cially abundant in the flexures of joints.
Willan remarked some modification in the appearance of the
papulae, according to the region in which they are developed.
Thus on the face the papulae are large and rounded in form ;
on the neck, trunk, and limbs, they are smaller, more vivid in
colour, and acuminated, and on the hands they are somewhat
paler than in other situations.
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244 DEPOSITIVE INFLAMMATION OF THE DERMA.
The ordinaiy seat of the acute variety of lichen simplex is the
face and tnink of the body. The chronic form of the disease
appears to attack by preference the backs of the hands, fore-
arms, and arms ; and on the lower limbs, the hams, and ankles.
LICHEN LIVIDUS.
404. Lichen lividus is a form of lichen simplex, occurring m
persons of weakly and debilitated constitution, or in those who
are ill-fed, badly-clothed, and live in unhealthy and confined
situations. This disease is occasionally met with among the
squalid inmates of our workhouses at the period of admission ;
it is imaccompanied by constitutional disturbance. The papuls
in lichen lividus are soft and somewhat flattened, they present
a purplish red or livid hue, are of longer continuance than those
of simple lichen, and are developed on the arms and legs, but
chiefly on the latter. They are not unfrequently intermingled
with petechias, and small purple patches. The disease termi-
nates by epidermal desquamation, and is frequently prolonged
by successive eruptions for several months.
LICHEN PILARIS.
405. Lichen pilaris (Plate 5, b.) is a modification of lichen
simplex, the pimples being'developed aroimd the pores by which
the hairs issue from the skin. They are red and inflamed, ex-
tend deeply into the follicle, give rise to much tingling and
itching, and are chronic in their course. The pimples usually
decline at the end of a week or ten days, and terminate by fiir-
friraceous desquamation of the epiderma, but the disease is pro-
longed by successive eruptions to several months or years.
This form of lichen occurs under the same circumstances with
the simple variety. It is seen in persons of unsound and irri-
table constitution, and is frequently coincident with disorder of
the stomach and bowels. The abuse of spirituous drinks is a
frequent cause of the eruption.
LICHEN CIRCUMSCRIPTUS.
406. Lichen circumscriptus (Plate 5, e. f.) difiers from
lichen simplex only in the mode of aggregation of the pimples.
They are collected into one or several patches, of a cimilar or
oval form, and bounded by a well-defined margin, consisting of
the largest and most inflamed papulas. The patches in the first
instance appear as small aggregated clusters, which progres-
sively increase by their circumference, while they fade in the
centre, so as to form rings of variable size. Those which are
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LICHEN CIRCUMSCRIPTUS. LICHEN URTICATUS. 245
most active in their increase, coalesce by their margins, and
produce an irregular tracery of curved and broken lines. The
areae of the circles present a lightish red and yellowish tint, and
become covered by a furfuraceous desquamation. And as the
first developed patches decline, others arise, and prolong the
disease for several weeks. The eruption is most frequently seen
on the fore-arm and back of the hand, on the flexure of the
knee, and on the breast. Lichen circumscriptus is occasionally
observed in association with vaccinia.
LICHEN GYRATUS.
407. Lichen gyratus, a variety described by Biett, is a modifi-
cation of lichen circumscriptus, and consists in the aggregation
of the papulsB into one or several narrow and tortuous bands of
variable length. Cazenave and Schedel observe, " We have
lately seen an instance of this disease in the hospital Saint
Louis ; the papulae, collected into little groups, formed a kind
of riband, which, commencing on the front of the chest, curved
downwards along the inner border of the arm, and continued
onwards, precisely in the direction of the course of the ulnar
nerve, to the little finger.'* Rayer remarks that he has seen
it form " a kind of collar in front of the neck, extending from
one ear across to the other.''
LICHEN URTICATUS.
408. In lichen urticatus, (Plate 5, d.) a variety described by
Bateman, the papulae are of larger size than in other forms of
the disease. They are inflamed and prominent, and resemble
at their first appearance the bite of a gnat or bug. They gene-
rally show themselves suddenly, and disappear, unless irritated
by scratching, in the course of a day. More frequently, how-
ever, from the burning heat and pungent itching which attends
them, they are scratched, and bleed, and a small black crust is
formed upon their summits. The disease seems to be peculiar
to children, and is remarkable for its obstinacy. The following
case is an illustration of this disorder :
A little girl, three years and a half old, delicate, but healthfid
in her functions, has been subject to an eruption attended with
itching since the age of ten months. In January, 1846, she had
measles, and since that period the attacks of the cutaneous
disorder have been more frequent. The eruption shows itself
in the form of large red pimples, generally isolated, but fre-
quently in clusters, particularly on the face, neck, and shoulders.
The pimples are excited by warmth ; for example, by the
warmth of bed, so that she is sometimes awaked in the night
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246 DEPOSITIVR INFLAMMATION OF THE DERMA.
by the itddng. They are also exoited by mental emotion ; thus,
if she be scolded, the itching begins ; and, to use her modier^s
expression, she can at all times ^^ rub them up wherever she
likes." When left to themselves the pimples subside in the
course of twenty -four hours, but when scratched, a little blood
oozes from their summits, and desiccates into a small black
scab. On some of the pimples a little pus forms at their points ;
and on the soles of her feet they run into a vesicular form.
Each pimple, when it does not subside at once, continues for
about a fortnight, but as fresh ones are continually appearing,
the eruption has now been prolonged without amendment for
three months.
Such was the state of the case when I first saw the patient
I prescribed for her citrate of iron with hydriodate of potash,
and the following local application : —
B
Misturs amygdalanim amar., ^rij.
Spiritos rorbmarioi. ^j.
Hydrarfryri bichloridi, gr. v.
Miflce, m fiat lotio.
The lotion relieved the itching, but the eruption continued un-
changed, although the child was obviously improved in health.
I then had recourse to quinine with nitric acid ; but finding no
amendment at the end of another fortnight, I prescribed for her
one grain of chloride of mercury, with two of nitrate of potash,
twice in the day. Nothing, however, seemed to produce an
impression on the disease, and I was glad to avail myself of an
opportunity of sending her into the country, to try the effect of
change of air.
LICHEN TROPICUS.
. 409. Lichen tropicus, or prickly heat, is the usual form of
this eruption, when it occurs in warm climates. Willan gives
an excellent description of the disease, in a communication by
Dr. Winterbottom. From this account the following passages
are selected : —
" The prickly heat appears without any preceding disorder of
the constitution. It consists of numerous papul®, about the size
of a small pin's head, and elevated so as to produce a consider-
able roughness of the skin. The papulse are of a vivid red
colour, and often exhibit an irregular form, two or three of them
being in many places united together, but no redness or inflam-
mation extends to the skin in the interstices of the papulae.^
" The eruption is diffused over those parts of the body which
are usually covered, as the neck, breast, arms, legs, and inside
the thighs. It does not often appear on the fiice, excepting on
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LICHEN TROPICUS. PRICKLY HEAT. 247
the opper part of the forehead contiguous to the hair ; neither is
it ever found in the palms of the hands, soles of the feet, nor on
the hairy scalp. The number of the papulae is much increased
by wearing flannel, or clothes too warm and thick for the climate*
When perspiration is very copious, small vesicles containing a
limpid humour, are often intermingled with the prickly heat,
more especially on the breast, and about the wrists ; but they
terminate in scales, having no disposition to uloerate though
violently scratched. A troublesome itching attends the prickly
heat, and prevents sleep during the night. There is likewise a
frequent sensation of pricking, as if a number of pins were
piercing the skin. This often takes place suddenly after drink-
ing a dish of tea, or any warm liquor, so as to cause the person
affected to start from his seat. The eruption is in general sta-
tionary, and appears equally vivid in the day and in the night.
It does not leave one part and arise on another, unless the
former be much exposed to cold, and the latter be heated by
additional clothing, or by friction. An increase of heat, indeed,
in all cases, produces a greater number of papul®. They some-
times disappear on a sudden, and return again as suddenly,
without any obvious cause ; but whenever the eruption continues
for a lengdi of time, the papulae throw off minute scales, and are
succeeded by a fresh crop, no vestiges being left in ihe skin.
The prickly heat is in general considered as a salutary eruption,
whence we are cautioned not to repel it from the skin by cold or
other external applications. Such a repulsion cannot, however,
be easily effected ; it is certainly not produced by bathing, which
has been hitherto thought highly prejudicial. A vivid eruption
of the prickly heat is a proof that the person affected wit^i it is
in a good state of health, altiiough its absence does not always
indicate the contrary. The sudden disappearance of it, which
frequentiy happens, is rather an effect than a cause of internal
disorder, as of fever, or of any slight complaint of the stomach ;
in the latter case, a temporary stimulus applied to the stomach,
as by spirits, tea, or other warm liquids, has the power of re-
storing the eruption. Its appearance on the skin of persons in
a state of convalescence from fevers, &c., is always a favourable
sign, indicating the return of health and of vigour.''
^^ Various means have been employed to alleviate the itching
and tingling of the prickly heat ; the favourite remedy at Sierra
Leone is the juice of lime rubbed on the skin, which, however,
has no considerable effect. I have found it of most advantage
to use a light cool dress, and to avoid the drinking of warm
liquors."
Dr. James Johnson, who was a sufferer from the prickly heat,
gives the following animated description of the disorder: —
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248 DEPOSITIVE INFLAMMATION OF THE DERMA.
" This unwelcome guest assails us at all, and particularly the
most unseasonable hours. Many a time have I been forced to
spring from table, and abandon die repast which I had scarcely
touched, to writhe about in the open air for a quarter of an hour ;
and often have I returned to the charge with no better success
against my ignoble opponent The night affords no asylum.
For some weeks after arriving in India, I seldom could obtain
more than an hour's sleep at one time, before I was compelled to
quit my couch with no small precipitation, and if there were any
water at hand, to sluice it over me, for the purpose of allaying
the inexpressible irritation. But this was productive of tempo-
rary relief only, and what was worse, a more violent paroxysm
frequently succeeded."
" The sensations arising from prickly heat are perfectly inde-
scribable, being compounded of pricking, itching, tingling, and
many other feelings for which I have no appropriate ap-
pellation."
" It is usually, but not invariably, accompanied by an eruption
of vivid red pimples, not larger in general than a pin's head,
which spread over the breast, arms, thighs, neck, and occasionally
along the forehead. This eruption often disappears in a great
measure when we are sitting quiet, and the skin is cool, but no
sooner do we use any exercise that brings out a perspiration, or
swallow any warm or stimulating fluid, such as tea, soup, or
wine, than the pimples become elevated, so as to be distinctly
seen, and but too sensibly felt."
In reference to the imagined dangers of repelling this enip-
tion, Dr. Johnson continues, " Indeed, I never saw it even re-
pelled by the cold bath ; and in my own case, as well as in many
others, it seemed rather to aggravate the eruption and disagree-
able sensations, especially during the glow which succeeded im-
mersion. It certainly disappears suddenly sometimes on the
accession of other diseases, but I never had reason to suppose
that its disappearance occasioned them. I have tried lime-juice,
hair-powder, and a variety of external applications, with little or
no benefit ; in short, the only means which I ever saw productive
of any good effect in mitigating its violence, till the constitution
got assimilated to the climate, were, light clothing, temperance
in eating and drinking, avoiding all exercise in the heat of the
day, open bowels, and last, not least, a determined resolution to
resist with stoical apathy its first attacks. To sit quiet and un-
moved under its pressure is undoubtedly no easy task, but if we
can only muster up fortitude enough to bear with patience the
first few minutes of the assault without being roused into motion,
the enemy, like the foiled tiger, will generally sneak, and leave
us victorious for the time."
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LICHEN AORIUS. 249
The author very truly observes, that an affectioii similar to
liehen tropicus is sometimes seen during the summer season in
this country. I have myself suffered from its annoying attack on
one or two occasions, and can add my testimony to that of Dr.
Johnson.
LICHEN AGRIUS.
410. Lichen agrius (Plate 5, g. h.) is the most severe form
of lichenous disease ; the papulaB are acuminated and prominent,
of a vivid red colour, and numerous ; they are aggregated into
clusters of irregular form and size, are attended by much heat,
smarting, and itching, and by a painful sensation of tension, and
they are surrounded by considerable inflammation.
These symptoms continue to increase for several days, when
the less inflamed papulse diminish in redness, and become
covered by a fiirfuraceous desquamation. The more inflamed
papulae, however, and especially those which are collected into
clusters, have their points torn off by scratching, and form small
superficial ulcerations, which pour forth a sero-purulent fluid,
and this secretion desiccates into yellowish crusts. The skin
around the papulse is at the same time thickened by the con-
tinuance of the inflammation, and fissured by deep cracks, from
which a copious secretion exudes. In milder cases, the disease
subsides before reaching this extreme, the redness and painful
symptoms diminish, and the eruption dies away by the twelfth
or fourteenth day.
In the severe form, as soon as the crust falls off and desqua-
mation occurs, new papulae are developed, which pursue the
same course with their predecessors, and the disease is pro-
longed to several weeks, or even months ; at other times, the
eruption appears and disappears several times in succession
before a cure is accomplished.
Lichen agrius is generally partial in its eruption, being con-
fined to one or more regions. It is most frequently seen upon
the arms, the shoulders, the loins, the legs, as also upon the
chest and face. The itching and smarting are sometimes into-
lerable, and are much aggravated towards the evening, or by the
warmth of bed,* exercise, stimulating food and drinks, &c.
Occasionally the papulse are intermingled with small vesicles,
which speedily burst, and terminate by desquamation.
The constitutional symptoms which precede and accompany
lichen agrius are, rigors, flushes of heat, lassitude, pains in the
limbs, headache, nausea, pain at the epigastrium, white, furred
tongue, and quick pulse. These symptoms make their invasion
* Mr. Planibe remarks, that the parts smart for an hour or more as if they ** had
been severely scalded."
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250 DEPOSITIVE INFLAMMATION OF THE DERMA.
for several days previously to the appearance of the cataaeoos
affection, and are, for the most part, relieved by its eruption.
When the disease has been suddenly repelled by treatment
or other cause, serious visceral disease has sometimes been
established.
411. Diagnosis. — The diagnostic characters of lichen are, its
solid and prominent pimples, the colouration of these pimples,
and their attendant itching, which is of the tingling kind. The
diseases with which it might by inattention be confounded, are
the pruriginous affections: prurigo, scabies, and eczema. In
prurigo, however, the papulae are paler than those of lichen, and
there is a general unhealthiness of appearance, and oftentimes a
disorganization of the skin. The little black scabs, which sur-
mount the papulae of prurigo when torn by the nails, and the
scratches by which the skin is marked, must also be borne in
mind. Scabies resembles lichen only in the presence of itching,
but this is different in its character ; moreover, it may be re-
marked, that lichen selects by preference those parts of the body
in which the derma is thickest, as the back, the face, and the
outer sides of the limbs, whilst only the thinnest regions are
those affected by scabies. Eczema, it will be recollected, is a
vesicular eruption, and totally distinct from the solid papulae of
the disease under consideration. When the points of the papulae
of lichen are torn off, the crusts which succeed are thinner and
more scale-like than those of eczema.
Lichen circumscriptus bears some resemblance, in the form of
the patch, to erythema circinnatum, erythema marginatum, and
herpes circinnatus, but from these the diagnosis is by no means
difficult In erythema circinnatum the sui^ce is smooth, in ery-
thema marginatum, although raised and papulated, there are no
scattered papulae in the neighbourhood of the patch, while in
herpes, there are vesicles, or their detrita, and a greater degree
of redness.
Lichen urticatus differs from urticaria, in the irregularity of
form and size of the papulae, their greater redness, and chronic
character; and from erythema papulatum, by the small and
irregular patches of the latter being merely papuloid, by their
inferior degree of redness, and by tfie comparative absence of
pruritus.
Lichen agrius is especially characterized by the close aggre-
gation and highly-inflamed state of the pimples, by the severe
smarting and tingling, by scaly crusts, the superficial ulcera-
tions, the fissures and chaps which so frequently form, and by
the thickening and condensation of the integument.
412. Causes, — Lichen occurs principally in persons of nervous
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CAUSES AND TREATMENT OF LICHEN. 251
and irritable temperament, and at all periods of life. It is most
frequently observed in the spring and summer season, and espe-
cially in die latter. Increased temperature appears to have great
influence in producing the disease, as we see evinced in lichen
tropicus, or prickly heat ; for the same reason, the eruption is
frequency met with on the arms and face of persons employed
near the fire, as of cooks and smiths. Local irritation is not un-
frequently the cause, in persons of irritable skin, from the use of
flannel or woollen raiment, or coarse body linen. Other ex-
citing causes are, depressing moral or physical conditions, irre-
gularities of diet, intemperate habits, &c. Sometimes it appears
critically in fevers, and in acute or chronic visceral affections.
Lichen agrius would seem to be most frequent in elderly per-
sons, females, and young persons of sanguine or nervous tem-
perament. It is usually referrible to fatigue, anxiety, stimulat-
ing food, and especially to spirituous drinks. But the most
troublesome cases of lichen agrius with which I have had to
contend, have occurred upon ^e legs of men who had passed
the mid-period of life. These cases were all accompanied with
cedema, and sometimes with varicose veins.
413. Prognosis. — Lichen is not dangerous to life, but is often
exceedingly troublesome and intractable. That which originates
from the more simple causes in young persons, and pursues an
acute course, generally terminates in two or three weeks, but the
ehronic kinds may last for several years. Lichen of the face is
especially obstinate and distressing.
414. Treatment, — In lichcnous eruptions, the diet must be
particularly attended to ; the regimen should be moderate and
cooling, and all stimulating food and drinks especially avoided.
If the subject be plethoric, moderate bleeding must be adopted,
particularly if the eruption be acute and general. In less exten-
sive cases, gende laxatives or remedies to act on the large intes-
tine will usually suflice. Under all circumstances, every means
must be employed to regulate the secretions, and restore the
digestive frinctions to their healthful condition. When this is
effected, the mineral acids should be administered, either alone
or combined with tonics, as the state of health of the patient
may indicate. In obstinate cases I have had recourse to the
Uquor hydriodatis hydrargyri et arsenici and liquor arsenicalis
with advantage,
The external applications, in cases of lichen, are, cold or tem-
perate baths, and emollient and soothing washes ; warm baths
and all stimulating remedies are highly objectionable. The best
application for the relief of the pruritus is a weak lotion of acetic
acid, or vinegar and water.
When the disease assumes a chronic form, stimulating sub-
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252 DEPOSITIVE INFLAMMATION OF THE DERMA.
stances, with a view to modify the action of the skin, are indi-
cated ; such applications are, weakly alkaline baths, the vapour
douche, lotions of supersulphate of alumina, nitrate of silver, or
bichloride of mercury, ointments of the protochloride* or deuto-
ioduret of mercury ,t sulphur, &c. The sulphureous bath is
sometimes useful ; and Mr. Plumbe suggests that the sulphur
vapour bath might be found beneficial.
The remedy from which I have derived the greatest benefit in
the chronic forms of this disease is the tincture of croton (§ 275).
415. Lichen simplex et offritis. — A commercial traveller, ag^
50, of full habit, and accustomed to free living, had an itching
eruption on the outer side of the right leg, which he believed to
have been occasioned by the friction of his boot. This happened
in the spring of 1844; it annoyed him for some time, but even-
tually got well. In the spring of 1845 the eruption returned
upon both legs, and was attended with troublesome itching, con-
siderable swelling, and a copious oozing of ichorous fluid. He
received some relief from the medicines given him by his medical
adviser, but not advancing so fast as he thought right, he went
to Harrowgate, and returned after some time in the same state
as when he went.
I first saw him in October, 1845. Every part of his skin, with
the exception of the face, hands, and soles of the fee^ was
covered with an eruption of a bright red colour ; there were
isolated pimples, entire, abraded, and covered with small brown-
ish and blackish scabs ; aggregated pimples, so close as to dot
every part of the surface ; and large oozing and scaly patches
of lichen agrius ; the latter being chiefly seated on the lower
limbs. The legs below the knee were swollen and infiltrated.
As the disease had assumed a chronic form, although highly
inflamed, I ordered him an ointment containing half a drachm
of croton oil to two ounces of ceratum cetacei, to be rubbed upon
the skin. Four days afterwards, I allayed the artificial irritation
caused by the croton oil, by means of an oleaginous cerate con-
taining liquor plumbi, and at the end of another four days pre-
scribed a lotion of tannin of the strength of two drachms to a
pint. He was now so far recovered as to be enabled to under-
take a business journey.
The constitutional treatment consisted in taking four pills
daily, containing twelve grains of tannin, with extractum rhaei
and extractum hyoscyami.
Hydrargyri protochloridi, 33. Hydrarg3rri dento-iodureti, gp. x
Campborse pulveris, 3j. Adipis suUIsb, Jj.
Adipis suUls, §j. Ft. UDguentomi
Ft unguentum
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CASES ILLUSTRATIVE OF LICHEN. 253
Early in December, he had a second severe attack of this
troablesome disease ; the irritation of the skin attending the
first having not entirely subsided. This is so common with
lichen agrius, that I was prepared to expect such an occurrence.
But it is difficult to make patients understand the necessity for
continuing a course of treatment after the local disease appears
to be cured, or to take the necessary precautions to prevent a
relapse. The habit of disease seems more difficult to contend
with in the skin than in any other of the tissues of the body.
On the second occasion the disease in this gentleman was as
severe as the previous attack. I again had recourse to the stimu-
lant application, but with less success than in the first instance.
Internally I gave him small doses of sulphate and carbonate of
magnesia with nitrate of potash ; and the infiision of gentian with
nitric and muriatic acid. I dismissed him, much improved, in
the beginning of January, 1846; but there were still many
pimples on the skin, and a good deal of congestion.
In March, he had a third attack, with considerable disturbance
of the digestive organs. I prescribed as before the saline ape-
rient, followed by mineral acids and bitter infusion ; and as soon
as the tongue became clean, gave him Donovan^s solution in doses
of twenty drops three times a day. Locally, he employed aqua
calcis as a lotion ; the lime-water liniment, and vapour ba^s.
Under this treatment he entirely recovered.
During nearly the whole of this treatment the patient followed
his ordinary pursuits. When the disease is local and the patient
submits to lay up, the water-dressing is an important means of
relief.
416. Lichen a ffritis ; chronic; treated toith Tincture of Croton. — A
lady, aged 54, had suffered about six years back, from an eruption,
which, from her account, I take to have been eczema. It occurred
at the change of life, and lasted eighteen months. In August,
1845, she had an attack of lichen which affected the face ; in
November it made its appearance in circumscribed patches on
the neck, flexures of the elbows, backs of the hands and wrists ;
and was attended with considerable itching.
On the 19th of March she first applied to me ; the disease
was located on the neck, flexures of the elbows, and backs of the
wrists. The skin was thickened, red, chapped, covered with
whitish and yellowish scales, and sprinkled with oozing points.
She was pallid, felt weak and languid, and had a broad white
tongue. I gave her nitric and hydrochloric acid, with gentian
and calumba ; and pencilled the diseased skin with tincture of
croton ; ordering her to apply a cold compress as soon as she
felt pain and heat in the parts. I repeated this application four
times. On the 7th of May she was quite weU.
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254 DEPOSITIVE INFLAMMATION OF THE DERMA.
I haTe selected this case from many similar ones recorded in
my note-book, as Ulustrating the ordinary result of treatment of
chronic cutaneous disease by the tincture of croton.
PRURIGO.
Syn. Prurittis,
417. Prurigo (Plate 5.) is a chronic and noncontagious affec-
tion of the skin, characterized by a thickened and discoloured
state of that membrane, and by an excessive and burning pru-
ritus. Moreover, this state of the skin is generally accompanied
by an eruption of isolated and scattered papulae, not differing in
colour from that of the general surface. The thickening of the
skin gives it a coarseness of character, and upon close examina-
tion it is found raised into small flat elevations, caused by the
svrelling of the little angular compartments between the Unear
markings (§. 31.) It is also more or less marked by scratches
made by the finger nails, and the torn papulae are each sur-
mounted by a small, thin and black scab. The colour of the
skin is yellowish and dirty. The disease is unaccompanied by
constitutional symptoms.
418. The principal varieties of prurigo, as a general affection,
are three in number ; to which may be added several local forms.
The general varieties are,
Prurigo mitis,
„ formicans,
„ seiiilis.
PRURIGO MITIS.
419. In the milder form of prurigo (Plate 5, n. n.) the morbid
change in the skin is less decided than in the severer kinds ; but
the pruritus is vexatious and annoying. It is brought on by
mental emotion, the taking of food, or by change of temperature,
and is augmented by scratching, by exercise, and the warmth of
bed. The skin, which at first presented no appearance different
from health, becomes by degrees thickened, indurated and coarse ;
the pimples, few in number at first, become numerous, many have
their points torn off, and are surmounted by a small black crust ;
there are scratches here and there upon the skin ; it becomes
yellowish and dirty ; and the epiderma is thrown off as a for-
furaceous and pulverulent desquamation. Occasionally tiie
extreme irritation produced by tiiis eruption gives rise to the
development of ecthjonatous pustules.
Prurigo mitis makes its appearance in the spring and summer
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PRURIOO MITIS. PRURIGO FORMICANS. 255
months, without premonitory symptoms. It is developed upon
every part of the surface of the body, but its more usual seat is
the posterior surface of the trunk, the shoulders, the outer sides
of the limbs, as of the arms and thighs, the chest, and sometimes
the face. When the disease terminates mildly, it declines at the
end of two or diree weeks ; at other times the affection is pro-
longed for several months.
PRURIGO FORMICANS.
420. Prurigo formicans (Plate 5, n.n.) is a severe degree of
prurigo mitis, differing from the latter in the longer duration of
the disease, and in the greater violence of the pruritus. The
itching is incessant, frequently insupportable, and accompanied
by a most distressing sensation, compared, by the sufferers, to
having their flesh devoured by thousands of ants, or to the
piercing of the skin with red hot needles. Rayer observes, that
patients describing their sufferings speak of heat of the bloody
burning Jires, maddening itchiness^ &c.* It is increased by
every alternation of temperature, particularly by the warmth of
bed ; so that patients affected by this disease tear themselves
cruelly with their nails throughout the entire night, and are
totally unable to sleep until, towards the morning, they sink
from exhaustion into forgetfiilness, or after a night of disturbed
sleep, they are awaked with the first dawn by their unsparing
tormentor. The violence of the scratching to which the sufferers
so afflicted yield themselves, produces considerable redness
of the skin, and by removing die heads of the papulse, gives rise
to the formation of numerous small black scabs ; these little scabs,
resulting from the oozing of a minute drop of blood from each
of the wounded papulae, with intermingled scratches, are fre-
quently the only indication of the disease. Pnirigo formicans
is very tedious in duration, extending to several months, and
sometimes, with intermissions, to years. At the termination of
the disoic<ler, the skin remains dry and thickened, and the epi-
derma exfoliates by a furfuraceous and mealy desquamation.
Prurigo formicans is frequently associated with some visceral
affection, in which case it may be preceded and accompanied by
febrile disorder. When suddenly repelled, serious symptoms
have been seen to arise, and call for active treatment The dis-
* The Abb4 Morellet was afflicted with this distressing disease at the adyanced
age of eighty years. It obliged him to rise several times in the conrse of the night,
to sponge hi8 body with yinegar and water, containing the acetate of lead. Writing
to Atibert, be expressed himself as writhing on the ** gril de Sl Laurent." A sol-
dier, affected with the same disease, compared his sufff rings to being pierced all oyer
with halberds. Alibert records several distingaished men among those who have
been afflicted with this persecuting malady, as Plato, Charles V., and Charles IX.
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256 DEPOSITIVE INFLAMBCATION OF THE DEBMA.
ease occurs both in children and adults, and at all seasons of
the year.
PRURIGO SENILIS.
421. The prurigo of aged persons bears a close resemblance
to prurigo formicans ; but the disorganization of the skin is more
complete, and the itching incessant. The disease is very obsti-
nate, and frequently endures for years.
In severe cases, write Cazenave and Schedel, " the skin be-
comes swollen and inflamed ; eruptions of vesicles, pustules, and
boils, appear, and sometimes abscesses are formed. Under such
circumstances there are frequently symptoms of fever, restless-
ness, and sleeplessness, and sometimes indications of gastro-in-
testinal irritation, &c. Finally, in these serious and excessively
rebellious cases, the patient is tormented with dreadful itching."
In one very severe case of prurigo senilis, Willan discovered a
number of minute pulices upon tiie skin, and he remarks upon
the frequent association of the pediculus vestimentorum vrith
the eruption; of course he means upon the lower classes of
persons.
Local varieties.
422. The principal local varieties of prurigo are three in num-
ber : they are characterized by intense itching, and by the alte-
ration of the dermal tissues above described as constituting the
general affection. Willan describes under this head several other
forms of distressing itching, which are unaccompanied by papulse,
and are ascribable to an altered sensibility of the cutaneous
nerves. I have therefore thought it advisable to arrange tiie
latter affections under the head of pruritusy and treat of them
separately in a distinct section of the work. The local varieties
of prurigo are, —
Prurigo podicis.
„ scroti.
„ pudendalis.
PRURIGO PODICIS.
423. Prurigo podicis consists in an alteration of the skin,
similar to that already described, around the anus, and upon
the neighbouring regions of the perineum and thighs. The itch-
ing is severe and distressing, and increases at night, commenc-
ing shordy after the sufferer has retired to bed, and continuing
incessantly for several hours. As a consequence of scratching,
the papulae become covered by minute black scabs, which
serve as a diagnostic character. This disease is exceedingly
obstinate, and unless relieved by treatment, will last for severed
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DIAGNOSIS AND CAUSES OP PRURIGO. 257
months. After it has continued for some time, the integument
becomes very much thickened.
PRURIGO SCROTI.
424. Prurigo scroti is frequently an extension of the preceding
disease ; the papulae are developed on the scrotum and root of
the penis, and give rise to unappeasable itching. The patient,
in making attempts to relieve the pruritus, often produces painful
excoriations, ^hich increase his misery.
PRURIGO PUDENDALIS.
425. Prurigo pudendalis is a most distressing affection, but,
happily, one of unfrequent occurrence. The disease is situated
chiefly on the labia majora, and mucous membrane of the ^nllva,
but sometimes extends upwards along the vagina. The pruritus
is generally constant, and so violent as to induce an unceasing
necessity for friction with hard substances, or scratching. The
continuance of the itching produces inflammation and swelling
of the parts affected, and induces symptoms approaching to
nymphomania.
426. Diagnosis. — ^Prurigo is distinguished from other papular
eruptions by the morbid alteration of the skin, and by the burn-
ing pruritus. These characters serve to render the diagnosis
between prurigo and lichen very simple. The minute scabs
which succeed the broken apices of the papulae of prurigo are
very similar to those of lichen simplex and scabies.
Prurigo cannot be confounded with scabies, when it is re*
collected that the signs of the latter are a ragged and under-
mined state of the epiderma, the presence of vesicles, and,
above all, of the acarus scabiei. The pruritus of the two dis-
eases is also different ; in prurigo it is burning and tingling, and
occurs in paroxysms, while in scabies it is constant and more
supportable.
427. Causes, — Prurigo appears at all seasons of the year, and
at all periods of life, being modified by its occurrence at certain
ages. Thus, in children and adults, the first two varieties are
most frequent, while in old persons and weakly children, prurigo
senilis generally appears. It has been remarked that prurigo
Initis is chiefly seen during the spring and summer months. The
causes of prurigo are, want of cleanliness, insuflicient clothing,
residence in unhealthy situations, amenorrhoea, dysmenorrhcea,
uterine irritation associated with pregnancy, &c. Prurigo formi-
cans is occasionally induced by the presence of visceral disease
and mental affections of long continuance, improper and over-^
s
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258 DEPOSITIVE INFLAMMATION OF THE DERMA.
stimulating diet, stimulating drinks, deficient and improper
food, &c. Prurigo senilis appears to depend upon debility of
the system — a state which is popularly expressed by the term
impoverished blood.
428. Prognosis. — ^Prurigo is often exceedingly obstinate, and
resists every kind of treatment, and in old persons, by the con-
tinuance of irritating and unappeasable pruritus, may be destruc-
tive of life. In young persons and the adult it is not attended
with danger.
429. Treatment, — The first point, and one of the most im-
portant in the treatment of prurigo, is the employment of baths,
which should be used daily. The temperature of the badis
should not be higher than seventy degrees, and they may consist
of simple water with soap, the alkaline, or sulphur bath. When
the daily use of the alkaline or sulphur bath is found to irritate
the skin, it should be alternated with the simple soap bath. A
mucilaginous bath in some cases may be found advisable, and
the cold water bath and sea-bathing may also be useful in re-
storing the tone of the nervous system and skin, and promoting
recovery.
With a view of exciting anew action in the diseased skin, and
modifying its morbid condition, I am in the habit of using stimu-
lating applications, such as the tincture of croton, either pure
{§ 275) or diluted with an equal part of spirit of rosemary. Pre-
viously to the use of the croton, the skin should be prepared by
repeated frictions with a damp sponge dipped in fine oatmeal,
and then washed ; and after the decline of the eruption which
the croton excites, the firictions with oatmeal should be continued.
After a few applications of the croton in this way, the bichloride
of mercury in almond mixture, in the proportion of five or ten
grains to the half-pint, will often complete the cure. I have also
obtained considerable benefit firom the use of the tincture of
iodine, painted on the morbid surface. Another local applica-
tion that I have found of service in allaying the itching in pru-
rigo senilis is glycerin, applied by means of a sponge.
The applications best suited for the temporary relief of pru-
ritus are, vinegar, weak solution of bichloride of mercury, tinc-
ture and watery solution of opium, creosote, ointment of opium
with camphor, the diluted nitrate of mercury ointment, ointment
of lime, lotion of muriate of ammonia, sulphuret of potash^
chlorate of soda, &c. It is always necessary, as well as desir-
able, to have a number of anti-pruritic remedies at hand, for it
frequently happens that one may be successful while all the rest
fail, and it is constantly found that a remedy which may be per-
fecdy effectual for this purpose in one case, may be utterly
useless in the next^ I therefore subjoin several formulae rq-r
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TREATMENT OF PRUBIOO. 259
oammended by French dermatologists, and quoted by M.
Gibert:—
Hydrate of lime, 5 ij.
SobcarboDEte of soda;
Lamdaoam, aa 588.
Lard, iJ.
Anti-pruriginous ointment recommended by Alibert: —
ft
Laadanam;
Sablimed salphar, aa 5S8.
Oxide of ziuc, 3J.
Oil of atmonda, 5 j.
Lard, ^iy.
M.
Ointment employed successfully by Biett for an obstinate
prurigo of the hands : —
ft
Cinnabar;
Laadanum, aa 3^.
Sablimed sulphur, ^88.
Lard, iv.
M. ^
Ointment for local prurigo : —
ft
Muriate of ammonia, z j.
Powder of white helletK>re, ^88.
Lard, 2iij.
M. ^
The general treatment of prurigo must consist of a light and
cooling regimen, the avoidance of stimulating food and drinks,
laxative medicines, diuretics, acid tonics, &c. Milk of sulphur
in moderate doses night and morning, for two or three weeks, is
sometimes found useful, particularly in the prurigo mitis of
children. If the patient have a full pulse, and be plethoric, the
loss of a quantity of blood proportioned to his strength is requi-
site, especially in cases of prurigo formicans. Indeed, I have
seen bleeding in such cases act like a charm in allaying the un-
appeasable torture from which the patient was suffering. In
prurigo senilis, a generous and nutritious diet is indicated, with
occasional laxative and tonic medicines. When the disease
resists the influence of milder means, Donovan's solution, or
the liquor arsenicalis may be exhibited without hesitation ; of
the former of these medicines, twenty drops three times a day ;
of the latter, five, with meals. It is necessary, in directing the
use of these solutions, to advise the common precaution of
avoiding acids, fruits, and vegetables, and the omission of the
drops whenever any pain, giddiness, or uneasy sensations in
s2
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260 DEPOSITIVE INFLAMMATION OF THE DERMA.
the head or pinchings in the stomach are experienced. Thej
may be resumed after a rest of a day or two ; or as soon as the
sjrmptoms have subsided, and if necessary be continued in a
diminished dose.
Prurigo podicis and prurigo scroti must be treated on the
general principles stated above ; in most oases, constitutional
treatment is required. The local means for relieving the pru-
ritus are especially needed in prurigo podicis and prurigo scroti,
and in the former, abstraction of blood from the verge of the
anus, by means of leeches, is frequently usefril. Additional
local applications are, cold poultices, or compresses, ice, cold
hip-baths, gelatino-sulphureous baths, opium suppositories, cold
cream, acetate of lead ointment, the dilute nitrate of mercury
ointment, the yellow and black wash, chlorate of soda lotion, &c.
In prurigo pudendalis the local remedies recommended above
vrill be found useful, and their use must be aided by general
means, and by depletion, by leeches, from the vulva.
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CHAPTER VIL
SQUAMOUS INFLAMMATION OF THE DERMA.
430. Under the designation " Squamous inflammation of the
denna," I have assembled a group of diseases which are espe-
cially characterized by inflammation and hypertrophy of the
derma ; by the appearance of the disease, for the most part in
patches, which are frequently circular in form ; and by the pro-
duction on the diseased skin of laminae or scales of abnormal
epiderma. The diseases forming this group are three in num-
ber— namely,
Lepra.
Psoriasis.
Pityriasis.
431. All dermatologists since the time of WiUan are agreed
as to the close analogy between these diseases, and the only
innovation which has been suggested with regard to them is that
of combining lepra and psoriasis under a single genus. If any
useful purpose were to be gained by this reunion, I would
cheerfully record my vote in its favour, for the similarity of
lepra and psoriasis in their essential nature is so complete as to
render them almost identical. On the other hand, it may be
fairly advanced, that the terms are so well imderstood that no
error can arise out of their separate existence, that time has
rendered them classic sounds, which could not well be dis-
pensed with, and, moreover, that certain difierences of moment
are admitted between them, such as extent of surface occupied,
duration, and severity.
432. As respects their pathological nature, there can be no
doubt of the analogy subsisting, not between lepra and psoriasis
only, but between the three diseases ; and whatever differences
we may establish in their external appearances, the principle
of treatment must remain the same lor all. The distinctions
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262 SQUAMOUS INFLAMMATION OF THE DERMA.
which I should draw between them, amounting to nothing more
than specific differences, are as follows : —
Lepra — hypertrophy of the skin greatest ; patches circular
in form, most elevated above the surface, healing from centre,
never attaining a large size ; scales thick, regular in structure ;
most amenable to treatment.
Psoriasis — ^hypertrophy of the skin less ; patches irregular
in form, less elevated, healing irregularly, always attaining a
large size, and often involving the greater part of a limb; scales
thinner, irregular in structure ; less amenable to treatment.
Pityriasis — hypertrophy of the skin least; patches irregular
in form, only slightly elevated, healing irregularly, generally
attaining a considerable size ; often occupying an entire re^on
of the body; scales thinnest and smallest; less amenable to
treatment.
433. The type of these affections, established by Willan, is
the development of a squama or scale, which he defines to be
"a lamina of morbid cuticle, hard, thickened, whitish, and
opaque. Scales, when they increase into irregular layers, are
denominated crusts." WiUan was desirous of rendering the
language of dermatology so precise, that no misunderstanding
could possibly arise with regard to the exact signification of the
terms employed, but his followers have not trodden in his foot-
steps, and even he himself has shown some inconsistency.
With the intention of superior precision, he limited the term
crust to the layers of morbid epiderma developed in the scaly
diseases. But at the present day we use it, somewhat loosely,
to signify such collections on the surface of the skin as from
their extent and thickness convey the impression of a mass
greater than the acceptation usuaUy assigned to the word scab.
For instance, the thick, greenish-yellow concretion which forms
in impetigo faciei, and covers the face like a mask, and which
is truly a scab, we commonly call a crust, and Willan would
seem to sanction the employment of the term in such a sense by
retaining the ancient appellation of this disorder— <nru8ta lactea.
434. The hypertrophy of the derma in the squamous diseases
is very evident ; the papillae are often so much elongated as to
be apparent to the naked eye on the removal of the scale ; and
the latter, on its under surface, is pitted for their reception hke
the epiderma of a wart. The cells composing the scale are
seen, when examined with the microscope, to be imperfectly
formed, to exhibit, in fact, an arrest of development referrible to
their early stages of growth, when they are composed of granules
(§22). In consequence of this imperfection of formation, and
probably as the result of a watery efiusion accompanying the
growth of the cells, the latter lose the cohesion which diej po»-
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CHARACTERS OF THE SQUAMOUS DISEASES. 203
sess in normal epiderma, and the crevices and spaces which
exist between them become filled with air. It is this peculiarity
of structure that gives to the scales of lepra and psoriasis their
peculiar white and silvery character. In lepra vulgaris the
central part of the scales is usually condensed, and therefore
yellowish in colour, while the silvery whiteness is most con-
spicuous upon the raised border of the patch. On the small
elevations of lepra guttata, the entire scale presents the cha-
racter of the peripheral portion of the patches of lepra vulgaris;
hence the name lepra aJphoides, which was assigned to it by
Willan. In psoriasis the scales are more condensed, and there-
fore jthinner and more yellow than in lepra. And in pityriasis
they are thrown off as they are produced, and are consequently
whitish or greyish, and extremely thin.
435. In his order " Squamae," in addition to the three before-
mentioned diseases, Willan admits a fourth — ^namely, ichthyosis.
In this arrangement he is decidedly in error, ichthyosis bears
no analogy whatever to the leprous affections. There is no
redness of the skin in ichthyosis, no production of scales of
morbid epiderma ; the disease being, indeed, one affecting the
sebiparous system and not the derma. Alibert still continues
to consider the squamous affections under their ancient title,
^^ herpes," and ranges them in his group of '^ dermatoses dar-
treuses," in association with acne, impetigo, and lupus.
LEPRA.
Syn. Alphas. Lepidosis. Dartre squammeuse, Alibert.
Atissatz. Germ.
436. Lepra (Plate 6) is a noncontagious and chronic in-
flammation of the derma, consisting in the eruption, on various
parts of the body, of raised and circular patches, which are
speedily covered by thin, semi-transparent scales of white and
morbid epiderma. The patches are prominent around their
circumference, and somewhat depressed in the centre ; they
increase by the extension of their periphery, while the central
area gradually returns to the natural state. During the progress
of the patches, the scales are often thrown off, and are replaced by
successive formations. The local disorder is unaccompanied
by constitutional symptoms ; it is most strongly marked in the
neighbourhood of tibe knee and elbow joints, where it frequently
forms continuous patches of large size (Plate 6, o.), and it
endures for a considerable length of time, sometimes recurring
at particular periods for several years, and lasting for several
months at each recurrence.
437. The varieties of lepra, with the exception of the syphi-'
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264 SQUAMOUS INFLAMMATION OF THE DERMA.
litio form, are mere modifications of the same disease, dependent
on trivial circumstances. Willan distinguishes four Tarieties,
one of which, namely, lepra alphoides, so closely resembles the
variety of psoriasis, termed guttata, that I have not hesitated to
include both eruptions under the designation, lepra guttata.
This change will assist in removing one of the perplexities of
dermatology, the unnecessary subdivision of diseases, while no
violence will be done to the generic distinctions. The varieties
of lepra will, therefore, stand as follows : —
Lepra vulgaris. Lepra nigricans.
„ guttata. „ syphilitica.
LEPRA VULGARIS.
SjD. Dartre furfuracke arrondU, Herpes furfuraceus circinnaius, AHbert.
438. Lepra vulgaris (Plate 6, a. b.) commences by small,
smooth, and prominent spots of a dull red colour, usually in
the neighbourhood of the knee and ankle joints, in the lower
extremities, and of the elbows and wrists in the upper limbs.
In the course of a day or two from their first appearance, the
spots are covered widi thin whitish scales. In three or four
days they have increased in size by the extension of their cir-
cumference, which is raised and red, while the central area
loses a portion of its redness and becomes depressed, the whole
patch being covered by a laminated scale of moderate thick-
ness. After increasing gradually in this manner to a size vary-
ing from that of a fourpenny piece to a half-crown, the eruption
usually becomes stationary, excepting about the joints, and
upon the scalp, where the circles run into each other by their
periphery, and form a continuous patch of large size. These
large irregular patches are also produced occasionally in other
situations. The scales of lepra are remarkable for their greyish
white and silvery hue, being sometimes almost metallic in ap-
pearance. They are composed of thin lamellae, which gradually
increase in size from the centre to the circumference, so as to
project beyond each other in an imbricated manner, a disposi-
tion which is marked on the surface of the scale by a series of
concentric lines. When rubbed off by the attrition of dress, or
thrown off spontaneously, they leave upon the skin a surface
which is of a dull red colour and smooth in recent cases, and
rough and furrowed when the disease has already existed for
some time. After tlieir fall, the thin crusts are speedily re-
produced.
Lepra is rarely accompanied by constitutional symptoms, and
is attended with very little local inconvenience, the latter not
exceeding a slight degree of itching on getting warm in bed, or
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LEPRA VULGARIS. LEPRA GUTTATA. 265
on exposure of the body to changes of temperature. When the
patches are so extensive as almost or completely to surround a
joint, they are productive of some degree of stifiness. The
disease is slow in its march, and usually continues for years,
sometimes for life, rarely getting v^ell when left to itself.
The first patches of lepra appear about the knee or elbow
joint, and often symmetrically on the two limbs at the same
time. Willan indicates a point immediately below the patella
as the most frequent site of commencement of the disease. Ex-
tending from the knee, the patches appear in various points
upon ^e leg as far as the ankle. WUlan has remarked, as a
peculiarity of lepra, that it invariably occurs in the situation of
a superficial bone, as in the course of the tibia, of the crests of
the Uiac bones, &c., and rarely on the muscular parts, as upon
the calves of the legs. The patches also proceed upwards
towards the trunk, invading in their turn the upper parts of the
limbs and the trunk of the body. Sometimes the disease attacks
the scalp, and occasionally the pubic region.
When lepra afiects the scalp it confines itself to the limit of
the hair, extending for a short distance only upon the neigh-
bouring skin. In this situation the disease is highly incon-
venient, exciting much pruritus, and producing an irritation,
which is increased by scratching, and followed by a morbid
secretion. Nearly the same inconveniences attend the afiection
when it invades the pubic region, where, in the female, it is fre-
quently accompanied by a distressing pruritus pudendi. When
the ends of the fingers are the seat of lepra, the formation of the
nails is disturbed ; they are thickened and irregular in appear-
ance, and a yellowish curdy matter is deposited beneath them.
As the patches of lepra decline, the central portion of the
area resumes its healthy state, and ceases to produce scales.
By degrees the scales upon the circumference of the patch be-
come smaller and thinner, the prominence of the skin subsides,
and the ring breaks at one or several points, the remains of the
patches returning very slowly to the state of the neighbouring
skin, (Plate 6, d. e. f.)
LEPRA GUTTATA.
Syn. Lepra alphoides. Ptoriatis guttata. Willan. Psoriasis discreta. Raver.
Dartre furfuracke arrondie, Alibert Weisse Aussaiz, Germ.
439. Lepra guttata (Plate 6, c.) occurs in the form of small
convex and flattened scaly spots, raised above the surface, and
varying in dimensions from one-sixth of an inch to half an inch
in diameter. In general aspect, the smaller spots resemble a
number of drops of water sprinlded upon the skin ; hence their
name. They are distributed over all parts of the body, partis
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266 SQUAMOUS INFLAMMATION OF THE DERMA.
cularly on the dorsal aspect of the limbs and trunk, and upon
the scalp and face. The eruption commenoes by small red
papular elevations, upon the summit of each of which a small
white scale is developed. The papulae advance quickly in
growth, and the scales become larger and better defined, being
reproduced as frequently as they are removed. On the decline
of the eruption, the affected skin retains a dark-red, or bluish
and yellowish stain for one or two weeks. Some of the larger
patches fade gradually from the centre towards the circum-
ference, and assume die annular form presented by lepra vul-
garis during its progress towards cure.
The eruption of lepra guttata is sometimes, though rarely,
preceded by symptoms indicating constitutional disorder. These
symptoms, when they occur, are usually relieved by the out-
break of the eruption. In children, the invasion of the disease
v^th precursory febrile symptoms is frequent ; the eruption ex-
tends over the whole body in a few days, and is equally rapid
in its course. The local symptoms, as in lepra vulgaris, are
merely a trifling degree of pruritus when the skin is heated and
at night
LEPRA NIGRICANS.
Syn. Schwarze Aussatz, Germ.
440. Lepra nigricans is the form sometimes assumed by lepra,
when it occurs in persons of a languid and debilitated constitu-
tion. The form and distribution of the patches are the same as
in common lepra, but they are not so large, and the central
depression which marks the commencement of a curative process
does not exist. The patches, instead of being of a dull red or
rosy colour, are bluish and livid, and the scales thin, so that the
lividity of the surface is seen through them. The scales are
easily detached, leaving behind a tender, and, frequently, aji
excoriated surface, from which a morbid serous fluid, often mixed
with blood, is poured out. This secretion hardens by degrees
into an irregular and friable crust. Lepra nigricans is parti-
cularly inconvenient when it affects the scalp.
Willan observes that " the lepra nigricans affects soldiers,
sailors, scuUermen, stage- coachmen, butchers, brewers, labourers,
and others whose occupations are attended with much fatigue, and
expose them to cold and damp, and to a precarious or improper
mode of diet. Women habituated to poor living and constant
hard labour are also liable to this disease.^
LEPRA SYPHILITICA.
441. Lepra syphilitica resembles in all its characters the pre-
ceding variety, occurring in persons who have suffered from
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DIAGNOSIS AND TREATMENT OF LEPRA. 267
syphilis, and who have taken mercury for its cure. There is
much reason for the belief that the lepra nigricans of Willan is
simply the disease which we are now considering. The patches
rarely exceed in size the diameter of a shilling, their surface is
soft and pliable, and the scales are thin and white. The spots
decline at the end of six or eight weeks, leaving behind them a
red and coppery discoloration of the skin, which endures for a
considerable time. See the chapter on syphUitic eruptions.
442. Diagnosis. — The pathognomonic characters of lepra are,
the perfectly circular form of the patches, together with their
elevated border and depressed centre. Their circularity of form
is traceable bj means of two or three broken arcs of circles,
even when a number of disks have run together and formed one
continuous patch of large size. Psoriasis differs from these
characters in the want of regularity of the patches, in the
absence of a depressed centre, in the less inflamed condition of
the skin, and in the occa^onal presence of deep chaps and
fissures.
Lichen circumscriptus, with its circular clusters of pimples
fjEuling towards the centre, may sometimes be mistaken for lepra
in process of cure, but the identity of lichen is without difficulty
established by the presence of a few marginal papulse ; whereas
in lepra, the inflamed surface, denuded of its scales, is perfectly
smooth.
443. Causes. — Lepra is a constitutional affection, occurring at
all periods of life, often hereditary, and generally developed in
persons having an habitually dry and harsh skin. In such per-
sons, the circulation is feeble, and the natural fimctions of the skin
torpid. Hence it is frequently developed in old persons, and
in them is particularly obstinate. The occasional causes of this
eruption are, long continued mental emotions ; exposure to cold
and moisture ; deficiency, or poverty of food ; highly-stimulating
food, and abuse of spirituous drinks ; dry and salted provisions ;
game ; the abuse of acids, &c.
444. iV<^no57>.— Lepra is at all times obstinate; in young
persons and children it sometimes gets well spontaneously in the
course of a few months, while in the aged, it often lasts for life.
I have seen two cases illustrative of the counterirritant influence
of this disease ; the one was a young man, in whom the eruption
succeeded to epileptic fits, and seemed to act as the cure ; the
other was a gentleman of advanced age, in whom the sudden
disappearance of a cluster of leprous disks from around the
ankle, was immediately followed by a severe and intractable
dysentery.
445. Treatment, — The first and most important indication in
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268 SQUAMOUS INFLAMMATION OF THE DERMA.
the treatment of lepra is, to speak theoretically, the restoration
of the disturbed balance of the vital functions. This object is to
be effected by a judicious and well-devised regimen ; and that
which is best suited to the disease, is one of a cooling and un-
exciting kind. Such a regimen will often cure the eruption
without any aid from specific remedies. In truth, the specific
remedies for lepra are greatly assisted in their action by the diet,
and practice of ablution, with which their use is accompanied.
The functions, moreover, require to be brought into healthful
condition by means of laxatives, alteratives, or tonics, as the case
may be. And where the strength of the patient will permit,
benefit will be derived from the repeated abstraction of blood in
small quantities.
The internal remedies recommended for lepra are, a course of
purgatives ; bichloride of mercury in decoction of sarsaparilla, or
dulcamara ; hydriodate of potash ; tincture of cantharides ;
liquor arsenicalis; liquor potasses ; sulphuric acid; decoctions of
guaiacum, mezereum, and elm bark ; infusion of nettles ; milk
of sulphur, &c.
Of these remedies, that on which I place the greatest reliance
is the liquor arsenicalis, or the liquor hydriodatis hydrargyri et
arsenici (§ 446). The former of these solutions in doses of five
drops, and the latter, ten to thirty, three times a day, with meals.
The latter is the milder remedy of the two, and rarely produces
any disagreeable constitutional effects. Of course it is necessary
in using arsenical preparations of every kind to counsel the
avoidance of acids, fruits, and vegetables, and to explain to the
patient the symptoms which call for the suspension or omission
of the remedy.* The effect of arsenic on the leprous patches
is, in the first instance, to increase their redness, activity, and
heat, and subsequently to diminish these symptoms, and render
them brownish and dull. When the latter change takes place,
the eruptions quickly fade' and disappear. The medicine re-
quires to be taken regularly, and to be persisted in for several
months.
Dr. Anthony Todd Thomson t remarks — "I have found no
combination of mercury equal to that with iodine, in the treat-
ment of lepra. The biniodide, in doses of a sixth to a fourth of
a grain, seems to exert almost a specific influence upon the
morbid state of the skin ; and when given at the same time as
the iodide of arsenic, and aided by bloodletting, it has rarely
failed in rapidly and permanegatly curing the most inveterate
cases of the disease. As the acnmony of the preparation has
sometimes greatly disturbed the alimentary canal, I have usually
♦ See note, page 213.
f Commentaries on Diseases of the Sltin, &c., page 24.
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TREATMENT OF LEPRA. 269
combined it, either with opium or coniimi, and I have always
carefully avoided pushing it to ptyalism. Candour obliges me to
admit, that as I have usually prescribed the biniodide in con-
junction with the iodide of arsenic, it is difficult to say what
share the mercurial had in the cures ; and, in cases where idio-
syncrasy prevented me from employing arsenicals in any form,
I have seen the beneficial properties of the biniodide very ob-
viously displayed."
Dr. Thomson prefers to the liquor arsenicalis, as a remedy for
lepra, the iodide of arsenic ;* the dose of this medicine should
not, at first, exceed one-tenth of a grain ; and in no instance has
it cuimitted of being carried beyond one-third of a grain. " Its
obvious effects are, quickness and hardness of the pulse, with
slight puffiness of the lower eyelids ; but, generally, before these
symptoms of its influence display themselves, the disease has
begun to yield." " The symptoms which indicate a necessity for
reducing the dose are, heat of the mouth and fauces, and anxiety
at the prsBCordia, with pain at the epigastrium, or griping. If
besides these there is tension, with an uneasy sensation of stiff-
ness around the eyes, and erythema of the face, thirst, a white
tongue with the edges and tip of a florid red hue, and a quick
pulse, the use of tibe medicine should be suspended for some
days. If nausea, cough, vertigo, or salivation, supervene, it
should be left off* altogether. The employment of any arsenical
medicine is inadmissible, if it cause an uneasy sensation of the
chest from the first." Iodide of arsenic is incompatible with
cinchona in any form.
446. A triple compound of iodine, arsenic, and mercury has
been prepared by Mr. Donovan,t and recommended very
strongly, on the credit of numerous successful cases, by several
distinguished nhysicians of Dublin. The liquor hydriodads
arsenici et hydrargyri is exhibited in doses of half a drachm,
three times a day for the adult It ib liable to give rise to head-
ache and nausea, and sometimes to salivation, during its use, and
on the occurrence of these symptoms it must be suspended for
two or three days- The best vehicle for its exLibition is tinc-
ture of ginger, and it may be employed with advantage as a local
application.
The mode of preparation of the liquor hydriodatis arsenici et
hydrargyri is the following:! — Triturate of finely levigated me-
* ** As the iodide of traenic," writes Dr. Thomson, ''is not t pharmaceotictl
preparation, I subjoin the mode of preparing it Take seventy-five grains and a
half of metallic arsenic, and six handred and thirty-one grains and a half of pore
di^ iodine ; rab them well together in a mortar, and sablime. The salt is thus ob-
tained in the form of brick-red, shining scales."
t Dublin Journal of Medical Science, Nov. 1839, Sept 1840.
X See Dublin Journal Unr November, 1839.
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270 SQUAMOUS IlfFLAMMATION OF THE DERMA.
tallic arsenic, 6.08 grains; mercury, 15.38 grains, and of iodine,
50 grains, with one drachm of alcohol, until the mass be diy, and
changed in its colour, from a deep brown to a pale red. Next,
triturate the mass for a few moments with eight ounces of dis-
tilled water, transfer the solution to a bottle, add to it half a
drachm of hydriodic acid, and filter, making it up to eight
ounces by means of distilled water, if there be any deficiency.
The solution is of a golden yellow colour, and each drachm con-
tains
Water 3J.
Protoxide of ftraenic • gr. ^.
Protoxide of mercarj ST< i-
Iodine, converted into hydriodic acid S^* f-
447. The local remedies are, lotions of sulphuret of potash,
alkaline baths, vapour baths and douches, sea-bathing, spirituous
solution of bichloride of mercury, zinc ointment, white precipi-
tate ointment, calomel ointment, nitrate of mercury ointment,
ointments of acetate and phosphate of mercury, of sulphate and
deutoxide of antimony, ioduret of sulphur ointment, from ten to
twenty grains to the ounce, creosote, blisters, nitrate of silver,
&c. M. Gibert speaks favourably of an ointment of the ioduret of
ammonia, in the proportion of a drachm to an oimce ; and also
of the ointments of Anthrakokali and Fuligokali. In the em-
ployment of these applications, care must be taken, in acute
cases, to use them only after the reduction of the local ex-
citement, by means of fomentations, emollient baths, &c., and
then only of moderate strength. In chronic cases, however,
they may be employed fi-om tihe commencement, and in a more
concentrated form, with the view of modifying the diseased
structures.
"My own practice," says a distinguished author* on cuta-
neous diseases, " is to begin with the white precipitate ointment,
or with that of the protochloride of mercury, unless in those
cases where the disease is of very long standing, when I try the
ioduret of sulphur in preference."
M. Lemery, of Saint Louis, has lately recalled the attention
of practitioners to an old, but valuable application, in leprous
affections — namely, tar. Finding, however, that this remedy
was objectionable on account of its colour and odour, he had re-
course to one of the products of tar, concrete napthaliney which
afforded him the most successful results. The preparation
which he employs is an ointment, composed of
Napthaline . . . two to four parts.
Lard thirty parts.
M.
♦ Rajer.
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TREATMENT OF LEPRA. 271
This he applies to the diseased skin, on folds of linen, night and
morning. The ointment is highly stimulating, and has a powerful
smell, which quickly passes away. By means of the napthaline
ointment, M. Lemery succeeded in curing eight patients out of
fourteen, in from five weeks to three months.
Cases illustrative of the treatment of Lepra,
448. Lepra vulgaris cured by bleeding and purgatives, — A gen-
tleman, fif^ years of age, had patches of lepra on his arms, back,
and legs, which had made their appearance during the two
months preceding his application to me (September, 1843). He
was red-faced, and of full habit, and as I learned from his
medical adviser, right fond of good cheer. I ordered him to
be bled to twelve ounces ; to take eight grains of compound
colocynth with one grain of calomel every alternate night ; and
two ounces of decoction of sarsapariUa with iodide of potassium
twice a day. He was also to take a shower-bath daily. At the
end of a month the eruption had entirely gone ; and he has had
no return.
449. Lepra vulgaris of twenty-five yeari standing cured in five
months. — A female servant, forty-six years of age, had an attack
of lepra at the age of one-and-twenty, which she attributes to
fright. Her grandmother hjtd suffered from a similar disease.
The skin has been once free from the eruption during the twenty-
five years, and remained so a few months. In the beginning of
February (1846) I prescribed for her thirty drops of Donovan's
solution, to be taken vrith her meals three times a day. In
March, finding that she suffered no inconvenience from the
remedy, I increased the dose to forty drops, which she continued
to take, without a single uncomfortable symptom, until the end
of May, when a slight change began to be apparent in the erup-
tion. I then gave her five drops of liquor arsenicalis, three
times a day. The eruption now began to fade, the movement
taking place with so much rapidity, that by the end of June the
seat of the patches could only be discovered by the temporary
stains which they usually leave in their train. The local treat-
ment consisted merely in sponging the skin vrith a moist sponge
dipped in oatmeal.
The quantity of Donovan's solution taken by this patient was
six ounces, and of the liquor arsenicalis one ounce ; tlie quantity
of arsenic, consequently, ten grains.
450. Lepra vulgaris cured by DonovarCs solution. — A boy, twelve
years of age, had an attack of lepra, of which he was cured by
taking Donovan's solution. Twelve months afterwards, the erup-
tion returned, covering nearly his entire body. I put him again
upon Donovan's solution (August, 1845), twenty drops three
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272 SQUAMOUS INFLAMMATION OF THE DERMA.
times a day, which he increased to forty, and continued without
a single had symptom, until July, 1846, eleven months, when
eyery trace of the disease had disappeared. I think that a change
to the liquor arsenicalis, as in the previous case, might have
shortened the period of treatment ; hut he only once showed
himself to me in the interim.
PSORIASIS.
Syn. Dry tetter. Dartre farfuracie. Kleinaussatz. Germ.
451. Psoriasis (Plate 6, h. i. k.) is a chronic and noncon-
tagious inflammation of the derma, characterized hy the deve-
lopment of patches, which are irregular in size and form, and
covered hy thin, irregular, and whitish scales of altered and de-
siccated epiderma. The patches are raised above the level of
the surrounding skin ; they are flat upon the surface, or some-
what more elevated in the centre than at the circumference, and
are frequently intersected by deep fissures and chaps, parti-
cularly where the disease occupies a surface of large extent
Psoriasis may be general in its eruption, being dispersed over
the entire surface of the body, or it may be purely local. The
former is sometimes accompanied by slight constitutional dis-
order, and is liable to recur at certain seasons, as in the spring
and autumn, for several successive years.
452. The varieties of psoriasis are founded on the form of the
eruption, its intensity, and locality, the latter constituting a local
group. In a tabular scheme, the varieties may be thus arranged :
General varieties.
Psoriasis vulgaris,
„ gyrata,
„ inveterata.
Local varieties.
Psoriasis palpebrarum, Psoriasis scrotalis,
„ labialis, „ palmaris,
„ prseputialis, „ unguium.
PSORIASIS vulgaris.
Syn. Psoriatis diffvsa. Willan. Psoriasis con/luens. Rayer.
453. In the common variety of psoriasis (Plate 6, h. i.) the
patches are of large size, very irregular in their form, and of
variable extent The surfELce of the patch is of a dull, red colour,
rough, and elevated above the surrounding skin, intersected by
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PSORIASIS VULOAIIIS. 27S
deep furrows, which correspond with those of the epiderma, and
generally fissured by several chaps of considerable depth. The
patches are surmounted by numerous thin scales of dried epi-
derma, which are continually exfoliating, and giving place to
new and successive layers. The chaps are dry, and covered by
thin epidermal scales;- they frequently bleed, but very rarely
pour forth any secretion. The patches of psoriasis vulgaris are
developed in three principal modes ; firstly, by a roughness of
the epiderma and congestion of the subjacent derma, to an ex-
tent corresponding vndi the size of the future patches ; secondly,
by a number of small elevations, like those of lepra guttata, which
run together and form one continuously afiected surface ; and
thirdly, by several small patches, which speedily increase in size,
and coalesce. In each of these three modes, the patches are
two or three weeks before they attain their complete growth ;
and it frequently happens that the eruption assumes the cha-
racter of small patches over the greater part of the body, and of
large ones around the joints.
Psoriasis vulgaris presents several degrees of intensity and
extent ; it may occur as a single patch of small or large size, or
there may be several. The disease may appear upon all parts
of the body, but some it would seem to select by preference. I
have seen the eruption most frequently on the fore-arms, or
about the elbow and wrist. Unlike lepra, psoriasis affects
chiefly the fleshy parts of the limbs. The duration of psoriasis
vulgaris is always tedious ; in milder cases, it continues for several
weeks or months ; while in severer examples, it may be intract-
able for a much longer period.
Several modified varieties of psoriasis vulgaris occur in cer^
tain parts of the body as consequences of a local cause, in per-
sons predisposed to this disease. One of these forms is the scaly
eruption which commences on the knuckles of bakers, and thence
extends to the backs of the hands, constituting the disease which
is popularly designated baker's itch. In an advanced stage of the
baker's psoriasis, the surface is red and glossy, and scales cease
to be produced.
Psoriasis vulgaris, when extensive, is usually preceded by
symptoms of constitutional disturbance, such as pains in the
head, pains in the stomach, loss of appetite, nausea, and general
languor and debility. These symptoms subside as the local
affection becomes developed, and return at each recurrence of
the disease. The local sjnmptoms are heat, some degree of
pruritus, particularly at night, a sense of constriction, and,
where chaps and fissures have formed, a little pain and tender-
ness.
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274 SQUAMOUS INFLAMMATION OF THE DERMA.
PSORIASIS INFANTILIS.
454. The term infantilis is applied by Willan to psoriasis vul-
garis, as it is occasionally seen in the irrfant, between two months
and two years of age. The disease at this early period is very
rapid in its progress, and more acute than in the adult. It is
modified also by the greater susceptibility of the skin. The
tettery surface is intersected by numerous chaps and fissures, and
frequently excoriated to a greater or less extent by the friction
of dress, or of contiguous surfaces. From these excoriations an
ichorous secretion is poured out, which dries into hard scabs of
considerable size. Other modifications of the infantile variety
of psoriasis are, phlyzacious pustules, a morbid secretion from
the mucous membrane of the nares, loss of the eyelashes and
eyebrows when the orbital regions are afiected, and the occur-
rence of hardened elevations, like those of psoriasis without the
scales, either of the natural hue of the skin, or somewhat red, in-
terspersed among the patches. When the latter eruption occurs
about the anus, it frequently terminates in suppuration.
PSORIASIS GYRATA.
455. Psoriasis gyrata is another modification of psoriasis vul-
garis ; in this variety the eruption assumes the form of narrow
bands, disposed longitudinally, or in variously curved and tor-
tuous lines. The dull red and raised surface of the patches is
intersected by numerous furrows, and covered with exceedingly
delicate epidermal scales, which exfoliate repeatedly, and are as
constantly reproduced. This eruption is attended with very
trifling pruritus, and but little inconvenience. The disease
occurs for the most part upon the trunk of the body, but some-
times on the arms and legs. Psoriasis gyrata is exceedingly
rare ; Biett saw only two cases at St Louis during his connexion
with that hospital. Mr. Samuel Wood, of Shrewsbury, informs
me that he has seen one.
Willan describes a syphilitic psoriasis as appearing in the
gyrated form. The eruption in such cases presents the ordinary
characters of syphilitic disease of the skin ; it is dark-coloured
and smooth, presents but few scales, and assumes, as it sub-
sides, a copper-coloured tint.
PSORIASIS INVETERATA.
Syn. Dartre squameme lichhioide, Alibert
456. Psoriasis inveterata (Plate 6, i.) is the most severe and
obstinate of all the forms of scaly tetter, and may be regarded
as an intense degree of psoriasis vulgaris. It extends over a
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PSORIASIS INVETERATA. 275
considerable surface, usually occupying the entire of the limbs,
but sometimes spreading over the whole body, with the excep-
tion of the palms of the hands, the soles of the feet, and the
face. The skin in this variety is thickened, congested, andhot^
and there is constant pruritus, which is increased, and very
troublesome during the night. It is, moreover, dry, harsh, stiff,
deeply fissured by cracks and chaps, and covered by epidermal
scabs, which are produced and thrown off in great abundance.
The harshness and thickening of the integument are some-
times so great as to interfere with the action of the muscles and
movements of the joints. When the surfaceis abraded by pres-
sure, by the violent use of the nails, or by any other cause, a
profuse discharge is set up, which concretes into dry scabs of
variable size.
Psoriasis inveterata presents certain peculiarities in different
parts of the body ; thus, on the scalp the scales collect in great
number, and when removed, are succeeded by a foBtid ichorous
secretion. When the nails are affected, they become yellow,
thick, and irregular; they are subsequently thrown off, and re-
placed by shapeless crusts.
The duration of psoriasis inveterata is indeterminate ; it
usually lasts for several years, and in old persons for the rest
of life.
The constitutional symptoms accompanying psoriasis inve-
terata are generally very trifling, consisting merely in some
degree of gastro-intestinal iiTitation. At other times, no trace
of constitutional disturbance can be observed.
Local varieties,
PSORIASIS PALPEBRARUM.
457. Psoriasis palpebrarum is a chronic inflammation of the
integument of the eyelids, which commences at their outer
angles, and extends inwards towards the inner canthus. The
surface of the diseased skin is red, shining, and chapped, and
covered by thin epidermal scales. The disease is attended with
troublesome itching, it produces thickening of the skin, which
renders the lids rigid, and interferes with tibeir movements, and
when the inflammatory action is propagated to the conjunctiva
palpebrarum, there is a constant effusion of tears. When
psoriasis palpebrarum has continued for a long period, the con-
junctiva oculi is liable to become affected, in which case the
disease is exceedingly intractable.
Psoriasis palpebrarum may be purely local in its origin, or it
may result from an extension of psoriasis vulgaris already
afecting the face.
T 2
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276 SQUAMOUS INFLAMMATION OF THE DERMA.
PSORIASIS LABIALIS.
458. This variety occurs around the lips, often to the extent
of an inch, and more frequently upon the lower than the upper
lip. It is constituted by thickening, scaliness, redness, and
puckering of the integument, the puckered appearance depend-
ing on the presence of deep furrows, which converge towards
the mouth, and are the seat of painful chaps and fissures. The
scales are of small size ; they exfoliate constantly, leaving the
skin redandtender,butarespeedily succeeded byarenewed crop.
The disease is by no means common, it occurs and continues
through all seasons, and is tedious in its duration, extending to
months and often to years. Willan remarks, in reference to
psoriasis labialis, that ^^ in a man who had it for thirty years, I
observed that the gums and inside of the upper lip were con-
siderably corroded, and that his arms were covered by a thick
incrustation."
PSORIASIS PRiEPUTII.
459. This disease resembles in every respect the foregoing
variety ; the prepuce is red, thickened, covered by thin scales,
and fissured by chaps. The disease is exceedingly painful and
obstinate, bleeding whenever an attempt is made to draw back
the prepuce, and giving rise eventually to phymosis. Psoriasis
praeputii often occurs alone, sometimes it is complicated with
psoriasis scrotalis, and occasionally is coincident with psoriasis
palmaris.
PSORIASIS SCROTALIS ET PUDENDALIS.
460. Psoriasis scrotalis is attended with much heat, pruritus,
and thickening of the integument of the scrotum. The heat and
pruritus are greatly augmented by change of temperature, and
particularly by the warmth of bed. The affected skin becomes
harsh and dry; it is traversed by chaps and fissures of consider-
able length, and the disorder is frequently aggravated by exten-
sive excoriations, which secrete an ichorous fluid. Psoriasis
scrotalis occurs usually in the spring and autumn ; it is exceed-
ingly painftd and troublesome, and endures for a lengthened
period.
Psoriasis pudendalis is an analogous disease to the preceding,
affecting the labia majora of the female, and giving rise to dis-
tressing sufffering and annoyance.
PSORIASIS PALMARIS.
461. Psoriasis palmaris (Plate 6, k.) is a variety of the
diffused tetter, which is limited to the palmar surface of the
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PSORIASIS PALMARIS. PSORIASIS UNGUIUM. 277
hands^ the fingers^ and the wrists. It makes its appearance by
one or several elevated patches of large size, which increase in
breadth, and spread over the entire palm, extending upwards
upon the wrist, and downwards on the fingers. The patches
are of a dull red coloiur, hot, and painful ; d^ey are attended by
troublesome itching, and by a distressing sensation of pricking
and tingling. Soon after their eruption, the patches become
covered wiUi dry epidermal scales, which speedily increase in
number and thickness, and cover the entire of the diseased sur-
face. As the disease progresses, the epiderma becomes dry and
hard, it cracks in the direction of the natural furrows oi the
hand, and exhibits at the bottoms of these furrows chaps and
fissures in the derma of variable depth and extent. The thick-
ening of the skin consequent on the inflammatory action gives
rise to much pain and stifihess in extending the hand, and any
sudden movement is accompanied by bleeding.
462. Another variety of psoriasis palmaris has been desig-
nated by Rayer, centrifuga ; it is characterized by the develop-
ment of a single elevated spot, of small size, near the centre of
the palm of the hand, upon which a small thin scale is formed.
Around this elevation a series of eccentric red circles are suc-
cessively produced, each circle being surmounted by a firesh
epidermal scale. In this manner the disease spreads more or
less rapidly over the palmar surface of the hand. The integu-
ment is red, thickened, and fissured by numerous deep chaps,
which bleed frequently, and the entire hand is rendered stiff and
painful.
Psoriasis palmaris is very slow in its course, enduring for
several months, and sometimes for years, or declining during
the summer and autumn season, to re-appear successively in the
winter or spring, for a number of years. It occasionally attacks
the soles of the feet, but in this situation the severity of the
symptoms is mitigated by the protective coverings of the part,
and the fissures are consequently much smaller, or fail to occur.
Psoriasis palmaris is sometimes coincident in females with
psoriasis pudendalis, and in males with psoriasis prseputialis.
PSORIASIS UNGUIUM.
463. Whenever psoriasis difiusa extends to the extremities
of the fingers, the nails are considerably altered by the disease.
Sometimes, as Willan has observed, the affection of the nails
occurs alone, in which case scaly patches are frequently de-
veloped on other parts of the body, as upon the wrists and arms.
The nails, when diseased, are altered in their colour, becoming
yellowish and tawny ; they are thick and irregular in structure,
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278 SQUAMOUS INFLAMMATION OF THE DEBHA.
and rough and ragged at their extremitieB, bemg not unfre-
quendy bent downwards over the ends of the fingers.
464. Diagnosis. — Psoriasis presents the closest analogy to
lepra — an analogy which approaches to, if it be not in truth,
identity, as far as the essential nature of the disease is con-
cerned; but in respect of external character there are certain
differences. Indeed, it not unfrequently happens, that in the
same person the disease assumes in one part of the body the
characters of lepra, and in others, those of psoiiasis ; or that
lepra of long continuance, and improperly treated, degenerates
into psoriasis inveterata.
Comparing the two affections, we find that in lepra the patches
are circular, depressed in the centre with elevated margins, and
covered with moderately thick, and but slightly adherent scales,
while in psoriasis the patclies are irregular, not depressed in the
centre, and covered with thinner and more adherent scales.
Pityriasis is another scaly affection with which psoriasis
might be confounded; indeed, I am disposed to agree with
Rayer, that Willan has not sufficiently distinguished certain
varieties of psoriasis palpebrarum and labialis from pityriasis.
The distinction between the two diseases lies chiefly in the
depth of affection of the skin; thus in psoriasis the morbid
patch is always raised above the level of ^e surrounding skin,
while in pityriasis there is scarcely any elevation, the integument
being simply congested. Another difference is remarked in
relation to the size and appearance of the scales, for in psoriasis
the scales are larger and flicker ; the epidermal exfoliation in
pityriasis being merely a furfuraceous desquamation. More-
over, the integument in psoriasis is always more or less deeply
chapped and fissured, which is rarely the case in pityriasis.
465. Causes, — Psoriasis is not undfrequently hereditary in its
origin ; it may occur in both sexes and at all ages, but is most
common in the adult and in females. It usually makes its ap-
pearance in the spring and autumn, and follows upon a variety of
exciting causes, such as mental emotions, irregularities in diet,
salted food, deficiency of nourishment, exposure to cold, chlorosis,
arthritic affections, gastro-intestinal irritation, or some constitu-
tional indisposition, drinking cold fluid when the body is heated,
&c. The disease appears for the most part in those who are
remarkable for dryness of the skin.
The exciting causes of the local varieties of psoriasis are irri-
tants applied to the surface of the skin, such as flour, in that form
of the disease which affects the backs of the hands in bakers,
soap in the case of washerwomen, &c. In like manner, we find
it remarked by Willan, that ^^ shoemakers are subject to this
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TREATMENT OF PSORIASIS. 279
eomplaint from the irritation of the wax they so constantly em-
ploy. In brazierSy tinmen, silversmiths, &c., it seems to be pro-
duced by handling cold metals. A long predisposition to it from
a weak, languid, hectical state of the constitution, may give effect
to different occasional causes. I have observed it in women
after lying-in ; in some persons it alternates with arthritic com-
plaints.'' Sometimes the disease appears to result from the irri-
tation of other local cutaneous disorders, such as prurigo, lichen,
eczema, &c.
Psoriasis is unquestionably non-contagious ; but Willan has
observed that the psoriasis guttata and the annular form of
psoriasis gyrata ^^ affect several children at the same time in large
families and in schools, especially those who sleep together.''
466. Prognosis. — Psoriasis is at all times and under all forms
a very troublesome, and often an intractable disease, but it is
rarely dangerous to life. Psoriasis inveterata is so unmanage-
able as to deserve to be considered incurable.
467. Treatment — The observations previously made with re-
gard to the treatment of the allied affection lepra, are strictly
applicable to psoriasis, the treatment required is identical in both.
In this disease, baths, particularly the vapour bath and douche,
are of the utmost importance.
Several cures of psoriasis have followed the employment of the
liquor hydriodatis arsenici et hydrargyri. Dr. Graves* records
a case of severe psoriasis in the adult, that was cured within
three months by tiie exhibition of half a drachm of this solu-
tion, taken three times a day. The patient took in all one
hundred and fourteen doses — that is, seven ounces and one
drachm, containing seven grains of arsenic, fourteen grains of
the protoxide of mercury, and forty-four grains of iodine. He
was obliged to suspend the medicine for two or three days on two
occasions.
Dr. Elliotsont succeeded in curing a case of psoriasis inve-
terata by bleeding and wine of colchicum, in half-drachm doses,
given three times a day. The patient was a man of frill habit
of body.
For allaying the irritability of mucous membrane that so fre-
quently accompanies psoriasis. Dr. Thomson recommends the
liquor potasses in conjunction with diluted hydrocyanic acid,
and administered in the emulsion of bitter almonds ; the com-
mencing dose of the alkali should be thirty drops twice a day,
and this should be increased to as large a quantity as the stomach
will bear. If the patient be weakly, it may be taken in infrision
of cinchona or cascarilla.
* Dablin Joarnal, September, 1840. f Lancet, toI. viil
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280 SQUAMOUS INFLAMMATION OF THE DERMA.
Whenever the cause of the disease is obvious, it must instantlj
be removed, especially in the local varieties, for it would be un-
reasonable to expect the cure of a disorder when the causes pro-
ducing that disorder are still in activity. This remark applies
especially to the psoriasis of bakers, washerwomen, and handi-
craftsmen generally.
When the disease is obstinate, and resists all our measures,
the more powerful of the local remedies may be employed with
the view of modifying the action of the dbeased skin. With this
object, in the more rebellious forms, Rayer recommends the use
of the tartarized antimony ointment. The same author, after
commenting on the dangers attendant on the internal use of
cantharides and arsenic, makes the following observations : —
^' It is undeniable, that by means of these active medicines seve-
ral of the varieties of psoriasis, even the most inveterate, have
been cured ; but it is no less certain, that the majority of the
cures thus accomplished have been but temporary, relapses hav-
ing occurred the following spring or autumn ; that such relapses
are more especially frequent among the labouring classes of the
community; and lastly, that the greater number of cases of
psoriasis inveterata treated by such means have been in nowise
amended, although the medicines were continued for five or six
months. I am therefore of opinion, that it is, in general, inex-
pedient to put patients affected with psoriasis inveterata upon an
arsenical course, in the faint hope of deriving a mere temporary
improvement, with the fear before our eyes of inducing some
obstinate derangements of the digestive organs, or of perma-
nently injuring tiie general constitution.*'
In psoriasis palpebrarum, the best remedies are, a weak solu-
tion of nitrate of silver, a lotion of sulphate of zinc, the diluted
nitrate of mercury ointment, the calomel ointment, zinc ointment,
&c. I have found the latter especially serviceable in psoriasis
labialis, praeputialis, scrotalis, and pudendalis. In psoriasis
palmaris, in the chronic state, I have succeeded in effecting a cure,
by modifying the surface with a spirituous lotion of bichloride
of mercury, followed by water dressing ; nitric acid has also been
used successfully with the same object*
Case illustrative of the treatment of psoriasis.
468. Psoriasis vulgaris of four yeari duration. — A young man,
aged twenty-five, a tailor by trade, had been subject since child-
hood to periodical (every six or eight weeks) attacks of pain in
the stomach, attended with loss of appetite ; but has been free
from these attacks during the last seven months. The eruption
* Lancet, toL x. 1826, p. 416.
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PSORIASIS. PITYRIASIS. 281
first appeared, four years ago, on his scalp and forehead, and was
followed by two patches on the loins. In the autumn of 1844,
the eruption became more severe on the parts originally at-
tacked, and at the same time made its appearance on the arms,
legs, and trunk, the whole of which parts are now mapped by
the large irregular patches of this disease. The eruption has,
he thinks, increased since the gastric symptoms abated.
On the 11th of April, 1846, 1 instructed him to wash the
patches every day with soft soap, and dry them by firiction
with a rough towel, and take ten drops of Donovan's solution
with his meals, three times a day. At the end of a week, I in-
creased the dose to twelve drops, and at the end of the first
month, to fourteen. In the beginning of July, the eruption had
disappeared from all the afiected parts, with the exception of
two spots on the abdomen, which showed signs of incipient
£Eiding. I ordered him to reduce his dose of iiie drops to ten,
and continue them until no traces of the patches remained.
In this case I started with the intention of ascertaining how
small a dose of Donovan's solution would show its effects upon
the economy ; with a view to establish as a principle, in the
treatment of diseases of the skin by arsenical preparations, that
time is of more importance than dose. I believe that in this case,
in which the patient never felt the slightest monitory symptom
of irritation caused by the remedy, no earlier effect would have
been produced by a larger dose, while constitutional symptoms
must in all probability have resulted. The dose of Donovan's
solution usually prescribed is, half a drachm three times a
day.
PITYRIASIS.
Syn. Dartre furfuracie. Herpes furfuraceus^ Alibert. —
Schuppen^ Germ. Dandrvff,
469. Pityriasis* (Plate 6, l.) is a chronic inflammation of the
skin, which is characterized by the production of minute white
scales in great abundance, on patches of irregular form, and
variable dimensions. The patches are of a dull red colour, but
sometimes so light as scarcely to be distinguishable from the
surrounding skm. They are developed on all parts of the body,
frequently in succession, and are attended with heat and con-
siderable pnuritus and tingling. The scales are thrown off as
soon as formed, and are reproduced with great rapidity;
they are for the most part small and micaceous; in certain
situations, however, where the integument is thick, they are
* Der. xcrvpov, chaff, from the chaff-like desqaamatioii by which it is attCDded.
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282 SQUAMOUS INFLAMMATION OP THE DERMA.
large and lamellar, and in those parts where the integument
is thin, as in the flexures of joints, are pulverulent and mealy.
Pityriasis is a disease of long continuance, but is not conta-
gious.
470. The varieties presented by pityriasis are distinguishable
into general and local ; of the former, Willan enumerated three,
and of the latter, one. The general varieties of Willan are, pity-
riasis rubra, pityriasis versicolor, and pityriasis nigra; the first
of these, alone, deserves to be considered as a squamous dis-
ease ; the other two are remarkable for their alteration of colour,
rather than for the scales which they produce, and are conse-
quently referrible to the chromatogenous disorders.* I shall
therefore describe the general afiection under the generic desig-
nation. Pityriasis. The local variety indicated by Willan is pity-
riasis capitis ; to which Rayer has added, pityriasis palpebrarum,
labrum, palmaris et plantaris, prseputialis, pudendalis, and pity-
riasis oris. In a tabular form, the local varieties are.
Pityriasis capitis,
„ palpebrarum,
„ labiorum,
„ palmaris et plantaris,
„ praeputialis,
„ pudendalis,
„ oris.
PITYRIASIS VULGARIS.
Syn. Pityriasis rubra, Willan.
471. Pityriasis vulgaris (Plate 6, e.) occurs indiscriminately
upon all parts of the body, but particularly in the flexures of the
skin, and on those regions which are exposed to the influence of
the air, as the face, the neck, and the hands. It is distinguished
by the eruption of red superficial patches, upon which the scales
are produced, at first in small number, so as to give rise to some
degree of roughness only, but subsequently in large quantities.
This afiection is very commonly met with, in children and per-
sons possessing a delicate skin and fair complexion, upon the
sides of the chin, around the mouth, and on the forehead. When
extensive in its attack, pityriasis is attended by excessive itch-
ing and tingling, more particularly at bedtime, and during the
night. By successive eruption on different parts of the body,
the disease may gradually extend over the entire cutaneous sur-
* After writing the above, I was much pleased to read in Rayer the following
passage, in speaking of pityriasis versicolor and nigra: — ^** diseases which I have
felt called upon to transfer to another order, that merely of the adveDtitioos pig-
metUary discolorations.*'
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PITYRIASIS CAPITIS. PITYRIASIS LABIORtJM. 283
face, disappearing in some parts, while it breaks forth in others.
In this manner it is frequently prolonged for months, and is very
obstinate; the subcutaneous areolar tissue is apt to become
thickened and infiltrated, and if the surfeu^e be abraded by
scratching, an ichorous fluid is poured out, which desiccates into
thin scabs, and complicates the diagnosis of the disease. After
the decline of pityriasis, the skin presents for some time a yel-
lowish stain. When the disease is general, or a large surface
of the body is implicated, the eruption is accompanied with lan-
guor and slight constitutional disturbance.
PITYRIASIS CAPITIS.
Syn. Dandruff,
472. Pityriasis capitis appears upon the head chiefly in
children and old persons, commencing usually upon the temples,
and around the forehead, and thence extending to the rest of
the scalp. It is a troublesome affection, attended with much
itching, and at its first invasion, with some degree of redness,
which gradually disappears, and leaves the integument whiter
than its natural hue. Occasionally it extends to the eyebrows,
the whiskers, and the beard. Pityriasis may continue for months
and even for years, particularly in old persons ; and in severe
cases, may be accompanied by an ichorous discharge, which
agglutinates the hairs, and produces one form of that appearance
denominated by Alibert, " teigne amiantacee."
PITYRIASIS PALPEBRARUM.
473. Pityriasis palpebrarum may exist independently of the
appearance of the disease in other parts of the body. It is not
noticed by WiUan as a separate aflection, and is probably in-
cluded in his description of psoriasis palpebraiiim. It is cha-
racterized by the diUl red and abundant scaliness of the typical
pityriasis without thickening, or with but trifling thickening of
the lids, without elevations of the surface, and without chaps
and cracks. It generally occasions the fall of the eyelashes,
and frequently spreads to the conjunctiva, producing chronic
thickening of that membrane.
PITYRIASIS LABIORUM.
474. " Pityriasis labiorum," says Rayer, " is a variety that has
hitherto been confounded with psoriasis, a disease, however,
from which it differs in being evolved on the lips and surround-
ing skin, not as papular elevations followed by thick squamae,
but under the semblance of minute red stains, to which succeed
a general redness, and a continual desquamation of the epithe-
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284 SQUAMOUS INFLAMMATION OF THB DERMA.
lium of the lips, and occasionally of the cuticle of the neighbour*
ing skin.'' In this affection, the lips are hot and swollen, and
constantly throw off a desquamation of dry epithelium and epi-
derma, leaving the skin beneath red and tender. On the mucous
membrane of the prolabium, the exfoliation is produced in thin
lamellas, which remain partially adherent for some time, and are
then thrown off, while on the skin around the lips the desqua-
mation is furfuraceous and mealy. Pityriasis labiorum is ex-
ceedingly obstinate and intractable : Rayer remarks that he has
seen two cases of this disease ; I have seen one, which has lasted
for years, and appears to be incurable.
PITYRIASIS PALBiARIS ET PLANTARIS.
475. Rayer remarks, that pityriasis palmaris and plantaris have
hitherto been confounded with psoriasis in these regions ; cer-
tainly there is sufficient difference between the two to obviate
the risk of such confusion, if the diseases be carefully examined.
I have seen two cases of this affection, the one in the soles of the
feet, the other in the palms of the hands. The former of these
was particularly distressing ; there was constant and intolerable
heat, with painful tingling and tenderness of the inflamed parts,
and the epiderma was constantly thrown off in laminae of vari-
able size. The heat was sufficiently unpleasant during the day,
but at night it deprived the patient of^ rest ; he always lay in
bed with his feet uncovered, and he was under the necessity of
rising repeatedly to stand upon the cold floor, and bathe his
feet in cold water.
PITYRIASIS PRiEPUTIALIS.
476. This affection is very troublesome, and is apt to give
rise to phymosis. I have seen one case of phymosis produced
by it The characters of the disorder are similar to those of
the general affection.
PITYRIASIS PUDENDALIS.
477. Pityriasis pudendalis, like all pruritic disorders in this
region, is excessively annoying. The inflammation generally
extends to the mucous membrane of the vulva, and is very in-
tractable.
PITYRIASIS ORIS.
478. This variety, like the preceding, rests upon the authority
of Rayer, who says, with regard to it — " I have observed the
inside of the mouth affected with chronic inflammation and habi-
tual desquamation of the epithelium, especially about the base
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CAUSES AND TREATMENT OF PITYRIASIS. 285
of the tongue, without any antecedent or concomitant affection
of the pharynx, stomach, or lungs — pityriasis oris. This state
continued during five or six years, with but brief intermissions,
the principal functions being all the while performed with great
regularity. At the time a desquamation oi this kind was going
on, one patient complained of heat, and often of painful sensa-
tions, difficult to define, in the interior of the mouth. In a woman
who was similarly situated, almost the whole of the mucous mem-
brane of the mouth was habitually of a greyish-white colour,
and when the epithelium was thrown off from the tongue, its
surfiEU^ presented several patches of a bright red colour, which
continued until the inyesting membrane was either formed anew,
or again rendered thick and opaque.*^
479. Diagnosis. — The chief diagnostic characters of pityriasis
are, the copious production of epidermal scales, tlie erythema-
tous redness of the skin, and the troublesome pruritus. These
characters serve to distinguish it from the yellow sebaceous crusts
seen in newly-born children, and remaining adherent to the skin
for several weeks. The same signs also serve to distinguish it
from simple desquamation of the epiderma, and from psoriasis.
In psoriasis, it must be recollected that the skin is raised in
tubercular elevations, upon the summits of which the scales are
produced ; the scales also are thicker and larger ; there is, be-
sides, frequent chapping of the skin, and less pruritus. The
same characters serve to mark the difference between an altera-
tion of the pigment of the skin, attended with moderate desqua-
mation ; and a profrise production of epidermal scales, without
discoloration.
480. Causes. — ^Pityriasis probably owes its origin to some un-
known modification of innervation of the cutaneous textures,
and is developed for the most part in persons remarkable for the
delicacy and susceptibility of their skin. As a general affection,
it is more commonly met with in females than in males, and in
the aged than in the adult The local form so frequently seen
on the face is often produced by the evaporation caused by cold
winds, by chills produced in the same manner, by the irritation
of soap, shaving, &c. Sometimes the disease appears to result
from irritation of the gastro-pulmonary mucous membrane.
481. Prognosis. — General pityriasis is a very obstinate, but,
happily, a rare disease. It frequently resists all treatment^ and
in one instance Rayer saw it terminate fatally. The local forms
are also intractable, but not dangerous, and they are very apt to
recur at intervals.
482. Treatment. — In general pityriasis, if the patient be strong
and robust, blood may be taken from the arm, and followed up
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286 SQUAMOUS INFLAMMATION OF THE DERMA.
by antiphlogistic remedies and regimen. The local disorder is
to be treated by emollient baths, fomentations, alkaline baths,
and opium to lull the pruritus. Dr. Thomson remarks that he
found the following lotion —
PotassfB liqaoris, xy
Hydrocyaoici acidi diluti, ^j.
Misturs amygdal: amar:, ^vg.
M.
more useful in quelling the pruritus than those containing either
the biborate of soda, or alum, or the acetate of lead. Sedatives
are ofben required to diminish the gastro-intestinal irritation and
diarrhcea which so frequently accompany pityriasis. Tonics and
alteratives are frequently indicated, and great benefit is often
obtained from a course of alkalies, or of the hydriodate of
potassa. The following remark by Rayer is deserving of atten-
tive consideration : — " But it is with general pityriasis, as with
almost the whole of the chronic diseases of the skin, that are in-
dependent of appreciable causes ; a solid and enduring cure is
only to be obtained by a general change of the constitution,
brought about by dietetic means, long and regularly pursued,
effected naturally by the progress of years, and the modifica-
tions undergone by the organization, or accidentally induced by
some intervening disease, such as measles, scarlatina, &c.*'
Local pityriasis, when severe, demands the same constitu-
tional treatment as the general form, and if convenient, the local
abstraction of blood. The local disease, when it affects the
scalp, requires the closest attention to cleanliness, and this, in-
deed, will frequently be sufficient for its cure. The hair should
be removed, and when the inflammatory action is subdued, some
weakly stimulating application may be used to the surface, such
as an alkaline lotion, a drachm of liquor potassse to half a pint
of emulsion of bitter almonds, camphor spirit, or a weak solu-
tion of bichloride of mercury. A solution of bichloride of mer-
cury, in emulsion of bitter almonds, in the proportion of two or
three grains to the half pint, is the application best suited for
patches on the face ; and the zinc ointment for pityriasis palpe-
brarum, prsepudalis, and pudendalis. The vapour douche, vrith
the white precipitate ointment, are the remedies most likely to
be useful in pityriasis palmaris et plantaris.
In a case of unusual irritability of constitution, wher^ the
eruption of pityriasis was accompanied by a teasing pruritus,
relief was afforded by the application of glycerin.
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CHAPTER VIII.
INFLAMMATION OF THE DERMA INDUCED BY PARASITIC
ANIMALCULES INHABITING THE EPIDERMA.
483. The only disease belonging to this division is,
SCABIES.
The preceding groups of diseases, whether they originate in
a local or a general cause, depend upon some pathological con-
dition of the nerves and vessels of the system, or of the part
affected. As a consequence of this pathological condition, we
may have inflammation of the derma in the various forms herein-
before discussed — namely, congestive, effusive, suppurative, or
squamous. The present group differs from the rest in obeying
a specific cause, which may be present without exciting any
general or local disorder of the nervous or vascular system, the
seat of the cause being the extra-neurous and extra-vascular
epiderma. When, however, the cause has been present for a
certain period, varying with its number and with the tempera-
ment of the individual, we find such local effects produced as
would result from the presence of the most common irritant.
In the first instance, there is simple excitation of the peripheral
nerves, giving rise to prmitus ; next, there may be congestion
of the capillary vessels ; thirdly, there may be effusion of trans-
parent lymph beneath the epiderma, constituting vesicles ; and
lastly, there may be suppuration, and the formation of pustules ;
each of these stages following an ascending grade of irritation ;
the degree in which the irritation is evinced depending in a
greater measure on the temperament of the individual than upon
^e quantity of the cause.
Guided by the Willanean classification alone, we should be
led, seeing the alterations above described, in their first stage,
to refer the disease to that group which includes erythema ; in
its second degree of severity, we might follow the example of all
the dermatologists of the present day, and regard it as a vesi-
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288 INFLAMMATION OF THE DERMA FROM PARASITES.
culax disease, while in the highest and less frequent fonn of
aggravation we should place it, as did Willan, among the pus-
tules. It is clear, from the differences of such distinguished
men, that any attempt to deduce its true position in cutaneous
nosology from the accidental appearances respective of degree
of irritation that it may present, must not only fail, but lead to
serious errors in diagnosis. I have seen cases of scabies in
which there were no vesicles and no pustules, but, nevertheless,
the acarus revelled there in undisturbed enjoyment. Where
would be the reputation of the medical practitioner who took no
steps in such cases to protect the families among which it existed
against the transmission of so repulsive a disease ?
Another and a serious error has arisen out of the present
position of scabies in the nosological scheme ; I allude to the
belief that I have heard expressed and seen recorded, that
scabies may originate in a disordered state of the fluids of the
system ; that an eruption of scabies may be consequent upon
constitutional causes, or be elicited by a particular mode of
diet. As well might we conclude that constitutional disease
was capable of engendering other external parasites, and treat
our patients with internal remedies while we neglect the ex-
ternal conditions on which their increase absolutely depends.
SCABIES.
Syn. Psora, Itch, Scabies papuliformisj lymphatica, purulentOj
cachectica, Willan. — Gak, Fran. — Kraetze^ Germ.
484. Scabies* is an affection of the skin, characterized by
scaliness of the epiderma, by vesicles, and in severe cases by
pustules; to which may be added accidental abrasions and
scratches produced by the nails. It is accompanied by exces-
sive itching, the itching being augmented by warmth and by the
use of stimulating food and drinks.
The above appearances are due to the presence of a minute
animalcule, the acarus scabiei, which burrows beneath the epi-
derma, and excites irritation in the papillary surface of the
derma. The burrowing of this little creature gives rise to the
scaliness (scabrities) and undermined state of the epiderma.
The vesicles, which are few and scattered, bearing no propor-
tion to the number of the acari, and little relation to their seat,
present some differences in form and character, respective of
their position. Thus in the thin epiderma of the lateral sur&ces
of the fingers they are distinctly conical and acuminated ; on the
* Quasi scabrities.
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SCABIES. ITCH. 289
wrists and other parts of the body they are frequently more or
less rounded, and resemble the vesicles of eczema ; while in the
latter situations they are also variable in size. The vesicles
differ in reference to their contents ; in those of a conical form,
the contained fluid is transparent and viscous ; in the rounded
vesicle the fluid is also transparent, but in some it is more or
less opaque and puriform. The pustules are present only in
severe cases, or in persons with an extremely sensitive skin ;
they are generally psydracious, and vary in size, from the small
pustule of impetigo to the larger pustule of ecthyma.
When one of the early vesicles of scabies is examined with
attention, a minute spot or streak may be observed upon some
one point of its surface. This is the aperture originally made
by the insect on its flrst entrance beneath the epiderma, and
from this spot or streak a whitish line may be traced either in a
straight or a curved direction, into the neighbouring epiderma.
The whitish line is the cuniculusy or burrow of the acarus ; it
necessarily varies in length, being sometimes as much as five or
six lines in extent, and at its termination, under a slight eleva-
tion of the epiderma, the little inhabitant lies concealed. The
acarus may be easily distinguished by the experienced eye as a
small dark point at the end of the cuniculus, and if a thin cap-
sule of epiderma be raised in this situation with the point of a
needle, the little creature is brought into view. It should be
needless to remark, that eyes must be properly selected for the
manipulation, and a bright light carefully chosen.
The spot or streak which is here described is not met with on
all the vesicles, for the same animal may excite a series of these
in its course ; and a number may be developed in the vicinity of
its habitation, while in the primitive vesicle alone — that formed
by the entrance of the acarus — it is, that the trace of its entrance
can be expected. The aperture, again, does not communicate
with the interior of the vesicle ; it is, the too close neighbourhood
of the little grubber that acts as the cause of formation of the
vesicle ; the vesicle is consequently a provision of nature to pro-
tect the derma £rom the nearer approach of the orator^ and the
vesicle is formed with the judgment which usually marks Nature's
operations — namely, before a defensive provision would be too
late. The acarus scabiei, therefore, is ne^er situated within the
vesicle or within the pustule, and there is no communication
between the vesicle and the cuniculus.
The eruption of scabies usually makes its first appearance
between the fingers ; from these it extends more or less quickly
to the wrists, flexures of the elbow, the axillae, and the abdomen.
In weakly constitutions, it may be limited to the hands for a con-
siderable period without extending further, while in severe cases
u
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290 INFLAMMATION OF THE DERMA FROM PARASITES.
and sanguine constitutions it may speedily spread over the entire
body, with the exception of the feice, which is very rarely aflFected.*
The excessive itching causes persons suffering from this annoy-
ance to scratch, with violence, the seat of the eruption ; but the
scratching serves only to extend the pruritus, and the skin is often
severely torn and abraded. When the points of the vesicles are
broken, they become covered with small, thin, yellowish scales,
and when they are made to bleed, they are occasionally followed
by little black scales, like those of prurigo. When, in conse-
quence of superadded irritation from susceptibility of the skm,
Kora scratching, from injudicious remedies, or from a plethoric
state of the system, the vesicles take on the characters of pus-
tules, the disease assumes the appearance which has been de-
scribed by Willan under the designation of pustular itchy (scabies
purulenta.)
The seat of the eruption of scabies is occasionally found to be
modified by circimistances. For instance, while, in die generality
of cases, the disease is observed between the fingers and on the
wrists, in those who, from hard labour or the manipulation of
hard substances, have the epiderma of the hands and arms much
thickened, it would be sought for in vain on those parts. In
tailors and needlewomen, the eruption is first developed on the
hands ; and in infants, Rayer remarks, that the vesicles are first
perceived upon the breech.
The activity and extent of scabies are strikingly modified by
the state of constitution of the patient, its energy maintaining an
exact relation vdth the vigour of the system. When the person
is of sanguine temperament, and robust, the scabies spreads
rapidly, and gives rise to insupportable pruritus ; when, how-
ever, die subject is weakly and infirm, or reduced by the presence
of other disease, its progress is slow, the eruption partial, and
the pruritus moderate.
Although in cold and temperate climates scabies may be le-
garded as a mild and unimportant affection as respects the
health, producing but little local disease, and no constitutional
symptoms, yet in warmer climates, as has been well observed bj
Dr. Adamsf in Madeira, it is for the most part accompanied by
pyrexia, and the local effects are often very severe. The itch*
animalcule is very common in the island of Madeira, where it is
called augou or ougam. The following case, illustrative of
these remarks, I quote from Dr. Adams's account of tiiese ani*
malcules : J —
* The only case on record with which I am acquainted, of scabies affecting the
face, is one mentioned by Alibert The sabject was an infimt, and was supposed
to have received the disease ttom the mammsB of its nurse.
t On Morbid Poisons. % Page 398.
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DIAGNOSIS OF SCABIES. 291
^A patient (an European) applied to me on account of a
spreading inflammation, attended with large vesications, coUec*
tions of serum, in some places of pus, wi^ intolerable itching,
sometimes intense pain and smart fever. All these symptoms
were much exasperated at a certain period of the day. I ti*eated
it like any other inflammatory complaint, with evacuants, and
poultices to the part. The latter afforded some relief, but my
patient grew extremely impatient from the fever and frequent
violent pains, which deprived him of sleep. This induced me
to examine the part with more care, and to convince myself that,
how great soever the pain might be, the mischief extended only
immediately under the cuticle. In the meantime, the female
servant, who assisted with the poultices, pronounced the disease
ou9oes, and to convince him of the truth of her assertion, ex-
ducted two from the edges of the sore, which he saw crawling
on his nail. This appearance of the disease, so entirely local,
and the part affected with such violence, was so different from
anything I had met with before, that no evidence less than the
above would have satisfied me. The pain indeed was less sur-
prising, when we consider the disease was immediately on the
rete mucosum. Subsequent experience taught me that these
symptoms are by no means uncommon. The disease yielded
instantly to the usual topical remedy."
485. Diagnosis. — One of the most important features in the
hisloiy of scabies is the distinction of the disease from other
eataneous affections ; and this not only with reference to the
mind of the patient, but also with regard to the management to
be adopted. The treatment which is applicable to scabies would
be highly mischievous in other diseases with which it might be
oonfoimded ; while, on the other hand, the means appropriate
for the cure oi other diseases would leave the itch in full pos-
session of its mischievous activity. The chief diagnostic features
of scabies 9ae— firstly^ a peculiar scaliness and undermined state
of the epiderma, which are not met with in other cutaneous affec-
tions ; secondly J its conical vesicles, with acuminated and trans-
parent points ; and thirdly y and principally, the presence of the
aeams, which may be extracted from its retreat beneath the
loosened epiderma, with the point of any sharp instrument
The diseases vdtli which this disease may be confounded are,
eczema, prurigo, lichen, impetigo, and ecthyma.
Eczema is a vesicular disease, and therefore bears some re-
semblance to one of the characters of scabies, but tlie vesicles
are globular, and scarcely raised above the surfetce ; they are
always collected in dusters, and give rise to a sensation of
u2
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292 INFLAMMATION OF THE DERMA FROM PARASITES.
pricking, rather than of itching ; moreover, eczema is not com-
municable by contact
Pnirigo is a disease attended with thickening and consider^*
able alteration of the skin, and unaccompanied by vesicles ; it
occurs on the back and shoulders^ and the outer sides of the
limbs, where the skin is thickest. The pimples of prurigo are
frequently torn by the nails, and surmounted by little black
scabs, which are characteristic of prurigo ; whereas the scabs
which form on the ruptured vesicles of scabies are mere scales,
and yellowish in colour, a few only being black, when the
scratching is caiTied to the extent of making the vesicles bleed.
The pruritus of the two diseases, again, is different ; in prurigo,
it is burning and painful, which is not the case in scabies, and
moreover, t£e disease is not communicable. Prurigo is occa-
sionally met with as a complication of scabies, and in this case
the diagnosis requires a nice discrimination.
Lichen simplex, again, is a papular disease without vesicles,
the pimples being for the most part thickly disseminated. When
lichen occurs on the hands, it affects the dorsal surface, and not
the interspaces of the fingers ; the pruritus accompanying lichen
is trifling when compared with that of scabies, and the disease
is not contagious. Lichen sometimes complicates the eruption
of scabies.
Scabies can only be mistaken for impetigo and ecthyma when
complicated with pustules ; however, die limitation of the pus-
tules to the hands or flexures of the joints, and the presence of
the scaly epiderma and conical vesicles of itch, will be suflicient
to determine the diagnosis.
Another complication of scabies firequently results from the
irritation of substances employed in the treatment of the disease ;
it is, an eruption of eczema simplex. I have seen cases wherein
the treatment of scabies has been continued for upwards of six
months, and the disease, to all appearance, has resisted the
remedies employed for its cure. But in these cases, the scabies
was long since eradicated, and the obstinate eruption which con-
tinued was an eczema simplex, induced and perpetuated by
the irritating applications used for the cure of the supposed
itch. These cases immediately recovered when treatment was
laid aside.
486. Causes. — Scabies affects all ages, both sexes, and all
ranks of society, but is most frequently seen among the lower
classes, in whom personal cleanliness is neglected, and the oppor-
tunity of communication consequently greater. When the disease
makes its invasion in respectable families, its source may gene-
rally be traced to laundresses, servants, and their connexions.
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CAUSES OF SCABIES. 293
The disease is always communicated by contact, either imme-
diately, or through the medium of articles of clothing which have
been in the possession of the infected individual. But there are
many circumstances predisposing to its influence, such as luxu-
riant health and vigour, sanguine or Ijrmphatic temperament, the
spring or summer season of the year, warm climate, youth, con-
fined atmosphere, want of cleanliness, &c. The period at which
the vesicles make their appearance after the invasion of the
acarus, presents several important and remarkable modifications,
having relation to the state of health and age of the subject, and
the season of the year. Thus, in strong and healthy children,
the vesicles have been observed at the end of two days after
contact, the ordinary period for children being four or five days,
while in those that are weakly, the period of eruption may be still
further postponed. In adults, the ordinary period of incubation
is a week or ten days, but in the winter, the eruption may not
appear for a fortnight or three weeks. Old persons, again, re-
qmre a still longer time for the development of the vesicles, par-
ticularly in the winter season.
The proximate cause of scabies is the acarus scabiei,* which
is transferred by the infected to those who are sound by actual
contact. In some instances, it may be conveyed to the sound
person in the adult state ; while in others, ova, or embryos sus-
pended in the fluid of the vesicles, may be the mode of trans-
mission. Certain it is, that the application of one of these
animalcules to the skin of a sound person will give rise to the
disease.
Some highly interesting and conclusive experiments on the
habits of the animalcule were made, on the revival of the acarus
scabiei in France, by M. Albin Gras, a pupil at Saint Louis, and
published by that gentleman in the year 1834.
Exp. 1. — " On the twenty-eighth of August," writes M. Gras,
" in the presence of several physicians and students, I placed
two living acari on the middle and anterior part of my fore-arm,
and covered them with a watch-glass kept in its place by a
bandage. On removing the apparatus on the thirtieth, we found
two superficial cuniculi (sillons) half a line in length, and at
their extremity two little white points, indicating the presence
of the acari. Substituting a fold of linen, retained in its place
by a piece of adhesive plaster, for the watch-glass, the acari were
left undisturbed for six days longer. At the end of this time, the
white points were no longer perceptible, and the cuniculi having
become obliterated, had disappeared "
* The history of this aBimalcule will be found recorded in a separate chapter, at
the conclusioD of the yolume.
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294 INFLAMMATION OF THB DERMA FBOM PARASITES.
Exp. 2. — " On the first of September, I placed seven living
acari on my fore-arm, and covered them with a fcdd of linen, and
piece of diachylon plaster. Four days after, we found four or
five well-marked cuniculL On the sixth of September, two of
the acari being extracted from their cuniculi, were found active,
they were then replaced. On the twelfth, another animalcule
was removed and examined ; it was quite lively. On the four-
teenth, there was considerable itching, with the development of
a vesicle ; the cuniculi were two lines long. On the sixteenth,
there were severed new vesicles near to the cunicuKy but not on their
line. On the seventeenth, the vesicles of the previous day had
been rubbed ofi* by the linen, but two or three new ones were
visible. On the following day I put an end to the experiment,
by rubbing some sulphuro-alkaline ointment into the part
During the course of the experiment, I suffered pruritus from
time to time."
Exp. 3. — *^ On the ninth of the month, I imprisoned six acaii
on my ring finger, by means of the finger of a glove. Next day
there were two cuniculi half a line long. The acarus of one of
these burrows was apparent for ten days, the other for three
weeks, but after this period they both disappeared. During this
interval, I cauterized several suspicious vesicles developed on
the same finger, and discovered two new cuniculi originating in
acari that had fixed themselves without having been observed.
None of the vesicles appeared on the line of the cuniculi. "
Exp. 4. — " I lately placed nine acari in the bend of my left
arm, and retained them there by a compress and bandage. Four
hours after, I felt considerable pruritus, and next day perceived
four cuniculi. Several days aner, some vesicles showed them-
selves on my fore-arm."
Exp. 5. — " Having placed two acari in the flexure of the
elbow of two persons, who expressed their willingness to submit
to my experiments, on one three or four vesicles were apparent
on the finh day, and were accompanied by severe itching. On
the other there were two cuniculi, with pruritus, but no vesicles."
Scabies is not limited to man ; it is not unfrequently seen in
animals, and by them may sometimes be communicated to man.
During the spring of 1840, 1 had the opportunity of seeing and
treating a case so communicated, in the person of a veterinary
surgeon, who had received the contagion from an ass upon which
he was performing a physiological experiment.
487. Prognosis. — Scabies is a mild disease, and little affective
of the strength of the system. Some few cases have been re-
corded, in which the eruption has subsided during an acute dis-
ease, to re-appear as soon as that disease had become somewhat
mitigated. Instances have also been advanced, with a view to
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TREATMENT OF SCABIES. 29d
prove that certain serious yisoeral diseases have occasionally
been developed, upon the sudden xetrooession of scabies. These
statements, however, are not borne out by observation, but
there is good reason for the belief that a brisk attack of itch
would rather be useful than otherwise, as an effective counter-
irritant.
488. Treatment. — The treatment of scabies is purely local ; in
some instances, it is true, where the subjects are strong and ple-
thoric, benefit may be obtained by the exhibition of aperients,
or by the abstraction of blood. But in the majority of cases, no
constitutional means are required.
Numerous therapeutic remedies have been employed from time
to tim^ for the cure of this disease, and as the main object to be
attained is the extermination of the acarus, many have been suc-
cessful. Several of these medicines act by means of their stimu-
lating powers, and at the same time that they destroy the para-
site, excite considerable irritation in the skin. Others, again,
effect this object without causing irritation, or they give rise to
much less inconvenience. In selecting our measures of treat-
ment, therefore, our attention should be directed to the employ-
ment of remedies which will act with certainty, and will produce
the least possible degree of excitement in the cutaneous surface.
Such a remedy is presented to us in sulphur, which may indeed
be regarded as a specific in the treatment of scabies. To effect
the cure, the sulphur is well rubbed into the skin, and is con-
veyed by imbibition into the texture of the epiderma. Here it
probably combines with hydrogen, and sulphuretted hydrogen
gas is evolved, which acts as a deadly poison to the acarus, and
destroys its ova. In some instances, the sulphuretted hydrogen
gas in solution is employed as a wash or bath, and answers the
purpose perfectly, but is longer in effecting a cure than the sul-
phur, probably on account of the gradual and constant genera-
tion of the gas in the tissue of the epiderma in the latter case.
The sulphuretted hydrogen lotion gives rise to less irritation than
the sulphur ointment, and is therefore a preferable mode of treat-
ment in children, and persons with a delicate skin. Before either
of these or any other remedies are employed, however, it is de-
sirable to prepare the skin for their reception by a thorough
ablution with a warm solution of subcarbonate of potash,
containing about half a pound of alkaline salt to a gallon of
water.
To effect the cure of scabies in the shortest possible time, the
best preparation of sulphur is the compound sulphur ointment,
of which, in the adult, four ounces should be well rubbed into
the skin before the fire, and particularly into the affected por-
tions, morning and evening, for two days. It is desirable, also,
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296 INFLAMBfATION OF THE DERMA FROM PARASITES.
that the patient should wear a flannel shirt, and retain the same
during the whole of the treatment. When this eovering is not
sufficiently large to envelop the entire bodj, he should also lie
between blankets. On the morning of the third day, the patient
should take a warm bath, and wash the skin thoroughly with
plenty of soap, when the cure will, generally, be found to be
efiected. Much, however, depends upon the manner in which
the alkaline ablution and the friction of the afiected parts
shall have been performed. In some cases, it may be desimble,
as a matter of precaution, to continue the inunction for a third
day, or to use the white precipitate ointment* to the afiected
parts for a week or ten days, in case any ova may have escaped
the influence of the sulphur treatment In children, one half of
the above quantity of ointment will be found sufficient This
method, while it ofiers the advantage of a rapid cure, is liable to
the inconvenience of producing accidental eruptions.
When time is not a main object in the cure of the disease,
recovery may be effected in the course of a week, with less risk
of exciting unpleasant irritation, by means of the simple sulphur
ointment combined with subcarbonate of potash, in the propor-
tion of an ounce of the alkali to a pound of the ointment ; of
this, two or three ounces may be rubbed into the affected parts
three times in the course of the day. Or again, by the com-
pound sulphur ointment, used in the same quantity, and at the
same intervals.
The sulphuretted hydrogen treatment consists in bathing the
surface of the body in a solution or bath of sulphuret of potash^
containing one or two ounces of the salt to a pint of tepid water;
or in sponging the skin with a mixture of two ounces of each of
the following solutions in half a pint of tepid water, many times
in the course of the day : —
ft ft
Salphureti potassse, ^ij. Acidi mariatioi, |j.
Aquse, OJ. Aqosc, Oj.
M. ft solatia M. ft. solmio.
The former of these methods is well adapted for young chil-
dren, but the latter frequently creates considerable irritation,
and produces accidental eruptions. The duration of treatment
is a week or ten days.
Numerous other preparations, sulphureous and not sulphu-
reous, and each possessing, according to their advocates, peculiar
advantages, have been recommended by different authors.
• ft
Ung. h^drarg. ammoDio-chloridi, ^j.
Mofichi, gr. ^.
Olei layandulae, nxij.
Oiei amygdalaimn, 3 j.
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TREATMENT OP SCABIES. 297
Among the more deserving of mention of these remedies are
the foUowing : —
Saporuiceaus compounds,
ft ft
PotesMB flabcarbonatis, 59. Snlpharis sabUmati'
Aqaa, |j. Si^dIs alb, aa lb as.
Olei oUvaram, ^ss. ^ M.
Camphors gam mi, 5ij.
Sulpharis subiimati, ^v.
M,
The saponaceous compounds possess the advantage of not
soiling the habiliments of the patient
Pyhorel recommends the niction of half a drachm of sul-
phuret of lime with sweet oil into the palms of the hands, with-
out any application to the surface of the body, the treatment
being continued for fifteen or twenty days. Fantonetti advocated
the use of chloride of lime ; and Delpech, the employment of
firictions of sweet oil alone. This last remedy would, doubtless,
act most destructively upon the acarus, should the oil reach the
animalcule* Sulphureous fumigations are less advantageous
than the ointments, and acid lotions of little benefit, and liable
to be attended with much inconvenience. Tar ointments, mer-
curial ointments, and ointments of ioduret of sulphur, have also
been employed against this disease.
In young children, and in families, where the odour of sul-
phur is made a point of serious objection, I have found camphor
dissolved in oil, in the proportion of one drachm to the ounce,
answer every purpose of eradicating the disease.
Among the simples recommended from time to time by dif-
ferent physicians, or employed popularly, are, solution of
tobacco, used by Boerhaave, but liable to many objections;
stavesacre ; hellebore ; scabious ; sweet-scented rush ; elicam-
pane ; and onions.
Especial care should be taken that the whole of the garments
worn by the patient, and the bedclothes in which he has lain,
should be disinfected by exposure to sulphureous acid gas.
This is a measure of great importance in the observance, since
the acari and their ova remain attached to all articles of apparel,
and are easily communicated by them. Indeed, whenever prac-
ticable, it would be desirable that the infected clothing should
be destroyed. To complete the eradication of the animalcules,
perfumes should be worn in the dress for several weeks.
The treatment of scabies has been greatly enriched by the ob-
servations of M. Albin Gras, in the work before alluded to. I|e >
observes : —
^^ I was enabled to obtain living acari from a patient who had
taken two or three sulphur baths, containing four ounces of sul-
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298 INFLAMMATION OF THE DERMA FROM PARASITES.
phuret of potass to the bath. On the contraTy, I have frequently
found them aU dead after a single friction with the sulphuro-
alkaline ointment.^ *^ But although the insects are dead, vesicles
still continue to appear for several days."
^^ Immersed in pure water, the acarus was yet alive after three
hours; in saline water it moved feebly at the end of three hours;
in Goulard solution it lived after an hour ; in olive oU, almond
oil, and castor oil, it survived more than two hours. In croton
oil it was living after the lapse of an hour, but dead at the end
of four ; in lime water it was dead in three quarters of an hour ;
in vinegar, in twenty minutes; in alcohol, also in twenty
minutes; but in naphthaline still more quickly ; in a solution of
sulphuret of potass, it was dead in twelve minutes ; in spirit of
turpentine, in nine minutes; in a concentrated solution of
hydriodate of potass, the acarus ceased to exist in from four to
six minutes ; in a solution of arsenious acid it was dead in four
minutes; in sulphuric acid, diluted with three parts water, it
died in three minutes; in pure creosote, and in concentrated
acids and alkalies, its death was immediate. Placed overnight
on powdered sulphur, the animalcule was found dead the next
day; and it required to be exposed to the vapour of burning
sulphur for sixteen minutes before it died."
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CHAPTER IX-
TUBEECUL0U3 AFFECTIONS OF THE DERMA.
489. In the physiological classification which I have adopted
as the groundwork of this treatise, I have omitted altogether the
order " Tubercula" of Willan. My reasons for this omission
are, in the first place, the incongruity of the diseases which he
assembles togedier under that designation ; and secondly, the
insufficiency of so artificial a character to convey any idea of
the only disease which may, correctly, be retained as an alSec-
tion of the skin. The disease to which I refer is luptts, Rayer
recognises the order, but omits several of the diseases proposed
by Willan, and the enumeration of those which remain will,
better than any commentary, show the propriety of their rejec-
tion by me. The diseases comprised in Rayer's order are,
lupus, cutaneous scrofula, cancer, Greek elephantiasis, syphi-
litic tubercles, and accidental or excited tubercles.
490. The varieties of lupus are two in number — namely,
Lupus non exedens.
Lupus exedens.
LUPUS NON EXEDENS.
Syn. Herpes exedens, VUiligo, Leuce,
491. Lupus non exedens (Plate 7) makes its appearance in
the form of one or more elevations of a circular or oval shape,
slightly raised above the surface, and about two lines in dia-
meter. The tubercles are of a dull red hue, or salmon-coloured,
and semi-transparent; and not unfirequently they resemble a
reddish transparent jelly effused upon the skin, and streaked
with the ramifications of a few small bloodvessels. When
pressed under the finger, they are found to be soft, and when
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300 TUBERCULOUS AFFECTIONS OF THE DERMA.
the finger is remoyed, they are blanched and flattened. The
epiderma covering the tubercles is, at the beginning of the
disease, smooth, but later, it cracks and peels ofi*, and its white
and broken margins are apparent around the circumference of
the elevations. When more than one tubercle exists, they are
usually found clustered together, and they generally assume an
annular disposition. The more common seat of this disease is
the face, and more particularly the nose. I have also seen it
on the lower eyelid, beneath the chin, on the arm, and upon the
backs of the hands.
The tubercles of lupus give rise to litde or no inconvenience
beyond their appearance, and may exist for months without
undergoing any change. Occasionally they are scratched, and
then a thin scale forms upon their summit Then this scale is
torn off and another is produced ; each successive scale being
larger than the preceding, and being the cause of a repetition of
the violence of scratching. After a variable period of time, more
tubercles begin to be apparent around the borders of the original
patch. Perhaps, this second crop assumes an annular form,
and the primary tubercles have subsided and disappeared. The
process by which subsidence and disappearance of the tubercles
is effected, seems to be one of absorption. There is no ulcera-
tion, and yet the tubercles leave deep cicatrized pits behind
them. Sometimes the disease spreads superficially and more
quickly over the skin, and then the surface which it has left is
crossed by white scar-like ridges and bands. Every trace of
the normal structure of the skin has disappeared; it has slightly
sunk below the level of the surrounding integument, and the
spaces between the white lines are pale, and salmon-coloured,
and semi-transparent, the epiderma being smooth, thin, and
glossy. Occasionally firesh tubercles spring up on this surface,
and the disease is in this manner perpetuated. Sometimes I
have seen the patches covered by thick crusts from an oozing of
an ichorous fluid following the abrasion of the skin.
When the disease has subsided, the skin never resumes its
original appearance, even where tliere are no cicatrices. The
epiderma is very thin, the linear marking of the skin is lost,
and it looks flabby and loose. Moreover, the natural sensibility
of the skin is also destroyed, a change which may be perceived
from the first appearance of the disease.
When the tubercles attack the border of the ala of the nose,
their absorption causes a loss of substance of that organ, and
gives to the external aperture a notched and irregular outline.
When this change occurs towards the anterior extremity, the
point of the nose becomes unnaturally acute.
There are fragments of Bateman^s description of vitiligo
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LUPUS EXEDENS. NOLI ME TANGERE. 301
which are peculiarly applicable to lupus non exedens ; and I am
disposed to believe that it was this disease which he had in view
in writing his description. For example, referring to the
tubercles, he remarks : — " As they gradually subside to the level
of the sur£EU)e, they creep along in one direction, as for example,
across the face, or along the limbs, chequering the whole super-
ficies with a veal-sldn appearance.^^ The veid-skin appearance
relates to the inside of me skin, an explanation without which
the text is hardly intelligible. To the above comparison Bate-
man adds, '^ this white and glistening appearance bearing some
resemblance to the flesh of calves (vituli), seems to have given
rise to the generic term." Again, he observes, in reference to
the state of ^e skin, ^* a smoo^ shining surfstce, as if polished,
being left, and a morbid whiteness remaining through life. The
eruption never goes on to ulceration." Now, all this corre-
sponds perfectly with the appearance of the area of a circular
patch of lupus non exedens, or with the skin on which its de-
vastations have been committed. The disease termed by Celsus
" leuce," I also believe to be the affection now under considera-
tion. Bateman, wishing to show that leuce differed from vitiligo,
observes, that 'Heuce deeply affects the skin and subjacent
structure, occasioning a loss of sensibility, and ultimately of
vitality, in those parts."
LUPUS EXEDENS.
Syn. Noli me tangere. Dartre rangeante. Esthiomene, Alibert
492. Lupus exedens commences, like the preceding, by a
tubercle of a dull red colour, but harder and denser in structure
than those above described. The more frequent seat of the
tubercle is the nose, either the ala or tip, and sometimes the
border of the ala or columna. After a variable period of time,
during which the tubercle remains indolent, a thin brown and
adherent scab forms upon its summit This scab is usually
scratched off, and another is produced in its place by the de-
siccation of an ichorous fluid which escapes from the abraded
tubercle. On the removal of this latter scab, the skin beneath
is found more or less deeply ulcerated, and the ulcer soon be-
comes concealed by another and a larger scab, resulting from
the drying up of the sero-purulent secretion which is poured
out on its surface.
The ulcer, like the original tubercle, offers much difference in
respect of rapidity of progress, being one while very slow, and
another while very speedy, in its devastating course. When the
latter tendency exists, the entire nose has been seen to be de-
stroyed in less than a month ; a character which has been dis-
tinguished by the name of lupits voreix. The surface of the ulcer
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302 TUBERCULOUS AFFECTIONS OF THE DERMA.
of lupus exedens is uneven^ sometimes studded with unhealthy
granulations, but more frequently cohered with white patches of
lymph. Its edges are thickened and red, and it frequently
pours forth a considerable quantity of a foetid, ichorous, and
semipurulent fluid.
Wben the ulcer of lupus exedens heals, the cicatrix is re-
markable for the white and corrugated bands, and the unhealthy-
looking skin described in connexion with the preyious disease ;
and the recurrence of the morbid action on these cicatrized spots
is far from being uncommon.
Lupus exedens sometimes attacks the interior of the nose, and
then a foetid discharge usually precedes the extension of the
disease outwardly. It occasions much swelling of that organ.
The disease makes its appearance also at the angle of the
mouth, or upon the upper lip, and sometimes on the cheek ;
and in these situations causes considerable tumefaction, with
redness of the surrounding skin.
Lupus exedens is occasionally seen as a superficial phagedasnio
ulceration of the skin. Such a case I have now under my
treatment; it is remarkable for its perfectly circular figure.
Now and then it appears in the annular form, leaying a circular
island of unafiected skin. When its tendency is to proceed
inwards to the deeper tissues, the devastation which it occasions
is often frightful; all the structures in its course, including even
the bones, are destroyed ; the nares are laid open, the superior
maxillary bones are necrosed, and the eyeballs, losing their
support, sink into the chasm which the removal of the subjacent
parts occasions. And all this without producing much pain, for
the ulcers of lupus exedens, like their tubercles, are remarkable
for deficiency of sensibility.
493. Diagnosis. — Lupus is easily distinguished from other
affections of the skin. Its dull-red, indolent tubercles, in the
first instance, their incrustation or ulceration subsequently, and
then the unhealthy-looking or deeply-pitted cicatrix, are patho-
gnomonic characters. To these may be added, its seat ; the
nose, lips, eyelids, and neck being its more common situations.
Bayer observes, that " the solitary tubercles of lupus exedens of
the cheeks have frequently been mistaken during their stationary
period for small sanguineous tumours or naevi." I have seen the
tubercles of lupus non exedens present precisely this character.
494. Causes. — Occasionally lupus seems to depend upon a
scroftdous taint of constitution, but more frequently it is impos-
sible to assign a cause. It is more common in women than in
men, and in the lower than in the middle and hi^er classes of
society.
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TREATMENT OF LUPUS. 308
495. Prognom. — Uncertain and unsatisfactory ; the disease is
always tedious, lasting for years or for life, and resisting the
best planned treatment. The indolent form is more favourable
than the active kind.
496. Treatment, — I have obtained the best results in both
forms of lupus from a prolonged course of liquor hydriodatis
hydrargyri et arsenici ; modifying the local disease by the occa-
sional application of the acetum cantharidis made with strong
acetic acid. As a constitutional remedy, unless special indica-
tions call for a different course, I believe that there is no better
medicine than the above solution. Other remedies that have
been favourably spoken of are, iodide of arsenic, liquor arseni-
calis, and iodide of potassium combined vnth decoction of sar-
sapaxiUa.
The local remedy which I most prefer for lupus non exedens
is the acetum cantharidis mentioned above. Other escharotic
remedies have also been suggested, particularly the chloride of
zinc diluted with plaster of Paris, and applied in the form of a
paste.
Lupus exedens requires the local treatment usually employed
for phagedaenic sores. For example : the nitric acid and
chloride of zinc are well suited to destroy the ulcerated surface
and excite the capillaries to a more healthful action ; and pre-
parations of arsenic have been used vnth a like object. To
promote the healing of the ulcer, a weak solution of nitrate
of silver or a lotion of chloride of lime vnll be found useful.
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CHAPTER X.
HYPEETROPHY OF THE PAPILIJE OF THE DERMA.
497. There are certain abnormal states of the cutaneous tex-
tures, the external signs of which are an increase in the growth
of the skin without any appearance of inflammation. For ex-
ample, there are those prominences which are known by the
name of warts, and those other thickenings and indurations of
the surfeice of the body which are termed callosities and corns.
The most obvious character of these enlargements is the accu-
mulation of epiderma, not diseased epiderma as in some of the
preceding affections, but an epiderma in nowise, except thick-
ness, differing from that of the rest of the body. Now, the
epiderma, it is well known, depends for its thickness upon the
papillary layer of the derma, being considerable when the pa-
pillary layer is highly developed, and vice versd. Hence an
unusual thickening of the epiderma is an evidence of an abnor-
mally developed or hypertrophous condition of the papillary
layer upon which it is fashioned and rests. This is precisely
the patnological state of the diseases comprehended in the pre-
sent group. The papillae of the skin are unnaturally enlarged;
in the case of warts, without any apparent cause ; in the case of
corns, in consequence of the irritation caused by pressure ; and
their enlargement is associated with an augmented formation of
epiderma. I have already had occasion to remark, that in lepra
and psoriasis there exists an hjrpertrophied condition of the
papillae of the skin, but the enlargement is associated with other
morbid conditions which give a speciality to those diseases.
There is another form of hypertrophy of the epiderma, con-
sequent on a previously diseased state of the part of the body
upon which it occurs, which I have also included in this group,
under the name of pachulosis. In the former edition of this
work, pachulosis was described under the title of ichthyosis
spuria.
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VERRUCA. WARTS. 306
498. The diseases included in this group are therefore —
Verruca.
Tylosis.
Clavus.
Pachulosis.
VERRUCA.
Syn. Warts. Sessile toarts,*
499. A wart is a state of hjrpertrophy of the papillss of the
derma,t attended with an increased production of epiderma.
Warts are usually of small size, and of a rounded figure ; some-
times, however, they appear in the form of bands severed lines
in breadth, and of variable length. They are generally insen-
sible, rough to the touch, and their mediimi projection from the
surface is about a line. They may be developed at any period
of life, but are most frequent in children and elderly persons,
and arise without any apparent cause, to continue for the rest
of life, or disappear unexpectedly. Their usual seat is the
hands, less commonly they are seen upon the trunk of the body,
or the face.
Hypertrophy of the papillae of the derma in the production of
warts takes place without apparent cause, and without premoni-
tion. The papillffi, for the extent of a line, more or less, gradually
increase in length, and constitute a small tuft Each of these
papillae forms around itself an epidermal sheath, and these epi-
dermal sheaths are held together in the form of a bundle by me
epidermal mesh formed between and around them by the bases
of the hypertrophied and the surrounding normal papillae. It
very rarely happens that the whole of the papillae included by
the area of the wart are elongated ; several of them retain their
natural size, and these contribute to the production of the inter-
fibrous epidermal mesh.:^ When warts have grown to some
* Under the name of Verruca achrochordon, a pedunculated wart is described by
some authors. This is an error; warts according to the above definition are hyper-
formations of epiderma, but the pedunculated warts are invariably productions of
the derma, and in many instances, as I have ascertained, the emptied tegumentary
sacs cf small sebaceous tumours. (MoUuscnm Contagiosum.)
t My researches into the structure of warts date as far back as IS30, when my
attention was directed to their nature by a remarkable bleeding wart, which I had
at that time on my finger. Since this period, their structure has been investigated
by Ascherson, {Camer^M WochenMchrif% 1835,) and more recently by Dr. Gnstav.
Simon, of Berlin (MiUler's Archiv., 1840). Tbe latter writer speaks doubtingly of
^eir origin in all instances by hypertrophied papillsB, and states that they arise
sometimes where there are no papillie. I differ entirely from him in this opinion.
X This interfibrous mesh is not present in all warts; when it is absent, the fibres
adhere but slightly by means of their surface?, and are kept together by the thick
rim of epiderma which surrounds them.
X
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306 HYPERTROPHY OF THE PAPILLiE OF THE DERMA.
length, their extremity becomeB rough, and the fibrous structure
of the wart is distinctly apparent ; it not unfrequently happens
that warts of long standing split and break up in the direction
of these vertical fibres.
The structure of a wart is also shown by making a succession
of horizontal sections of its mass ; by this means, the longest
papillae will be cut across, and a slight oozing of blood will take
place ; and if the sections be continued, more and more of the
apices of the papillae will be divided. The structure of a wart
is also well exhibited by thin sections cut horizontally and ver-
tically, and examined under the microscope vrith a lens of low
power.
Rayer compares warts formed of isolated papillae, very apdy, to
" coarse plush." He quotes from M. Rennes a remarkable in-
stance of a wart of great extent, and presenting the appearance
of a band : " a band of agglomerated warts, from eight lines to
an inch in breadth, extended from the upper and anterior part
of the right side of the breast, underneath the clavicle, along
tiie arm and fore-arm of the same side, till it reached the carpus,
where it increased considerably in breadth, and finally over-
spread the whole palm of the hand."
500. Causes, — ^Warts frequently originate without apparent
cause ; at other times, they seem to depend on local irritation
of the integument. Such causes are, want of cleanliness, con-
tact of foreign substances, exposure to cold, &c. Some persons
exhibit an especial predisposition to the development of these
productions. It is popularly believed that the blood proceed-
ing from warts is capable of exciting their growth in unaffected
persons. Such a supposition is too absurd to deserve further
attention.
501. Treatment. — Warts are easily removed ; the way to pro-
ceed in effecting this object is to cut off the top of the wart, and
touch it daily with nitric or strong acetic acid ; removing from
time to time the stratum of disorganized and hardened epiderma
with the knife. The cure is accomplished in a few weeks.
Other substances capable of effecting die same object, but more
slowly, are, the nitrate of silver, the juice of the chelidonium
majus, &c.
Mr. Plumbe recommends the use of a small piece of blistering
plaster laid on the crown of the wart, and covered by adhesive
plaster.
TYLOSIS. CLAVUS.
Syn. CaUosUies, Corns.
502. A com is an increased degree of thickness of the epi-
derma, resulting from hypertrophy of the papillae of the derma;
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LAMINATED CORNS. 807
this hypertrophy being determined and kept up by the irrita-
tion caused by undue pressure and friction on the part affected.
So long as the causes which first gave existence to the com con-
tinue, die epiderma accumulates, and by its pressure on the
vascular derma may give rise to ulterior and serious conse-
quences. But as soon as the pressure and friction are removed,
the derma regains its natural state, and the epiderma ceases to
be produced in abnormal quantity. The ordinary seat of corns
is the feet ; they may, however, be developed on every part of
the body.
503. Corns present us with three modifications in relation to
structure and degree, which I shall consider as varieties ; these
are,
Laminated corns.
Fibrous corns.
Soft corns.
LAMINATED CORNS.
Sjn. Tylosis, CaUosity,
504. Investigating the manner of development and growth of
a com, we find that wherever a portion of skin is pressed and
rubbed by a hard and irritating substance, as in the case of the
integument of the foot by the shoe, and particularly when the
part itself is unable to yield sufficiently, in consequence of its
seat over a bone, to escape the pressure or friction, the vascular
rete of the derma becomes congested. If the process were now
to cease, the congestion of the derma would subside, and the
skin gradually return to its natural state. But instead of ceasing,
the pressure and firiction are continued from time to time, and
for some hours together, for months, and even years ; the derma
becomes more and more and habitually congested, and the
papillae are at first temporarily and afterwards permanently en-
larged, the lengthening of the papillae being most considerable
in file centre, where the greatest pressure exists.
The enlargement or hypertrophy of the papillae of the derma
is a perfectly natural process, and the mere result of excitation
of the cutaneous nerves in the first instance, seconded by vas-
cular determination to the part, and subsequently, increased vas-
cularity, with the associated consequence, augmented nutrition.
With the hypertrophy of the papillae, the fiinction of these organs
is likewise increased, and a proportion of epiderma, correspond-
ing with the enlarged papillae, is producea. The formation of
this epiderma over the hypertrophied papillae constitutes a cal-
losity, or com, and the diickness of the com bears an exact
relation to the thickness of the epiderma of the surrounding
x2
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308 HYPERTROPHY OF THE PAPILLiE OF THE DERMA.
skin, plus the increased dimensions and yascularity of the for-
mative papillae.
This is the mode of formation of every com, and this the
structure which all newly-formed and moderately-sized corns
present. It follows, from this description, that if we make a ver-
tical section of such a com, and examine the cut surface with a
lens, we shall find the epidermal thickening perfectly homoge-
neous, and this is the general fact. Sometimes, however, it
happens that the section of the com presents a distinctly strati-
fied texture, and the successive laminae differ from each other in
colour. I have seen the laminae presenting the various tints of
light brown, dark brown, and even black. This peculiarity of
structure is easily explained. A more violent pressure dian
usual, such as that produced by a new boot, or an unusually
long walk, upon the enlarged papillae, has caused an effusion of
blood beneath the epiderma, or among the epidermal cells. A
new formation of epiderma carries this ecchymosed part towards
the surface, and it is seen on the face of a section as a dark
lamina. Minor degrees of pressure will give rise to smaller san-
guineous effusions, and consequently to lighter coloured or
tfiinner laminae; and, moreover, the effused and desiccated
blood will lose a considerable proportion of its colour as it ap-
proaches the surface.
FIBROUS CORNS.
Syn. Clavus.
505. The preceding is a sketch of the history of the common
laminated com, or callosity, but those who have paid attention
to the subject will have observed in certain corns something
more than this. On the summit of the com they will have re-
marked an appearance resembling the ends of fibres; in cutting
the summit horizontally, there is an appearance as though these
vertical fibres were cut across, and they may possibly associate
with this appearance the popular belief in the existence of a core
and root to the com. If a vertical and central section be made
of a com of this kind, the existence of vertical fibres generally
slightly different in tint of colour from the homogeneous epi-
derma, and frequently intermingled with traces of opaque white,
is distinctly demonstrated. To explain the nature of this ap-
pearance, 1 must take up the detail of the mode of growth of a
com from the point where my description last ended.
In examining the structure of the skin microscopically, ten
years since, with my much esteemed friend, Dr. Jones Quain, I
observed that the papillae of the derma were not uniformly of
the same length, but that every here and there a single isolated
papilla might be seen, longer by one half than the neighbouring
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FIBROUS CORNS. 309
papiUsB. In directing my researches to corns, I found that the
derma of corns of old standing, and such as presented the
fibrous central appearance to which 1 have alluded above, was
remarkable for a tuft of these long papillae in the centre of the
hypertrophied patch, and that these elongated papillae con-e-
spooded uniformly with the fibrous portion of the com. Con-
tinuing my investigations, I perceived that in the laminated com,
the papillae, though hypertrophied, were pretty uniformly of the
same length, and not so long as to interfere with the ordinary
laminated mode of formation of the epiderma ; that by degrees,
however, the papillae of the centre of the congested patch of
derma became more and more elongated ; at first this elonga-
tion was confined to three or four papillae, but subsequently tfie
change extended to a tuft of greater or smaller size. It is clear
that this elongation of the central papillae is dependent on the
greater degree of pressure effected on the central point of the
com, and on the continuance of the pressure in that situation,
even when the rest of the surface is protected. Indeed, the
larger growth of the central papillae, with the consequent larger
formation of epiderma, serves for a time as a means of protec-
tion to the circumjacent papillae.
Whenever hypertrophied and isolated papillae of the derma
reach a certain length, they act as independent organs, and
instead of combining with the shorter papillae in producing a
laminated epiderma, they form, each for itself, a distinct sheath,
which becomes elongated, by a continuance of growth, to an in-
definite length. On the tongue, where the papillae are widely
separated from each other as compared with the derma, I have
collected specimens of elongated epithelial sheaths, fully half an
inch in length ; and in this situation, in consequence of the wide
separation of the papillae, the sheaths are perfectly distinct; but
in the derma, the lengthened papillae, though isolated, are sur-
rounded by multitudes of shorter papillae, which form a consoli-
dating epidermal mesh around the papillary sheaths, and retain
them in close connexion with the laminated epiderma. It is the
existence of these papillary sheaths in the centre of corns of
ancient date that gives rise to the fibrous structure apparent on
the surface of a vertical section. These sheaths are sometimes
of an opaque white colour, and differently tinted from the rest of
the epiderma, from some trifling disturbance in the formative
process, such as that which gives rise to the opaque white spots
on the finger nails.
The following experiment, which I have repeatedly made, will
prove the accuracy of these views: — If you pare an old com
slice after slice with a sharp knife, and observe the face of each
section, you will come to a semitransparent surface, immediately
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310 HYPERTROPHY OF THE PAPILLA OF THE DERMA.
beneath which, in two or three spots, may be perceived a red-
coloured point. This point is the extremity of an hypertrophied
papilla, much longer ^an the rest The next section will cut
off the point of this papilla, and there will be a slight oozing of
blood. Another section will cut off the heads of several, and
another, again, of still more.
Corns sometimes give rise to serious consequences ; by pres-
sure on bursas, they produce bunions ; when seated on joints,
they often excite inflammation of the structures entering into
the formation of the articulation, exostosis of bones, &c. I once
dissected a com situated on the metacarpo-phalangeal articula-
tion of the little toe, which had made its way into die joint, and
had produced absorption of the articulating ends of both bones.
SOFT CORNS.
506. These productions are exceedingly painful and annoying,
and more troublesome than the two preceding varieties. They
occur between the toes, are always of small size, present no con-
vexity on the surface, and from being constantly immersed in
the perspiratory secretion which collects in the situation of their
growth, they are soft to the impression of the knife.
The mode of formation and growth of soft corns is very dif-
ferent from that of the preceding. From the pressure of the
toes one against another, some point of the skin, either corre-
sponding with or on the soft parts immediately opposite the pro-
minent head of a phalangeal bone, becomes slightly inflamed,
and a greater thickness of epiderma than usual is formed. At
this stage of growth of the com, it frequently happens that an
increase of irritation gives rise to effusion of a serous fluid be-
neath the white and thickened epiderma. The epiderma is
rendered soft by impregnation with the serous fluid, and& small
aperture is formed in the centre of the disk, through which the
serum escapes. In this state I have seen a soft com remain for
several months during the summer season, the surface of the
derma continuing to secrete semm, and the serum being retained
or escaping through the small central aperture. At odier times,
and when the irritation is less severe, the epiderma is thickened
by the addition of fresh epidermal formations to its under sur-
face, until a convex mass is formed, which, by pressure on the
papillae of the derma, effects their absorption, and puts a stop to
the continuance of the formative process. If a soft corn be ex-
tracted at this period, it will be found to be plano-convex in its
form, the plane surface corresponding with the level of the ad-
jacent epiderma of the toe, and the convex surface projecting
more or less deeply into the derma.
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TREATMENT OF CORNS. 311
The soft com sometimes gives rise to the fonnation of an ulcer,
and, being separated from the adjacent tissnes by suppuration, is
thrown off. In one case, I saw a sinuous ulcer, excited bj a soft
com, extend as far as the phalanx ; it was followed by exfolia-
tion of the surface of the bone, and a permanent stiffness of the
joint.
507. Causes. — The causes of corns are pressure and friction.
They occur at all periods of life, and under various circum-
stances. On the feet, they are usually produced by the friction
and pressure of shoes or boots, which are either too tight or too
loose. Between the toes, they result from pressure of these
members against each other. They may also be the conse-
quence of club-foot, where parts of the skin unused to pressure
are made to support the weight of the body. On the hands,
corns are met with as a consequence of the pressure or friction
of tools in certain trades. On the knees they result from much
kneeling ; and are also found on various other parts of the body.
508. Treatment — The treatment of corns offers two indica-
tions, one curative, the other palliative. The first consists in
the removal of the cause, namely, pressure and friction ; and
the latter in pruning from time to time the homy growth. The
first indication may be fulfilled, where practicable, by rest and
disuse of the article of dress which occasioned the affection ; or
by means of plaisters of thick soft leather, perforated in the
centre by a round aperture that fits the summit of the com, and
relieves it from pressure. The plaisters of Amadou, recom-
mended by Mr. Wetherfield, are well adapted for this purpose.*
The palliative treatment consists in the removal of the thickened
epiderma, either by scraping or filing, after the corns have been
well soaked and softened in an alkaline solution ; or by cutting
either in the soft or bard state. In cutting a com, the summit
only should be removed, and this should be done in such a
manner as to render the surface concave. The chiropodists
contrive to grub out the central part of the com, the root, as
they call it, by a patient process of cutting and tearing, leaving
the circumference to serve as a circular cushion of protection to
the more tender central part
Other modes of removing the epiderma are, by nitrate of
silver, by plaisters containing the solvents of albumen, namely,
soda and potash, &c. It should, however, be recollected that
the formation of a com is not a morbid process, but simply an
augmentation of a natural fiinction, kept up by irritation.
The only cure for the soft com is its entire removal. This
may most easily be accomplished by the help of a pair of
• Lancet, vol. i., 1841-2, p. 189.
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312 HYPERTROPHY OF THE PAPILLiB OF THE DERMA.
scissors ; all the thickened epiderma being taken away at the
same time. The formation of soft corns may be preyented, and
when present they may be rendered bearable, by daily ablation
with soap, and by placing a piece of cotton wool between the
toes after each ablution.
PACHULOSIS.
509. Afifcer certain chronic affections, in which the skin is
secondarily involved, particularly that of the lower extremities,
the epiderma is produced in abnormal quantity; it becomes thick,
dry, and harsh, and cracks into scales of irregular form and size.
This appearance of the skin has been admitted by WiUan into
his description of ichthyosis, and referred to by other writers,
under the title of accidental ichthyosis, but it is quite clear, from
the description of ichthyosis given in die chapter on the diseases
of the sebiparous system, that the present disorder bears no
relation to that affection* As an inordinate production of
epiderma dependent on hypertrophy of the papiUae of the skin,
it has a title to a place in this group, while its principal charac-
ter, namely, that of thickening and condensation of the skin,
seems to point to pachulosis {jca%osj crassitude) as a fitting
designation.
This state of the skin occurs for the most part in elderly per-
sons, and not unfrequently after the healing up of an old ulcer
of the leg. I have also seen it follow some lasting cutaneous
disorders, such as chronic lichen. It is sometimes a sequela of
anasarca.
510. Treatment — The treatment of pachulosis consists in
sponging the scaly surface, vdth a damp sponge dipped in fine
oatmeal, diligently, for five or ten minutes, and then anointing
the surface vnth tlie limewater and oil liniment; adding to this
liniment, as the torpor of the skin gradually yields, a few drops
of liquor ammoniac. In the course of a short time, the natural
tone of the skin may generally be restored by this treatment
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CHAPTER XI.
DISORDERS OF THE VASCULAR TISSUE OF THE
DERMA.
51 L Under this head I propose to consider two disorders —
namely,
Naevus,
Purpura.
The former of these depends, obviously, on hypertrophy of the
vascular tissue of the derma; the latter, on morbid alteration of the
capillary vessels, Naevus occupies by right a position among
disorders of the cutaneous textures, but purpura is a disease of
the entire vascular system, and is admitted into the present
classification simply on account of the pathological change in-
volved in its appearance upon the skin, and for the purpose of
pointing out the pathognomonic characters by which its con-
fusion with other discolorations of the derma may be prevented.
N^VUS.
Syn. Teleangiectasia. Vascular ncevus. Erectile tumours. Arte-
rial TUBvi. Venous ncevi. Ncevus araneus. Ncevus Jlammeus.
Gefassmuttermdler. Germ. — Siynes. Taches de vin, Fran. —
Mother^ s marks.
512. The vascular rete of the derma is liable to become dilated,
and to give rise to the formation of red patches and slightly
elevated tumours, called vascular ntsvi. Vascular nsevi present
considerable variety in relation to extent, tint of colour, and
tumefaction. Occasionally the vascular dilatation is limited to
a mere point, from which several enlarged venules pass off in
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314 DISORDERS OF THE VASCULAR TISSUE OP THE DERMA.
different directions. This kind of naevus rarely increases in
size, it is met with on the fieice and on the limbs, and from the
peculiarity of its appearance has been named ncevus araneus.
Proceeding upwards from this nseTus araneus, the diseased spots
may be found presenting every degree of size, and their dimen-
sions are frequently so large, that they have been seen to cover
the whole of one side of the face, the ear, and part of the scalp.
The tint qf colour of vascular naevi is dependent on two condi-
tions— the extent of dilatation of the capillary rete, and the
degree of excitation of the vascular system. Thus, if the capil-
laries be only moderately dilated, so as to offer little impediment
to the circulation, and the latter be active, the blood will retain
its arterial hue, and the colour of the naevus be brightly and
vividly red. If, on the contrary, the vascular rete be dilated in
a high degree, the blood will travel slowly through the tortuous
tubes, and, assuming its venous character, the nsevus will pre^nt
a purple, and even a livid hue. Intermediate degrees of dilata-
tion, or impediment to the circulation, will naturally produce
different tints of red. Similar changes of colour are apparent
in the same naevus, under different degrees of excitation of the
vascular system. Thus, in a state of repose of the individual,
the spot may be only moderately coloured and livid, while, in a
state of temporary excitement, the spot will assume a most in-
tense and vivid red. The circumstances which affect the colour,
modify also the degree of tumefaction. In a state of repose it
is ordinarily flaccid, and probably scarcely raised above the sur-
face ; but in a state of excitement of the circulation, it will be-
come tense and tumid. In relation to tumidity, as great variety
is met with among naevi as is found in their other characters.
Some are not perceptibly raised above the level of the sur-
rounding skin, while others, on the contrary, form prominent
tumours.
Vascular naevi, when of small size, give rise to little or no
inconvenience ; but when larger, they are hot, painful, and throb-
bing. In the latter state, they communicate a distinct pulsation
to Ae finger, synchronous with that of the heart's beat Vascu-
lar naevi are sometimes stationary, but more frequently they
increase slowly in size by the gradual extension of the morbid
state of the capillary rete to the vessels of adjacent parts. Their
growth, however, is not limited to the skin, for they are apt to
extend more or less deeply into the subcutaneous tissues. Left
to themselves, they will sometimes continue the whole of life,
without giving rise to any inconvenient results ; at other times
they may ulcerate and slough, or throw out a fringous growth,
this change being accompanied by repeated haemorrhage, and
terminating fatally. At all times, the haemorrhage is trouble-
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TREATMENT OF VMVVS. 815
some, and even dangerous, when yasculax nsBvi are accidentally
wounded.
Dupuytren has the merit of first pointing out the analogy of
structure of vascular naevi with erectile tissue, and since the
announcement of this similarity, they have been commonly
termed erectile tumours. These naevi have been described from
the earliest times as mother^s marks, and have been referred by
the imaginative to the influence of moral emotion on the part of
the mother during pregnancy. In pursuance of this romantic
explanation, we still hear them spoken of, by the vulgar, as
bunches of red and black currants, strawberries, raspberries,
blackberries, lobsters, &c., and they gravely tell us that the
mother, in these cases, had a particular longing for the object
represented.
From the above description it will be seen that all vascular
naevi are identical in structure, and that difierences, when they
exist, are referrible to more or less dilatation of ihe vascular
rete. Where the rete is dilated to a moderate extent, and the
colour of the naevi is brightly red, we may call them, for the sake
of distinction, arterial fUBvi; and where the capillary rete is very
much dilated, and the colour is blue or livid, we may call them
venous ricBvi, The term varicose nsevi has been sometimes ap-
plied to the latter; but the use of this term is objectionable, for
two reasons: in the first place, it would seem to indicate a dif-
ference of structure, which does not exist; and in the second
place, the term is wanted for those bluish subcutaneous enlarge-
ments which consist in a plexus of small varicose veins, and are
so frequently associated with varix of larger veins.
As far as my observations have gone, — and I have dissected
many vascular naevi, — there is no addition to the normal num-
ber of capillary vessels in the affected part. They are enlarged
in calibre, with corresponding hypertrophy of their coatB, with
enlargement of their meshes, with hypertrophy of the inter-
vascidar tissue, and dilatation of their appertaining arterial and
venous trunks.
513. Treatment. — When the naevus is of large size, gives rise
to little inconvenience, and advances but tardily in its growth,
it had better be left alone, or simply treated with cold and
styptic' applications, with moderate pressure. When, however,
these conditions are reversed, an attempt may be made to destroy
it bit by bit, by pencilling a small portion of its surface, from
time to time, with nitric acid. In this way, in the course of
time, a naevus of large size may be cured.
When the nsevus is small, it may be removed by excision, or
if it be of moderate size, and danger be anticipated from division
of the arteries which supply its base, it may be dislodged by the
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316 DISORDERS OF THE VASCULAR TISSUE OF THE DERMA.
operation proposed by Mr. Liston, which combines with iacision
the use of ligatures passed through its base, and firmly tied.
This plan has the advantage over all others of getting rid of the
morbid structure expeditiously, without the chance of hsBmor-
rhage. In certain cases, the ligature passed through the base of
the nsevus may be used without the incision ; and where the
tumour is pedunculated, a simple circular ligature may be em-
ployed.
The spider naevi, and those of very small size, may generally
be cured by introducing into them the point of a probe, armed
with nitrate of silver, or potassa fiisa, or a small fragment of
either salt ; while, in some instances, touching the exterior with
the caustic will suffice for their destruction.
Dr. Marshall Hall has recommended the breaking up of the
vascular structure of nsevus by means of a cataract needle with
cutting edges, avoiding any external opening, save that through
which the instrument has entered. Sereral instances are re-
corded in which the carotid artery has been tied for naevi of
large extent.
Numerous methods besides the above have been suggested
from time to time for the treatment of vascular nseri, such as
vaccinating the vascular growth ; applying the potassa fusa; in-
jecting them with dilute nitric acid; passing a seton through
them ; applying the actual cautery, quick lime, tartarized anti-
mony, &C.
PURPURA.
514. Purpura is a morbid state of the capillary system, cha-
racterized by the effiision of blood into the different tissues of
the body, this effusion giving rise to the formation of sanguineous
patched in considerable numbers, and of various size. The
capillary vessels of the skin participate in this morbid disposi-
tion; hence purpura has obtained a place, by courtesy, among
cutaneous disorders. When the sanguineous spots are minute,
they are termed petechicBj but when of larger size, eccht/moses.
The spots of purpura are usually seated in Ae superficial layer
of the derma, more rarely the extravasation takes place beneath
the epiderma, and in some cases ecchymoses are formed in the
subcutaneous areolar tissue. The colour of the spots varies with
the quantity of blood effiised, and with their duration; petechias
are usually red, passing with age through the various tints of
purple, livid, reddish brown, and eventually disappearing as
yellow stains ; ecchymoses, from the larger quantity of collected
blood, are of a dark purple at first, becoming by degrees almost
black, and then passing through the tints of reddish brown^
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PURPURA SIMPLEX. PURPURA HiEMORRHAGICA. 317
greenish yellow, and yellow, until they vanish entirely. Both
kinds of spots are darker in the centre than at the circum-
ference, fading in the latter into the tint of the surrounding skin.
515. Purpura admits of classification into purpura sine febre
and purpura febrilis. Of the former there are five varieties —
namely, purpura simplex, purpura urticans, purpura hsemor-
rhagica, purpura senilis, and purpura cachectica.
PURPURA SIMPLEX.
516. In purpura simplex, the petechias and ecchymoses are
developed without apparent cause, and with but trifling consti-
tutional disorder. They are sometimes simultaneous, but more
frequently successive in their appearance, and they occur either
on part or upon the whole surface of the body. When succes-
sive, they present at the same moment all the tints of colour
characteristic of progressive stages of their duration ; and when
partial in their occurrence, are usually seen upon the lower
extremities. The effused blood is ordinarily absorbed in the
course of one or two weeks; but when the disease appears in
successive attacks, the spots may continue apparent for several
months. When petechiae occur on the face, ihey are also seen
upon the conjunctiva, and in the mucous membrane of the mouth
and fauces.
PURPURA URTICANS.
517. Purpura urticans is recognised by the existence of oval
and roundish elevated spots of a light red colour, in combina-
tion with the petechisB and ecchymoses of purpura simplex. The
elevated spots bear some resemblance to those of urticaria, and
the similarity is further increased by the tingling sensation by
which they are sometimes accompanied. The association of urti-
caria with purpura is not unfrequent, either preceding or accom-
panying the attack. The prominent spots differ from simple
urticaria in their larger size, the deeper red or livid hue which
they assume at their decline, and also in their association with
true petechiae. This affection appears usually on the legs, and
is often attended with oedema of the subcutaneous areolar tissue.
It is the least serious of the forms of purpura, and is prolonged
by successive attacks for about a month.
PURPURA HiEMORRHAGICA.
518. Purpura haemorrhagica is a much more severe form of
disease than the two preceding, and is characterized by anhaemor-
rhagic state of the entire system. This disposition is shown
in the occurrence of haemorrhage from the mucous membranes ;
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318 DISORDERS OF THE VASCULAR TISSUE OF THE DERMA.
there is bleeding from the nose, bleeding from the mouth
with spongy gums, bleeding from the fauces, haemoptysis, hsema-
temesis, haemorrhage from the intestinal canal, haematuria, and
metrorrhagia, one or other of these haemorrhages being pre-
dominant in different cases. The ecchymoses and petechiae are
more abundant upon the skin than in the simpler forms ; they
are general in distribution, and the susceptibility to extrava-
sation is so great, that ecchymoses occur from the slightest
pressure on the skin. Considerable bleeding follows the most
trifling wound, and collections of blood frequently form beneath
the integument.
Purpura haemorrhagica is accompanied, and often preceded,
by disorder of the digestive organs, by pains in the head, loins,
and pit of the stomach, nausea, constipation, and great lassitude
and languor. Its duration is uncertain ; where it is likely to ter-
minate favourably, it may continue for a lengthened period, but
where it tends to a fatal close, the legs become cedematous, and
efiusions take place into the serous cavities. Death is not un-
frequently sudden in its consummation, from repeated and abun-
dant loss of blood.
PURPURA SENILIS.
519. Dr. Bateman has applied this designation to a kind of
purpura which he observed a few times in elderly women. "It
appears," he says, " principally along the outside of the 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 ; in all, the
skin of the arms was left of a brovm colour. The heallh did
not appear to suffer ; nor did purgatives, bloodletting, (which
was tried in one case, in consequence of the extraordinary hard-
ness of the pulse,) tonics, or any other expedient, appear to
exert any influence over the eruption." I have seen these cases
repeatedly in old women, but have not deemed them of suffi-
cient importance to require treatment. Rayer remarks that he
has observed them in old persons of both sexes, and continues,
that they last longer than a month. He adds, moreover, that
these cases must not be confounded with true purpura affecting
the aged.
PURPURA CACHECTICA.
520. Under the designation of purpura cachectica are in-
cluded all those cases in which petechiae and ecchymoses occur
upon the skin, as a consequence of a reduced and debilitated
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PURPURA SENILIS. PURPURA FEBRILIS. 319
State of the system, from whatever cause the latter may arise.
We frequently see instances of this kind during the last stage of
various diseases, as of dropsies, or whenever the venous circula-
tion is obstructed.
PURPURA FEBRILIS.
521. Purpura febrilis is denoted by the well-marked fever,
and general constitutional disorder by which it is preceded
and accompanied. All the ordinary symptoms indicating mor-
bid disturbance of the nervous system are present^ — namely,
pains in the head, back, and limbs, rigors, and sense of oppres-
sion ; the pulse is quick, there is nausea and vomiting, consti-
pation, a dry tongue, and diminished secretions. On tibe third
or fourth day from the invasion of the precursory symptoms,
petechia and ecchymoses begin to appear in the skin, and con-
tinue to be formed until the body is more or less covered with
purple spots.
When these symptoms are present without haemorrhage from
the mucous membranes, the case is one of purpura febrilis sim"
plex; but when, as sometimes happens, haemorrhages from the
different mucous surfaces complicate the affection, it then be-
comes one oi purpura febrilis JuBmorrhoffica,
A variety of purpura is occasionally seen, in which a number
of erythematous patches precede the haemorrhagic spots, and
upon these, as well as upon the intervening uncoloured skin, the
petechiae and ecchymoses appear.
Febrile purpura may occur at all periods of life, and in every
constitution ; its ordinary duration is from two to three weeks,
and it has sometimes been observed as an epidemic.
622. Diagnosis. — The characters already mentioned are suffi-
cient to distinguish purpura from every other disorder affecting
the skin. The spots differ from congestions by remaining un-
changed under the pressure of the finger, and they may be dis-
tinguished from flea-bites, by the central dark point of the latter,
and the surrounding areola. Petechiae are uniform in colour,
and many of them are smaller than flea-bites.
523. Causes, — Purpura is a disease of debility of the nervous
powers, although not unfrequently associated with increased ac-
tivity of the arterial system. It occurs at all periods of life, but
is most common in children, and particularly in such as are
weakly and unhealthy. Occasionally it is met vrith in persons
who enjoy an apparently sound health ; or it may be developed
in association with constitutional disorder, as in small-pox, and
even after vaccination. It is not unfrequently observed as the
consequence of a long continuance of the erect posture. I have
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320 DISORDERS OF THE VASCULAR .TISSUE OF THE DERMA.
lately seen a well-marked case of purpura simplex, affecting both
legs as high as the knees in a compositor odierwise in average
health. The disease is sometimes hereditary.
524. Prognosis, — Purpura being an indication of debiUty of
the nervous powers, is always a disease of which the sequel
must be regarded with anxiety. The favourable indications
are those which denote a sound and uninjured constitution, but
where the latter is feeble, the prospect is most unsatisfactory.
Purpura urticans is the least serious of the varieties ; purpura
simplex follows next; while the haemorrhagic and cachectic
forms offer reasonable grounds for apprehension. Purpura
febrilis, though sometimes suddenly fatal from sanguineous ex-
travasation in the brain, is more amenable to treatment thau the
chronic forms.
525. Treatment. — The treatment of purpura is founded on
the general principles of management of constitutional disor-
ders. If the subject be strong and plethoric, bleeding is fol-
lowed by the best results, and should be aided by antiphlogistic
remedies and regimen. When, however, the tone of the nervous
system is obviously deficient, tonics and acidulated drinks are
indicated. The treatment proposed by Willan is too exclu-
sively tonic; purgatives are always indicated by the nausea,
constipation, and pain at the epigastrium, which attend the dis-
ease ; and a course of purgative remedies will, in most cases,
bring the case to a successful issue. Purgatives have the ad-
vantage of being applicable in a debilitated as well as in a
robust state of system. The stools in this disease are, without
admixture with blood, of a very dark colour, and exceedingly
offensive. In purpura febrilis, bleeding succeeded by antipUo-
gistic medicines is attended with great benefit, and is often in-
dispensable.
The general treatment of purpura sine febre should be ac-
companied by the use of the cold plunging or shower bath, if
the patient can bear it, and if not, of sponging the surface of the
body with water containing salt or vinegar. Tepid sponging
with water containing vinegar is also applicable in the febrile
variety.
Accidental haemorrhages complicating purpura must be treated
according to the general principles usually applicable to similar
eases, unconnected witii this disease.
Mr. Plumbe has given an excellent digest of cases of purpura,
with their treatment ; his observations on this subject are de-
serving of attentive perusal.
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CHAPTER XII.
DISORDERED SENSIBILITY OF THE DERMA.
PRURITUS. — HYPERiESTHESIA.
526. Under the influence of disordered nervous excitability,
depending sometimes on constitutional and sometimes on local
causes, the sensibility of the skin is altered, and a painful sen-
sation of itching, or pruritus, produced. This disordered sen-
sation is independent of local disease, the skin retains its
wonted appearance and structure, and the affection is generally
referrible to sympathy with an excited condition of some dis-
tant part
527. Pruritus is sometimes general, but more frequendy
local; of the latter, several forms deserve attention. These
are,
Pruritus ani. Pruritus urethrae.
„ scroti. „ pudendi.
„ prsputii.
GENERAL PRURITUS.
528. In general pruritus, the peripheral extremities of all the
cutaneous nerves of the body are, in turn, the subject of altered
sensation. The pruritus is excited by the most trivial causes,
and continues unabated for hours, depriving the sufferer of
every chance of comfort and repose. The only period of the
day that persons affected with this distressing complaint can
look forward to for an interval of quiet is the morning. As
soon as they have taken dinner, or the most trifling stimulus,
their worrying tormentor begins. Alteration of temperature has
the same effect ; they suffer immediately that they change their
dress, and especially so soon as they experience the warmth of
y
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322 DISORDERED SENSIBILITY OF THE DERMA.
bed. Scratching, instead of relieving, serves only to augment
the evil, and they are kept in a state of wretched discomfort and
excitement during the greater part of the night, to forget their
annoyance at last, only in a sleep made irresistible by absolute
exhaustion.
It is interesting to remark the extent to which these painful
sufferings are subject to the influence of the nervous system. So
long as the mind is engrossed with agreeable occupation, or is
diverted from the disorder, the morbid sensation sleeps ; but the
instant that the thoughts are turned to the affection, the pruritus
is aroused, and rages with severity. The apprehension of an
attack will, in this way, often excite it, and every effort for its
relief will but prolong its continuance.
The attacks of general pruritus are variable in length of dura-
tion ; sometimes they continue for hours without alleviation,
while at others their periods are shorter, and broken by inter-
vals of calm. The disorder may last for several months, and
even for years.
General pruritus is usually the consequence of irritation of
one or other of the mucous membranes of the body. In some
instances, the gastro-intestinal mucous membrane is in fault ;
in others, the pulmonary mucous membrane ; and in others,
again, the genito-urinary. The affection is sometimes associated
with amenorrhoea, or dysmenorrhcea, and not unfrequently with
pregnancy. In some instances, it is an attendant on jaundice,
and is attributed to the presence of bile in the blood. .
PRDRITCJS ANI.
529. Pruritus ani is *a severe and distressing itching of the
mucous membrane of the verge of, and immediately vn^in, the
anus, and of the neighbouring integument. The itching is
greatest at night, commencing shortly after the sufferer has re-
tired to bed, and continuing for several hours. There is no
trace of morbid alteration in the skin, but sometimes the parts
are excoriated by scratching, and a morbid secretion is poured
out, which increases the irritation, and gives rise to erythema of
the surrounding parts. Unless relieved by treatment, pruritus
ani will continue for many months, and even for years.
The causes of pruritus ani are numerous, being partly refer-
rible to the state of the constitution, and partly to local irritation.
Among those of the latter class are, ascarides, hsemorrhoidal
swellings, fistula, and chronic inflammation of the mucous mem-
brane of the rectum. The general causes are, sedentary occu-
pation, disordered health, heat of weather, irregularities of diet,
cessation of the catamenia, &c. Dr. Lettsom was of opinion,
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PRCJRITUS ANI. PRURITUS PUDENDI. 823
that in certain cases, this disease acted as an useful counter-
imtanty and he records several instances in which visceral and
cerebral congestions were relieved hj its attack.
PRURITUS SCROTI.
530. Pruritus scroti is identical in most respects with the pre-
ceding affection, and originates in similar causes. It is usually
dependent upon the existence of ascarides in the rectum, or upon
a morbid and irritating fluid secreted by the abraded skin. In
attempts made to relieve the pruritus by scratching, painful ex-
coriations are often produced.
PRURITUS PRJSPUTII.
531. This form of pruritus depends upon irritation, usually
excited by morbid secretion from the mucous membrane of the
prepuce. The disease originates in neglect, and may be relieved
by attention to cleanliness, and frequent alkaline ablutions. It
occurs, for the most part, in the summer season, and is exceed-
ingly distressing whilst it continues.
PRURITUS URETHRA.
532. Pruritus urethralis occurs at the extremity and along the
canal of the urethra in females, and gives rise to great discomfort
and annoyance. This troublesome affection usually depends on
some irritation of the mucous membrane of the bladder, and is
analogous to the pruritus which is experienced at the meatus
urinarius of the male in calculus of the bladder.
PRURITUS PUDENDI.
533. Pruritus pudendi is a most distressing affection. It in-
vades chiefly the external labia and the vulva, but sometimes
extends inwards along the vagina, giving rise to excessive dis-
comfort, and often exciting symptoms approaching to nympho-
mania.*
This disease affects all ages : I have twice seen it in young
children ; more frequently it occurs at the period of puberty, or
of the cessation oi the catamenia. It is sometimes a very
distressing accompaniment of pregnancy, invading at about
the fourth month or after parturition. Among other causes
which have been indicated as originating this disease are, asca-
rides in the rectum, haemorrhoids, and varicose veins of the labia
or vagina. Pruritus pudendi is sometimes experienced as a con-
comitant of lepra vidgaris, when that disease invades the mons
veneris, or the parts adjoining the vulva. *
y2
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324 DISORDERED SENSIBILITY OF THE DERMA.
534. Diagnosis, — Pruritus may be distinguished from prurigo
by the absence of the alteration in structure which is character-
istic of the latter disorder ; and from other affections it is at once
recognisable by the sound state of the skin.
536. Treaiment. — The treatment of pruritus must be general
or local, according to the nature of its cause. The general
treatment must be directed to the regulation of the secretions ;
in a debilitated state of the system, tonics are indicated, and
sedatives are in most cases indispensable. The diet should be
light, easily digestible, and nutritious, and all stimuli avoided.
The best local application for soothing the pruritus is a weak
solution of acetic acid, or lemon-juice mingled with water.
For the local varieties, constitutional treatment is equally ne-
cessary with local. In pruritus ani, if there be symptoms of
congestion of the mucous membrane of the bowels, leeches
should be applied to the verge of the anus, and the region sub-
sequentiy fomented. If ascarides be present, they must be
destroyed by a turpentine enema. I have found an opium
injection relieve the irritation after all other means had failed.
The local remedies most serviceable in pruritus ani are, a weak
solution of acetic acid, or bichloride of mercury, solution and
tincture of opium, creosote, the nitrate of mercury ointment,
&c. The bichloride of mercury is contra-indicated, if there be
abrasion of surface.
Besides the general remedies applicable to pruritus ani, a
lotion of acetate of lead, of sulphate of zinc, or pencilling with
the compound tincture of benjamin, will be founa useful in pru-
ritus scroti.
Pruritus urethrae may best be relieved by the application of two
or three leeches to the adjoining mucous membrane, followed by
poppy fomentations. If these means should fail, cold astringent
lotions may be tried.
Pruritus pudendalis especially requires medication adapted to
its cause. Where the presence of the foetus in utero is the only
apparent irritation, we must rely upon the restoration of the se-
cretions and the administration of sedatives. If there be heat
and dryness of the vulva— symptoms which indicate congestion of
the mucous membrane of the vagina — leeches should be appUed
to the inner surface of the labia, and fomentations of poppy-
heads afterwards used. I have employed the creosote lotion
and a solution of the bichloride of mercury with advantage in
this form of pruritus. Frequent ablutions with tepid water, con-
taining a small quantity of subcarbonate of soda, supersulphate
of alumina, or sulphuret of potash, are also beneficial. In a
very troublesome case, when every other remedy had failed, I
^succeeded in removing the pmritus by the application of a
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TREATMENT OP PRURITUS. 326
blister upon the upper part of the thigh, near the vulva. M.
Trousseau praises the effects of injections as warm as the patient
can bear ; he remarks, that he has seen great benefit result from
the injection of hot water simply; and that the solution of
bichloride of mercury used hot has proved successful after years
of unavailing attempts with other remedies. Lisfranc recom-
mends, that in cases where the pruritus bears relation to the
menstrual periods, several small bleedings should be practised
successively, and these, after a few repetitions, he never found
to fail. He also advises nitrate of silver in the form of lotion
and injection.
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CHAPTER XIIL
DISORDERED CHEOMATOGENOUS FUNCTIONS
OF THE DERMA.
MACUKffi.
536. Under tMs head, corresponding with the order MaculsB
of Willan, are assembled those affections of the cutaneous tex-
tures which are characterized by discoloration of the skin. The
precise seat of these alterations is the rete mucosum and papil-
lary layer of the derma. The cause may be referred to three
principal conditions ; firstly, the original organization of the in-
dividual ; secondly, alteration of function of the derma without
apparent change of structure ; and thirdly, alteration of nutrition
of the epidermal cells of the rete mucosum.
537. Macul8B may be arranged in three principal groups —
namely, 1. Those which are characterized by AugmentatUm of
the natural pigment of the rete mucosum ; 2. Those in which
there is Diminution of pigment ; and 3. Those which present a
Morbid alteration of pigment. To these characters, which are
indicative of important differences, both as regards quantity and
kind, in the natural pigment of the skin, I propose to add a
fourth group, with the view of including that remarkable alter-
ation in the colour of the skin which is produced by the in-
ternal use of nitrate of silver. The seat of this discoloration
is different from the preceding, inasmuch as it occupies solely
the papillary layer of the derma, arid may, I think very properly,
be considered under the designation of Chemical coloration of
the skin.
I. AUGMENTATION OF PIGMENT.
MELANOPATHIA.
Nigrities,
538. When we compare the distribution of the pigment of
the rete mucosum throughout the members of the human £Eunily ,
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BfBLANOPATHIA. NIORITIES. 327
we are strack by two remarkable extremes of difference, as illus-*
trated in the jetty black of the tropical zone and the fair com-
plexion of the natives of colder climates. Between these two
extremes, every shade of tint may be found in intermediate
latitudes ; and, indeed, by the alteration of the solar influence, the
pigment may be increased in those of fair skin, and, on the other
hand, may be diminished in the dark to a very considerable ex-
tent ; but we require not to proceed further than our own hearths
for an illustration of the £GU)t, that the blonde complexion may
be rendered dark by the stimulation of the light during the sum-
mer months, and the quantity of pigment will be again reduced
during the vrinter season. To state this fact in physiological
language, the activity of the functions of the skin is increased
during the summer, and under the stimulus of the sun ; while
in the winter season it is diminished to its minimum. One of
the functions of the skin is the formation of pigment ; and
under the influence of the stimulus of light and heat, and of the
sun's rays,, this function is greatly augmented, and the skin,
consequently, assumes a darker tint
But it is scarcely necessary to remark, that the phenomena
involved in the functions of Ae skin are not wholly referrible to
external agencies. That which the stimulus of light and of the
sun's rays is to the skin, under natural circumstances, the
stimulus of morbid action may be in a disordered state of the
system. Hence we occasionally meet vrith instances in which
the skin is altered in its colour in a brief period of time, either
temporarily or permanently, as one of the consequences of
disease, this alteration being confined to a limited region, or
being more or less generally diffused over a large surface.
Again, it is clear that especial organization must also con-
tribute very largely to the differences of tint which are observed
in the human race. The long winter of the colder climates, or
protracted imprisonment in a darkened cell, woidd not blanch
the skin of the negro any more than would the long blaze of
light and the intense heat of the torrid zone confer upon the
skin of the European the rich jet of the native African. We are
yet, however, to learn how far colonization for a number of
years might not give rise to these results. It is to especial or-
ganization that we must have recourse, to explain the great
difference in shade of colour that exists among the inhabitants of
the same island, and the differences which we often meet with
in different parts of the body of the same individual. In persons
of dark complexion, certain parts of the cutaneous surface always
present a deeper tint than the rest One of the natural changes
occurring at puberty is the alteration of the skin of the sexual
apparatus to a brovm colour, more or less deep in different in-
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328 DISORDERED CHR0MAT06EN0US FUNCTION OF THE DERMA.
dividuals, while, in rare instances, the skin in this region pre-
sents a deep black. Haller, in his Physiology, relates a case
of this kind. The alteration of colour which takes place in the
areola around the nipple of pregnant women is an analogous
change. In some persons, the cutaneous pigment in the genital
region is partial in its distribution, and appears in the form of
patches of various size. Again, patches of a darker colour than
the surrounding skin, but identical in every other respect, may
be developed upon any part of the surface of the integument in
individuals of every shade of complexion.
Casei illustrative of Melanopathia.
539. For the following interesting case of general melano-
pathia, I am indebted to Dr. Pereira.
" John Daniels, aged 17, weaver, applied at the London Hos-
pital on account of the dark colour of his skin. He states that
for some months past he has been changing colour and becoming
darker ; and that his companions have annoyed him by saying
that he is changing to a negro.
" His appearance is that of a dark-coloured gipsy. The dark-
ness of the skin, though general over the body, was most marked
at the nape of the neck, and least so on the nose and upper lip.
His hair is light-coloured and his eyes grey ; these, his mother
states, have undergone no change during the alteration of the
colour of the skin.
^^ His mother is remarkably fair, and she tells me that his
father is equally so ; and that until about fifteen months ago,
the son was considered very fair. The darkening commenced
in the summer; but the boy had not been particularly exposed
to the sun prior to the change. He worked with his father at
weaving, principally of black goods.
" The tint of the skin was brown, and in this respect differed
Irom the slate-colour induced by the use of nitrate of silver. It
somewhat resembled that which I have seen induced by the
inhalation of arseniuretted hydrogen ; but in the latter case the
sclerotic coat of the eye was discoloured ; whereas in Daniels's
case the sclerotica was remarkably white.
" I carefully questioned both the boy and his mother as to the
use of medicine, or of any other agent which could have in-
duced this change of colour in the skin, but without avail. The
boy had taken no medicine, and to the knowledge of himself and
mother had been subjected to no deleterious influences.
" The colour obviously depended on some alteration in the
quantity or quality of the colouring matter of the skin. It could
not depend on the presence of any colouring matter in the blood,
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CASES OF MELANOPATHIA. 329
since neither the conjunctiya nor the mucous membrane of the
mouth was altered in colour.
^' The total absence of desquamation and itching readily
distinguished the case from melasma (Pityriasis nigra.)
" A blister was applied to the nape of the neck. After it had
caused vesication, it was obvious that the dark colour of the skin
resided in the derma and not in the cuticle.
'^ The motlier states that the intensity of the colour is not
always alike, being sometimes much greater than at others.
'^ No great hopes being held out that medicine would affect
the change going on, the boy ceased to attend the hospital after
a few weeks."
540. In a case of melanopathia which I had an opportunity
of seeing, through the politeness of Mr. Acret, of Torrington-
square, the blackness affected the entire skin, with the exception
of the feet and legs as high as the calf. The subject of this
curious affection was a young woman, twenty-eight years of
age, who had enjoyed good health up to the first of December,
1844. At this date, she suddenly felt unwell, and suffering
from nausea, took an antimonial emetic, which failed to procure
vomiting. She was then attacked with typhus fever, and was
seriously ill for somewhat more than a month, being unable,
during the greater part of this period, to sleep, and being fire-
quently delirious. Previously to the illness, menstruation was
regular and the menses copious ; but since her recovery, she has
suffered from amenorrhoea, with much periodical pain, until the
last three months. Her health at present is what she styles
" good," that is, her strength is not impaired, but she is liable
to headach, has an eczematous eruption on the scalp, and
delicate appetite.
It was on her recovery from the above illness that the change
of colour in the skin was first observed. Her hair and eyes are
black, and her complexion was originally that of a brunette ;
but she has now the colour of an East Indian. The darkest
parts of her body are the back of the trunk and the backs of
the hands and arms. On the face, the red tint of the cheeks
blended with the black, and the yellow of the forehead and
nose struggling for mastery with the deeper tint, give her com-
plexion a singularly Indian appearance. And the peculiarity
of her colour is heightened by the extension of the blackness to
her lips, and in patches to the mucous membrane of the mouth.
Even the teeth have a bluish tint, the lips and teeth seeming as
if stained by the eating of black cherries. The sclerotic coat
of the eyeball is brilliantly white.
On close inspection of the skin, the blackness is seen to be
not perfectly imiform ; there are small patches in which the
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3S0 DISORDERED CHROBfATOOENOUS FUNCTION OF THE DERMA.
depth of colour is greater than in others, the darker coloured
spots corresponding with the apertures of follicles. The areol»
of the nipples approached in depth of colour to a negro-black-
ness.
541. Another interesting case of partial melanopathia has
been communicated to me by Mr. Jackson, of High Wycombe,
Buckingham shire.
^ Martha Weston, aged eighteen, came into the Union House
in June, 1843, to be confined, being in the last month of her first
pregnancy. My attention was directed to her by the matron,
in consequence of an unusual darkness of the skin. Upon ex-
amination, I found the anterior surface of the body from the
clavicles, downwards to about the middle of the thighs, of a
negro blackness.
<« From the girl's statement I learned that, shortly after she
became pregnant, the areola around each nipple looked yeiy
dark, but no furdier perceptible change took place until she
quickened, when an evident darkness of the whole breast was
visible, extending upwards to the throat, and downwards to the
thighs, gradually assuming a deep black colour. Over the
hips it extended laterally, but no part of the posterior surface of
the body was affected. Her complexion was naturally rather
dark, with black hair and eyes. Her health had been always
good, neither had she experienced more than the usual degree
of irritation resulting from pregnancy. At her labour, I was
called in by the midwife to the Institution, in consequence of a
presentation of the hand and umbilicus ; turning was resorted
to, and the girl did well. She left the house a month aft;er her
confinement, at which time there was no alteration in the black-
ness of the skin ; but on my last meeting her, about a year
afterwards, she assured me it had entirely (Usappeared.**
PIGMENTARY NAVI, OR MOLES.
Sjn. PigmentmuUerm&Ur. Germ.
542. Besides the patches before described, which are even
with the surrounding skin, and in every way identical in struc-
ture, excepting as regards the increased production of pigment,
there are other discoloured spots and patches found upon the
integument, which are termed pigmentary tubvi. The subject of
naevus, or mother's mark, does not belong to this division of
cutaneous afiections ; but it is necessaiy here to allude to the
spots in question, on account of their dissimilarity to the rest of
nsBvi, which latter are vascular alterations of the skin, (i 313.)
Pigmentary nsevi, on the other hand, are not more vascmar than
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PIOMENTABT NiBVI. LEUCOPATHIA. 331
the rest of the integument ; they are characterized bj a yellowish
or brownish, and sometimes a black colour, are yerj slightlj or
not at all raised above the level of the skin, and are frequently
covered with short bristly hairs. The dark colour of these
patches evidently depends on augmentation of the pigment of the
rete mucosum, and deposition of pigment in the papillary layer
of the derma. Pigmentary nsevi are various in point of size,
being sometimes small, and at other times so large as to cover
nearly one half the face, or a considerable extent of the trunk
of the body, or of one of the limbs. They are met with on
all parts of the surface, but particularly on the face and back.
When they are raised above the level of the adjacent surface,
the elevation depends chiefly on the presence of the hair-follicles,
and their contained hairs, which give an increased thickness to
the skin.
Although perfectly innocuous in their nature, pigmentary naevi
are generally unsightly ; in such cases, the medical practitioner
is appealed to, and it becomes necessary to adopt measures for
their cure. For this purpose, all applications, particularly those
of an escharotic kind, are worse than Useless, for should they,
after a painful process, succeed, an indelible scar, more ugly
than the mole, is left behind. The only resource left both to ^e
surgeon and ibe patient is the removal of the spot with the bis-
toury. When this is effected by two incisions inclosing an ellip-
tical portion of the skin, in the direction of its natural folds, all
trace of the operation is speedily obliterated.
II. DIMINUTION OF PIGMENT.
LEUCOPATHIA.
543. As, in the preceding section, we had occasion to reflect
upon the production of an excess of pigment in the skin, origi-
nating in causes whoUy unknown, so now we have to consider
an opposite state as regards the pigment — ^namely, that in which
there is a diminution or total absence of this production, leuco-
pathia. The former state, when unassociated with disease, is
usually accompanied by robust health and augmented strength
in the individual, while, on the other hand, destitution of the
natural pigment is indicative of debility of the nervous and
vascular systems, and weakness of the physical and moral
energies. Diminution of the natural pigment of the skin may be
congenital or accidental, and in distribution it may be general or
partial.
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332 DISORDERED CHROMATOGENOUS FUNCTION OF THE DERMA.
GENERAL LEUCOPATHIA ; ALBINISMUS.
544. Albinoes are met with among all races of mankind,
among the dark-complexioned nations of the south, as well as
among the fair-haired inhabitants of the coldest regions of the
earth. They are remarkable for a congenital and entire absence
of pigment, not only in the rete mucosum of the skin, but also
in those other parts of the body which are usually characterized
by their dark colour. The skin in these persons is of a milk
white colour, the hair is blonde, and usually soft and silky ;
sometimes, however, it is harsh and wiry in texture, and the
entire body is covered with a soft white down. The eyes are
red, from the absence of pigment in the choroid membrane, and
the iris presents a pinkish tint* There is great intolerance of
light, the pupil is small, from the contraction of the iris to ex-
clude the luminous rays, and the person bows his head habi-
tually towards the ground, in order to shadow the retinas as
much as possible from the light At dusk, however, when die
luminous rays are fewer in number, the albino rears his brow,
and walks erect, his eyes are no longer overwhelmed by excess
of light, and he is enabled to see surrounding objects in the night
of other men. The albino is usually short of stature, and weakly
in his powers both of body and mind.
Albinism is sometimes accidental in its development, arising,
without any apparent cause, upon some part of the body, and
thence extending to the entire siurface. Instances of accidental
general leucopadiia have only been observed among the natives
of Africa.
PARTIAL LEUCOPATHIA.
545. Partial leucopathia,t or the diminution or absence of
pigmentary secretion upon one or more parts of the body, as a
congenital peculiarity, is most frequently observed among the
darker races of mankind, in whom it is likely to attract most
attention; it also occurs, but more rarely, among the white
races. Several instances of the " pied negro" have been recorded,
and such defects of development are not very uncommon among
the African race. When the patches are seated on the scaJp,
the hair participates in the change, and is produced of snowy
whiteness.
Partial leucopathia is sometimes accidental in its develop-
* In India " the irides are blae and the hair is silvery white.'' Brett od the
Surffical Diseases of India. 1840.
f Partial leucopathia and vitiligo have been coDfonnded by several writers on
diseases of the skin, and in the first edition of this work were used synonymously.
More careful observation has convinced me that they bear no relation to each other
whatever. See page 301.
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EPHELIS. SUNBURN. 333
menty occurring without apparent cause as one of the natural
changes of the system. A remarkable case of this kind, which
happened in a native of Virginia, is recorded in the fifty-first
volume of the PhUosophical Transactions.
In Europeans, this alteration is most frequently met with on
the scrotum of old persons, where it appears under the form of
irregular patches, and sometimes of longitudinal stripes. M.
Guyon observed partial leucopathia in Algiers, where it is apt
to take place in Europeans as well as in the Arabs. Mr. Brett
remarks, that in India partial leucopathia " occurs in circum-
scribed patches, which are quite insensible, though the disease
commences by itching pain, redness, and other marks of inflam-
mation." These patches are apt to extend over the whole sur-
face of the body.
546. Treatment. — In a case of partial leucopathia which came
under ray observation in a young lady whose health was in
other respects very considerably deranged, I had tlie pleasure of
seeing the natural hue of the skin entirely restored by means of
tonics, and the shower-bath, and by the application of stimulat-
ing liniments to the faded spots. Mr. Brett, in his essay on the
Surgical Diseases of India, where this disorder is common, ob-
serves : " The treatment consists in the exhibition of the asclepias
gigantea in combination with alterative doses of mercury and
antimony, and topical stimulants. A blister applied to the white
patch will be found advantageous. Stimulating the affected
part with sulphureous douches and with sulphur ointment and
volatile liniments, is also of great advantage. The disease is
considered by the natives as incurable."
III. MORBID ALTERATION OF PIGMENT.
547. The affections which may be arranged under this desig-
nation are four in number— namely,
Ephelis,
Lentigo,
Chloasma,
Melasma.
EPHELIS.
Syn. Sun-burn. Sommersprossen. Germ.
548. The term ephelis (Ivl ^>io$-, the sun) is intended to ex-
press that change which is produced on the skin of raany per-
sons by exposure to the influence of the sun's rays. This dis-
coloration is developed in small patches of irregular form, and
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334 DISORDERED CHROBfATOOENOUS FimCTION OF THE DEBIIA.
of a yariable tint of brown, upon those parts of the body, as the
face, neck, shoulders, hands, &c., which are unprotected by
dress. The spots of ephelis are most remarkable in children
and women, and in persons possessing a thin and delicate skin.
They disappear during the winter season.
Peter and Joseph Franck indicate a difference of appearance
in the spots by the terms ephelis umbrosay and ephelis lentigo^ the
former referring to the irregular brown patches, and the latter to
circular yellow spots, somewhat resembling those of lentigo.
Rayer, moreover, constitutes the mottled appearance seen upon
the legs and thighs of women who sit over a charcoal brazier a
third variety, under the name of ephelis ignealis,
549. Treatment. — The best treatment for sun-bum is the ap-
plication of a liniment composed of equal parts of aqua calcis
and oleum olivarum ; to which, if the heat of surface be consi-
derable, may be added liquor plumbi in the proportion of .twenty
minims to the ounce.
LENTIGO.
Syn. Freckles, Sammersprossen. Germ.
550. Lentigo has received its name from the lentil-shaped
spots which characterize the affection ; in popular language they
are called freckles. Freckles are small, round, yeUow, or
greenish yeUow spots, of various size, but rarely larger than the
diameter of a split pea. They are seated in the rete mucosum,
and are most abundantly distributed upon those parts of the
body which are exposed to the influence of the light, as the fetce,
the neck, the hanas, &c. On these parts they are sometimes
assembled in thick clusters, which form patches of considerable
size, and are very unsightly. They are also met with on those
regions of the body which are usually protected by the dress.
Lentigo is sometimes a congenital affection, appearing soon
after birth, and continuing for the rest of life, or subsiding and
disappearing at the age of puberty. Sometimes the spots vanish
at other periods, and wiUiout appreciable causes. They are
almost peculiar to persons of light complexion and hair, and are
especially frequent in those whose hair is red.
The diagnosis between lentigo and ephelis is the permanence
of the former, its independence of season, and its accustomed
seat in the skin of persons of light complexion. Ephelis, on the
other hand, disappears during the winter, is excited by the sun's
rays, and occurs in persons of all complexions.
551. Treatment, — The treatment of lentigo consists in the ap-
plication of some moderately stimulating therapeutic agent, which
may excite the skin to a more healthy frmction. The lotion of
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CHLOASMA. MACULiB fiEPATICiB. 335
bitter almonds contaiiuBg five grains of the bichloride of mer-
cury to the half pint is well adapted for this purpose ; or a weak
solution of citric acid in infusion of roses. I have seen the lini-
ment of lime water and oU, with a small quantity of liquor am-
monia also of use in this unsightly affection.
CHLOASMA.
Syn. PUyriasis versicolor. Willan. MaculcB hepatica.
Leberflecke. Germ.
552. Chloasma is characterized by the development of one or
more patches, of irregular form and size, and of a pale or safiron
yellow, or brownish yellow colour, upon any part of the surface
of the body, particularly on the face, neck, and trunk. The seat
of discoloration is the rete mueosum ; it is accompanied by a
slight degree of local inflammation, and lasts from a few days
to several months or years.
Chloasma first makes its appearance in the form of small spots,
of a dull, reddish colour, which increase in size, and present a
yellow tint, approaching more or less to a safiron, or brownish
yeUow hue. These spots are at first distributed irregularly
upon the cutaneous surface, they then enlarge and communicate
with each other, so as to form patches of considerable extent
Indeed, these patches are sometimes so extensive that they may
be mistaken for the sound skin, while the intervening parts of
the natural hue may be regarded as the discoloured integument.
They are frequently developed without accompanying symptoms ;
at other times, they are attended with considerable itching, which
continues throughout their course, and gives rise to great annoy-
ance; for the more the parts are scratched, the greater the
itching becomes. The pruritus is greatly increased by mental
emotion, by impending catamenia, by stimulating food or drink,
and by the warmth of bed, and is often exasperated at the latter
period to such a degree as to deprive the sufferer of sleep.
When the disease subsides, desquamation of the epiderma en-
sues, and is repeated several times after the total decline of the
symptoms.
The symptoms above detailed apply to chloasma when re-
cent and in an active state; when chronic, it gives rise to very
little inconvenience. Its location on the skin offers some little
variety. In women, I have generally observed it on the front of
the chest, on the abdomen, and pit of the stomach ; in men, it
seems most frequently to occupy the abdomen, running up-
wards along the sides of the trunk to the armpits and back of -
the neck, and downwards into the groins and inner parts of the
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836 DISORDERED CHROMATOOENOUS FUNCTION OF THE DERMA.
thighs. In one gentleman it affects also the bends of the elbows;
and in another is situated onlj on the back, extending down-
wards on the trunk to the waist. On examination with a lens,
there is a conspicuous alteration and elevation of the skin, and
a mealy and pulverulent desquamation resulting from the &ct
of the hyper-pigmentous cells being more friable and less adapted
to assume the condensed character of the scales of healthy
epiderma.
553. Diagnosis. — There is little danger of mistaking chloasma
for any other cutaneous affection; its yellow colour, the trouble-
some pruritus, and the mealy epidermal exfoliation, are its
characteristic signs. In pityriasis there is a more altered and
rougher state of the skin ; a greater degree of redness ; a mix-
ture of soreness with pruritus after scratching, and larger
scales.
554. Causes, — Chloasma may occur at all ages, and in both
sexes, but is most frequent in women, and particularly in those
who possess a fair and delicate skin. The most frequent cause
of the affection in females is uterine irritation, induced by im-
pending cataraenia, amenorrhcea (maculae amenorrhceicse), preg-
nancy (macula; gravidarum), &c. It is by no means uncommon
to observe chloasma a short time previously to the appearance
of the catamenia, but the disease ceases as soon as the latter are
established. In like manner, the affection sometimes lasts
through a considerable period of pregnancy, invading at its
commencement, and terminating in its course ; or commencing
at a later period, and ceasing after the completion of parturidon.
Other exciting causes of chloasma are, gastro-intestinal irritation,
stimulating food and drinks, hepatic irritation, &c.
555. Treatment — The indications for treatment are the re-
moval of the cause, and soothing the local irritation. In effect-
ing the first object, the usual remedies for uterine irritation must
be employed, when the uterus is the erring organ ; for irritations
of the alimentary canal, gentle laxatives will be required, with
diluents, and abstinence from stimulating diet. The medical
treatment, where no such constitutional cause is apparent, should
consist of the milk of sulphur, in drachm doses, once in die day,
internally ; and a simple or sulphur bath twice or three times a
week. Wherever practicable, the sulphuretted vapour douche
wiU be found a valuable remedy.
In two cases, occurring in adult men, I adopted a tonic
aperient course, followed, as soon as the digestive organs were
relieved, by the liquor arsenicalis in doses of five minims three
times a day; while, locally, I prescribed a stimulating lini-
ment.
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MELASMA. CHEMICAL STAIN. 337
MELASMA.
Syn. Pityriasis nigra. Willan.
556. Melasma is an alteration of the chromatogenous function
of the skin analogous to chloasma, and differing from the latter
only in the darker colour of the abnormal pigment Melasma
is a rare disease, and has been chiefly observed in persons of
weakly constitution. It makes its appearance in the form of
blackish patches, of irregular size, upon one, or several parts of
the body. The affected skin is dry, and granular to the touch,
and the epiderma cracks and desquamates in fiirfuraceous scales.
On the fall of the morbid epiderma, the newly-formed membrane
usually presents the normal tint
Willan observed this affection in children bom in India, and
brought to this country, and regarded it as a variety of pityriasis ;
pityriasis nigra. In Willan's cases, the disorder " commenced in
a partially papulat^d 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.*' Alibert describes and delineates it as a discoloration of
the skin, under the name of " ephelide scorbutique ;" and Rayer
assigns to it the title under which it is considered in this place.
The latter author remarks on its frequent occurrence in asso-
ciation with pellagra, and observes that it " appeared among a
certain number of individuals of both sexes, and of all ages, in
the epidemic of Paris, in 1828."
The same characters which distinguish chloasma from pity-
riasis'form the principal diagnostic characters of this disease ;
substituting the yellow tint of the former for the black of
melasma.
557. Treatment. — The indications for treatment are the same
in this disease as in chloasma.
IV. CHEMICAL COLORATION OF THE DERMA.
OXIDE OF SILVER STAIN.
558. Persons who have taken nitrate of silver for a certain
length of time are liable to be affected with alteration of colour
of die skin. In the first instance, this alteration consists in the
suffusion of the surface with a bluish tint, which subsequently
becomes of a greenish slate colour. The discoloration takes
place upon all parts of the surface of the body at the same time,
but is most remarkable in those regions which are exposed habi-
tuaUy to the influence of light, as the face and hands ; and in the
z
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338 DISORDERED CHROMATOOENOUS FUNCTION OF THE DERMA.
latter situations it not unfrequently assumes a more or less deep
black. The colour is curiously modified in certain localities by
admixture with red ; hence, in the conjunctiva, and on the lips, it
S resents a livid brown tint, and on the general sur&ce it is much
eepened by those causes which, under other circumstances,
would produce pallor ; for the same reason, the discoloration is
more apparent upon persons naturally pale than in those who
possess a fresh tint
Once established, the discoloration produced by nitrate of
silver lasts for the entire life of the individual, without alteration.
In some few instances only it has been observed to diminish
slightly in the course of years.
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CHAPTER XIV.
DISEASES OF THE SUDORIPAEOUS GLANDS.
559. OtJR knowledge of the existence and nature of the sudo-
riparous system is comparatively recent. It was first made
known by the researches of Purkinje, Breschet, and Boussel de
Vauzeme, and their discovery has thrown much light on the
pathology of the sudoriparous organs. It had long been ob-
served by dermatologists, that the perspiratory secretion may
become morbidly augmented without fever, and without apparent
visceral disease, a disorder which has been termed ephidroris.
The sweating sickness which prevailed in England during the
sixteenth century, and which still continues to make its appear-
ance from time to time in France, receives much elucidation
from our knowledge of the anatomy and physiology of the sudo-
riparous organs. The observation of this fimction will probably
discover to us also certain morbid phenomena, which may be
referred to deficiency of perspiratory secretion, and numerous
instances are recorded of alteration in the physical properties of
the secretion. So that the diseases of the sudoriparous system
may be referred to the three heads which are generally applicable
to secreting organs — ^namely,
Augmentation of secretion.
Diminution of secretion,
Alteration of secretion.
1. Augmentation of Secretion.
IDROSIS.
Ephidrosis, Sudatoria.
560. Idrosis* is an excited action of the sudoriparous glands,
attended with symptoms which indicate inflammatory determi-
♦ Der. i^pufc* sudor.
z2
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340 DISEASES OF THE SUDORIPAROUS GLANDS.
nation. It is characterized by excessive perspiration, the per-
spiratory secretion being altered in its qualities ; by more or
less recbiess of the skin ; by heat, and tingling or itching ;
and by frequent shooting and lancinating pains. When the
disease is general and acute, it is attended with febrile symp-
toms, and often with the development of serous vesicles, or suda-
mina. (§ 351.)
561. Idrosis presents two principal varieties— namely,
Idrosis simplex,
„ maligna.
IDROSIS SIMPLEX.
Syn. Ephidrom. Sudatoria simplex. Sudatoria miliaris. Miliaria,
Miliaria rubra. Miliaria alba,
562. Simple idrosis is a subacute affection, sometimes ge-
neral, but more frequently partial in its attack. When genend,
it is apt to be accompanied, after the lapse of three or four days,
by sudamina, constituting that form of the disorder termed
sudatmia miliaris. These vesicles first make their appearance
on the neck, then on the trunk and abdomen, and then on the
skin of the arm-pits, and inner sides of the thighs. The disorder
is accompanied by febrile sjrmptoms, and torpor of the alimen-
tary canal, and its sudden arrest is sometimes followed by
visceral congestion. Subacute idrosis usually terminates in a
week or a fortnight.
Chronic idrosis is less apt to give rise to constitutional symp-
toms, and to the production of miliary vesicles. ^^ M. Dupont
has published an account of a curious case of a chronic general
ephidrosis, which lasted upwards of six years. The woman who
was thus affected became pregnant during this time, and was
happily delivered of an infant, which she nursed herself. This
ephidrosis, which, according to him, was independent of any other
affection, after having been fruitlessly combated by various reme-
dies, yielded at last to extract of aconite, given at first in doses
of half a grain, and gradually raised till sixteen grains a day
were taken."*
Partial idrosis is more common than the general form ; some-
times it is confined to the feet alone, at other times to the axillae,
perineum, or scalp, and ^^ Hartmann cites the singular fact of a
woman who, during pregnancy, perspired only on the right side
of her body.^t
The perspiration in idrosis is acid and disagreeable in odour,
and so profuse as to produce softening and opacity of the epi-
derma, which, on the soles of the feet is often corrugated, like
* Rayer, TraoBlatioD, page 920. t Rayer, loc cit
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IDROSIS SIMPLEX ET MALIGt^A. 341
that of waaherwomen. The disease is most commonly met with
in the summer season, occurring during extreme heat, excessive
exercise, &c.
IDROSIS MALIGNA.
Sudatoria maligna.
563. The malignant form of idrosis appears to correspond
with the sweating sickness of the sixteenth century — a disorder
which is no longer met with in England, but which would seem
by the numerous reports made to the Academic de M6decine, to
be still prevalent in France. The disease is infectious and con-
tagious, and occurs epidemically. The following brief notice of
the disorder is an abstract of the description given by Rayer.
Malignant idrosis is commonly associated with inflammation
of the stomach and intestines ; inflammation of the lungs ; in-
flammation of the bladder, or inflammation of the cerebro-spinal
axis. When the digestive organs are especially affected, the dis-
ease is characterized from the commencement, or at an early
period, by a severe constriction at the epigastrium, spa§m of the
diaphragm afiecting respiration, distressing anxiety, deeply
drawn sighs, feeling of weight on the chest, with a sense and
alarm of suffocation, and, in some cases, vertigo, violent headache,
and nausea. When the lungs are the seat of inflammation, there
is a deeply seated pain in the chest, crepitating rattle in the
bronchi, oppressed breathing, frequent fiill pulse, and sanguino-
lent expectoration. When the bladder is inflamed, there are
pains in the hjrpogastrium, difficulty in passing the urine, with
high colour, and deficiency of that secretion. And when inflam-
mation of tlie cerebro-spinal axis is present, there is headache,
flushed countenance, full, starting eyeballs, throbbing temples,
contracted or fixed pupil, coma, and convulsions.
These symptoms occasionally prove fatal in twenty-four or forty-
eight hours, or the disease may run on for two or three weeks.
564. Treatment — The indications for treatment in idrosis are,
to restore the secretions, to allay the irritation of the inflamed
perspiratorj' organs, and to engage with local congestions as they
arise. The first of these indications is effected by means of
abstinence, diluents, and the ordinary antiphlogistic remedies.
The second calls for the use of the warm bath. The third may
require general or local bleeding, blisters, mustard plasters,
mustard foot-baths, &c. ; these remedies being employed accord-
ing to the seat, and in proportion to the severity of the symp-
toms. The suggestion of M. Dupont relative to the extract of
aconite is worthy of recollection. A sulphureous bath is recomr
mended by Rayer, and in chronic cases sulphureous vapour
might be found useful.
After regulating the secretions, tannin will be found a valu-
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842 DISEASES OF THE SUDORIPAROUS GLANDS.
able remedy in these cases. I have employed tannin in idrosis
of the feet with considerable advantage, conjoining with it chlo-
ride of lime as a lotion for local application. A strong solution
of alum is also serviceable, and I once saw a gentleman who in-
formed me that he had relieved himself of this discomfort by the
use of brine foot-bath every night.
CcLses illustrative of Idrosis.
565. The following three cases of idrosis were observed by
M. Marrotte, in the Hotel Dieu, at Paris, at the close of an
epidemic of typhus fever, which raged in that city in 1842.
M. Honors, in whose wards the patients lay, had never before
seen cases of this disease ; and M. Bayer, who is well acquainted
with the disorder, had never seen it in Paris.
Case 1 . — A young man, twenty-three years of age, was received
into the hospital, July 29, complaining of pain in his head, lassi-
tude, great prostration, thirst, and drowsiness. His slcm was
hot, pul3e frequent, tongue and teeth foul ; had had no action of
bowels, which could only be brought to move by medicine ; no
rumbling in the iliac fossae. There were none of the lenticular
spots which accompanied the prevailing epidemic. The skin,
though very hot, was neither dry nor burning ; on the contrary,
it was moist He complained, moreover, of an uneasy sensa-
tion and feeling of anxiety at the pit of the stomach, which led
to the administration of an aperient emetic.
The present symptoms have lasted for three days. His first
indications of disease were, general uneasiness and loss of appe-
tite, which were not sufficiently pressing to induce him to relin-
quish his duties. Suddenly, in the middle of the day, he was
seized with pain in the head, and great prostration, which forced
him to take to his bed, but he had no rigors, no diarrhoea; his
skin was at the same thne covered with a moderate, though con-
stant perspiration.
For two or three days after admission the patient continued
in the state above described, without having been benefited by a
bleeding from the arm, practised previously to his application
at the hospital. After diis period, the disease assumed all its
severity, the prostration and drowsiness were more marked, the
perspirations and oppression became more intense. The per-
spiration streamed forth continually from the skin, the heat
of skin increased, the pulse became stronger and more frequent,
the oppression was accompanied by cough and mucous expec-
toration, and auscultation discovered mucous rales throughout
the whole extent of the bronchi.
This combination of S3anptoms persisted in all tlieir force for
ten or twelve days ; at the expiration <rf that period, the patient
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CASES OF IDBOSIS. 343
felt improved. His amendment seemed in some degree to have
been effected by a change in the position of his bed to a better
ventilated situation. Under the influence of this change of posi-
tion, the perspirations diminished, the tongue became soft, moist,
and simply ftirred, the teeth became clean, and the thirst was
diminished.
On the 25th of August, the patient is progressing ; the surface
is still moist in situations where the skin is naturally perspirable.
Vesicles are dispersed about the neck and trunk, some being
filled with a milky serum and surrounded by a slight areola ;
others being transparent. The return of appetite is more tardy.
566. CcLse 2. — A man, upwards pi six feet in height, thirty
years of age, had felt, every evening, a sensation of feverishness,
for about twelve days ; lus appetite failed ; he suffered from
thirst ; his skin felt burning hot, and he experienced consider-
able drowsiness. Since his admission, the fever has become
increased and continued ; his skin is covered by a constant per-
spiration ; he has headache, pain in the left side, anxiety, and
oppression at the praecordia.
In the course of five or six days, the anxiety and oppression
have assumed an excessive degree of intensity ; he has cough
and expectoration, and mucous rales are very obvious through-
out the whole of his chest. The perspirations have increased,
together with the heat of skin, and the hardness and frequency
of the pulse. The abdomen is distended, the tongue Aickly
furred; there is great prostration, and perpetual drowsiness.
An eruption of red pimples appeared upon the neck, and spread
thence to the face and trunk ; in two or three days these pimples
were surmounted by vesicles, containing a lactescent fluid, and
were followed by successive eruptions of sudamina, chiefly of the
phly ctenoid kind, which occupied the vacant spaces between the
papulae.
As the eruption increased and advanced in development, the
oppression diminished, the pulse became sofiter, and the abdo-
men diminished in bulk. In this patient, as in the former, the
bowels were inactive, and required the aid of medicine. His in-
tellectual - powers were unaffected, and the appetite returned
gradually to its normal standard during recovery. On the 25th
of August he was convalescent.
567. Case 3. — A young man, twenty-four years of age, for
some time past suffering from uneasiness, loss of appetite, and
lassitude, for which symptoms he was bled from the arm without
benefit He was next seized with headache, vomiting, diarrhcea,
ajid perspirations, and was forced to take to his bed, where hfs
remained for eight days, suffering with perspirations during the
whole period.
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844 DISEASES OF THE SUDORIPAROUS GLANDS.
On admission, August 16th, he was in a state of extreme pros-
tration, heaviness was exhibited in his features, his tongue and
teeth were covered with sordes, the perspirations were general
and continual, his abdomen was distended, and he suffered from
thirst. For several days he remained in this state, answering
with difficulty the questions that were put to him. He had re-
tention of urine, and upon the passage of a catheter, a full basin
of clear urine was withdrawn. In seven or eight days from this
time, his state was improved, the stupor has diminished, and the
tongue is moist The perspirations are mitigated, and this
mitigation became strikingly apparent as soon as the patient
was removed to a better ventilated situation. They have not
yet, however, wholly ceased ; the hardness and frequency of the
pulse have yielded.
From this period, amelioration was as speedy as in the former
cases, but the return of appetite was not so marked as is custo-
mary after typhus fever ; he was not so much emaciated as are
patients convalescent from the latter disease, but he appears
more debilitated.
M. Marrotte remarks, with regard to these cases, on the ex-
acerbation which took place at the close of the fifth or sixth day ;
the continuous perspirations which existed at that period both
day and night ; the intensity of the prostration and orowsiness ;
the cutaneous eruption which at this period made its appearance,
but without being critical ; the oppression and anxiety at the
praecordia appearing with the perspirations ; the protraction of
amendment to the term of two weeks from invasion ; the continu-
ance of perspirations to the close of the third week, and the
marked benefit resulting from better air and ventilation ; all of
which symptoms he looks upon as pathognomonic.
Contrasting the disease with typhus fever, he recals the nega-
tive characters of sudatoria. There was no diarrhcea in the com-
mencement ; there were no headache, rigors, or vomitings ; the
prostration of the physical powers is rarely so great ; it is rare
that the tongue and teeth axe so speedily covered with sordes,
or that drowsiness is so strongly marked. The first week passed
away without epistaxis, and without lenticular spots. The pulse
of sudatoria, again, has never the smallness and frequency of the
pulse of typhus.
2. Diminution of Secretion.
ANIDROSIS.
668. Diminution of perspiratory secretion from arrest of func-
tion of the sudoriparous glands has hitherto been observed only
in relation with febrile diseases. It is probable, however, that
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ANIDROSIS. OSMIDROSIS. 845
the perspiratory secretion, like that of other secerning glands,
may be diminished and checked as a consequence of inflamma-
tory disorder of the sudoriparous glands, independently of the
rest of the organism. The drjTiess of skin wluch we occasion-
ally meet with in some individuals bears no reference to the
sudoriparous system, but is dependent on the absence of secre-
tion of the sebiparous glands.
8. AUeration of Secretion,
OSMIDROSIS.
569. Alteration in the physical properties and chemical com-
position of perspiration, is co-existent with augmentation of
secretion, and may also occur independently of increase in
quantity. The most apparent alteration in physical properties
is that which relates to odour, osmidrosis. * The perspiration
frequently assumes an acid smell, probably from containing a
larger proportion than usual of acetic acid, or a rancid odour
from excess of butyric acid, or a combination of both, constitut-
ing a foetid and disagreeable odour, which has been aptly com-
pared by Rayer to the smell of ** rotten straw.** The same
author remarks, ^^ I had a woman under my care in the Hopital
de la Charit6, affected with chronic peritonitis, and who, some
time before her death, exhaled a very decided odour of musk :
the pupil who called my attention to this circumstance had ob-
served the smell for several days, while dressing the patient, who
had been blistered, but thought it owing to a bag of musk put
purposely into the bed, to overpower other bad smells. The
woman, however, assured us that she had no description of per-
fume about her, and I satisfied myself that her linen, which was
frequently changed, was not impregnated with any perfume be-
fore being delivered to her from the laundry of the hospital.
The odour of musk, the existence of which was fully ascertained
by myself and several physicians, and which was very percep-
tible on the arms and other regions of the body, did not become
more powerful from rubbing. After continuing for about eight
days, the smell became fdnter, and nearly vanished the evening
before the patient's death. Speranzaf relates a similar case.
Schmidt has inserted in the Ephemerides Naturae Curiosorum
an account of a journeyman saddler, three and twenty years of
age, of rather robust constitution, whose hands exhaled a smell
of sulphur so powerful and penetrating as very soon to infect any
room in which he happened to be. I was once consulted by a
♦ Der. o(r/(f|, odor,
f Observation d'odenr aromatique exhalee par la peaa de raTant-bras. Archives
Generales de Medicine. Vol xxx. p. 899.
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346 DISEASES OF THE SUDOBIPABOU8 GLANDS.
valet de chambre who oould never keep a place in consequence
of the unpleasant odour he left behind him in the rooms which
he had been occupied in cleaning. There have been instances
of individuals who, to obtain their discharge, or immunity firom
military service, have simulated these offensive perspirations, by
rubbing their axillse with the animal oil of dippel, assafcetida, a
piece of much decayed cheese, putrid fish, &c."
Another author observes, " the sweat of persons with the itch
is. said to have a mouldy odour, while that of syphilitic patients
is said to smell sweet. The sweat of rheumatic and gouty per-
sons has an acid smell, while in putrid fever and scurvy, it has a
putrid odoiur ; in jaundice it is said to resemble musk in its
smell. In Stark's General Pathology we find it stated that the
odour of the sweat in scroftda resembles that of sour beer, while
in intermittent fever it smells like fresh-baked brown bread."
^^Anselmino found free acetic acid in the sweat of women
during their confinement ; and according to Stark, the quantity
of free lactic acid is increased in the sweat during scrofula,
rachitis, and certain cutaneous eruptions.'* ^^ Anselmino found
a larger proportion of ammonia in the sweat after an attack of
gout than in any other case. Berend states that the sweat in
putrid and typhus fever is ammoniacal, and in nervous diseases,
according to Nanche, it becomes alkaline. All sweat vnth a
putrid odour probably contains free ammonia. In cases of
gouty and urinary concretions, the quantity of phosphate of lime
appears to be increased."*
570. Dr. Piutti, of Elgersburg, has made some analyses of
morbid sweat, the leading feature of vdiidi is the absence of
the salts of lime. Simon thinks that the phosphate of lime ap-
pertains to the epiderma, while Berzelius, more correctly in my
opinion, believes it to be a constituent part of the secretion, and
held in solution by a free acid. Piutti omits all notice, likewise,
of sulphuric acid and potash. The three analyses made by
Piutti are as follows : —
Water
Chloride of Bodiam . .
Phoapbate of ammonia .
Acetate of ammonia . .
Hydrosulphate of ammonia
Extractive matters . .
1. 8. a.
995-5 ... 9930 ... 994*6
8-0 ... 4-0 ... 8 8
•6 ... -8 ... 11
•5 ... -6. ... -6
trace trace
•6 ... 1-6 ... -5
Specific gravity 1003*5 ... 1004 ... 1003
The first was from a man aged thirty-six, suffering from atonic
gout ; the second was also from a patient with gout ; Jind the
third from a girl of twenty-two, labouring under paralysis of the
lower limbs.
* Simon *8 Animal Cbemiatry, vol. iL page 108.
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GHROMIDROSIS. R£MIDROSIS. 347
Of the abnormal constitaents which have been found in the
perspiratory fluid, are, albumen in rheumatic fever, gastric,
putrid, and hectic diseases, and also on the approach of death ;
blood, uric acid, bilin and biliphaein, uro-erythrin, and fat.
^ The following substances enter into, and have been detected
in the sweat : quinine, sulphur, mercury, iodine, iodide of po-
tassium, assafoBtida, garlic, saffiron, olive oil, rhubarb, indigo,
Prussian blue, and copper.''*
571. Treatment. — I have several times been consulted in cases
of osmidrosis, and have succeeded in relieving my patients from
a most distressing malady, by a plan of treatment directed to
regulate the secretions and other functions of the body. In one
case, where the general means had failed, tannin efiected a per-
fect cure. Locally, the chloride of lime lotion should not be
omitted.
CHROMIDBOSIS.f
572. Numerous instances of ^abnormal coloration of the per-
spiratory secretion are scattered through the works of the older
medical writers and through the various periodicals. Cases of
blue perspiration! have been recorded by several authors.
Green perspiration§ has also been observed. The rarest of the
discolorations of the perspiration seems to be that in which
the secretion is yellow. || BlacklT is not so uncommon; it
was probably of the same nature as the disorder described in
a future page of this work under the name of stearrhoea nigri-
cans.
573. Treatment, — I have never seen a case deserving of being
considered as one of chromidrosis. Were such a case to pre-
sent itself, I should not doubt of being able to restore the
healthy functions of the skin, by regulating the general health
and using stimulants locally.
HiEMIDROSIS.
574. The most common of the morbid discolorations of the
perspiration are those of a red hue, which probably owe their
* Simon, quoted from Stark's Geoeral Pathology, p. 1127; and Baamgartner,
Elements of Physiology and Therapeutics, page 486.
t Der. XP'^M^ color.
X Conradi. Blue perspiration of one half the scrotum, Anat p. 292. — Lemery,
Histoire de rAcadcmie des Sciences, 1701. Fontenelle, sur les sueurs bleues;
Journal de Chimie- medicate, vol. i. p. 330. Billard, Frorieps Notizen, No. 32. —
Dr. Bleifass in Wnrtemberff Med. Correspond. Blatt 1835. No. 26.
§ Borellns, Hist et Obs. Med. Phys. Cent. 2. Observatio 54.--PauUini Cent 1.
Observatio 38. John Peter Franck, De curandis hominum morbis.
0 Ephemerid. Nat Cur. Dec 1. Ann. 6 et 7. Obs. 78.
^ Bartholinus, Acta. Hafn. 1. Obs. 70.— Ephemerid. Nat Cur. Dec. 1. Ann. 2.
Obs. 19.
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348 DISEASES OF THE SUDORIPAROUS GLANDS.
peculiar tint to the colouring principle of the blood ; hence they
appear to me to call for separate consideration. Landerer*
observed a red perspiration which flowed from the axilla of a
patient labouring under fever. Yoigtel, also, has noticed an
instance of sanguineous perspiration.t M. du Gard has re-
corded the case of a child three mondis old, that was ^* taken
with a bleeding at the nose and ears, and in die hinder part of
the head, which lasted for three days, and afterwards the nose
and ears ceased bleeding, but still blood like sweat came from
the head. Three days before the death of the child, which hi^
pened the sixth day after it began to bleed, the blood came
more violently from its head, and streamed out to some distance.
It also bled on the shoulders and at the waist ;" " it bled also
for three days at the toes, at the bend of its arms, at the joints
of the fingers, and at the fingers' ends.**^
The greater number of cases of efiusion of blood, or of a san-
guineous fluid from the skin, occur in yoimg women, and are
referrible to vicarious menstruation. I lately saw a young lady,
in whom a discharge of this nature took place every fortnight
from five circular spots, each about the size of a half-crown, and
situated symmetrically on the face ; one being on each cheek,
one on the forehead, and one on the chin. In the ^' medical
cases" above quoted, a young woman of eighteen suffered a loss
of blood from " her ears, a little after at the points of her fingers,
and then at her toes ; presently after, at the umbilicus and cor-
ner of the eye ; several times by sweat, and at length it burst
out from the middle of her breast ; afterwards in the foot, where
the saphena is pricked in bleeding ; then at both palms and
back of her hands. Two days after, it flowed from her chin, and
in the night time from the tip of her tongue, and all this in a
fortnight's time.'* Whenever it flowed from her "breast or
other parts like sweat, there was no vestige of an orifice to be
seen."
675. Treatment — The treatment of hssmidrosis depending on
an hemorrhagic diathesis, must be regulated accoroing to the
various indications which present themselves. When the cause
is imperfect uterine function, the treatment must be the same as
for amenorrhoea.
* Baohner*8 Repertoriam, Sod series, vol v., p. 234, quoted by Simon,
t Stark's General Pathology, p. 1131.
X Medical Essays, abridged fVom the Philosophical Transactions, voL i. p. 52.
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CHAPTER XV-
DISEASES OF THE SEBIPAROUS GLANDS.
576. The sebipaxous glands are subject to the same patholo-
gical laws that govern other secreting glands. The secretion
maybe increased, diminished, or altered, without manifest disease
of die structure of the glands and their excretory ducts. Fourthly,
the altered secretion may be accompanied by distention of the
tubular structure of the glands, and of their related hair-follicles.
Fifthly, the glands, with their immediately adjacent tissues, may
be the subject of inflammation, the secretion being at the same
time more or less altered. Under these five heads I shall pro-
ceed to consider the disorders of the sebiparous glands.
I. AUGMENTATION OF SECRETION.
STEARRHCEA SIMPLEX.
Syn. Sebaceous flux,
577. Great diversity exists among individuals, in relation to
the quantity of sebaceous secretion naturally poured out upon
the surfEu^e of the skin. In certain instances, we have occasion
to remark a great increase of this secretion, particularly during
the progress of constitutional affections, in which the activity of
the cutaneous circulation is excited. When this condition is
present, the skin is bedewed with an oily fluid, which is especially
abundant on the nose, face, and head, and upon all those parts
of the body in which the glands are present in considerable num-
ber. The augmented secretion, after continuing a variable
length of time, gradually diminishes without requiring medical
treatment, and without giving rise to any unpleasant symptoms,
further than those which are necessarily associated witii the un-
sightly appearance of a greasy skin. This affection may be
often seen in persons otherwise enjoying excellent health, in
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850 DISEASES OF THE SEBIPABOUS GLANDS.
whom an oTer-stimiilating diet, or some slight disorder of diges-
tion, can alone be assigned as a probable cause.
In more severe cases of the sebaceous flux, the skin is some-
what congested and thickened, the common apertures of the
excretory ducts and hair-follicles are enlarged, and the secretion
poured out spreads in considerable quantity on the epidernuu
This profuse form of the disease is usually met with on the face,
continues for a great length of time, and evinces no disposition
to improve without medical treatment. Such cases are accom-
panied by pruritus, and often by severe shooting pains.
Treatment. — Attention to regimen, laxatives, alterative doses
of mercury, the fulfilment of such peculiar indications as the
state of health of the patient may offer, and moderately astringent
lotions locally.
II. DIMINUTION OF SECRETION.
XERO-DERMA.*
578. The opposite condition to the preceding is occasionally
observed, particularly in aged persons ; I have also seen it in
children and adults. The natural consequence of diminished
function of the sebiparous glands is a disagreeable dryness and
harshness of the skin, with their usual accompaniments, cracking,
and desquamation of the epiderma. This state of the glands
sometimes originates in neglect of personal cleanliness, but in
most instances is due to natural predisposition. When the
former is the cause, the bath, frequent ablutions with soap, and
!)lentiful frictions with a rough towel, are the proper expedients
or procuring relief. Indeed, in every case, frequent sponging
of the skin and friction are advantageous.
In two cases of this disease, one in an adult, the other in a
child, which have come under my observation since the publica-
tion of the first edition of thJte work, I succeeded completely in
removing the dryness and roughness of the skin, and restoring
it to its natural pliancy. In a third case now under treatment,
I hope to be equally fortunate. Both the adults were young
men between twenty and thirty years of age, enjoying, to all
appearance, perfect health, and presenting, in the ftlice, no indi-
cation of disease. To hear them speak of an a£3icting cutaneous
disorder seemed strange ; but when they bared their arms and
showed the shrivelled, parched, and scaly skin of sordid age, the
contrast with their face was wonderful and a£3icting. In the
child the face also was affected, and the little fellow had the
wrinkled aspect of an elderly man. The perspiratory secretion
* Cilpoc» uidnt.
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TREATMENT OF XBRO-DERBfA. 351
was not arrested in these cases^ but it was less than natural,
and there was a total absence of the oily product of the sebi-
parous apparatus.
579. Treatment — The treatment of this state of the skin may
be best illustrated by reference to that pursued in the case of
the little boy above referred to. In October, 1844, when I saw
him for the first time, I ordered him a soap ablution every night,
and the following ointment to be well rubbed into the skin dA/QX
the bath, and in the morning : —
a
Olei oliyae optatte, ^iy.
Cer» albidffi, 3ij.
Liquefec simnl dein adde—
Mellis, 5ij.
Olei CrotouU Tiglii, mxx.
M.
I also prescribed for him a teaspoonfiil of sulphur sublimatum,
with ten grains of supertartrate and five of nitrate of potash,
twice a week. At the end of a month I increased the croton oil
to thirty minims ; and at the end of a second month, to forty
minims. By the conclusion of the third month the skin had
almost regained the pliancy and softness of health ; the epi-
derma ceased to crack and break up into dry scales, and the
skin was so sound that I was enabled to dismiss him, enjoining
a continuance of the soap ablution once a week, with cold
sponging every morning, and the daily use of the Uieesah, the
exceUent flesh-glove made by Savory and Moore.* The oint-
ment was now laid aside, as being no longer necessary.
In the case of the adult, I prescribed friction of the diseased
skin every morning with a damp sponge dipped in fine oatmeal ;
a sponge-bath or shower-bath; and after drying the surfeuse,
the application with friction of a liniment containing a drachm
of liquor ammonia to an ounce of olive oil. For the face I
ordered the lotion of bichloride of mercury, with spirit of rose-
mary and mixture of bitter almonds. The internal treataient
consisted of a draught of sulphate and carbonate of magnesia,
* The kheesah, or Indian flesh-glove, comes recommended to oi bj the experience
of ages, and certainly offers ad?antages superior to anv other kind of rubber for the
skin in existence. It is the gloye, or rather mitten, which has been used, from time
immemorial, in Hindoostan, Persia, and throughout the East, and by a race of
people, both firom necessity and luxury, more attentive to the skin than any other
upon the face of the globe. The gloTC was introduced into England by Mr. J.
Ranald Martin, of Grosvenor-street, and Messrs. Sayory and Moore have succeeded
in procuring the manufacture of a similar glore in London. Their Imitation is
perfect, both in appearance and properties — indeed, is superior to the original ; and
It if a snlject of much satisfaction to me to be enabled to recommend so admirable
a contrivance for promotini; the health of the body, throagh the agency of the
skin. The glove is made of goat-hair, the material used in the mannaeture of the
Burrock or Ferstan gkivcHsloth, of wluoh the Oriental kheesah is composed.
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352 DISEASES OF THE SEBIPABOUS GLANDS.
with nitrate of potash, every morning ; and nitric and moriatic
acids in infusion of gentian, twice a diay. This gentleman was
quite well at the end of six months.
III. ALTERATION OF SECRETION.
580. In addition to simple increase in quantity, it not unire-
quently happens that the secretion of the sebiparous glands is
altered in its quality. For example, it may be changed in
colour, and by its accumulation on the skin form a thin film of
a yellow or black hue ; or it may be altered in consistence, and
after being spread out upon the surface, dry into a hardened
crust, which breaks up into fragments corresponding with the
linear markings of the skin, the fragments maintaining their
adhesion to the epiderma, and increasing in size by subsequent
deposition. These states of the sebaceous secretion constitute
a small group of cutaneous disorders, which I shall consider
under the names of
Stearrhoea flavescens,
Stearrhoea nigricans.
Ichthyosis.
STEARRHCEA FLAVESCENS.
581. In this disorder the abnormal secretion is of a golden
or dirty yellow colour, and forms a film on the surface, which
gives die skin a coarse and disagreeable appearance. The
substance is soft, and may be removed more or less easily from
the epiderma ; sometimes it can be wiped away with the hand-
kerchief, but at other times adheres very tenaciously. When
removed, it is produced again in the course of twelve hours,
and in twenty-four hours regains its original thickness. The
seat of this afiection in the cases which have come under my
observation, is the nose and cheeks, and the scalp. The sub-
jects of the disorder on the face were ladies, while the afiection
of the scalp, though more common in women than in men, I
have seen in both.
Stearrhoea flavescens sometimes assumes a chronic character,
and the abnormal secretion, instead of being soft and removable
by ablution, forms a hard and dense crust, which adheres firmly
to the skin, and can only be separated by means of a poultice.
The skin also becomes secondarily diseased in consequence of
the irritation caused by this crust, and the afiection puts on a
serious character. A case of this kind is at present under my
care, which has existed for six years, and was originally excited
by exposure to the heat of the sun.
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STEARRHCEA FLAVESCENS ET NIORICANS. 358
STEARRHCEA NIGRICANS.
582. The abnormal sebaceous substance poured out upon the
skin has occasionally a greyish appearance ; and in an instance
which lately came under my observation, it was almost black.
In other respects — namely, as relates to consistence and thick-
ness— it resembled precisely the deposits which are formed in
stearrhoea flavescens.
Examined with the microscope, I found this deposit to
resemble ordinary sebaceous substance, but the nuclei of the
cells, instead of being colourless, were perfectly black, and
every here and there formed masses of considerable size.
Indeed they were identical in point of structure, with the deepest
coloured cells of the rete mucosum of the negro skin ; the nuclei
being composed of an aggregation of granules more or less
shaded with pigment. These appearances correspond with
what I had previously observed in some black matter removed
from the §lan of the face by Mr. Gregory Forbes, in a young
lady who was under the care of Dr. Maclntyre, of Harley-street.
In Dr. Maclntyre's case, the abnormal secretion could be
removed by washing, leaving the skin beneath perfectly natural,
but it was reproduced in the course of twelve hours. In another
case of this kind, which occurred to Mr. Teevan, and of which
an account, with a drawing of the appearance of the patient, is
published in the twenty-eighth volume of the Medico-Chirurgical
Transactions, the skin was so sensitive, that the young lady was
induced to abstain from any attempt at washing away the secre-
tion ; and each fresh effusion was preceded by a pricking and
burning heat. The most remarkable features in the case of Mr.
Teevan's patient are the suddenness with which the effusion
took place after the skin was perfectly cleared, and the occur-
rence of black vomitings, black dejections from die bowels, and a
black pigment in the lurine, when the secretion on the face was
arrested. The young lady who was the subject of this unplea-
sant affection had been under the care of Dr. Read, of Bel&st,
for a severe pain in her side. At that time the cutaneous
affection had not attracted much attention, and Dr. Read was
of opinion "that it was connected with imperfect menstrual
function."
In an analysis of the black secretion from this patient, made
by Dr. G. O. Rees, it was found to be composed of carbon,
iron, lime, albuminous matter, fatty matter, and chloride and
phosphate of soda.
It is more than probable that some of the cases of black
perspirations recorded by the older writers, were of the same
nature as the cases quoted above. An instance very similar to
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354 DISEASES OF THE SEBIPAROUS GLANDS.
the one last narrated is published in the Philosophical Transac-
tions, by Mr. Yonge.
683. " A girl, sixteen years old, a daughter of Mrs. Elizabeth
Worth, of Plymouth, about the end of April, 1709, had a few hot
pimples rose on her cheeks, which bleeding and a purge or two
cured. She continued very well till about a month afterwards,
when her face, so far as is usually covered ¥rith a vizard-mask,
suddenly turned black like that of a negro. This surprising
accident much frightened her, especially after some foolish people
persuaded her she was bewitched, and never to be cureo. By
prayers, exorcisms, &c., which they used, in order to relieve the
fascination, they increased the passion and terror of mind to a
great degree— even to distraction, and then desired my assist-
ance. By the arguments which I used, and some composing
anti-hysterical remedies, the violence of her fits became much
pacified. I directed a lotion for her face, which took off the dis-
coloration ; yet it returned frequently, but with no regularity ;
sometimes twice or thrice in twenty-four hours, sometimes
five or six times. It appears insensibly, without pain, sickness,
or any symptoms of its approach, except a little warin flushing
just before it appears. It easily comes away, and leaves the
skin clear and white, but smuts the cloth that wipes it from the
fsLce ; it feels unctuous, and seems like g^rease and soot, or black-
ing mixed. It has no taste at all. She never had the menses;
is thin, but healthful ; the blackness appears nowhere but in the
prominent part of her face. There are a thousand eye-witnesses
to the truth of this uncommon case. The anomalar blackness
of the girl's face is now (November 1) divided into a few dark
cloudy specks, which appear but seldom, and nothing so livid
as formerly."
ICHTHYOSIS.
584. Ichthyosis, the fish-skin disease, is the name which has
been assigned to certain scale-like and spine-like formations
which are occasionally met with on the skin, and which occupy a
variable extent of surface. In the preceding edition of this work,
I regarded certain of these exodermal productions as hyperfor-
mations of epiderma, resulting from enlargement of the papUlK
of the derma ; while I retained others in the present group, under
the designation of Ichthyosis sebacea. I have since prosecuted
my inquiries fruther into this sulgect, and have obtained clear
evidence, that all the forms of ichthyosis are of the same nature ;
that they are, in fact, all concretions of altered sebaceous sub-
stance.
585. The varieties of the fish-skin disease, admitted by Willan,
are two in number, ichthyosis simplex and ichthyosis cornea ;
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ICHTHYOSIS SQUAMOSA. 355
names which so ill represent the diseases to which they refer,
that I have thought it desirable, for the sake of clearness of
definition, to describe them under the appellations : —
Ichthyosis squamosa.
9, spinosa.
In my former edition, I entitled an hypertrophy of the epi-
derma which bears some resemblance to the fish-skin disease.
Ichthyosis spuria. This, of course, must be left behind in the
chapter devoted to enlarged papillae of the skin, where it has
been treated of under the name of Pachulosis.
ICHTHYOSIS SQUAMOSA.
Fish^skm disease.
586. We call that state of the skin Ichthyosis squamosa in
which, after the efiusion of the abnormal sebaceous substance in
the form of a thin layer, the latter dries and hardens, and breaks
in the direction of the linear markings of the skin, into small
polygonal portions, corresponding in form vnth the aresB of the
compartments bounded by these cutaneous lines. The small
polygonal divisions are increased in thickness by the accumula-
tion of fresh sebaceous secretion, they become discoloured from
exposure to dust and dirt, and they assume a brownish or grey-
ish tint, approaching more or less to dirt colour. In the latter
state, the small masses have the appearance of scales, closely
adherent to the epiderma, hard and dense in texture, and pre*
senting various degrees of thickness. This affection may occur
upon any part of the body, but is most frequent on the face,
particularly on the forehead and nose, upon the abdomen, ana
upon the flexures of joints ; indeed, upon all those regions
in which the greatest number of sebiparous glands exist, and
which are most protected from the friction of dress. The scales
are sometimes cast from time to time, particularly during the
summer season, and give place to others formed by successive
concretion ; at other times they remain adherent for months, and
even for years.
This aifection of the sebiparous glands is generally unaccom-
panied by signs of local inflammation of the skin. There is, in
many cases, no redness, and no heat, and when the scales are
thrown off, the skin is natural both in colour and texture ; in
others, the skin is congested and thickened ; it is studded with
numerous apertures of sebiferous ducts, and frequently painful.
By accumulation, the scales obstruct the mouths of the excretory
ducts, and the latter become much distended. The disease is
rarely accompanied by constitutional symptoms, but in a few
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350 DISEASES OF THE 8EBIPAR0US GLANDS.
cases when general, some degree of gastro-intestinal irritation
may be present
587. In an instance of this affection which fell under mj ob-
servation about ten years since, I had tiie opportunity of examin-
ing the skin after the death of the patient from visceral disease.
In this case, the scales were remarkable for their thickness ; after
being well washed, they were greyish in colour upon the surfEu^e,
but white beneath, and evidentiy consisted of concreted sebaceous
substance. On removing a portion of the epiderma by macera-
tion, the ducts of the sebiparous glands and hair-follicles were
found distended with inspissated white secretion, and had a very
beautiful and brilliant appearance, projecting like cones of pearl
from the under surface of the membrane. The derma presented
a number of small deep pits, corresponding with these dilated
ducts. The mouths of the distended excretory ducts opened
upon the surface of die epiderma, some immediately beneath,
and in the middle of the scales, and others by their borders. In
the former situation, they could be seen as small white points
through tiie scale, and still more evidentiy when the epiderma
was separated by maceration.
From the careful examination of tiiis case, of which a prepara-
tion is now before me, and of others which I have subsequently
observed, I have been led to the conclusion, tiiat the scales, in
this disorder, increase in thickness in two ways, fir8tiy,by addi-
tions to the free surface, by means of the secretion poured out
in the linear furrows of the skin, and, consequently, between the
scales; and, secondly, by additions successively made to the
attached surface by the effusion of inspissated secretion beneath
them. Jn the preparation before me, the grov^th of the scales
by both of these processes is distincdy evident.
588. A remarkable case of this disorder, disseminated in
patches over the surface of the head, neck, and trunk, is recorded
by Dr. Jacobovics,* under the erroneous appellation of" tuber-
cules bigarres," a new variety of moUuscum. Dr. Jacobovics'
case differs from ordinary instances of this disease, in the longer
duration of the malady, its disseminated character, the excoria-
tions which resulted from its continuance, and the presence of
inflamed tubercles intermingled with the patches.
The patient, M. N., was a tailor of bilio-sanguine temperament,
liflby-six years of age, the nineteenth child of healthy parents.
His mother had a slight cutaneous affection on the neck ; a brother
had fiirfuraceous desquamations on the face ; two sisters had
several small tubercles on the neck and bend of tiie elbow ; a
sister's child had a similar growth. At the age of thirty, M . N.
* Da Molloscum. recberches critiques, &c., suivies de la description detaillee,
d*aii« nouyelle variete. Par M. M. Jacobovics. Paris, 1840.
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ICHTHYOSIS SQUAMOSA. 357
was attacked with severe pneumonia, which left him in unsoond
health for some years. On reaching his thirty-seventh year, the
cutaneous disorder first made its appearance ; it commenced on
the neck in the form of small yellowish spots, beneath which one
or more white points, the apertures of sebiferous ducts, loaded
with secretion, were perceptible. These yellow spots gave rise to
pruritus during the summer season, which subsided in the winter.
Three years afterwards, on the occasion of a severe mental afflic-
tion, the disease showed a disposition to increase, and quickly
spread over his neck, breast, and back. The disorder now
assumed the appearance of little crusts,^ having a roundish or
irregular figure, and various colour ; for instance, some were yel-
lowish-white ; others fawn-coloured, and brownish ; others again
blackish and livid, and covered with slight desquamation ; but
there was no constitutional disturbance, nothing to induce the
patient to apply for medical assistance until the year 1833, when
annoyed by the violent pruritus and unsightly appearance of
the disease, he presented himself at Saint Louis. He was
treated at this hospital for two months without benefit, and he
returned to his business. Three months later his case was
undertaken by Dr. Jacobovics, and presented the following cha-
racters:—
His hair was remarkable for its greasiness, as were several
other parts of his body, particularly the skin of the firont of the
neck, which the author describes as feeling viscous and unusually
soft. At the roots of the hair were numerous yellowish patches
and scales of sebaceous substance ; these greasy scales were also
met with dispersed over many parts of the skin. On the fore-
head, the alse nasi, the cheeks, the back, and in several other
situations, the apertures of the sebiferous ducts were very per-
ceptible, and many of them were obstructed by inspissated
secretion, which was dark-coloured in some, yellowish in others,
and rose above the level of the surrounding skin in several. In
other situations the sebaceous substance retained its softness
* With no better reason, apparentl j, than that of adhering to the erroneous appel-
lation which he had assigned to this disease. Dr. Jacobovics styles the crosts, tttber'
c/!e«, or tumtmrtf throogfaoat his essay. They were nnqaestionably extrayascnlar
formations, and mere depositions on the sorface. In accordance with this yiew, I
haye, in every instance, altered the terms tubercle, or tumoar, to crust Besides, it
does not accord with my notions of pathology to admit the possibility of a tubercle,
or tumour, being conyerted by progressiye deyelopment into a crost But to agree
with Dr. Jacobovics, such a doctrine must be embraced ; for, after indicating a nom-
ber of progressiye stages of growth completed by the crust, he remarks, in conclu-
sion,— ** Les tubercnles blen&tres «t noirkres, les cro^Ues noires et yerd&tres, et les
taches qui leur succedent sont des formes secondaires." That is to say, that the black
an greenish crusts are the secondary forms of '* les tubercules brunJUres." Those
who would peruse the statements of Dr. Jacoboyics, I most refer to his essay pre-
sented to the ** Academic Royale."
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358 DISEASES OF THE SEBIPAR0U8 GLANDS.
and whiteness, and distending the excretory ducts, appeared
like white points in the midst of the yellowish and discoloured
laminae* by which its escape was prevented. The crusts com-
mence by a whitish-yellow or brownish spot, of the diameter of
a millet seed or lentil, but without prominence, and pass through
a succession of stages which the reporter has accurately detailed
The yellow spot is attended witli pruritus, and, examined with
a lens, a minute white point may be discerned in the centre of
each. In a more advanced stage the yellow spot has increased
in diameter, and is raised in the centre, when it presents three
or four white points in place of one. By degrees the yellow
spots become transformed into brownish crusts, having a maxi-
mum elevation from the surface of two lines (French), and a
maximum diameter of six lines. These brownish crusts appear
studded beneath the surface ¥rith white sebaceous points, which
give the mottled (bizarre) character to the production, which
awakened in the mind of Dr. Jacobovics the specific designation
which he has assigned to the disease. The succeeding stages
which the author has observed the sebaceous concretions to
assume, are, bluish crusts, punctated with white, and having a
lobulated appearance, occasioned by the linear markings of the
skin, and blackish crusts, punctated only around the edges, and
intersected by deeper furrows, corresponding with the dermal
lines. These latter were chiefly met with in the dorsal region ;
after a time, the linear furrows increase in depth, even to the
splitting of the crust into a number of small polygonal masses,t
which adhere firmly to the epiderma, and assume a deep black
colour. The dessicated patches, rubbed by the dress, or scratched
with the nails, are liable to excite suppuration of the derma, and
the pus, oozing from between the fractured masses, forms upon
the surface a succession of irregular crusts, which resemble those
of impetigo. Other crusts of a yellowish-green colour are also
met with, resulting from the immediate desiccation of the brownish
punctated patches, and these also become broken in the direction
of the natural furrows of the derma.
Besides the sebaceous crusts above described, there were
* Dr. Jftoobovioe speaks of patches of a dirty jellow, or jellowish-wbite colour;
these patches he seems to regard as discoloured epidenna, and he describes tiie white
points as being beneath the eptderma. From the observation of cases of this kind,
and particularljof the one aboye recorded (§ 587), I feel oonTinced that the yellov
patch is a thin layer of inspissated sebaceous substance, adhering yenr elosely to the
epiderma ; this I oonoeive to be gradually raised by the deposit of fresh sebaceous
matter beneath it, until the elerated crusts are formed, which are the distinguishing
feature of this case. The white points will consequently be seen beneath the seba-
ceous scale. I haye already alluded to this appearance, and have before me a pre-
paration in which it is well shown.
t The masses are identical with those described at the c(MnmeiicemeBt d this
section.
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ICHTHYOSIS SPINOSA. 359
interspersed on this man^s skin a number of small tumours and
tubercles. Some of these were round or oval, prominent in
the centre, of a bright red colour, smooth, and shining, covered
by a thin and desquamating epiderma, and the seat of a trouble-
some pruritus. OAers were of a bluish-grey colour, with raised
and livid borders. These were the principal cause of a violent
itching, and indulgence in scratching gave rise to excoriation
and chapping of the edges, with a discharge of sero-purulent
fluid. A third variety were vividly red, indolent, and of small
size, varying from that of the head of a pin to that of a small
lentU. But these tnmoiu's bore no proportion to the sebaceous
crusts. They were, probably, the consequence of irritation
caused by the sebaceous concretions, and can only be regarded
as a complication of the sebaceous disease.
As regards diagnosis, Dr. Jacobovics unfortunately allowed
himself to be dazzled by a word, and that word the most
unmeaning in the entire vocabulary of cutaneous disease, I
mean, moUtucum. Thus, after recapitulating the physical charao*
ters of the preceding case — e. g., hereditary tubercles, varying
in size £rom that of a lentil to that of a pigeon^s egg (there were
none so large in his case), round or irregular, usually sessile,
brownish colour, consistent or softish, generally solid, no con-
stitutional disturbance, &c. — he remarks, ^^ Among the tuber-
culous diseases of the sMn, none but the present genus is
capable of assuming the whole of these characters, so I am
bound to establish this in the genus mollusoum.^' An imfor-
tunate preference, for molluscum is already synonymous wiA
beterogeneum. In the treatment of this case the author employed
purgatives and warm baths, but with only partial success.
ICHTHYOSIS SPINOSA.
Syn. Ichd^otis simplex, WilUm. Parcupme dueait.
589. The spinous varielr of ichthyosis is characterized by
the formation of hardened masses of altered sebaceous sub-
stance, which acquire by growth the form, thickness, and length
of short spines. This disease may be developed upon any
part of the body, or upon the entire skin, with the exception of
the palms of the hands and soles of the feet; the spots ot
election in the partial kind being the thick skin of the outer
sides of the limbs, the convexities of the joints, more particularly
on the elbows, the wrists, and the knees, and the dorsal surface
of the trunk. Ichthyosis spinosa is for the most part congenital ;
it is associated with a dry skin, in which the perspiratory function
is deficient; it is unaccompanied by redness, heat, or local
uneasiness, and it endures for a lengthened period, often for
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360 DISEASES OF THE SEBIPAROUS GLANDS.
the lifetime of the patient. In the earlier periods of the disease
the integument is unaffected, retaining its natural softness and
pliability ; at a later period, however, it becomes thickened and
hard from infiltration and deposition in its tissue, and the
morbid action appears to extend deeply into the subjacent
tissues. The spines are dense and hard, and for the most part
of a dirty brown, or greenish brown colour.
The form and length of the spines in this disease are deter-
mined by certain laws, the former depending upon the shape of
the small areas of the epiderma marked out by the furrows of
the skin, and the latter upon the powers of the system, and
consequent energy of secretion. In illustration of this view, it
will be remarked that, of the spines produced upon the con-
vexities of the elbows and knees, where the dermal are© are
large and somewhat quadrilateral, the section has a similar
form ; while on the anterior aspect of the fore-arms, particularly
near the joints, where the aresB are narrow and elliptical, the
spines are transversely flattened and slender. With regard to
length, I have never seen any of the spines longer than a quarter
of an inch ; but Willan records instances in winch they attained
a fiill inch in some places. They stand out perpendicularly
to the surface of the skin, their sides are polygonal, and
when the limb is in its natural position, they fit closely side by
side so as to present by their free extremities an even and
continuous surface. The free ends of the spines are more or
less rounded and polished by attrition with the dress of the
patient, and the sharp angles of their shafts are rounded off by
friction against adjoining spines caused by the movements of
the limbs. Their base generally corresponds with the small
area of skin upon which it is implanted, and to which it is
firmly adherent ; but by degrees, as the activity of the secreting
function subsides, the base becomes reduced to a slender pedicle,
and is easily broken off.
590. Examined with the microscope, the spines of ichthyosis
are found to possess all the general features which might be
expected a priori to be present in small cylinders of desiccated
sebaceous substance ; they are sub-fibrous, and obscurely lami-
nated ; the surface is more or less notched and jagged, the apex
somewhat split, and the base frequently connected willi a broad
lamina of exfoliated epiderma. Their internal structure is,
however, still more characteristic, for they generally contain
embedded in their substance several minute hairs, sometimes
running in a serpentine manner through their entire length, but
more frequently very much coiled and twisted, and evidently
fixed in that position previously to their excretion by the
sebiferous ducts. These observations lead to the inference
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DIAGNOSIS OF ICHTHYOSIS. 861
which I believe to be true, that the spines of ichthyosis are
frequently, if not generally, formed upon the short hairs of the
body as diey issue from the skin ; the hairs being naturally, and
as a consequence, very much interfered with in their growth.
This disease is not usually accompanied with constitutional
symptoms; the persons affected appear to enjoy undisturbed
health. Sometimes, however, irritation of the mucous mem-
branes is coincident with the cutaneous affection. Willan has
observed, that inflammatory pustules or boils occasionally appear
on some part of the skin. The epiderma of the palms of the
hands and soles of the feet is dry and harsh, and there is frequent
scaliness of the face.
591. Willan has pointed out two appearances which the local
forms of this disease sometimes present, and distinguished them
by the name of ichthyosis cornea. In one of these the spines
are curved or twisted, and unusually long, and suggest the idea
of miniature ram's horns. In the other the spine is broad and
single, and constitutes a horn-like mass. These peculiarities
are rare, and no purpose is gained by their separation from the
typical disorder.
692. Diagnosis, — Cazenave and Schedel, who refer to M.
Biett's description of this affection, state that, when it has
appeared upon the nose, it has been mistaken for noli me
tangere. This error is not likely to be committed by those
who examine the scales with attention. The presence of dense
scales, or spines, and their regularity of position and form, suffi-
ciently distinguish ichthyosis from every other disease of the
skin.
693. Causes, — This affection occurs at all ages, especially in
persons of phlegmatic temperament, in whom the skin is thin
and delicate. It is sometimes accompanied by an unctuous state
of the integument, but more frequently by a dry and parched
condition of the epiderma, and shrivelled appearance of the
skin. Occasionally it has been seen after parturition. The
most frequent cause I believe to be the absence of a proper
excitation of the skin by ablution and friction.
Ichthyosis spinosa is for the most part hereditar}', appearing
in the male branches of a family only, as in the instance of the
Lamberts, but often originating without any similar disease having
been known to exist in the family of the diseased person. In rare
instances, it appears a few days after birth, but more frequently
shows itself for the first time at the end of two or three months.
Bayer alludes to a foetal monster preserved in the anatomical
museum of Berlin, the whole surface of whose body is covered
by a layer several lines in thickness, which being broken up
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962 DISEASES OF THE SEBIPAROUS GLANDS.
into small pieces, gives it the appearance of a coat of mail.
When the disease occurs after puberty, or in the adult, it would
appear to be dependent on local and endemic causes. Among
these have been enumerated, the ingestion of bad fish, bad
water, humidity of atmosphere, &c. Bufibn states the disease
to be endemic in Paraguay, and several places on the sea coast
have, equally incorrecdy^ obtained a similar reputation.
594. Treatment. — ^The first indication presented to the mind,
in considering the nature of ichthyosis squamosa with reference
to treatment, is to remove the scaly concretion ; and the second,
to excite the sebiparous glands to healthy action. The former
object is to be efiected by means of the warm bath, or warm
fomentation, rendered alkaline by subcarbonate of soda or
potash, several times repeated. The second may be attained
by frequent ablutions with warm or cold water, succeeded by
brisk frictions with a rough towel ; sea-bathing ; and astringent
lotions. An useful application to the sur&ce, in this affection,
will be found in the foUowing ointment: —
T%
Elder flower ointment, |j.
Sulphate of copper or zioc, 9j.
M. To be used twice or thrice in the daj.
The lapis divinus, in the form of lotion or ointment, is also an
usefril remedy. During the progress of the local treatment, it
will be desirable to administer some laxative medicine, and to
regulate the diet of the patient
In ichthyosis spinosa, the spines are to be softened by warm
alkaline ablutions or baths, and then some stimulating applica-
tion made to the skin ; such as a lotion containing a drachm of
tincture of croton to the half-pint, or a liniment containing a
small quantity of liquor ammoniae. Constitutional remedies,
such as the symptoms may indicate, are to be used internally,
such as alteratives, tonics, &c., and in some instances Donovan's
solution will probably be indicated. The liquor potassae, with
decoction of sarsapanlla, may also be tried with expectation of
relief. Willan, Bateman, and Elliotson have reconunended
pitch, in doses of an ounce daily.
IV. RETENTION OF SECRETION.
595. The present group of diseases of the sebiparous glands
is characterized by distention of their ducts, and related hair-
follicles, with more or less alteration in the quality of the
secretion, the alteration tending chiefly to inspissation. This
group admits of division into two sub-groups, or families, in
one of which the excretory hair-follicle still remains open, the
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COMEDONES) OR GRUBS.. 363
secretion is inspissated, and is in communication with the ex-
terior. In the second family, the excretory hair-follicle is dosed
at its apertm-e, and the escape of the secretion prevented.
(a.) Retention of secretion in the sebiferous ductSy the excretory
aperture remaining open.
COMEDONES.
Syo. Grubs, Worms, Mitesser, Germ.
596. The simplest form of this disease is that which is popu-
larly known under the name of wormsy or ffmbs. In this affection,
the sebaceous secretion is inspissated, and produces complete
distention of the related hair-follicle. -^Reacfiing the mouth of
the latter, the secretion hardens, and becomes deeper in colour,
and at the same time, from being exposed to the dust and dirt
of the atmosphere, the extremity is rendered dingy and dark-
coloured. This discoloration of the sebaceous substance at its
extremity gives rise to the appearance of a round black spot,
with which, in some persons, the skin of the face, particularly of
the nose, is more or less thickly studded. If a fold of skin,
including one of these spots, be pressed between the fingers,
the concreted secretion is squeezed out, under the form of a
Uttle white cylinder, about a line in length, and blackened at
its extremity. It is the lengthened form of this little cylinder,
with its dark extremity, ^at has gained for it its popular
designation.
Instead of being soft, and easily pressed out from the hair-
foUicle, it sometimes happens, where the secretion has remained
undisturbed for some time, that the little cylinder has become
desiccated, and resembles horn, both in appearance and density.
In this case, the concretion requires to be dislodged by a pointed
instrument, or withdrawn by means of a pair of ciliary forceps.
In a remarkable instance of this kind now before me, there are
several patches of skin, of about the size of a crown piece, on
different parts of the body, closely studded with these homy
comedones, every hair-foUicle in the affected area being occupied
by its little spine, sHghtly projecting beyond the plane of the
surrounding ddn.
The disorder of the sebaceous glands here described is very
commonly met with on the face of persons in whom the
cutaneous circulation is less active than natural, and particu-
larly among the inhabitants of cities and large towns, in whom
the brain and nervous system claim an undue proportion of
the Tital energies ; and in whom congestions of the viscera are
not unfrequent. It is generally associated with the presence of
other diseases of the sebiparous glands, and is always met with
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364 DISEASl^S OF THE SEBIPAROUS GLANDS.
in oombination with acne. Indeed, one form of acne, acne
punctata, is simply an inflammation of the sebiparous gland
and related hair-follicle, excited by the overload of inspissated
secretion.
597. When the substance expressed from one of these come-
dones is examined with the microscope, it is found that the
sebaceous mass of which it is composed is altered in its com-
position. For, instead of flattened epidermal cells or scales,
intermingled with myriads of oU-globules which compose the
normal secretion, the inspissated substance consists of cells,
containing in their interior a granular substance, and a variable
number of oil-globules. Besides these cells, several minute
hairs are seen in the dfentre of the mass; they are usually
twisted, or bent, and sometimes to such an extent, that the
tapering point is approximated to the basial extremity. I have
occasionally observed the epidermal follicle surrounding one of
the hairs, and more frequently when there exists but one in the
sebaceous mass. In this case, the bulb of the hair is perfect ;
its fibrous brush-like root, and the granular mass of the pulp,
are distinctly apparent. More frequently, however, the hairs
are broken at their larger ends, and the fibrous structure of the
hair is very evident. The number of hairs seen in the mass of
a comedo appears to have relation to the period of impaction
of the sebaceous substance ; for when the matter is soft, and of
recent collection, I have found only one hair, or at most two,
one of the two being suiTounded by its epidermal follicle ; but
when the mass has been impacted for some time, I have counted
upwards of twenty. Dr. Gustav Simon remarks, that he has
seen as many as forty in some comedones.*
This observation is an interesting illustration of the physiology
of the invisible downy hairs of the body, and serves to prove that
which, a priori, we should be led to infer, and indeed diat which
their presence in the ceruminous substance of the meatus audi-
torius in such numbers, also testifies, namely, that they are con-
tinually thrown ofi*, after attaining a certain length, and continually
reproduced. In the instance before us, the pathology of the
comedones, the sebaceous secretion is poured as usual into the
hair-follicle, but instead of being excreted from thence, and dif-
fused upon the skin, it collects, probably as a consequence of its
altered nature, and obstructs the follicle. The little hair, when
thrown off* by the usual process, is no longer conveyed away
from the follicle with the sebaceous secretion, but is surrounded
by the latter in its altered state, and remains enveloped in its
substance. By a continuance of this process, a number of hairs
may thus be amassed.
» Miller's Archiv., No. 2, 1842.
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SMALL SEBACEOUS TUMOURS. 365
Dr. Gustay Simon, of Berlin, has recently discovered, in the
sebaceoos substance of comedones, and in that which is squeezed
out from the cones of acne punctata, certain microscopic animal-
cules, supposed, by the entomologists of Berlin, to be related to
the genus acarus ; hence. Dr. Simon terms the animalcule, acarus
folUculorum, A description of this animalcule will be found in
Chapter XVIII., at the conclusion of the volume.
598. Treatment, — The treatment of comedones requires the
employment of such means as are calculated to stimulate the
skin gently, and excite it to the due performance of its proper
functions. The parts affected should be impregnated with soap,
and thoroughly washed ; they should then be rubbed briskly
with a rough towel, until the skin be felt to glow ; and this
should be repeated twice in the day. The immediate effects of
this treatment may possibly be a red and patchy state of the
skin, but this will speedily pass away. It would be well in these
cases to extend the ablution and firictions to the entire body, for
the appearance of the disease in one part is indicative of a gene-
rally torpid action of the skin. Cold bathing and sea-bathing
are also calculated to be beneficial. In some instances it may
be necessary to employ some medicinal stimulant, in which case
the following lotion wUl be found useful : —
Bichloride of mercury, gr. v.
Eaa de Cologne, ^ij.
Distilled water, ^ vj.
M.
or the same quantity of bichloride of mercury may be added to
half a pint of the emulsion of bitter almonds.
SMALL SEBACEOUS TUMOURS.
Sjn. MoHuscum contagiotum,
599. In a second group the secretion is not confined to the
excretory duct, but distends also the primary ramifications of
the former, so as to give rise to a small tumour, about equal in
size, in its fully developed state, to a ripe currant. This re-
semblance is not confined solely to size, for the sebaceous sub-
stance, rising to the aperture of the follicle in the centre of the
tumour, appears like the depression on the summit of the cur-
rant to which the corolla is attached, while the sebiferous ducts
swell out in the circumference of the tumour, and give it a slightly
lobulated appearance. When a transverse section of this little
tumour is made, it is found in reality to be divided into five or
six segments, each of the segments containing a dilated branch
of the excretory duct The swelling of these segments, more-
over, gives rise to a depression on the summit of the tumour, cor-
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360 DISEASES OF THE SBBIPAROUS GLANDS.
responding with the iq)ertiire of the duct, from which a portion
of die concreted sebaceous substance can always be removed bj
means of a pointed instrument, and it also produces a constric^
tion around the base of the tumour.
When these little tumours are left to themselves, they termi-
nate, according to my observation, in one of two ways, either by
ulceration of the summit, and discharge of the sebaceous sul>-
stance and gland en masse, (for the latter is but loosely connected
with the integument,) or by inflammation and sloughing of the
entire tumour. In the former case, the collapsed integument,
when the base of the tumour has become much constricted,
forms a small, pendulous, pyriform appendage, (verruca aero-
chordon, (§ 499,) which remains for ^e rest of life. In the
latter, the ulceration sometimes extends deeply into the skin,
and leaves behind permanent and unsightly cicatrices.
600. An instance of this disease lately (March, 1842) pre-
sented itself to my notice, which was remarkable for the active
development of the tumours. They were first perceived, about
fifteen or twenty in number, dispersed upon the skin of the
neck, fBtee, and shoulders of a little girl, four years of age. By
the advice of the family medical attendant she was sent into the
country, and in the course of a few weeks became quite well,
all the tumours having disappeared, and no new ones being
formed. Soon after her return to town, the mother brought her
two other children — an infant and a girl of six years old — to
me. The mother and children were of blonde complexion, they
had light hair, and a thin delicate skin ; the mother was much
alarmed at the development of these little tumours on her two
other children as well as on herself, " caught," as she imagined,
from the child first afifected. I quieted her alarms relative to
contagion, but was much struck by the fact of the almost simul-
taneous appearance of the disease upon four members of the
same family. On the neck of the mother I found four or five of
these litde tumours closely resembling and of the size of
currants, constricted at their base, and each presenting an
umbilicated depression of impacted sebaceous substance, the
aperture of the excretory follicle ; and she directed my attention
to three ugly scars upon the face left by similar tumours recently
healed. On the neck, feu^, and shoulder of the eldest child I
found eight or ten litde tumours, presenting all their stages of
growth. One upon the shoulder was so completely pedunculated,
that I was tempted to place a ligature around it, and in a few
days it fell off. On the infant Aey were less advanced, they
were just rising from the integument, and each possessed in its
centre the dark point of an excretory sebiferous follicle. The
little tumours presented no signs of inflammation, they were
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SMALL SEBACEOUS TUMOURS. 367
of the natural hue, or somewhat lighter than the surrounding
skin, from the whiteness of the secretion which they contained
in their interior, and there was no areolar redness around their
base.
Since the above account was written, I have again (August,
1842) been visited by this patient, on account of the develop-
ment of a small angry tumour of a similar kind upon the margin
of the upper eyelid of her little girl, involving two or three of die
Meibomian glands. With this exception the children have re-
mained free from any return of the tumours. Upon inquiry as
to the manner in which they disappeared, the mother tells me,
that they became black, and shortly after were rubbed off acci-
dentally. One of large size, and situated behind the ear, in the
child first affected, was snipped off by Mr.Tyrrell. The mother,
who is out of health, has three still remaining, one of small size
near the angle of the right eye, and two upon the back of the
hand. The former has supplied me with afresh stock of matter
for examination.
601. Upon examining these little tumours, I found them to
present all the characters of a small conglomerate gland,* con-
sisting of several lobules held together by areolar tissue, and the
lobules composed of ramified ducts and terminal sacculi. The
ducts were remarkably dilated, particularly the central one, and
were filled with inspissated secretion. The latter was identical
in composition with the concreted sebaceous substance of the
comedones (§ 596). The cells were of the same size, had the
same appearance, and were intermingled in considerable number
with epidermal scales. I differ in opinion with Dr. Paterson in
not considering these cells as peculiar organisms, capable of
nucleolar propagation when transferred to an appropriate nidus
in another individual. I regard them as the normal sebaceous cell,
which, as I have before remarked (§ 596), contains a granular
substance, filling it more or less completely.
The difference in the appearance of the cells examined by Dr.
Paterson and by myself appears to me to be immediately ex-
plained by reference to the physical difference in the contents of
the tumours. In Dr. Paterson's case, the contents, as in Bate-
man's were milky, and consequently, semi-fluid. Here, then,
were the conditions favourable to the production of cells, having
a considerable interval filled with fluid between the granulous
nucleolar substance and the membrane of the cell — a disposi-
tion which induced Dr. Paterson to regard them as being com-
posed of an external vesicle, and an internal vesicle, the latter
containing the granular substance. In my cases, on the other
* This obeeiratkm confinns the description giyen by Dr. Henderson, § 612.
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368 DISEASES OF THE SEBIPAROUS GLANDS.
hand, the contained substance was concreted, there was a defi-
ciency of fluid, and the granulous substance filled the cell, and
in exceptional cases only were any perceived in which a peri-
pheral interval was observed. But on the second day, when the
mass had been steeped in weak spirit for a number of hours, the
peripheral interval was evident in a considerable number.
On examining my new stock of sebaceous matter, (August,
1842,) fresh from the patient, I found it to consist of cells heaped
together like a pile of eggs, and intermingled with a large
quantity of epidermal scales in flakes. The mass consisted
solely of these two substances, without any granular matter or
oil-globules. The cells were variable in their form, some being
more or less cuboid, others irregular from compression, some
oblong like the eggs of the ant, others, again, oval, but the most
common form was ovoid, like that delineated in the figures of
Dr. Henderson and Dr. Paterson. The cells presented equal
diversity in size, varying in their long diameter from ^^ to ^^
of an English inch, and in their short diameter from ttsit ^
xriT • some of the cuboid cells measured -nnnr > ^^ general
size of the oval form was j^i^ long, and nnnr broad ; there were
several oblong cells, measuring ^ry by ytjw 9 ^^^ ^^ common
dimensions of the ovoid cell were y^ l>y "nnnr* This size cor-
responds very closely with the cells of ordinary inspissated
sebaceous substance, whether it be concreted or pulpy ; and
also with the dimensions of the epidermal scales lying scattered
among the cells. The contents of the cells were also various,
some were filled with granular substance, in the midst of
which, at some one point, a nucleus was perceptible ; others
contained a homogeneous substance, separated into polygonal
masses, mostly of a cuboid shape ; while others, again, were
more or less filled with minute oil-globules. It is difficult to
say which kind of cells were most numerous. I saw nothing
like the double vesicle described by Dr. Paterson, and I think
it possible that the appearance which he has delineated may
have been produced either in the manner I have already
suggested, or by the superposition of a single cell by several
connected scales of epiderma ; or again, by the accidental posi-
tion of the cell upon the epidermal scales in such a manner as
to constitute a thin margin around it.
602. Treatment. — In the case above detailed, I prescribed
laxative medicine, and touched the tumours with nitrate of silver
several times. By this treatment, I succeeded very speedily in
removing them. I have mentioned that a ligature was placed
around one ; a more expeditious mode of getting rid of them
would be to snip them off with scissors. In adults, they may
always be snipped off. On the mother of these children, I
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TREATMENT OF SMALL SEBACEOUS TUMOURS. 369
opened several with a lancet, and touched their interior with
nitrate of silver. Their return may be prevented by the plan of
stimulation of the skin, recommended for the treatment of come-
dones. Dr. Thomson used sulphate of copper, and Dr. Paterson
potassa fiisa, in their treatment In a case which I lately saw
under treatment in the wards of St Louis, M. Lemery employed
nitric acid.
In the mode of cure of these tumours, I perceive another ar-
gument against their contagious nature. They disappeared in
the first child, on the recovery of her health, during a short visit
to the country, without local treatment In the case of the other
two children, many of the little tumours fell off, and the disease
got well under the use of the compound senna powder. The
three at present upon the skin of the mother are attributable to
a disordered state of health. Indeed, I have no hesitation in
asserting that this family is the subject of a sebaceotis constitution^
and that any recurrence of disordered health will bring with it
a disposition to the formation of sebaceous tumours.
603. After having determined the nature of the small tumours
above described, and having assigned to them the position
which they appeared entitled to occupy in the natural system of
classification of diseases of the skin, I read, for the first time,
with attention, the cases narrated by Bateman, under the head
of Molluscum, and was struck with the identity of Bateman's
cases with those I had just witnessed. Pursuing my inquiry
with a view to ascertain the true meaning of the term, and that
which seemed to be intended in its original application, I came to
the conclusion expressed by Dr. Jacobovics,* that Bateman must
have borrowed the appellation from the essay of Dr. Ludwig,t
the reporter of the celebrp,ted case which occurred to Tilesius.
The author in his preface remarks — " Rheinhardi, visu fcedum,
corpus tectum est verrucis molUbus sivi moHuscis.^^ Alibert, Biett,
Cazenave, and Schedel, on the contrary, attribute the origin of
the term to some resemblance existing between the cutaneous
tumours and the knots on the bark of £he maple.
The earliest case on record of this affection, and the one in
fact which, according to the above supposition, gave the designa-
tion to the disease, is that of Tilesius, recorded by Ludwig. I
propose to make an analysis of this case, as well as of diose
which have been published on the same subject to the present
time, in order to ascertain the opinions entertained by their
respective authors of the cases which have appeared in their
names. The result of this inquiry will, I trust, be a confirmation
♦ Du Molluscana recherches critiques, &c. Paris, 1840.
f Hisforia pathologica 8ing;Qlaris cutis turpitudinis J. 6. Rheinhardi ?m 50 an-
noram, &c. By Dr. C. F. Ludwig. Lipsis, 1739.
B B
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376 mSEASES OF THE SEBIPAROUS GLANDS.
of mj opinion respecting the pathology and true position o(
moUuscum.
604. Case observed by TVesius. — ^John Grodfirey Beinhardt was
bom at Muhlbergy of healthy parents, in 1742^ At birth, his
body was coyered with excrescences of small size. When seen
by Tiksius in his fiftieth year, these excrescences varied in size
from that of a pea to a pigeon's egg. Their form was various,
some being like warts, others oval, others irregular, and others
flattened either by the clothes of the patient, or by pressure
against an adjoining part The most remarkable of these
excrescenees was one which was developed from the integu-
ment over the ensiform cartilage ; it was wallet-shaped, tubercu-
lated on the surface, flaccid, and hung as low as the umbilicus.
Its tuberculated appearance indicates its constitution of several
smaller excrescences. The prevailing colour of the tumours is
red ; here and there one may be seen of a dull yellow or reddish
brown hue ; they are spongy and soft in texture, axid the skin
which supports them is dirty-looking and earthy. *^ In medio
quarundam maxmarum excrescentiarum parvum foramen conspi-
ekuTf ex quo nigra corpora obhnga, qiuB altius in cute aBncantem
atqne tenerum processum habent^exprimi possufit^ qu€B vulffo, come-
dones, appellaniur.^
The excrescences are most numerous by the side of the verte-
bral column, on the thorax, the neck, and the sides of the
abdomen. On the head, one has the appearance of an encysted
tumour. Regularly every month, some of the tumours become
congested, and itch greatlpr, forcing the patient to scratch them
violently. He is the subject of habitual feverishness, which is
increased at each fresh attack of congestion of the tumours, and
is aooompanied by loss of appetite.
Beinhardt is short in stature, has a large head, knees some-
what incurvated, protuberant abdomen, and dull expression of
comntenance. His position in life is one of indigence and misery.
He has invariably refrised to permit the removal or puncture of
one of the tumours, so that their internal structure is entirely
unknown.
Such is the case observed by Tilesius. The question now
cornea to bip — ^What is the nature of the disease ? Let f» review
the evidence. An unhealthy child, bom with disordered sebi-
porous glands, the ducts of the glands loaded with inspissated
secretion, and forming small prominences' on the surfEice of the
skin. The child bred in ^^ indigence and misery;'* the skin
^^ dirt-coloured, and earthy in appearance ;'' the child and man
unsound in body, sluggish in Amctions. Here, then, are pre-
cisely the conditions which we should desire to bring together,
for die purpose of inducing the disease artificially. For the
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TILESIUS AND BATEMAN ON MOLLUSCUM. 37!
most oofftclusire of all evidence, mark the Lathi passage quoted
from the original ; the excretOTy aperture in the centre of the
largest tumours, the altered sebaceous substance squeezed out,
nay, more — its comparison Trith " comedones." One of the
tumours situated in the scalp we find to have taken on the
usual characters of a sebaceous encysted tumour. The seba-
ceous tumours in this case are remarkable for being the largest
on record. But why ? Because they were reared in excellent
soil, and because they possessed a growth of half a century.
One assumes the form of a wallet, but this we find is the
^ggregniioTi of several, growing from a limited spot of skin, and
one richly supplied with sebiparous glands. The wallet is
also favoiffcd in its growth by the constant irritation produced
by the pressure of the shoemaker's last. The constitutional
symptoms form no part of the disease, only so far that such an
abundance of unhealthy glands would necessarily excite general
disturbance, and, aided by "indigence and misery," and by
endemic conditions, would conduce to the development of inter-
mittent fever, under which the patient suffered several times.
One other observation is elicited by this case, namely, that no
suspicion of contagion appears to have occurred to the minds of
any of the persons named in the narrative. The father and
mother of the patient never suffered from a cutaneous complaint ;
his two brothers were free ; his two wives were equally exempt,
together with an infant child. But this is the typical case of
moUuscum, with which all fixture observations must be compared :
this is the case which has supplied dermatologists with their
definition of the disease — which enabled Bateman to announce
that moHuscum " is characterized by the appearance of numerous
tubercles, of slow growth and little sensibility, and of various
sizes, from that of a vetch to that of a pigeon's egg. These
contain an atheromatous matter, and are of various forms ; some
being sessile, globular, or fiattish, and some attached by a neck,
and pendulous."
None of the tumours were punctured in Reinhardt's case, but
that omission is of little moment, when we again advert to the
Latin quotation. The tumours from which no sebaceous sub-
stance escaped, upon which no aperture was apparent, were
undoubted instances in which the excretory aperture had closed,
as in encysted tumours.
605. Cetses observed by J?flrfem««.-r— This author reports six cases
of sebiparous tumours, which he considers, in reference to the
case of Tilesius, " a singular species of molluscum." In my
opinion, the only difierence between Bateman's cases and that
of Tilesius is one of duration ; and the same observation applies
to all the cases recorded since his time. The sebaceous tumours
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372 DISEASES OF THE SEBIPAROUS GLANDS.
of Reinhardt were of fifty years* growth. The assumption of
the contagion of these cases appears to me as unfounded as in
the four cases I have myself related. It will be remarked, that
of Bateman^s seven cases, three were children of the same
fiEunily, two were children, apparently, of another family, and
two were servants in the first fetmily ; one an undoubted case,
the other supposititious. But to proceed : —
^ The feu^ and neck of this young woman,^ writes Bateman,
" were thickly studded with round, prominent tubercles, of various
sizes, from tliat 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
skm. 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 only a few of them had attained a large
size." " She ascribed the origin of this disease to contact with
the face of a child, whom she nursed, on which a large tubercle
of the same 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 chUd had received the eruption from a servant, on whose
face it was observed. Since my attention was drawn to this
species of tubercle, I have seen it in another instance — in an
infant brought to me with porrigo larvalis ; and, on 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 tubercles, and may be presumed
to be the medium of contagion.**
606. Cases observed by Dr, John Thomson and Dr, CarsweU.* —
The first case occurred in the Ganongate, in April, 1821, in three
children of the same family. The eldest boy was supposed to
have brought the disease from school, and to have transmitted
it to his brother and sister. ^^The contagious nature of the
disease is well evinced in the child. On the back of its hands
a considerable number of tubercles are seen, which have been
produced by applying them to the face, and scratching those
situated there during their inflammatory stage. Some of the
tubercles are small, others large; some in a state of active
inflammation, others nearly of the same colour as the skin,
and quite free from pain. A few of them are pedunculated,
* Edinbur^ Bledieal and Sorgical Joamal, vol IvL, p. SSa Dr. Pmtenon's papec
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ALIBERT ON MOLLUSCUM. 373
bat the greater number are attached by broad bases.** ^^ The
mother, ^ough in the constant habit of nursing the youngest
child, has not been infected.'*
A second series of cases came more recently under Dr.
Thomson's attention. A farmer's child was affected with the
characteristic little tumours : he had taken the contagion from
the child of a farm servant. Some of the tumours were situated
on the eyelids, and gave rise to conjunctivitis. While suffering
from this disease, the child rested his face against the neck of a
servant girl as she tended him, and she too became the subject
of sebaceous tumours.
These cases are narrated in the true spirit of contagion, and
with an unconditional assent to the opinions of Bateman. I
regret that less attention was bestowed in ascertaining the state
of the skin and sebiparous system of the patients, their health,
and especially their habits of cleanliness.
607. Case observed by AUbert, — Alibert treats of the moUus-
cum of Bateman, under the name of mycosis fungoides, and he
associates the disease with the Amboyna and MoUucca pox,
vnth which it bears considerable analogy. His definition is
brief, but vague. He observes: "The disease appears upon
one or several parts of the body, in the form of fungoid (fon-
gueuses ?) and oval-shaped tumours, which arise and are deve-
loped successively upon the face, the upper and the lower
extremities. These tumours, which are very analogous in
texture vdth champignons, after having reached their full growth,
open like decomposing £ruits, and give exit te an ichorous
fluid, which is often punform, and sheds around it a disgusting
odour.**
The case from which he derives his definition T vrill shortly
narrate. The mother of the patient had upon the fewse an ulcer
that was cured by the application of a caustic ; his brother died
of a cutaneous disease, which resisted all medical treatment
The man, named Lucas, was fifty-six years of age ; his disease
was ushered in by a furftiraceous eruption, which was soon after
succeeded by the development of small tubercles, smooth and
polished on their exterior, and presenting, for the most part,
the ordinary hue of the skin, some few having a brownish tint.
They were distributed over nearly all parts of the body. They
resembled morrelles or agarics in form ; some were shaped like
an olive ; and they increased in number to such an extent that
foiuteen were removed from the face. Their base was large ;
they were spongy in texture, and they exuded a reddish fluid,
which imparted a greenish or yellowish stain to his linen.
This fluid concreted on the tumours into the form of a brownish
or greyish crust The majority of the tumours terminated by
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374 DISEASED OF THE SEBIPAROUS GLANDS.
bursting, ajid then falling into a flaccid state, leaving in their
place a withered skin, which the daughter of the patient re-
moved with scissors, without exciting pain. After experiencing
considerable mental affliction, he had an attack of pemphigus.
The tuberculax disease increased rapidly after this period ; the
tubercles, on breaking up, gave rise to ulcers, the patient
suffered from lancinating pains in these ulcers; he became
emaciated and hectic, and died, after keeping his bed for seven
months, and being the subject of this disease for five years.
Tim case is not satis&ctory : the seat of the disease in the
sebiparous glands is not proved ; indeed, Alibert suggests no
opinion with regard to the pathology of the tumours, but
contents himself with classifying them with the moUusciim of
Bateman. Examination after death was unfortunately refused :
had that been made, I have no doubt that serious visceral
disease would have been discovered. I think it very ^unlikely
tliat the man di^d of the cutaneous disease.
608. Bayer, who had never seen a case of this disease,
remarks with regard to it, that its ^^ seat appears to be the
sebaceous follicles."
609. Cases observed by Biett. — Biett, in the " Dictionnaire de
Medecine," referring to the case of Tilesius, remarks, that he
had seen two analogous cases, but that in these the tumours
were hard and consistent, and they contained neither athero-
matous matter,* nor liquid. He also cites the instaaoe of an
old man, whose skin was covered with these little tumours,
vrithout any disturbance of his health. Biett met with another
form, '^ non-contagious molluscum,'^ in young women after par-
turition. In these cases the little tumours were flattened,
slightly fissured (JeadiLUes) at their summit, irregular in form,
and b^ovmish or fawn-coloured in tint. They were indolent,
and more particularly distributed about the nedk.
Such is the evidence of the distinguished Biett; but with all
deference to his judgment, I see in these cases no reason for
altering my opinicm vrith regard to th^e pathology of the
tumours. Nor can I perceive any diflerenoe between the two
forms of non-contagious moUuscom, which he seems desirous of
establishing.
610. CcLse9 ch^eroed by Cazenave and Schedeh — Th^se authors
relate that they saw, in the Hospital St. Louis, a patient
* By the term ** atheromatoas matter^ is to be understood sebaceous substance
altered to the appearance and consistence of pap. The word ^ liquid" no doubt
relates to the ^ milky fluid" of Batepian. There was no sach fluid in my cases; the
sebaceous substance was concreted and dense; not soft, as in the case of Tilesios,
nor fluid, as in those of Bateman. Biett's appear to have been similar to mine.
Since the publication of my first edition, I have repeatedly ae^ the milky fluid
described by Bateman.
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GIBERT AND JACOBOVICS ON MOLLUSCUM. S75
affected with prurigo, on whose body we^ a number of Utde
indolent tumours. The largest were scarcely so large as •«
hazel*nut, others were no larger than a small pea. They
appeared formed of a dense fibrous substance, and pressure
produced no pain. After describing ^^moUuscum non conta-
giosum," they continue — ^^molluscum contagiosum is a very
rare disease, and does not appear as yet (1828) to have becQ
observed in France. It is chiaracterized by tubercles, rounded,
prcuninent, hard, different in size, smooth, transparent, sessile,
giring exit by their summit to a white fluid," &c.
611. Cases observed by Gibert. — This author does not conceive
it necessary, in his treatise, to describe moUuscum, of which he
remarks that he has seen but two or three undoubted cases in
the course of fifteen years. One of these occurred in the service
of M. Bi^ in a child ten years of age, afflicted widi chronic
enlargement of the liver and spleen, die consequence of a fsdl
on the abdomen. The entire skin was sprinkled over widi
small whitish tumours, of about the size of peas. They were
hard, indolent, and not unlike those little cretaceous tumours
we occasionally meet with in the substance of the liver. M.
Biett oonsidered that the disease should be referred to the
genus moUuscum of Bateman, a rsae aSbction in our climate,
but not unfirequent in India.
612. Cases observed by Dr. Jaoobaoios. — In the spring of 1830^
this author saw, at Saint Louis, two women, the one sixl^^, the
other seventy years of age, who were eov-ered with fungiform
tubercles. To describe t^ese tubercles, would be to repeat ih»
observation of Tilesius. The face, the necky the head, and the
members, were dosely set with the morbid excrescences; at
the base of the right hypochondrium of one patient, and on the
neck of the other, one of these tumours was as large as the fist,
and shaped like a wallet. The tubercles were red in colour,
and the greater part poured out a small quantity of ill-smeUing
sero-pnrulent flmd, which every here and there oonereted into
ihin crusts. No other member of the families of these two
wom^i had suffered £rom a similar^ disease, €md on one the
eruption had existed for two years. These cases were not
fiirdier observed.
In Ms essay on moUuscum, Dr. Jaxx)bovics attempts the
classification of aU the known diseases possessing the genend
diaracters of those of Tilesius and Bateman, as three varieties
of the genus moUuscum. In this attempt he has signally
&iled; he has sueoeeded only in bringing together the most
heterogeneous materials, under an unmeaning title— ^a title that
would far better be abolished altogether from cutaneous patho-
logy. His three proposed varieties are, tvbereula fongosa.
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376 DISEASES OF THE 8EB1PABOUS GLANDS.
tubercula atheramatosoj and tubercula variegata. Under the first
of these, which, to illustrate his meaning, should have been
fungiformiaj he has assembled the Amboyna pox, the eases of
Tilesius and Alibert, the cancer moUusciforme ! of Bayer ; the
cases of Biett, Cazenave and Schedel, and Gibert, and the
molluscum pendulum of Willan. Under the second variety, he
groups those cases which have been assumed to be contagious,
namely, those of Bateman and Thomson ; and he reserves die
third designation for his new variety, the " tubercules bigarres,"
which I have ahready transferred to a more appropriate place,
namely, the section treating of ^^ inspissated sebaceous secre-
tion, or squamous ichthyosis.*^
613. Cases observed by Dr. Henderson.'^ — Dr. Henderson has
seen five cases of this cUsease identical in their characters with
those which fell under my notice, and closely corresponding
with those of Dr. Bateman. They all occurred in the children
of poor persons ; and the finest case was that of an orphan boy,
eight years of age, an inmate of a workhouse. Relative to
contagion. Dr. Henderson speaks with caution. Three of the
children were members of the same feunily; one was a neigh-
bour's child; the remaining one, the orphan child, was an
isolated case. The children who exhibited the molluscum in
the most marked degree were very unhealthy, having a tumid
abdomen and tubercular deposits. The two youngest, twins,
died of acute hydrocephalus, the orphan boy of peritonitis and
other serious disease. One of the twins had only two tubercles,
the other twelve on the face and one on the ankle ; the two
other children had only one each, but in the orphan boy there
were considerable numbers. They were principally situated on
the lower part of the abdomen, die organs of generation, and
the inner sides of the thighs ; in these regions tibere were three
or four dozen. On the right arm there were four, and on the
left ten. They varied in size, from a millet-seed to a pea ; they
were, for the most part, rounded in form, constricted around the
base, and had each a smaU dark-coloured central point, firom
which might be squeezed a little milky fluid. On the back was
an elliptical swelling of large size, measuring one inch and a
half in its long diameter, and one inch and a quarter across.
In the centre of this swelling was a small elevation, a kind of
crater, and at the apex of the latter an excretory opening,
through which might be squeezed a quantity of soft white
substance, resembling finely-ground rice, boiled.
Examining the structure of these little tumours, Dr. Hen-
derson found them to consist of vertical cells opening towards
* Edinburgh Medical and Surgical Journal, vol. lyi., 1841, p. 2U»
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DR. HENDERSON AND DR. PATERSON ON MOLLUSCUM. 377
the centre, and discharging their contents into a common
cavity, which communicated with the exterior by the excretory
opening. The large tumour was lobulated in structure, and
upon its under surface had the '^ general appearance of a con-
glomerate gland ;^' it illustrated, on a ^^ larger scale, the confor-
mation of the smaller ones.^ The contained matter of these
tumours consisted of nucleated cells, which, according to Dr.
Paterson, were about the -^^ of an inch in diameter. Dr.
Henderson inoculated with some of this matter, but without
producing any result ; and he remarks, very justly, that if the
disease be considered to be an affection of the sebiparous glands
alone, the inoculated substance would not be likely to take
effect, unless it were brought in contact with the internal
surface of a sebiferous duct.* Some excellent figures accom-
pany this paper; numbers 1 and 5 are admirable for their
truthfulness.
614. Cases observed by Dr, Paterson,\ — This gentleman
records five cases of molluscum contagiosum. The first he saw
in a child eighteen months old, robust and healthy, and the
daughter of cleanly parents, the father being a fisherman. The
little tumours had the pathognomonic form, the constricted base,
the central aperture, and the oozing of milky fluid. They varied
in size from that of a pin's head to that of a horse-bean, the
smaller ones resembling "pearly granulations'* (sebaceous
miliary tubercles). They were seated chiefly on the face and
neck, and were not painful on being touched. After the appear-
ance of the disease in the child, some tumours of the same
character were detected on the breast of the mother at which
the child sucked. The bulk of these latter varied from a pea
to a hazel-nut, and on being pressed, exuded the same milky
fluid.
A second instance of these little tumours occurred in a female
child of two years old. They were between thirty and forty in
number, and were distributed upon the neck, shoulders, face,
and trunk. Their development is ascribed to being nursed by
a girl who had some tumours on her skin.
Dr. Paterson's third instance is not so satisfactory as the
preceding; it is that of a young man who had several little
tumours on the penis, which he said resembled similar tumours
situated on the vulva of his wife.
Dr. Paterson inoculated with some of the milky fluid, but
without producing any effect. This gentleman gives an admir-
able description of the minute structure of these tumours and of
* A more effectual mode of inoculation would be to rob the secretion briskly into
the skin in a situation where sebiparous glands are abundant
t Edinburgh Medical and Surgical Journal, vol Ivi, 1842, p. 279.
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378 DISEASES OF THE 8EBIPAR0US GLANDS.
their oontents, and a bea«tifol figure of 1^ disease aceon^iames
bis paper.
615. The renorkal^lie case of albuminous sarcoma of the
integument of neaily the entire body, described by Mr. Hale
Thomson*^ under the tide of ^ albuminous moUttscum/^ and the
case of carcinomatous integumentary tumours detailed by Dr.
TumbuUyt physician to the Huddersfidd Infirmary, must be
referred to a group, embracing disetues in the form of titmoun
affectinff the integument in common with other tismes of the body.
They do not, necessarily, originate in the skin ; indeed, they
more frequently take their origin in the subcutaneous textures :
they are not Itwted to the skin, but inyolve die ac^acent tissues,
and they are generally met with in other parts oif the body as
well as the integument
Since the publication of the first edition of this work, I have
repeatedly seen and treated the little tumours described in the
preceding pages. Notking is more easy ihsua their removal,
and of their non-cosytagious nature there cannot be a second
opinion.
SEBACEOUS ACCUMULATIONS.
616. In a third group of diseases of the sebiparous glands,
characterized by alterea secretion and distention of the excretory
duct and related hair-foUiole, the latter remaining open, die
follicle is dilated to an enormous extent, and pressing on the
structure of the gland finally causes its atrophy and absorptaon.
These sebaceous accumuladons attain considerable magnitude ;
they are generally oval in form, and I have seen diem measure
upwards of an inch in diameter. Their precise seat is tlie tissue
of the derma, and tiiey are more or less flattened by oompres*
sion between the deep layer of the corium widiin and die
surface of the skin without. The follicular sax) is filled with a
white and concreted substance, which is more or less apparent
through the dilated aperture of the du^ The opening of the
duct, however, bear^ no propoition to the size of the aocumula^
tion, and, from the Uttle pro^edion <tf the impacted substance, is
the principal indication of its existence. The walls of the sac
are extremely diin, apd are lined in their interior with epiderma.
Sometimes they are beset with hejus.
On examining the contents of one of tliesre sebaceous saos, I
wa9 much struck by finding the contained substance laminated
in structure, and presentii^g a silvery hue. The lamioaidon of
the substance afibrded me a convincing proof that die mass was
* Laocet, toI. ii., 1S41. The paper is iUustraCed with two exeell^it Utbogrftphie
drawings.
t Edinburgh Medical and Surgical Jouraal, vol. ItI, p. 463.
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CORNUA. HUMAN HORNS. «79
1^ product of the lining laaembrane of tibe sac, and its silvery
brUliancy further led me to believe that it must be composed ot
epidermal scales. The microscope established the correctness
of this conclusion. Hence^ a disease, originally a disorder of a
sebiparous gland aod of its secfetiouy subsequently becomes
one of the hair-follicle.
617. Treatment — The concreted substance may be removed,
without much difficulty, by means of a small sicoop introduced
through the aperture. If the aperture be small, it must be
dilated or enlarged by means of a trifling incision. After the
removal of the coacreted mass, the internal surfeboe of the aac
should be touched with nitrate of silver.
CORNUA.
Syn. Horns,
618. When the sebaceous substance impacted in the dilated
sac of a sebiferous duct or hair-follicle in the manner just
described, is, by a continuance of the process of formation, forced
through the aperture of the sac, it desiccates in thai sUniation,
hardens, and is converted into horn. By the addition of firesh
layers from below, (the formative power having increased by
the removal of superficial pressure,) the indurated mass is still
further forced outwards, dilating the aperture as widi a wedge,
and finally increasing its size to that of the entire bas^ of tii^
hypertrophied follicle. The process of formation of new
epithelial layers by the walls of the follicle (now becon^ the
base of the mass) will go on, unless interrupted by sur^^al
means, for years, and in this manner those singular bodies, of
which so many remarkable examples are on record, homSf ate
produced.
619. A well-marked instance of horn, of which I shall now
proceed to give an account, was shown to me by my friend, Mr.
Barklimore, of Charlotte-street, Bloomsburyrsquare, during the
month of October of the present year (1843). The patient was
an old female servant in that gentleman^s family ; she was fifty-
seven years of age, and gave the following history of her case : —
At the age of five-and-twenty, on the termination of a severe
attack of illness, she observed a small elevation, like a pimple,
on the site of the present growth ; the pimple increased in
size, was somewhat painful, and in about ten years from its
first appearance burst, and discharged a <iuantity of matter
resembling ^^ mashed potato.*^ From this moment a cavity
always remained, from the bottom of which some "scurfy"
matter could be raised by the finger nail. At t)»e bieginning of
the current year, the present growth made its appe^ance in the
situation of the cavity, and increasing in size, gave her mucl^
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380 DISEASES OP THE SEBIPAROUS GLANDS.
pain and uneasiness. The skin around it was red and inflamed,
and she applied a poultice, which had the efiect, according to
her, of making it grow still faster. During the summer she
suffered much from the frequent jerks which the growth received
from her dress, and from awkward blows which it sustained, and
in the month of October she applied to her master for relief.
At this period the growth had acquired a considerable size : it
was situated on the upper and front part of the thigh, and
presented the appearance and characters of horn. It was semi-
transparent, yellowish in colour, dense and homy in texture,
ribbed on die surface, insensible to the pressure of the nail, and
firmly rooted in the skin. In general appearance it resembled
the broad and curved beak of a bird, of large size, and had a
broad and extensive base. Around the base, the integument
arose to the height of several lines, and in two places to frdly
half-an-inch. The skin was thin and attenuated as though from
the effects of stretching, the epiderma being continuous with the
surface of the horn, and gave the idea of a degeneration of the
integument into the homy structure.
On the 12th of October, I proceeded, with the aid of Mr.
Barklimore, to remove the horn, by cutting through the integu-
ment around its base, and dissecting it from the subcutaneous
tissue. The removal was speedily and easily accomplished,
since the growth was limited inferiorly by the under surfBtce of
the corium.
On examining the horn after removal, I found its base to be
formed by the deep stratum of the corium, so that it was
obviously a cutaneous formation. The base was oval in shape,
and measured in its long diameter one inch and a hal^ and in
the opposite direction one inch and a quarter. The horn was
two inches and three quarters in length, by two inches in greatest
breadth, and its elevation above the surfeice was one inch and
a quarter. The latter measurement was that of the vertical
thickness of the horn ; for in consequence of its mode of growth,
its long diameter lay parallel vrith the surface of the skin. The
sebaceous accumulation must originally have formed a promi-
nent tumour, from the side of which the protrusion took place ;
the thin integument covering the other half still retaining its
elevation from distention. Traces of this mode of formation
are still apparent upon the surface of the horn. Subsequently,
the thin integument has become inflamed and ulcerated, and,
receiving no granulations from beneath, has desiccated upon its
homy contents. This ulceration was die cause of the redness
and pain of which the patient complained, and its extent is
marked upon the horn, by a rough discoloured surface of a
circular figure, surrounded for more than two-thirds of its extent
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HUMAN HORNS. 881
by a maxgin of thinned integument. The weight of the horn
was six drachms.
The section of the growth presents all the characters of horn ;
it is laminated longitudinally, the laminae being distinctly traced,
by their di£ference of tint, from the base to the apex of ^e horn.
At the apex, moreover, it is split in the direction of its laminsB,
and several external lamellaB are partly separated from those
beneath.
In minute structure it is composed of flattened epithelial cells,
closely condensed, and in some parts having a fibrous arrange-
ment The epithelial scales are somewhat larger than those of
the epiderma, and possess nuclei; a circumstance which con-
firms the analogy between the inflected follicles of the skin, and
those larger inflections lined by mucous membrane. The
flattened cells measured in long diameter from y^ to ^^ of an
inch ; and in the short diameter from xAir to -^ ; the average
of these measurements being 7^ for die long, and ^f^ for the
short diameter. The nuclei are for the most part oval in shape,
the long diameter measuring Tinnr^ ^^^ the short ^^^ of an inch.
I made no chemical analysis of the horn in the present case,
but this has been done repeatedly on the Continent. M. Dublanc
has published an analysis of human horn in the ^^ Journal de
Pharmacie,''^ and another analysisf was made of a horn which
is deposited in the Dupuytren Museum. Both analyses go to
show that horn is chiefly composed of albumen, a small quantity
of mucus, phosphate of lime and chloride of sodium, and a trace
of lactate of soda.
620. The subject of horns in the human person very early
attracted the attention of observers, and their occurrence seems
to have been more frequent among our forefathers than at the
present day. This circumstance may be explained by referring
to the improvement which has of late years been made in surgery,
and to the more general diflusion of a knowledge of its elemen-
tary principles. Upon a recent occasion, namely, the presenta-
tion of a paper to the Boyal Academy of Medicine of France, by
M. Lozes, the committee appointed to inquire into this subject
collected seventy-one observations of homy growths from the
skin, of which, thirty-seven were met with in females, thirty-one in
males, and three in infeuits. Of this number, fifteen were seated
on the head, eight on the face, eighteen on the lower extremities,
eight on the trunk, and three on the glans penis.]:
In pursuing this inquiry, I have succeeded in collecting ninety
♦ March, 1830.
f CruYeilhier, Anatomie Pathologique, liv. 24, vol. 2; and Joar. de Med. Prat,
de Bordeaux, 1835.
X M^moires de TAcademie Royale de M^decine, JaiD, 1830.
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382 DISEASES OF THE SEBIPAROUS GLANDS.
oases, of which forty-foar were females, and thirty-nine males ;
of the remainder the sex is not mentioned. Of this nrnnber,
fortj-eight were seated on the head, four on the face, four on the
nose, eleven on the thigh, three on the leg and foot, six on the
back, five on the glans penis, and nine on the tmnk of the body.
The greater frequency of this disorder among females than males
is admitted by idl andiors, but this fact is most conspicuously
shown in the instance of the thigh and of the head ; for example,
of the eleven cases of homy growth from the tWgh, two only
were males ; and of the forty-eight affecting the hes^, twenty-
seven occurred in females, and nineteen in males ; in the remain-
ing two, the sex being unmentioned. That old age is a predis-
posing cause of this affection, is proved by the greater frequency of
its occurrence in elderly persons ; thus, of the forty-eight cases
in which the scalp was the seat of the growth, thirty-eight were
above the mid-period of life ; several were over seventy, and one
was nmety-seven ;* three were young personsjt and three were
iii£aiits4
Ciuveilhier, in remarking upon the relative fr*eqnency of these
growths on different parts of me skin, states that they occur on
the posterior and inner part of the thighs, as often as on all
the other regions of the body taken together, a circumstance
which he attributes to the general use of the chaufferette. But
Cruveilhier's statement is not borne out by fects, and numerical
data are, as we have seen above, opposed to his opinion. More-
over, he confounds horns with warts and corns, and regards them
as the result of cutaneous irritation and enlarged papillae, with
increased secretion of epiderma.§
621. Several authors have mentioned the development of
homy growths from old encysted tumours, and have remarked
upon their frequent association with such tumours. Sir Everard
Home II was particularly struck by this circumstance ; it was pre-
sent in all the cases which he examined, but he fails in accounting
for the homy secretion, which he regards as an imperfect sub-
stitute for epiderma. Thomas Bartholin, who collected several
cases of human homs, speaks of the origin of one from an
encysted tinnoiir,1[ and Soemmering,** Qastellier,tt and Cal-
dani,|| notice the same fact.
622. Some curious speculations were excited in the minds of
the older physicians by the observation of cases of homy growths.
* Gastdlier. Hist de la Soe. Roy. de M^d, toL i., p. 311, 1776.
f Aldrovandos et Bartholinns.
X Amatus, CeDt 1, Cor. I, Zacatos Lusitanos, Prax. Med. Adm., lib. iii., obt. 83.
Joseph Lanzoni, Nat Cur. Ephem. Oerm., ann. 4, 1673.
§ Loc chat II Philosophical Transactions, vol. Ixxxi., p. 95, 1791.
^ Epistolis. ♦♦ Archives Generales de Med., vol xiiu, 1827.
tt Loco citato. JJ Diet, de Med.j Art Com^e.
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CASES OF HUMAN HOBN. SSS
Thus, Bhodius* met with a Benedictine monk who had a pait
of horns, and was addicted to nmiination, and Fabricius^t having
seen a man with a horn growing from hts forehead, whose son
rominated, is willing to give the fttther the eredit of transmitting
this disposition to line son, by virtue of the ruminant character
which be bore so obviouslj upon his head.
The most remarkable ease of human bom on record, is that
of a Mexicui porter, named Paul Rodriguez.^ The horn was
situated upon the upper and lateral p«u*t of the head, it was
fourteen inches in circumference around its shaft, and it divided
above this point into three branches. Yoigtel^ cites the case of
an old woman who had a bom with tbtee branches growing from
her forehead; and M. Dubois || had a woman under his care, in
the Hospice de Perfecdonnement, with a bom that measured
seven or eight inches in diameter at its baseband was six inches
in length. The length of die horn in some recorded instances
is also remarkable. Sir Everard Home? saw two cases, in both
of which the growth measmredfive incl^s by one inch in dUiameter.
They were curled, and had ihe appearance of isinglass. In one
case the horn was fourteen years growings Dr. Gregory** men-
tions a horn which was removed from the temple of a woman in
Edinburgh, which measured seven inches^ Dr. Chariere,tt of
Barnstaple, saw one growing from the nape of a woman's neck
which measured seyen inches. A bom in the British Museum
is said to measure eleven inches in length by two-and*a-haIf in
etrcomference^t <^d Bartholin,§§ Paget, and several other writers
have spoken of horns twelve inches long. A singular instance
of horn is mentioned by Cruveilhier, in his " Anatomie Patho-
logique^" as falling under the notice of Dr. Paget, of Bordeaux.
The subject was a Mexican Indian, and the horn was situated
in the lumbar region on the left side. After growing for three
years, it had attained a length of four inches by seven or eight
inches in circumference, and was sawn off by the patient's son;
after another three years it was submitted to a similar operation,
and, at the end of nine or ten years from its first appearance,
was extirpated by M. Paget. The portion removed by M. Paget,
with the two portions previously cut off, amounted in length to
about twelve inches.
623. In a scarce tract in small quarto, published in 1676,
there is '^ a brief narrative of a strange and wonderful old woman
that had a pair of horns growing upon her head.** ^< This strange
* Bartholinus, de ooicorn. aphor.
f De veBtrieolo. Alio, Bartholinus, de ooicorn. aphor.
I New York Me^tioal lUpoeitorf for 1820. § Handbadi ckal.
II Dictionnaire de Medec'me; Art Corn^e. ^ Loco citato.
** Sir £. Homers paper-, k>oo citato. ft Eodem loco.
tt Eodem loco. §$ Epistolk
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384 DISEASES OF THE SEBIPABOUS GLANDS.
and stupendous effect,^ continues the pamphlet, ^^ began first
from a soreness'' of the back part of the head where ^e horns
grew. " This soreness continued twenty years, in which time it
miserably afflicted this good woman, and ripened gradually into
a wen near the bigness of a large hen egg, which continued for
the space of five years, more sadly tormenting her than before,
after which time it was, by a strange operation of nature, changed
into horns, which are in show and substance much like ram's
horn, solid and wrinkled, but sadly gricTing the old woman,
especially upon the change of weather." The horns were shed
four times, the first ** grew long, but as slender as an oaten
straw ;" the second was thicker, and on the fall of the latter, two
were produced which were broken ofi" by accident. One of these
was presented to the King of France, the other is stated to have
been nine inches long, and two inches in circumference. The
periods of shedding were three, four, and four years and-a-half.
There is an engraving of this woman in Dr. Charles Leigh's
Natural History of Lancashire, Cheshire, and the Peak of Derby-
shire. Her portrait and one of the horns is in the Ashmolean
Museum, and another of the horns in the British Museum.
The authors who have given their attention to this curious
subject are more numerous dian might be expected. Bartholinus
and Borellus have each collected numerous cases. Vicq
d'Azyr* treats of the subject in his essay on " Animal Concre-
tions," in 1780 ; Franc,t in an essay " de Comutis," in Heidel-
berg ; Sir Everard Home, in the Philosophical Transactions for
1791 ; Alibert, in his " Precis Theorique et Pratique des
Maladies de la Peau ; Rudolphi,^ in a paper read before the
Academy of Sciences of Berlin, in 1815 ; Dauxais, in a thesis,
published in Paris in 1820; Breschet, in the article " Comee,"
in the Dictionnaire de Medecine ; Cniveilhier, in his " Anatomie
Pathologique." The latter author devotes the whole of his
twenty-fourth fasciculus to homy growths. And Sir Astley
Cooper and Mr. Travers, in their Surgical Essays.§
624. The following case is strikingly illustrative of the mode
of grovrth and appearance of a horn when developed on the face.
Louise Marino, an Italian peasant, fifty-four years of age, per-
ceived, in the month of January, a small tubercle of about the
size of a millet-seed embedded in the integument of the root of
her nose. The tubercle was attended widi a trifling degree of
pain and pruritus, but continued to grow with considerable
rapidity. On the 30th of October (same year), it had acquired
the length of an inch, was of a gi-eyish-brown colour, had the
diameter of a vniting quill, was grooved along its under surface,
♦ Hist, de la Soc Roy. de MCmL, p. 184, 1780-81.
t Tract Phiiolog. Med. de CoinuUs. X Vol iL § Part 2.
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SEBACEOUS MILIARY TUBERCLES. 385
and curved like the beak of a bird of prey. It adhered firmly
by means of a narrow base to the skin and subjacent areolar
tissue. Dr. Portal removed it by incision ; the areolar tissue at
its base, the periosteum and bone were perfectly sound.^
625. A similar case to this, in so far as seat and mode of
appearance are concerned, has just come under my care. Finding
the horn imperfectly adherent to its base, I displaced it with my
nail, and applied caustic to the surfSetce of the sac from which it
had originated.
626. Treatment, — The examination of the case mentioned in the
preceding pages, by showing the true nature of the growth, sug-
gests the appropriate mode of treatment, and proves, at the same
time, that the practice heretofore adopted of removal by incision
is altogether unnecessary. It is plain that the indications to be
pursued are, 1. To soften and dissolve the horn, that it may be
displaced without force from its follicular bed; and, 2. To
modify the secreting surface, in such wise as to prevent the con-
tinuance of the process of abnormal cell-formation. The first
of these indications is to be fulfilled by means of alkalies and
water-dressing ; the second, by the stick of nitrate of silver. By
these means, the growth may be removed ; the disposition to its
re-formation checked ; and a painfid operation avoided.
(b.) Retention of secretion in the sehiferous ductSy the excretory
aperture being closed.
SEBACEOUS MILIARY TUBERCLES.
Syn. FoOicuhr elevatioM, Rayer. Pearly hAercks,
627. Little tubercles of a white colour, of about the size of a
millet seed, and sometimes of a small pea, caused by the collec-
tion of the sebaceous substance within an excretory follicle, the
aperture of that follicle being impervious, are very commonly met
with on the face and neck of women and children, and persons
having a thin and delicate skin. Rayer calls them follicular
elevations, but I have thought the term sebaceous miliary tvber-
cles more appropriate. A very common seat of these little eleva-
tions is the thin skin of the lower eyelids, where they sometimes
attain an inconvenient size. I have seen several cases in which
the movements of the lid were interfered with by their growth.
They are very easily removed by puncture with a fine lancet, and
genUe pressure ; the operation is by no means painful, for the
integument covering them is reduced by distention to a mere
film. Touching the interior of their sac with a fine point of
nitrate of silver effectually prevents their return.
* II Filiatre^ Sebezio, February, 1842.
C C
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386 DISEASES OF THE SEBIPABOUS GLANDS.
CALCAREOUS MILIARY CONCRETIONS.
628. In place of sebaceous substance more or less inspissated,
it sometimes happens that the secreted matter partakes rather of
the calcareous character, being more or less dense and hard, and
having carbonate and phosphate of lime in combination. Meckel
found a number of these concretions in the skin of the gluteal
regiotf, and Voigtel* records an instance as occurring on the
forehead and root of the nose. Dr. Julius Vogelf has described
another case of this disease affecting the scrotum. The integu-
ment of the scrotum was the seat of severe itching ; on the ces-
sation of the itching a number of small conical tubercles were
developed, which increased to the magnitude of a pea or hazel-
nut. After reaching maturity, the litde tubercles wasted and
became dry, and were followed from time to time by successive
crops. At the period of detailing tiie case, they were one hundred
and fifty in number, seated in or beneath the corium. The con-
tents of these tumours were a white, greasy, and-softish substance,
like atiieroma. Examined chemically, it was found to consist of
carbonate and phosphate of lime, with a trace of soda, a small
proportion of fat, and some extractive matter.
Mr. Dalrymple has called attention to a similar fact, in rela-
tion with a small encysted tumour of the eyelid, and has shown
the seat of the calcareous matter to be the epitiielial scales of
which the tumour was composed. Instead of presenting their
natural transparency, the scales ^^ were thickened and hard, and
contained granular earthy molecules, which could be removed
by immersion in weak muriatic acid.*' Mr. Gulliver ascertained
the earthy matter to be phosphate of lime, with a trace of the
carbonate of the same earth4 Mr. Dalrymple informs me that
he has, since the publication of the preceding, seen a second
instance of the same disease.
SEROUS CYSTS,
629. Sometimes, instead of sebaceous or calcareous substance,
I have seen die excretory follicles of the sebiparous glands dis-
tended with a limpid serous fluid, and attaining tiie size of
small grapes. A gentieman lately consulted me, on whom
there were two of tiiese grape-like cysts, connected with the
border of the upper eyelid ; they were semitransparent and
tense, and interfered very much with vision. I punctured them
with a cataract needle, and, after the escape of the fluid,
* Handbuch der Pathologischen Anatomie.
t Algemeine Zeituog fur Chirurge innere Heilkunde und ihrer UulfiBwissen-
schaften, July, 1841.
t Medico-Chirurgical TranaactioDS, vol xxvL 1S43, p. 238.
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ENCYSTED SEBACEOUS TUMOURS. 387
touched the shrivelled cysts with nitrate of silver ; the integu-
ment soon healed, and they are not likely to re-appear.
ENCYSTED SEBACEOUS TUMOURS.
Sjn. Follicular tumours. Wen, Meliceris, Ather<)ma. SUatomtt,
630. These tumours, identical in manner of formation with
the sebaceous miliary tubercles, but somewhat more deeply
seated in the integument, attain to the size of a hazel-nut or
walnut, and sometimes to the magnitude of a small orange.
They may occur singly, or several may be developed in Ae
same person, particularly when situated on the head. Their
common seat is the scalp and face, but they are occasionally
seen on other parts of the body. A few years since, I removed
one of large size from the integument of the back, and I have
also seen diem on the abdomen and in the groin.
The sebaceous substance collected in these sacs is variously
altered in its qualities or appearance. Sometimes I have seen
it limpid and fluid, like serum, and containing crystals of
stearine; at other times, it is soft and white, reminding us of
pap, or bread sauce — this constitutes the atheromatous tumour ;
again, it is yellowish, and resembles sofi;ened bees'-wax — the
melicerotis tumour; or it may be white and fatty — the steatomatous
tumour; at other times, it presents various peculiarities of cha-
racter, more or less referrible to the above heads. The parietes
of these cysts are the walls of the excretory duct of the sebi-
parous gland and related hair-follicle, in a state of hypertrophy,
lined in the interior with epiderma. The sebaceous substance
which they contain is mingled vrith epidermal scales and hairs,
having a simUar origin to those found in the sebaceous accu-
mulation of comedones (§ 696). When the parietes of the cyst
inflame, its contents are often exceedingly foetid. In conse-
quence of the pressure exerted on the scalp by these tumours,
the neighbouring hair-follicles are frequently destroyed, and
the superjacent skin becomes bald.
The encysted tumours of the eyelids, and some of the polypi
of the meatus auditorius, are of the same nature.
631. Treatment. — ^The common practice in the treatment of
these tumours is to dissect them out, and this is usually done
with great care, under the impression that a particle of the cyst
left behind will grow, and develop another tumour. This
reasoning is most unphilosophical, and I doubt if empirically it
be correct. A portion of the cyst left behind may interfere with
the healing of the wound, but a portion of cyst can possess no
power of reproducing a dilated and hypertrophied hair-follicle
and excretory duct of a sebiparous gland. The removal of
these tumours is always a painful operation, and in certain
c c 2
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388 DISEASES OF THE SEBIPABOUS GLANDS.
cases, when seated in the scalp, dangerous, from the possibility
of the occurrence of erysipelas. I have succeeded several times
in curing encysted tumours, by laying them open with a lancet
or bistoury, pressing out their contents, and injecting the cyst
with a solution of nitrate of silver, or touching its internal
surface with the solid caustic^ and this plan I prefer to the
painful process of excision.
V. INFLAMMATION OF THE SEBEPAROUS GLANDS AND
IMMEDIATELY ADJACENT TISSUES WITH OR WITHOUT
ALTERATION OF SECRETION.
632. The diseases coming under this definition are two in
number, Acne and Sycosis, the former being developed in the
sebiparous glands of the general surface of the body, and the
latter being confined to those which open into the follicles of
the larger hairs, especially of the chin, the upper lip, and the
sides of the fEU^e. Both are chronic diseases, and of variable
duration.
ACNE.
Syn. lonthos. Varus, CouperosCy Fran. — Hautfinne.
Kupferfinne im Gesichty Germ.
633. Acne (Plate 8.) is a chronic inflammation of the sebi-
parous glands* and of their excretory hair-follicles. It is
characterized by the eruption of hard, conical, and isolated
elevations, of moderate size, and of various degrees of redness.
The apices of the elevations generally become pustular, and
burst, while their bases remain for some time in an indolent
* Dr. Gustay Simon regards acne as a disease of the hair-follicle alone, an opi-
nion which he supports by the observation of hairs, and sometimes a perfect bur-
follicle, bein^ found in the sebaceous mass squeezed out from their interior. I take
a different Yiew of the pathology of the disease, considering disease of the sebiparous
gland to be present in the first instance, or concurrently with that in the related
hair-follicle. Alteration of the sebaceous substance (§ 696) is the consequence of
that disease, (probably inflammation of the Tascular membrane of the gland ;) impac-
tion of the altered sebaceous matter follows, and in the suite of this impaction, im-
prisonment of hairs, which, in the normal state of the organs, would have been
thrown off and carried away with the sebaceous secretion. That the hair-follicle
must be implicated in disorder of the sebi^rous glands is obvious, from the struc-
ture of these organs ; for, with rare ezceptioni^ ever^ sebiparous gland in the body
opens bv means of its excretory duct into a hair-folUde, and the U^r performs tiie
office of an efferent canaL
Dr. Simon also suggests, that the steatozoon fblliculorum may, in some instances,
be the cause of acne, by exciting the sebiparous glands to increased action in the first
instance; and the hair-follicle being in consequence over-distended, becomes sub-
sequently the seat of inflammation. This author thinks that the effect of inflamma-
tion of the derma immediately surrounding the halr-foUiole is the separation and
ejectment of the follicle. Here he is undoubtedly in error; the epidermal lining may
be and is thrown off by the formation of pus by the surfiioe of the follicle beneath
it, but there is no sloughing of the follicle.
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ACNE VULGARIS. ACNE PUNCTATA. 889
State befcNre they disappear. On the apices of some of these
elevations, the opening of the hair-follicle is distinctlj apparent,
while in others, the aperture is destroyed by the pustule. In
some, the purulent fluid is mingled with softened sebaceous
substance, while others subside slowly without suppuration.
Some, again, scarcely difi*er in tint of colour from the adjacent
skin, while others are highly congested, and surrounded by an
inflamed base of vivid redness.
Acne is usually accompanied by other signs of disorder of
the sebiparous follicles: thus, in some situations, the glands
appear to be excited to undue action, and pour forth an inor-
dinate quantity of secretion, which gives the skin a ^ossy
appearance; in others, their action is torpid, the sebaceous
matter is concreted into a solid form, and distends the excretory
duct and hair-follicle even to the orifice, where coming in contact
with the dust and dirt diffused through the atmosphere, the
concreted matter is discoloured, and has the appearance of a
brownish or black spot. If a fold of skin including any one of
these black spots be pressed between the fingers, the concreted
matter is forced out, and resembles a small white maggot with
a black head. These concretions are popularly known as
maggots or grubs. Moreover, in this state of skin a number of
small, white, sebaceous miliary tubercles, may also be observed.
The term acne would seem to be derived from axm or axpiig,
as though it would imply that which is indeed the fact with
regard to this disease — namely, that it prevails during the mid-
period of life, from the age of puberty to the commencement of
old age. It may be developed on all parts of the body, but is
most frequently met with in those where the integument is thick,
as the back, the shoulders, the backs of the arms, and fore-arms,
and the breast, or on those parts which axe exposed to the in-
fluence of the atmosphere, as the face and neck.
634. The varieties of acne, according to Willan, are four in
number — namely, acne simplex, acne punctata, acne indurata,
and acne rosacea. The first three of these are mere modifications
of the same form of disease; indeed the same elevation may, at
difierent periods of its growth, present each of the appearances
indicated by these three designations. I shall therefore take
the more simple course of describing the afiection as appearing
under two principal forms — namely.
Acne vulgaris,
„ rosacea.
ACNE VULGAEIS.
635. The common variety of acne (Plate 8, a. g.) commences
by small red and inflamed elevations, which gradually become
prominent and conoid, and secrete a small quantity of pus at
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390 DISEASES OF THE SEBIPAROUS GLANDS.
their extremity, while the base remains hard and of a deep red
colour, and is surrounded by an inflamed areola of small extent
The suppuration is slow in attaining its completion, usually
continuing for six or eight days; at the end of this period the
pustule bursts, and the efiused fluid desiccates into a thin
brownish scab, which leaves at its fall an indolent tubercle of a
purplish or livid hue, and frequently a small white and per-
manent cicatrix. The tubercle remains for a considerable
period after the rupture of the pustule, and disappears very
slowly. The eruption of acne is generally unaccompanied by
pain or heat, and gives rise to little inconvenience beyond that
which is caused by its unsightly appearance. When, however,
it is developed near a filament of a sensitive nerve, as of the
fifth, upon the forehead, the pain is sometimes very distressing.
The elevations of acne are for the most part successive in their
eruption, so that they may be observed at the same moment in
all their stages; at other times, and more rarely, a numerous
crop may be developed at once.
It frequently happens, that in the centre of each of the conical
elevations, and always in some, a small round blackish spot may
be perceived. The presence of this spot is the especial charac-
teristic of acne punctata^ (Plate 8, a. b. c.) ; it is the aperture of
a hair-follicle, distended vrith inspissated sebaceous substance
(§ 596) up to the level of the skin, and discoloured at the surface
by exposure to the dust and dirt contained in the atmosphere.
After having suppurated and discharged the sebaceous substance,
the elevations duninish in size, they become purplish and livid,
and, at a later period, whitish in colour, and disappear by
degrees. The punctated form of acne is generally intermingled
with that in which the excretory puncta are obliterated.
Occasionally the eruption is remarkable for the indolence of
its course; the inflamed elevations are very hard, and deeply
rooted in the integument; the suppurative stage is prolonged
two or three weeks before reaching its height, and irequently
fails altogether, and after suppuration is completed, the purplish
or livid tubercles continue for months, sometimes becoming
permanent, and at other times leaving indelible cicatrices: this
is the acne indurata. (Plate 8, d.) When the indolent form
of acne aflects any region extensively, as, for instance, the face,
the features are greafiy disfigured; the entire surface is more
or less covered with tubercles of a deep red or livid colour, and
variable size, and the integument between the tubercles is thick-
ened and congested. The face and back are the more common
seat of this eruption.
* Acne punctata is consequently a comedo, with the snperaddition of inflammation
of the sebiparoos follicle.
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ACNE ROSACEA. BACCHIA. 391
ACNE ROSACEA.
Syo. Bacchia,
636. Acne rosacea (Plate 8. h.) is especially characterized
by the redness and congestion which attend its conoidal eleva-
tions; by the enlargement and frequently varicose state of the
veins of the derma; by the tardiness of course of the papular
elevations; the slowness of their suppurative stage, and the in-
dolent character of the livid and indurated tubercles which they
leave behind. The integument around the elevations is of a
deep purple or violet hue, the congestion is increased by a con-
tinuance of the causes which gave rise to the disease, and the
skin of the affected parts becomes permanently thickened, uneven,
and tubercular. The more usual seat of acne rosacea at its
outbreak is the nose, which is often considerably enlarged by the
morbid action; the integument and subcutaneous textures be-
come infiltrated and hypertrophied, and the cutaneous veins
tortuous and varicose. From the nose the disease extends to
the cheeks, the forehead, the chin, indeed, to the entire face,
disfiguring the features very seriously. The congestion of acne
rosacea is increased towards evening, by taking food, and by
the use of every kind of stimulant taken internally.
637. Diagnosis, — The diagnostic characters of acne are, the
conoidal form of the inflamed elevations, the suppuration of some
of these elevations at their apices, the tardy growth and disap<-
pearance of others, the livid and indolent tubercle lefi behind by
both, their evident seat in the sebiparous glands, and the dis-
order of neighbouring ^ands evinced by the increased secretion
of some, the concretion of t^e secretion of others, and the pre-
sence of sebaceous miliary tubercles. The particular characters
distinguishing the varieties of acne are, the absence of any ap-
pearance of excretory follicle in acne vulgaris; the presence of
an excretory aperture in acne punctata; the indolent course of
acne indurata and the general distribution of all these varieties
over the sur£Etce of the body. Acne rosacea is distinguished from
tiie preceding by the greater vascularity of the elevations, the
congestion and thickening of the surrounding skin, and the
especial seat of the eruption on the face.
Secondary syphilis sometimes assumes the characters of acne;
but the dull-red appearance of the eruption, its large, soft, flat,
and glossy tubercles, the ulcerations which succeed the pustules,
and the presence of other signs of syphilis, sufficiently mark its
nature.
638. Causes, — Acne vulgaris is developed at all ages between
the period of puberty and the fortieth year, and occurs in both
sexes, more frequency, perhaps, in the female than in the male.
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392 DISEASES OF THE SEBIPAROUS GLANDS.
Acne rosacea is a disease of adult life, and is also more firequent
in the female than in the male. The presence of acne indicates a
disordered state of cutaneous innervation, and, consequently, of
die yascular action of the skin ; in some instances it is induced
by direct congestion of the integument, as in acne rosacea, while
in others it would seem to depend on torpidity of the capillary
circulation, and obstruction to the current of blood by sudden
and irregular excitation. Torpidity of the capillary circulation
is indicated by the altered secretion of the sebiparous glands,
which so constantly accompanies the disorder, and, indeed, by
the general want of cutaneous activity in persons so affected.
The latter cause is present for the most part in the acne of young
persons, in that which occurs at puberty, or as a consequence of
close application and sedentary employment, or mental £atigue.
This kind of disorder of the cutaneous functions is also associated
vnth amenorrhcea.
Congestion, on the other hand, is the active agent in the erup-
tion when arising from general plethora, from the partial plethora
which occurs at the critical period of life in females, from ex-
posure of the face to strong heat, from excesses in diet or
stimulating drinks, from the use of cold drinks in a heated state
of the body, and from the local application of irritating substances.
Of the latter it is proper to mention the abuse of certain stimu-
lating washes and powders employed as cosmetics. Partial
congestion would seem to be the exciting cause of the eruption,
when it is induced by irritation of the gastro-pulmonary mucous
membrane.
639. Prognosis, — Acne vulgaris is removed without much dif-
ficulty ; but the rosaceous variety is always intractable, and often,
from the nature of its seat, incurable.
640. Treatment, — The treatment of acne must be adapted to
the cause of the affection ; in those cases in which a torpia action
of the cutaneous system is evident, stimulating remedies must be
employed, whereas in those which are dependent on congestion,
stimulants would be highly injurious, and would serve to prolong
the morbid action. In both cases the regimen should be judi-
ciously regulated; it should be light, cooling, and moderate, and
all stimulating diet careftiUy avoided. To this hygienic manage-
ment, gentle laxatives, antacids, tonics, &c., maybe added, with
a view to order the secretions, and regulate the digestive ftmc-
tions. Whenever other general indications present themselves,
they must be especially attended to ; thus, in young women at
the period of puberty, the state of the uterine fiimctions must be
ascertained, and at^e critical period of life derivative measures
may be employed, with every probability of success.
Whenever Ae indication is obviously congestive, bleeding
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SYCOSIS. MENTAORA. 393
should be had recourse to, locally, in the milder cases; generally
to a greater or lesser extent, as the state of the constitution may
decide, in the more obstinate forms.
In applying the local treatment, due regard should be had to
the ordinary principles of surgery ; when the pimple is congested
and painful, it shoidd be punctured, and the blee(Hng encouraged
by water dressing or poultice ; and where pus or sebaceous sub-
stance are suspected to exist embedded in the tubercle, a free
puncture, succeeded by a poultice, is especially indicated. Much
benefit is also to be derived from the vapour douche. When
the local determination has somewhat subsided, stimulants may
be employed; for this purpose, the vapour douche medicated
with iodine or sulphuretted hydrogen is likely to be usefrd ; or a
stimulating ointment, such as that of the ioduret of sulphur, in
the proportion of a scruple to an ounce of elder-flower ointment
or simple cerate. In the simple, as well as in the other varieties
of acne, when they present a chronic character, a solution pf the
bichloride of merciuy in emulsion of bitter almonds, such as that
of Gowland's lotion, or of the same salt in eau de Cologne, in
the proportion of a grain to an ounce, will be found of great
service. A solution of sulphur, in spirit of wine or brandy, has
been recommended as a local application, but this merely acts
upon the general principle of stimulation, and is inferior in every
respect to the solution of the bichloride.
SYCOSIS.
Syn. Mentagra,
641. Sycosis (Plate 8, i.) is a chronic inflammation of the
cutaneous textures, very analogous to acne, and apparently dif-
fering from that affection only in its site — namely, on the hairy
parts of the face, the chin, the upper lip, the submaxillary region,
the region of the whiskers, the eyebrows, and sometimes the nape
of the neck. The disease is most probably developed in the
sebiparous glands, and thence extends to the hair-follicles, and
their immediately related tissues, giving rise to conical elevations,
which become pustular at their apices, and are each traversed
by the shaft of a hair. The pustules of sycosis are of a pale
yellowish colour; they burst in the course of a few days, and
pour out their contents, which concrete into dark, brownish crusts.
The crusts fiedl at the end of one or two weeks, and leave behind
them purplish and indolent tubercles, which remain for some
time longer, and subside very slowly. The inflammatory action
accompanying this eruption often produces thickening of the
integument^ and frequently extends to the subcutaneous textures.
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894 DISEASES OF THE SEBIPABOUS GLANDS.
In this way, the roots of the hairs sometimes become affected,
and fall oul^ leaving the skin entirely bald.
The eruption of sycosis is preceded by a painful sensation of
heat, and tension of the skin; this is followed by seTcral small
red spots, which rise in the course of a few days into conical ele-
Tations, and upon the summits of these, the pale yellow pus,
characteristic of this eruption, is formed. At their first appearance,
these pustular elevations are few and scattered ; in subsequent
attacks their number is increased, until at last the whole of the
chin and sides of the face may become thickly studded. The
eruption is very variable in extent, sometimes affecting one side
of we chin alone ; at other times the whiskers and submaxillary
region are solely attacked, while in another case, the disease is
confined to the upper lip. When the subcutaneous textures are
affected, the integument is ndsed into tubercles and tumours of
considerable size, which are more or less covered with pustules
and crusts, and have a very repulsive appearance. In this state,
the integument retains its tuberculated, diickened, and congested
appearance for the rest of Ufe. When the disease declines, the
pustular elevations cea.se to be developed, the tubercles diminish
in size, and the epiderma is thrown off by repeated desquama-
tions.
642. Svcosis conioffiosum. — M. Gruby, of Vienna, who has
recently distinguished himself by his researches into the vege-
table nature of favus, and by the announcement of the discovery
of vegetable formations in other diseases, has just (September,
1842,) addressed a paper to the Academy of France, on a new
cryptogamic plant, existing in the roots of the hairs of the
beard, and around that portion which is contained within tlie
hair-follicle. By the transmission of the seeds of this plant the
disease is rendered contagious, and he proposes for it the name
of mcntayraphyte,
M. Gruby gives the following account of the disease: — ^It is
limited to IJie hairy part of the ^^ce, but is most frequently seen
upon the chin, the upper lip, and the cheeks. It covers all ihese
parts with white, greyish, and yellowish scales, which meaau^
from two to six millimetres in breadth, and from three to eight
in length. The scales are slightly raised in the middle, their
borders are angular, and they are pierced at all points by hairs;
they are but loosely connected with the skin, but so closely with
the hairs, that in removing a scale we at the same time puU out
a hair.
Examination with the microscope discovers to us, that the
scales are composed of epidermal cells, but the whole of the
dermal portion of the hair is surrounded by cryptogamic forma^
tions, which constitute a vegetable sheath around it, in such
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DIAOKOAIS AND CAUSIS OF SY008Ig. B95
manner, that the hair implanted in this vegetable sheath maybe
likened to the finger surrounded by a glove.
It is worthy of remark, that these cryptogamia never rise above
the surface of the epiderma ; they originate in the matrix of the
hair, and in the cells pf which the follicle is composed, and they
ascend so as to surround all that portion of the hair included
within the derma. They present everjnp^here a prodigious
number of sporules, which are adherent, on the one side, to
the internal surface of the follicle, and on the other, to the
cylinder of the hair ; to the former they are very closely con-
nected.
Each plant is composed of a stem, of several branches, and
of sporules.
This disease of the skin, continues M. Gruby, is an affection
of a purely vegetable nature, and is deserving of occupying a
place among those disorders — such as favus and aphtha — ^which
consist in the development of parasitic plants, and which might,
very properly, be termed Nosophyta.
643. Dioffnosis. — The diagnostic characters of sycosis are, the
conical form of the pustular elevations, the bright red colour of
their bases, their deep-seated relations with the integument, the
purplish and indolent tubercles which succeed them, and the
site of the eruption. They are distinguished from acne by their
situation, and by their relation to the hair.
The pustular diseases, ecthyma and impetigo, have a different
character of pustule to that of sycosis ; those of the former are
large, prominent, and phlyzacious ; while the pustules of impe-
tigo axe small, little raised above the surface, clustered, and
psydracious. The mode of termination of the pustules is
equally different: in ecthyma they form large and thick crusts ;
those of impetigo pour out an abundant secretion, which desic-
cates into bright yellow crusts ; while the crusts of sycosis are
hard, thin, and of a deep brown colour. Moreover, ecthyma
and impetigo leave behind them no tubercular thickening of the
integument.
Syphilitic pustules are distinguished from those of sycosis by
the absence of heat and tension, by the flatness of the pustules,
by their tardy progress, by their coppery and violet hue, and
by their general dissemination over the face. Syphilitic tuber-
cles differ from those of sycosis chiefly by their coppery hue
and glossy surface. They, axe not confined to the hairy parts
of the face, and they terminate in ulcerations of greater or
lesser depth.
644. Gauges, — Sycosis is s\, disease of the male sex, but in
rare instances has been seen in the female. It may occur at
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396 DISEASES OF THE SEBIPABOUS GLANDS.
any period of the year, but commonly makes its attack in tlie
spring or autumn season. The most frequent exciting cause
of the disease is the irritation resulting from the use of a blunt
razor, in persons predisposed to such affections, on account of
the susceptibility of the cutaneous textures. Other sources of
predisposition are, exposure to the night air, intemperance, ex-
cesses in diet, uncleanly habits, destitution, &c. A very common
direct cause is exposure to heat ; hence we find sycosis to be
prevalent among those who work near a large fire, as founders,
cooks, &c. M. Fovillehas observed the disease to be transmitted
by contagion, from the use of a razor employed in shaving an
affected person.
645. PrognosU. — Sycosis is a very troublesome and obstinate
affection, lasting for months, and often for years. This may be
inferred when it is recollected that shaving is frequently the
primary cause of the disorder, and the necessary continuance of
the cause cannot but protract the chances of cure. The disease
sometimes gets well spontaneously during the summer, to re-
appear in the colder months of the year.
646. Treatment. — The foremost indication in the treatment of
sycosis is the removal of the cause ; to this end, the razor must
be used with more care, or set aside for awhile. The stimulus
of excessive heat must be avoided, intemperate habits must be
restrained, and a light and cooling diet enjoined. To these rules,
which tend to the diminution of the general excitement of the
system, may be added the use of laxatives, as of the milder forms
of neutral salts, Seidlitz and Rochelle, preceded, according to
the judgment of the practitioner, by one or several doses of
calomel or blue pill. If the patient be full and plethoric, a general
bleeding will be found a necessary preparation for local remedies.
In the chronic state of the affection, it may be desirable to sub-
ject the patient to the influence of a mercurial course, and if the
system exhibit any signs of debility, tonic remedies or steel
medicines may be employed. In die congested state of skin
accompanying the eruption, leeches should be applied, or the
part well sciuified witn the point of a lancet, both of these
measures being followed by a vapour douche of half an hour
or an hour's duration, or by a poultice. The vapour douche
will be found an invaluable remedy at all periods of the erup-
tion, and should be frequently used. In the chronic state
of the affection, the use of iodine, either in the form of vapour
or ointment, may be tried, vrith a prospect of success, or
the nitrate of mercury ointment, of its full strength or di-
luted. Other remedies that may be beneficially used in this
dibcase are, zinc ointment, the spirituous lotion of bichloride
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TREATMENT OF SYCOSIS. 397
of mercmy, a solution of sulphuret of potash, nitrate of
silver, &c.
Whenever the hairs are found to be loosened, they should be
immediately puUed out, as in this state they are calculated to
act as agents of irritation. Mr. Plumbe regards the hairs as the
especial cause of the obstinacy of this disease ; I do not, how-
ever, vrholly agree with him in this respect
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CHAPTER XVI.
DISEASES OF THE HAIBS AND HAIR-FOLLICLES.
647. The hair is liable to a variety of modifications, some
resulting from altered nutrition, others from inflammation, either
of the formative structure of tiie hair, or of the hair-follicles.
These modifications, alterations, and diseases, I propose to con-
sider, under the six foUowing heads — ^namely.
Augmented formation of hair,
Diminished formation of hair,
Abnormal direction of tiie hair.
Alteration of colour of the hair.
Diseases of the hairs.
Diseases of the hair-follicles.
I. AUGMENTED FORMATION OF HAIR.
648. Augmentation of formation of the hair calls for consi-
deration in a twofold point of view: firstiy, as it relates to
simple increase of quantity or length in situations naturally
occupied by hair — abnormal quantity; and secondly, to in-
crease of quantity or length in unusual situations— 'O^n^TmuE/
situation,
(a.) Abnormal Quantity.
649. Great variety is met with among individuals in relation
to quantity of hair; in some persons I have observed the hairs
collected into groups of three, and in many situations two have
issued from the aperture of tiie same foUicle; while in other
persons the hairs are distributed singly at regular distances, and
are not clustered.
In tiie present age, when custom and convenience call for the
frequent shortening of the hair, we can form very littie notion
of differences involved in rapidity of growth. There can be no
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ilUOMENTSD FORMATION OF HAIR. 899
doubt, that in some persons the growth of hair is more active
than in others, but to what extent this difference may be carried
is unknown. Judging from female hair, which is permitted to
grow to its full length, as well as from hair on other parts of
die body, we may rightly infer, that hair left to itself grows to
a certain length, and then falls off, to be replaced by a fresh
growth. Widiof estimates that the hair of the beard grows one
line (French) in the course of a week, let us call it one line and
a half (English) ; this would amount to six inches and a half
yearly ; and if we suppose, with Withof, that the hair continues
to grow at this rate for fifty years, the old man of seventy must
have retrenched his beard upwards of twenty-seven feet in length.
Men with exceedingly long hair are frequently met with at our
country fairs, and Rayer quotes the following instance of re-
markable development of this production : — " I once saw a
Piedmontese, aged twenty-eight, strongly built, having the chest
broad and large, and the musdes of an athlete ; the arm was
above twenty-one inches, and the calf of the leg nearly two
feet in circumference. This man had little beard, and the trunk
was very scantily frimished with hair, but his scalp was covered
¥rith the most extraordinary crop ; frizzled on purpose, it was
above four feet ten inches in circumference; the hair was of a
dark-brown, approaching to black, extremely fine and silky."
650. It is interesting to remark, that increase in length of the
hair is sometimes associated with disease ; and in truth we know
little of the effects produced upon the system by the habit of
removal of the hair. I have known persons who always ex-
perience headache after having the hair cut, and many cases are
on record in which the removal of the hair is supposed to hare
given rise to remarkable effects. Moreau has published some
excellent observations^ on the advantages and dangers of cutting
the hair ; and he especially details die case of a young lady
cured of mania by that operation. The hair is often found of
unusual length in phthisis, and long black eyelashes are con*
sidered pathognomonic of strumous disease. This is an in-
teresting observation in relation to phthisis, inasmuch as it
serves to illustrate, in another point of view, the vicarious ac-
tivity which the skin assumes in disordered function of the
lungs.
(b.) Abnormal Situation.
PILOUS NiEVI.
Syn. Mok$. Mother^s marks.
651. When it is recollected that every part of the skin, with
the exception of the palms of the hands and soles of the feet,
* Journal Gen^rale de Medecine, toL iv. p. 280.
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400 DISEASES OF THE HAIR AND HAIR-FOLLICLES.
is organized for the production of hair, it will cease to be matter
of surprise that, under certain circumstances, hair should be
found to grow to a remarkable length in unusual situations. The
proximate cause of this increased growth is augmented nutri-
tion of the hair pulps, determined by local or constitutional
conditions, the local conditions being either special organization
of the skin, or external irritation of tiiat organ. In both, the
skin presents a deeper tint than usual, from increased formation
of pigment in the cells of the rete mucosum, and a greater
thickness from hypertrophy of tiie hair pulps and follicles.
Local increase of length of hair, depending on special organ-
ization of the skin, is usually congenital, and is exemplified in
the various forms of pilous ruBvi, or moles. In these naevi
there is no hypertrophy of the capillary structure of die skin,
as in vascular nsvi, but simple augmentation of colour, the con-
sequence of increased activity; and augmentation of thickness,
the natural result of enlargement of tiie hair-follicles and pulps.
POous naevi appear in various number, and in patches of dif-
ferent size, upon all parts of the body. They are slighdy raised
above the level of the surrounding skin, and are covered by hair
of variable length. In illustration of this subject, Alibert records
the case of a young lady, whose skin was studded over nearly
every part of tiie body witii moles of a deep-black colour, from
which a long, black, thick, and harsh woolly hair was produced.
M. yillerm6 again, in his article on the hair, in the Dictionnaire
des Sciences M^dicales, observes — " I saw at Poictiers,in 1808,
a poor child, between six and eight years of age, that had a
great number of mother's marks disposed in brown projecting
patches of different dimensions, scattered over various parts of
the body, with the exception of the feet and hands. The spots
were covered witii hair, shorter, and not quite so tiiick as the
bristies of a wild boar, but presenting considerable analogy
with them. This hairy covering, with the spots upon whidi
they grew, occupied, perhaps, one-fifih of the surface of tiie
body."
652. Sometimes the disposition to the growtii of hair is not con-
fined to so limited a spot as a naevus, but exists over a surface
of considerable extent. A few years since, I saw a young lad,
about twelve years of age, of healtiiy aspect and constitution,
who presented a most unusual growth of long, harsh, and black
hair, upon the outer sides of the arms, extending from the
backs of his hands to the shoulders. The integument upon
which the hair grew was of a brownish colour, and contrasted
remarkably with the lighter coloured skin of the rest of his arm,
and of the body generally. The contrast was less striking
near the circumference of the hairy growth, from the circum-
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PILOUS NJ£VI. mother's MARKS. 401
Stance of the brownish tint terminating imperceptibly in the
ordinary colour of the cutaneous surface. The skin, in other
respects, was uniform with the rest of the integument; it was
neither raised nor tumefied, nor did it differ in temperature firom
the neighbouring parts. The hairs in this case were about
three-quarters of an inch in length, much darker in colour than
the hair of the head, conical, and differing firom the eyelashes
only, in being longer and finer. On examining the skm with a
lens, the hair might be seen extending deeply, in an oblique
direction, into the integument On plucking out some of the
hairs, and placing them in the field of the microscope, I fotmd
them to be provided with a bulb, and to be identical in appear-
ance with the hairs of the head, or of the whisker.
Schenkius and Ambrose Par6 record instances in which the
body was completely covered with hair; and Daniel Turner
relates, quoting firom Peter Messias, on the authority of Damas-
cenus, ^' that upon the confines of Pisa, at a place caUed the
Holy Rock, a girl was bom all over hairy, firom the mother's
unhappy ruminating, and ofi;en beholding the picture of St
John the Baptist, hanging by her bedside, drawn in his hairy
vesture."
653. Bichat, in his treatise on General Anatomy, remarks,
that hairs are occasionally developed on the surface of mucous
membranes, as in the bladder, stomach, and intestines; he also
discovered them on the surface of renal calculi. In the gall-
bladder, he once found about a dozen hairs, evidently implanted
by the roots in the tissue of the mucous membrane. M. Yillerm^
states that hairs have been found on the tongue, pharynx, in
the rectum, uterus, and vagina, growing firom the mucous
membrane.
654. Local increase of length of hair, depending on external
irritation of the skin, is illustrated in the following cases : — In a
little girl recovering firom an attack of fever, a considerable
growth of hair took place on the site of a blister which had been
applied to the nape of the neck. The hair in this case increased
to the length of half an inch, but evinced no disposition to
grow longer ; it was nearly as dark in colour as that of the
head, was harsh, but smooth, and thickly planted in the skin.
Rayer records a parallel case ; and Boyer was wont, in his
lectures, to speak of a man who suffered firom an inflamed
tumour in the thigh, which subsequently became covered with
numerous long hairs. Rayer mentions another case, occurring
in a medical student, who had several hairy patches on the
skin, induced, apparently, by firequent bathing in the summer
season, and exposure to the scorching rays of the sun.
655. Augmented growth of hair in abnormal situations, arising
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402 DISEASES OF THE HAIRS AND HAIB-FOLLICLES.
from canxtUutional conditions, is illustrated in numerous interest-
ing instances which have from time to time been recorded. In
some of these, the unusual growth appears to result from general
disorder of the system; in others, it is the consequence of a
particular modification of the economy. Of the former kind is
the case of a young lady, narrated by OUivier:* she was re-
markable for the whiteness of her skin, and for a fine head of
jet-black hair; while recovering her strength after the effects of
a chronic gastro-enteritis, she perceived, one day, that the
entire surface of her skin, both on the trunk and extremities,
was raised into small pimples, resembling those produced by
cold, and commonly called goose-shin. At die end of a few days
the pimples presented a small black head, and shortly after,
they were found surmounted by a short hair, which grew very
rapidly, so that at the end of a month, every part of the body
with the exception of her face, the palms of the hands, and soles
of the feet, was covered with a short hairy coat. The individual
hairs reached the length of an inch, and were very closely
planted.
666. Hair is sometimes developed to a considerable length on
the upper lip and chin of women at different periods of age. It
occurs most frequently in those possessed of a naturally strong
growth of hair, and of a dark complexion. In young women, it
is frequently associated with disturbed menstrual function. This
fact is observed by Hippocrates, but I have seen several instances
in which no such disturbance existed, where the vital frmctions
were well performed, and where the subjects were remarkable
for robust health. The development of hair upon the upper lip,
and upon the chin, is more common in unmarried females of a
certain age, in whom, from inaction, the ovaries have become
atrophied; it is also observed in sterile married women. In
bodi these cases, other changes, evincing the deprivation of the
peculiar characteristics of the sex, are observed, such as dwindling
of the mammae, absorption of the subcutaneous adipose tissue,
harshness of voice, masculini^ of deportment, of action, &c. A
similar condition is remarked in women who have ceased to
menstruate, either from natural or pathological causes. John
Hunter, alluding to the circumstance of female birds, after
having ceased to breed, assuming the plumage and other attri-
butes of the male, says, ^^ We find something similar taking
place even in the human species, for that increase of hair observ*
able on the faces of many women in advanced life, is an
approach towards the beard, which is one of the most distin-
guishing secondary properties of man.'' '^ The female, at a
♦ Dictionnaire de M^decine, article Foil.
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DIMINISHED FORMATION OF HAIR. 403
much later time of life, when the powers of propagation cease,
loses many of her peculiar properties, and may be said, except
from mere structure of parts, to be of no sex, even receding from
the original character of the animal, and approaching in appear-
ance towards the male, or perhaps, more properly, towards the
hermaphrodite.*^
657. Treatment. — ^Where the growth of hfiur has become a
deformity, which the patient is desirous of having removed,
several modes of local treatment may be adopted. If its seat be
isolated and small, as on a pilous naevus, the best treatment is
excision, which, when carefiiUy performed in the direction of the
natural furrows of the skin, scarcely leaves any trace of cicatrix.
Another mode of getting rid of hair is by means of the ciliary
forceps, or tweezers. Their complete eradication will, however,
be found difficult, for the formative organ still remains, and the
hairs are constantly reproduced. A third mode of removing
hair is by depilatories; these are powders composed of quick
lime, subcarbonate of soda, or potash, and sulphuret of arsenic.
They are applied in the form of a paste, and washed off as soon
as dry ; they act by desiccating and dissolving the hair, and
require to be employed with caution, on account of their irritating
nature. Depilatories are merely temporary removers of the
hair, for it is clear that their agency can extend no deeper than
the epiderma ; the hair-pulps consequently remain, and the hair
is not long in being reproduced. Several formulae for depilatory
powders will be found in a ftiture page of this work.
II. DIMINISHED FORMATION OF HAIR.
ALOPECIA.
Syn. Defluvium pilorum.
658. Alopecia, or baldness, results from defective development
or atrophy of the formative organ of the hair, and occasionally
from disturbed circulation in that structure. Sometimes the
baldness is congenital; at other times it is accidental^ appearing
after the frdl growth of the hair, and causing its fall to a greater
or less extent; and again, it may be the natural consequence of
age — calvities. Under these three heads therefore, I propose to
consider the phenomena presented by the defective state of
formation of die hair — namely.
Congenital alopecia.
Accidental alopecia.
Natural alopecia.
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404 DISEASES OF THE HAIRS AND HAIR-FOLLICLES.
CONGENITAL ALOPECIA.
659. Congenital baldness is sometimes, but very rarely, ob-
served in newly-born infants, in whom, though weU-formed and
healthy with regard to every other function, the hair has been
retarded in its appearance until the end of the first year, and
sometimes so long as the second and third years. I have never
seen an instance of congenital absence of die hair of the head,
but I have met with cases of deficiency in other regions, as
upon the chin and pubes. *^ Congenital absence, and ulterior
defective development of the hair," says Rayer, " are phenomena
of considerable rarity, which I have, nevertheless, had opportu-
nities of observing. Such was the case of the man Beauvais, who
was a patient in tiie Hospital de la Charite, in 1827. The skin
of this man's cranium appeared completely naked ; although, on
examining it narrowly, it was found to be beset with a quantity
of very fine white and silky hair, similar to the down that covers
the scalp of infants ; here and there, upon the temples, there
were a few black specks, occasioned by the stumps of seversd hairs
which the patient had shaved off. The eyebrows were merely
indicated by a few fine and very short hairs ; the free edges of
the eyelids were without cilia, but the bulb of each of these was
indicated by a small whitish point ; the beard was so thin and
weak, that Beauvais only clipped it off every three weeks ; a few
straggling hairs only were observed on the breast and pubic
region, as in young people on the approach of puberty ; there
was scarcely any under tiie axillse ; it was rather more abundant
on the inner parts of the legs ; the voice had the pitch and into-
nation of that of a full-grown and well-constituted man. Beau-
vais is not deficient in the virile indications of his sex ; he has
had syphilis twice. He tells us that his mother and both his
Bisters had fine heads of hair, whilst his father presented the
same defect in the commodity of hair which he does himself.**
ACCIDENTAL ALOPECIA.
SyiL Porrigo dtcrdvans. Alopecia circumscripta. Area. Tifria, Ophiasis.
660. Accidental baldness is a more common affection than
congenital deficiency in the development of hair. I have seen
numerous instances, in which the baldness has been nearly com-
plete upon the scalp, one or two small islets of hair-bearing
integument alone remaining, while the hair of the eyebrows,
whiskers, and beard, was totally lost. In one of these cases, I
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CONGENITAL ALOPECIA^ ACCIDENTAL ALOPECIA. 405
found the soalp smooth and polished, thinner than natural, and
somewhat stretched over the cranium, giving the idea of an
abnormal increase in the convexity of the bones of the head.
There was, however, no such condition present. When examined
closely, the scalp was seen to be studded with numerous super-
ficial, minute, dusky points, the almost obliterated hair-follicles.
In the course of a few months from this time, with appropriate
treatment, the tenseness, thinness, and polish of the scalp became
diminished ; the follicles could be seen extending to a greater
depth into the scalp ; and the mouth of each follicle became the
seat of a small pimply elevation of the epiderma. This I regard
as the commencement of the second ana restorative stage of the
disease ; the entire surface at this period has the appearance of
the cutis anserina, and, in the course of a very few days, a minute
downy hair may be seen extending from the apex of each little
projection. This stage of the case is frequently accompanied by
an itching sensation, produced by the imprisonment of the hair
vrithin its follicle, the apertm'e being partially closed by the cor-
rugated edge of the epiderma, and, frequently, by a minute oper-
culum formed by the hardened secretion of the foUicle. The
operculum is rubbed off, in the attempts of the patient to relieve
this itching by friction or scratching, and the downy hair, before
invisible, becomes apparent The newly-formed hair is for some
time thin, dry, and slender, and lighter in colour than the adja-
cent hair, but after a time it gains its proper thickness and hue.
Instead of affecting the entire head, the hair sometimes falls
off, without any premonitory symptoms, to a limited and circum-
scribed extent only, leaving one or more roundish patches on
the scalp, of which the surface is smooth, white, and depressed.
On examining the skin at this part, it is evident that the hair-
follicles are either very much diminished in size, or in many
instances entirely gone, particularly towards the centre of the
patch, in which situation the scalp is obviously thinner than in
the surrounding part This, like general accidental alopecia of
the scalp, is clearly an atrophy of the hair-follicles of the part
affected. To this form of the disease various names have been
assigned by different authors. From presenting a regularly, cir-
cumscribed disk of baldness, surrounded by long and unaffected
hair, it has been named " alopecia circumscripta^^ and " areaP
When several of the patches run into each other, so as to present
a serpentine form, it has been called '^ ophians^^ but its more
common designation is that which it received from Willan.
Observing that, as in trichosis, the hair was lost in the form of
roundish patches, Willan assigned to the disease the name of
" parrigo decalvansJ*
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406 DISEASES OF THE HAIRS AND HAIR-FOLLICLES.
CALVITIES.
Sjn. Senile Baldness.
• 661. Alopecia, the natural oonsequcnce of age, is a change
taking place gradually in the follicles, by which the formative
structure, from deficiency of nutrition, becomes atrophied, and
the follicles themselves obliterated. The change is usually pre-
ceded by dryness, and loss of colour of the hair. But baldness
of this kind is not necessarily confined to old persons; it is
daily observed at an earlier period of life, as at forty, thirty, and
sometimes in persons still younger. Occasionally it results from
mental anxieties, severe afflictions, &c ; but at other times comes
on without apparent exciting cause.
In association with the baldness of age, it is interesting to
observe, that alopecia occurs on the vertex of the head, in that
situation in which the integument is bound down somewhat
tightly upon the bones of the cranium, and where the circulation
is least abundant, and most likely to be interfered with. We
frequently see it limited on each side by a line which corresponds
accurately with the parietal ridges, and posteriorly by the situa-
tion of the upper margin of the posterior portion of the occipito-
frontalis muscle, while, below this line, over the temporal muscle
at each side, and over the occipito-frontalis muscle behind, the
hair still remains comparatively unaffected. It is obvious that
in this case the cause of the fall of hair must be sought for in
the impediment to circulation through the texture of the scalp
of the upper part of the head ; and in correspondence wilii this
interference, we remark the exceeding paleness of the cranial
region. But the same cause may be supposed to have existence
also in women, unless we admit that a larger quantity of adi-
pose tissue situated beneath the integument of the scalp may
afibrd an easy and unimpeded transit for the minute vessels to
the capiUary plexus of the derma.
I am the more induced to suppose that this may be the case,
from observing the indisposition to baldness on the pubes, where
a thick cushion of fat is interposed between the hard parts and
the surfiGLce, and the vessels are enabled to make their passage
through a soft and yielding medium to their distribution in the
papillary layer of the skin.
The integument of the scalp of old persons who have been
bald for some time, is remarkable for its extreme smoothness.
Bichat observes, that he examiqed the scalp of several bald heads
by dissection, and he invariably found that the internal surfrice of
the integument, when raised from the fat and superficial fascia,
was remarkably even. There was no trace of me numberless
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CALVITIES. SENILE BALDNESS. 407
appendages constituting the follicles of the hairs which are found
in the hairy scalp. On the contrary, in a man recently bald from
typhus fever, the follicles were distinctly apparent, and contained
each a minute, colourless, down-like hair, the rudiment of a
fresh growth. Hence, he continues, there is this important dif-
ference between the baldness of the aged and that which succeeds
disease ; that in the first, the whole of the secreting structure dies,
(that is, becomes atrophied,) from the cessation of circulation in
the vessels of the part, whereas, in the latter, the hair alone
&lls, while the follicle remains behind.
Bichat has also remarked, that the follicles of the hair, when
seen from the external surface, appear to become more and more
shallow, until they at last reach the surface, and are obliterated
completely. The same change may be observed on the surface
of tumours forming in the scalp. The integument becomes
graduaUy thinned, the hair-follicles become more and more
shallow, until every trace of them has disappeared, and the hairs
which they once contained fall off.
662. Causes. — The proximate causes of baldness have been
already stated ; they are, defective development of the formative
organ, defective circulation in the formative organ, and defective
nutrition of the formative organ. The remote causes are, here-
ditary peculiarity, the termination of acute diseases, certain
diseases of the skin, certain general affections, syphilis, mer-
cury, coffee taken in excess, late hours, extremes in venery, old
age. The falling off of the hair, which occurs during con-
valescence from fevers and diseases, attended with extreme
depression of the vital powers, must be ascribed to the enfeebled
powers of the system, and consequently to defective nutrition
of the hair. Lemery^ mentions the case of a patient, who,
some months after a violent hypercatharsis, lost the whole of
his hair.
The hair may suffer from any disease in which the activity of
the nervous and vascular systems is directed especially to any
one portion of the body, as in some local diseases. I have seen
nearly the whole of the hair of the scalp lost during the progress
of an ordinary pregnancy. In rheumatism and gout, the hair is
liable to grow dry, and fall off. The loss of hair is sometimes
remarkably exhibited in phtiiisis,t in which disease not only the
hair of the scalp, but also that of the eyebrows and beard, is apt
to fall. This change is particularly observable in young women
possessed of extremely long hair. Numerous instances, in which
* Mem. de I'Acad. des Scieoces, prem. mem , vol. ii., p. 39.
t Hippocrates remarks, ** Qaibos tabe laborantibus, capilli de capite defluant,
hi, alri, noxa snpervenieDti, moriuntar.
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408 DISEASES OF THE HAIRS AND HAIR-FOLLICLES.
alopecia is attributed to syphilis, are detailed in the works of old
authors, but they are exceedingly rare at the present day, since
this disease has been thoroughly investigated and treated on
more scientific principles. I have only twice seen a partial loss
of hair, attended by dryness and fiirfiiraceous desquamation of
the epiderma, in patients affected with the secondary symptoms of
this disease ; and in both of these cases I was induced to ascribe
the source of the malady rather to the abuse of mercury than to
the original disease. Mercury, when taken for a length of time,
is apt to affect the secreting organs of the body injuriously, and
among these, the secreting apparatus connected with the skin.
M. Lagneau, in his article ^^ Alopecia,'' in the ^^ Dictionnaire de
M6decine," expresses a different opinion, as relates to the opera-
tion of mercury. He remarks, that it is erroneous to suppose
that persons affected with syphilis are rendered bald by the
abuse of mercury, for alopecia has been seen to manifest its
presence, occasionally, before the patients have employed this
remedy, or any other anti-syphilitic medicine whatsoever. On
the other hand, he continues, I do not believe that any one ever
saw alopecia developed, after the cure of other diseases in which
it is customary to exhibit mercury.
Baldness is much modified by sex ; in the male it is a common
affection, but in the female, on the contrary, it is rare. I am
disposed to believe that the difference between the sexes lies in
the greater proportion of subcutaneous fat existing in the female.
The scalp of bald persons is usually excessively thin, and
eunuchs, who are generally fat, are remarkable for the length
and permanency of their hair.
663. Treatment — The principal indication to be fulfilled in
the treatment of baldness, is to stimulate the capillary circulation
of the scalp, which is evidently below the natural standard.
With this view I am in the habit of recommending the washing
of the head every morning with cold water, drying it by friction
with a rough towel, brushing it with a hard hair brush until red-
ness is produced, and then applying some stimulating applica-
tion, rubbed brisldy into the scalp for the space of five minutes.
The best application for the purpose is a compound can-
tharidine pomatum, prepared at my request by Savory and
Moore. Various stimulating substances have been suggested
and used firom time to time, in the treatment of alopecia, with
advantageous results; such as mustard, horse-radish, walnut
leaves, the pomades of Dupuytren and Gibert, &c. The poma-
tum ascribed to Dupuytren, a most clumsy compound, is the
foUowing : —
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TREATMENT OF BALDNESS. 409
B»
Purified beef marrow, 3viij.
Acetate of lead, 3J.
Peruvian balsam, 5iij.
Alcohol, Jj.
Tincture of cantharides, cloves, and cannella, aa nxzv.
Mix.
The trichogenous ointment recommended by Gibert, con-
sists of
Purified beef marrow, 3 vj.
Oil of sweet almonds, x ij.
Powder of red bark, 3J.
Mix.
Avicenna recommends the use of leeches, slight scarification
or acupuncture in the first instance, followed by rubefacients.
The latter were in high favour among the ancients, and they
have left of them in their writings a goodly list, of which the
following are the principal: — oils of chamomile, wormwood,
bay, laurel, and dill ; hellebore, euphorbia, pomegranate, nas-
turtium, stavesacre, foenugreek, rosemary, sage, Peruvian bal-
sam, tar, firankincense, mastich, myrrh, and ladanum. Ladanum
is warmly praised by Dioscorides and Galen, and occupies a
place in most of the local applications for baldness.
It would not, however, in all cases, be judicious to limit the
treatment of baldness to external remedies. In cases where
disturbance of the secretive and digestive functions are present,
these require attention. Where the energies of the nervous sys-
tem are obviously reduced below their natural level, steel
medicines and tonics may be used with advantage.
When the hair begins to grow after baldness, it is at first of
a very light colour, d^, soft, and almost downy, like the young
hair of a newly-born child ; but by degrees, under favouring
circumstances, it resumes the colour and strength of the sur-
rounding hair. At other times this colourless hair remains
during life, and forms a remarkable contrast with the dark hair of
the rest of the head. The restoration of the hair to its primitive
strength is greatly favoured and accelerated by repeated shaving
of the scalp, the object of this operation being to confine the
nutritive fluids to the formative structure, until it shall have re-
gained sufficient power to produce hair of a proper degree of
size and strength. Many authors concur in the advantage of
shaving as a means of strengthening the hair. Fallopius
upon this subject observes, ^^ II y a quarante ans que nous por-
tons la barbe longue, en signe de notre d^shonneur et de notre
servitude; ayant cette epoquenous nous rasions et nos poils ne
tombaient pas. Les Espagnols en envahissant Tltalie, y ont in-
troduit la tyrannic, la verole, et Tusage de la barbe longue."
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410 DISEASES OF THE HAIRS AND HAIR-FOLLICLES.
III. ABNORMAL DIRECTION OF THE HAIR.
664. Under the head of abnormal direction of the hair, I have
assembled two instances of irregularity in its growth and arrange-
ment, not referrible to the preceding groups. They are.
Trichiasis,
Felting of the hair.
TRICHIASIS.
665. Trichiasis is an irregularity in the growth and direction
of the eyelashes. The cilia in ^s disorder grow inwards to-
wards the surface of the eyeball, and by rubbing against the
conjunctiYa, give rise to chronic inflammation of diat mem-
brane.
The treatment of trichiasis consists in removing the mis-
directed lashes by means of the ciliary forceps, and preventing
their future growth by the application of nitrate of silver.
FELTING OF THE HAIR.
666. Felting is a derangement of the hair arising from neglect,
and has no claim to consideration as a disease. It consists
merely in a state of inextricable interlacing of the hair, best
expressed in its name. Felting of the hair is rarely met with,
and when it exists, is seen in women whose long hair affords
the only excuse for such a state of disorder. 'It has been ob-
served after child-bed, and in cases of extreme distress.
IV. ALTERATION OF COLOUR OF THE HAIR.
667. Alteration of colour of the hair arises from disorder of
the chromatogenous function of the formative organ, and is
very commonly associated with alteration in tint of the rete
mucosum of the skin. It is by no means a rare occurrence to
find a lock of hair different in colour from that which surrounds
it. Less frequently, sudden alterations of colour have been
observed, while blanching of the hair, or canities, is the
natural effect of the torpor of function which accompanies age.
668. Two instances of reproduction of hair of different
colour to the original, after recovery from severe illness, are re-
corded by Alibert ; in one of these, a head of bright red hair
replaced one of dark brown, and in the other, hair of a deep
black colour took the place of brown. In the case" of baldness
from hypercatharsis, mentioned in the preceding section (§ 662),
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ALTERATION OF COLOUR OF THE HAIR. 411
the hair, originally of a brown colour, was reproduced blond, and
grey hair has been known to fall off in advanced age, and a
new crop, similar in colour to that possessed in youth, to be
substituted.
Dr. Isoard, in a paper entitled, " Observation relative a une
famille dont chaque individu presente plusieurs anomalies re-
marquables,'' in the " Journal Complementaire du Dictionnaire
des Sciences Medicales,** amongst other extraordinary physiolo-
gical and pathological anomalies observed in the members of
this family, remarks, that one of the daughters, seventeen years
of age, and deaf and dumb from birth, each time that she is
attacked by a fever peculiar to her constitution, undergoes a
change in the colour of her hair, from a pleasing blond to a
dusky red, but that so soon as the febrile symptoms diminish,
the natural colour is restored. In the second volume of the
** Memoirs of the French Academy of Sciences," is the narra-
tive of a case in which the hair of a female was changed from
brown to blond during her confinement, which otherwise pre-
sented no remarkable feature. M. Villerm6* relates the case of
a young lady, thirteen years of age, who, having never suffered
from any more serious illness than slight pains in the head,
perceived, during the winter of 1817-18, her hair to faU off in
several situations, until, at the end of six months, there was not
a single hair remaining. In January, 1819, the scalp began to
display a new growth, of a black-coloured wool, in the situations
first affected, and of brown hair over the rest .of the head. The
wool and the brown hair became white, and partly fell off after
they had reached the length of three or four French inches,
while the rest changed their tint at a certain distance from the
point, and became chesnut-coloured for the rest of their extent
towards the root. The hair had a singular appearance, half
white and half chesunt. The specimens sent to the society
were mingled with a number of short hairs entirely chesnut
coloured. In remarking upon the preceding case, M. Villerm^
observes, that he has more than once seen the hair, particularly
in phthisical patients, after having become white, and fallen off,
succeeded by a crop of new hair of a darker colour even than the
original hair of the patient. The late Dr, Chaumenton pre-
sented this phenomenon in a marked degree.
Dr. Bruley, a physician of Fontainebleau, communicated to
the Society of Medicine in Paris, in the year 1798, the history
of a woman, sixty- six years of age, named Castellane, whose
hair, naturally white and transparent as glass, became jet-black
four days before her death. She died of phthisis. Some of this
* Joarnal Gcnerale de Medecine, vol Ixix., p. 218.
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412 DISEASES OF THE HAIRS AND HAIR-FOLLICLES.
hair was transmitted to the society, and was found to be quite
black, with a few white hairs interspersed. On examination
after death, Dr. Bruley found the bulbs of the black hair of an
immense size, and gorged with dark pigment. The roots of the
white hairs which remained were dried up, and two-thirds
smaller in size than those of the black hair. In remarking upon
this case, Dr. Bruley observes, " It is certain that disease may
give rise to a change in a short period, that, according to Haller,
requires a long period to accomplish natumlly.**
CANITIES.
Syn. Trichosis poUosiB, Good. Blanching of the hair,
669. Under the term canities, I propose to describe white-
ness of the hair, whether it« production be congenital, or
dependent upon age, disease, or other causes. Dr. Copland
regards the term as applicable only to whiteness resulting from
an abnormal cause; hence he defines it, ^^ hairs prematurely
grey, hoary, or white." Canities present two varieties in decree;
in die one the hair is " snowy," of an opaque white, and cor-
responds in thickness with ordinary hair ; in the other, it is
clear and transparent, the *^ silvery hair" of age assuming a
yellowish tint on desiccation by the atmosphere, and not
unfrequently thinner than ordinary hair. These two offer
remarkable chemical differences; the former containing an
abundance of calcareous salts, and the latter a much smaller
quantity, or even jione.
670. Canities may be of three kinds ; congenital, accidental,
or senile ; it may also be, in either of ihe three groups, partial
or general.
671. Congenital whiteness of the hair is usually partial ; I
have seen two examples in young children where the pheno-
menon presented itself in the form of roundish patches ; both
were of the snow-white kind ; in the one the patch was situated
on the side of the head, while in the other it occupied one side
of the forehead. The skin upon which the hair grew was
remarkable for its whiteness, and contrasted strongly with the
neighbouring integument Bartholin saw an infant, the whole of
whose hair on one side of the head was brilliantly white, while
the opposite side was as equally remarkable for its jetty black-
ness. Ridlinus and others have seen the entire head of young
persons uniformly white, although different in appearance from
that of old age, and approaching very slightly towards the
blond. I have before alluded to the whiteness of the hair of
Albinoes, both of the European and of the African race. Rayer,
in the Adas accompanying his work upon the diseases of the
skin, gives a delineation, copied from a picture in the museum
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CANITIES. BLANCHING OF THE HAIR, 413
of the Jaxdin da Roi, of a young negro, upon the middle of
"whose forehead, and rising from the root of the nose so as to
include a moderately large patch of hair on the front of the
head, is a broad tract of skin wholly deprived of pigment : the
hair is perfectly white, and the white band on the forehead is
rendered the more striking, by presenting a roundish islet of
deep black near its middle. On the same plate is a figure,
representing the head of an Albino negress, copied from Buffon;
the skin of the feice and the wool upon the head are entirely and
completely white. Schenkius details the case of a young man,
whose beard grew white on its first appearance.
672. Accidental and senile canities present varieties in extent;
sometimes the whiteness is partial, being intermingled with the
ordinary hair over the entire head, and producing, according to
its proportion, the relative shades of grey. At other times it is
local, and confined to one or several spots, constituting so many
distinct patches ; or it may be general, and involve the entire
head of hair. It commences generally upon the temples, and
thence spreads gradually over the rest of the head. Blanching
of the hair occurs first upon the head ; it proceeds in the next
place to the hair of the face, and subsequently attacks the pilous
covering of other parts of the body. When white hair iaHls off
it is not reproduced, but the scalp beneath remains bald. In
Europe, canities would appear to be equally common in the
male and in the female ; but attacks the latter at a later period
of life, unless induced by other causes than age. " In China,"
says Mr. Lay, ^ the women turn grey sooner than the men ; the
former are often bald, the latter seldom."
Blanching of the hair commences at the root, and the coloured
part is gradually carried onwards, frirther and further from the
integument It is curious to see the hair undergoing this
change, partycoloured in appearance, and reminding us very
forcibly of the ringed hair of the grey cat and ichneumon. The
kinds of hair most liable to the invasion of whiteness are those
of a dark colour, as black and brovni ; blond and auburn hair
rarely become grey, but are more liable to fall off.
673. Causes. — Congenital canities depends upon some con-
stitutional peculiarity inherent in the organization of the indi-
Tidual. Senile canities is the consequence of diminished powers
of the nervous system, as evinced either in the alteration of the
pigment deposited in the formative cells of the hair, or in the
entire absence of the colouring principle.
The remote causes which have been observed to give rise to
accidental canities are, mental emotion, physical suffering and
privation, constitutional affections, disease, and injuries. Of
mental emotion, as of grief, anxiety ; fear, terror, anger, acting
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414 DISEASES OF THE HAIRS AND HAIR-FOLLICLES.
as exciting causes of blanching of the hair, there are namerous
recorded instances. In some of these cases the effects were
gradualy in others they were immediate, producing the silvery
tints of age, it is asserted, in the course of only a few hours.
" The different passions of the mind," says Bichat, " have
a remarkable influence over the internal structure of the hair;
often, in a short period, grief effects changes in its colour,
blanching the hair probably by means of absorption of the fluids
contained in its tissue. Many authors have recorded similar
facts. Some, and Haller among the rest, have doubted the
truth of these assertions, but I know at least five or six examples,
in which the loss of colour was completed in less than eight
days. In a single night, a person of my acquaintance became
almost entirely blanched on receiving some distressing news."
The hair of Marie Antoinette, the wife of Louis XVI., is said
to have become grey in a short period, from grief. The same
statement is recorded with regard to Mary Queen of Scots. It
is affirmed that Sir Thomas More became grey during the night
preceding his execution. Borellus asserts that two gentlemen,
the one a native of Languedoc, the other a Spaniard, were so
violently affected, the first by the announcement of his condem-
nation to death, the latter by the bare thought of having incurred
a serious punishment, that both became blanched in the course
of a single night. Borellus adds, with regard to the latter
gentleman, that his hair regained its natural colour on being set
at liberty. Schenkius and Boyle relate similar instances, but
without the subsequent restoration. Hermeman also records an
instance of sudden loss of colour of the hair.
Dr. Cassan, in a paper in the " Archives 6^n6rales de M6de-
cine," before referred to, records the example of a woman,
thirty-three years of age, who, on being summoned before the
Chamber of Peers to give evidence upon the trial of Louvel,
underwent so powerful a revulsion, that in the course of one
night the hair was completely blanched, and a furfuraceous
eruption appeared all over her head, upon her chest, and upon
her back. After the disappearance of the eruption, the hair
still maintained its abnorm^ colour.
Henry III. of NavaiTC, on hearing that the edict of Nemours
was conceded — a condition favourable to the supporters of the
league — was so exceedingly grieved, that in the course of a few
hours a part of one of his mustachios whitened. In a person
referred to by Rayer, several of the cilia became blanched,
accompanied by white spots over the arms and fore-arms, in
consequence of mental agitation.
M. Moreau* observes — " I once knew an aged man, for whom
♦ Journal G^o^rsle de Medecioe, vol iv. p. 280.
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DISEASES OF THE HAIRS. 415
snow-white hair, and a countenance deeply-marked by the
furrows of care, inspired the respect which we owe to age and
misfortune." " My hair," said he, ** was as thou seest it now
long before the latter season of my life. More energetic in their
effects than assiduous toil and lingering years, grief and despair
at the loss of a wife most tenderly loved, whitened my locks
in a single night. I was not thirty years of age. Judge,
then, the force •of my sufferings ; I still bear them in frighthl
remembrance.**
The poets make frequent reference to this remarkable and
sudden effect of violent mental emotion. Thus a Latin author
exclaims —
** O nox I qdUn longft es, qnse facis ana senem T
Byron also, in the " Prisoner of Chill on,*' refers thus beautifully
to the same phenomenon : —
** My hair is grey, but not with yean.
Nor grew it white
In a single night.
As men's have grown from sadden fears.**
Afber some disease of the scalp, it sometimes happens that the
newly-formed hair remains permanently white ; the same change
is occasionally observed upon cicatrices left by wounds.
v.— DISEASES OF THE HAIRS.
674. Two diseases only come stricdy under this denomina-
tion, as being characterised by a morbid alteration in the struc-
ture of the hair. One is amongst the most common of the
diseases of the scalp of this country, namely, ring- worm ; the
other is a disease of central Europe, and particularly of the
marshy districts of Poland, the plica polonica. Much confusion
has existed with regard to the former of these affections, in con-
sequence of the variety of names which have been assigned to
it, and also from the fact of the generic title comprehending
diseases of a totally different character. Moreover, the names
themselves are ill chosen, the term ^^ tinea** relating to the con-
dition of the hair at a period when the disease has been in
existence for some time ; while the term "porrigo** was selected
by Willan, only because it had been in use among the ancient
classic writers; neither of these terms having any reference
to the nature of the disease. Under these circumstances, I
consider that a first step to the proper understanding of this
affection, and the removal of existing difficulties, might be made
by adopting for its designation the term trichosisy proposed by
Dr. Mason Good. I am further induced to give a preference to
this term by finding it to coincide with what I believe to be the
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416 DISEASES OF THE HAIRS AND HAIR-FOLLICLES.
true pathological nature of the disease, namely, a morbid action
producing the degeneration and destruction of the hairs.
675. The proper diseases of the hair are, therefore : —
Trichosis furfuracea,
Trichosis plica.
TRICHOSIS FURFURACEA^
Syn. Porrigo furfurans. Porrigo scutulata, Willan. Tinea, Tinea tondens,
676. In common ringworm (Plate 8, k. l. m.), the leading
character of the disease is the formation of a thin layer of scurf,
either in separate scales around single hairs, or in patches
which include several or a considerable number of hairs. In
an early stage of this disease, nothing more is perceptible than
these scales, but the diagnosis is made evident by the observation
that the scurfiness is limited to particular hairs, and clusters
of hairs ; and that the patches corresponding with these clusters
have a circular or oval form. Moreover, the aperture of the
follicle of the diseased hair is generally more or less prominent
or papillated, having the appearance of being drawn up by the
growth of the hair, and bearing a close resemblance to the
papillated condition of the skin in '^ cutis anserina.^ Again, if
one of the hairs issuing from this iurfiiraceous base be gently
pulled, the probability is, that it will not come up by the root
as in die case of healdiy hairs, but will break off near the skin,
or within the follicle, according to the period of the disease.
The only inward symptom indicative of a disordered action in
the scalp is a slight degree of itching, which is relieved as soon
as the scurf is torn away by the nails, or removed by the aid of
a comb. Indeed, it is this symptom that first makes the parent
or guardian aware of the existence of disease.
The state of skin above described constitutes the first stage
of trichosis fiirfuracea, and may exist for two or three weeks
without being particularly noticed. At the end of this time,
however, the diseased hairs have grown beyond the follicle, and
break off at a short distance from the skin, leaving an uncovered
patch of scalp, of variable size, but generally of a circular form.
The disease has frequently arrived at its second stage before it
is discovered, and before a medical opinion is obtained. The
ftirfuraceous condition of the skin is now very distinct ; there is
also a slight redness, and sometimes an elevation of the patches
above the level of the surroimding surface. The broken hairs
are very uneven in point of length, ragged at the ends, and
have the appearance of having been eaten through by an insect
This peculiarity has evidently given rise to the term tinea^ one
of the synonyms of the disease ; and the same character, in con-
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TRICHOSIS FURFURACEA. RINGWORM. 417
junction with the circular form of the patches, to the popular
appellation ringworm.
The broken stumps of the hairs are also much altered in
appearance ; they are variously bent and twisted, and lighter
in colour than the original hair. In dark-haired children they
frequently form little black knobs at the mouths of the folli-
cles ; while in light-haired children, the short stumps have an
appearance which may be well compared to the fibres of hemp
or tow.
At a later period, if the disease be neglected, the scales
collect in large quantities, and become matted together into
thick greyish and yellowish crusts (Plate 8, m.) These crusts
are thicker and looser at the edges than towards the centre of
the patch ; and when the latter is large, the crust is broken up
into several angular compartments, the line of rupture being
remarkable for its white and silvery appearance. Moreover, on
the surface of the crust, which is dry and harsh, the tow-like
fibres of the diseased hairs may generally be perceived.
I have alluded, in the foregoing description, to the papillated
state of the mouths of the hair-follicles. This character is not
always present at the commencement of the disease, and in some
cases is more strongly marked than in others. It is, however,
a feature deserving of attention, inasmuch as it indicates a more
extensive affection of the hair-foUicles, and the disease which
it accompanies is generally more difficult of cure than the non-
papillated kind. The thickening of the integument which inva*
riably attends upon trichosisfurfuracea is greater in the papillated
than in the smooth form, and there exists a greater elevation of
the patches. It is in die papillated form of the disease, the
trichosisfurfuracea papulosa J that we are reminded of the designa-
tion given to this disease by Willan, " porrigo scutulata ;" for
the rounded and well-defined patches, studded over with pro-
minent papillae, are by no means unlike the scuta to which that
author has compared them.
The irritation caused by the crusts, and by the attempts made
to separate them by scratching, give rise, after a time, to more
or less inflammation of the subjacent skin. When this occurs,
discharges of ichor and pus are poured out by the inflamed
follicles, and small pustules are formed around the apertures of
the latter. These are complications of the original disease,
dependent on neglect, and may proceed to various degrees of
aggravation. Willan mistook these pustules for the primary
form of the disease, and arranged it, in consequence, with his
pustular group of diseases.
When trichosis furfiiracea afiects the scalp, it is not uncommon
to find small patches of a similar nature on the neck and arms,
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418 DISEASES OF THE HAIRS AND HAIR-FOLLICLES.
and sometimes on other parts of the body. On the surfiEice of
the bodj the scales are more minute than on the scalp, redness
being die leading character of the disorder. The patches
increase by their periphery, while the centre returns to its
original state, and they soon exhaust themselves when left to
take their natural course.
677. Pathology, — The dryness, discoloration, and friability of
the hairs in this affection, seem to point them out as the seat of
the disease. When examined with the microscope, this inference
is shown to be correct ; they are more than twice their natural
size, and a great change is perceptible in their structure. I
have in a former page (| 39) stated the average diameter of the
human hair to be -^ of an inch ; while a number of diseased
hairs submitted to measurement, ranged between 7^ and t^tt
of an inch. The diseased hair is composed of three distinct
parts — namely, a cortical portion like that of healthy hair, which
retains its normal character ; a fibrous part, which is considerably
altered from its natural appearance ; and, between these, a layer
of various thickness, wholly made up of colourless nucleated
granules, (Plate 8, o.) The breadth of the granular portion is
commonly about one-llurd the entire thickness of the hair.
The fibres constituting the fibrous portion of the diseased
hair are somewhat thicker than natural, and undulated in
arrangement, and their continuity is broken from point to point
by one or more of the nucleated granules of which the inter-
mediate layer of the hair is composed. Moreover, these grannies
are also observed between the fibres, which they press asunder,
and in this manner give an appearance of laxity of structure to
the fibrous portion. When a hair is broken across, the fibres
are separated at irregular lengths, and the ruptured ends have
consequently a ragged appearance.
The intermediate portion of the diseased hair is wholly made
up of transparent and colourless nucleated granules, closely
packed together, and forming a tesselated structure beneath
the cortical layer, (Plate 8, p. q.) The size of the granules is
about 77^ of an inch in diameter. In manipulating the hair
under dbe microscope, it sometimes happens that the oortical
layer is torn through, and drawn back in an inverted position
over the adjoining portion of the shaft of the hair. In this case
some of the granules adhere to the cortical layer, while others
retain their connexion with the layer of which they constitute
apart.
The question now arises — ^What are the nucleated grantdes
above described ? I believe them to be the constituent granules
(§ 50) of the hair in a state of morbid enlargement; that the
disease is, in fetct, a granular degenerathn of the hair. I am
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TREATMENT OP TRICHOSIS FURFURACEA. 419
aware that Grubj, who has observed these granules, regards
them as vegetable cells, and considers the disease to consist in
the production of a parasitic mucedinous growth. I cannot,
however, assent to the views of M. Gruby ; and the discovery
of the granular construction of the hair, as put forth in the first
chapter of this work, afibrds to my mind a more satisfactory
explanation. It is perfectly consistent with the pathology of
abnormal nutrition, that these granules should become enlarged,
and thus be the cause of the subsequent changes taking place
in the hair. But the hypothesis of vegetable growth within the
substance of the hair I find difficult to comprehend.
Another consequence naturally follows the admission of the
explanation here given, which is, that this disease being inherent
in the hair, and being due to an abnormal nutrition of the system,
is in nowise contagious. I need scarcely observe, that this is a
question of the utmost importance, as affecting the peace and
happiness of families and ^e education of youdi. The disease
occurs as commonly among the children of die wealthy as among
the poor ; and when the idea of contagion is entertained, the
scourge is rendered doubly severe.
678. Diagnom. — Trichosis furfuracea is easily distinguished
from every other disease of the scalp : the scurfy state of the
skin ; the dry, mealy, and papillated appearance of the patches,
their imperfectly bald state, and the broken and tow-like state
of the hair, are signs which are not met with in any other
disease.
679. Cause. — The cause of this disease I believe to be im-
perfect nutrition, which careful examination will never fail to
detect. The disease is of extremely frequent occurrence in
children bom in India, and, as I am informed, is very commonly
seen among the natives of Hindostan. Improper food is a
frequent predisposing cause, and one of the common causes in
schools. I have seen it in children fed too exclusively on a
vegetable diet. When the food is improper, exercise neglected,
and ventilation bad, the disease becomes endemic, as we find
to be the case in certain schools, particularly in public academies
and the schools of the poor. It is a disease confined to child-
hood and early youth.
680. Prognosis. — This disease, though often obstinate, is
entirely free from danger, and with judicious treatment may
be perfectly cured.
681. Treatment — The treatment of trichosis offers two indica-
tions : firstly, to correct the deranged nutrition by constitutional
means ; secondly, to excite a new action in the skin by means
of moderately stimulating local remedies.
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420 DISEASES OF THE HAIRS AND HAIR-FOLLICLES.
In effecting the first of these objects, diet, exercise, clothing,
and ventilation, are important and powerfid agents. And their
beneficial influence may be assisted by tonic medicinal remedies,
such as the mineral acids, quinine, steel, vegetable bitters, &c.,
given separately or combined. I have found the syrup of
quinine and steel a valuable medicine in this complaint, and
one which suits the taste of children better than other remedies.
The kind of tonic must, however, be left to the judgment of the
practitioner, and be determined by its effect on the economy.
In directing the local treatment, I have found it useful to
commence with some moderately powerful stimulant, such as
acetum cantharidis, or the stronger acetic acid, which I apply
once to the diseased spots ; and after the tenderness has abated,
anoint the patches daily with some moderately stimulating oint-
ment, such as the unguentum hydrargyri nitratis diluted vrith
ceratum cetacei. Ano^er ointment which I have foimd of great
service, is one composed of a drachm of sulphate of zinc to an
ounce of simple cerate. When an objection exists to ointments,
a lotion of bichloride of mercury or sulphate of zinc will be
found useful, correcting the dryness which follows the employ-
ment of lotions by means of pomatum or cold cream. It is
beneficial to wash the head with soap once a day, and when
dried to anoint it with pomatum. I regard the keeping the
scalp constantly moistened with some oleaginous matter as an
important adjuvant to cure.
The principle of local treatment being, as I have above
stated, moderately stimulant, the remedies applicable to this
disease, with advantage, are very numerous, and an extensive
choice is left to the practitioner ; so that no excuse exists for
using such as are disagreeable in their appearance, odour, or
effects. The preparations of iodine, for example, are open to
objection, on account of the stain which they leave behind, and
they are in no wise more useful in their effects than more
elegant compounds. A remedy which I frequently use in this
disease is liquor ammonise and olive oil, accommodating the
quantity of the alkali to the amount of stimulation which I
desire to effect. This preparation has the advantage of being
cleanly and easily removed by washing; while it clears the
patches more completely than any other that I am acquainted
with. Another elegant, as well as useful application, is a
pomatum of cantharidine, prepared at my request by Mr. Savory,
of Bond-street.
TRIGHOSIS PLICA.
Plica Pohnica,
682. Plica polonica is a disease of the hair, of which little
appears to be known in this country, and scarcely more in the
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TKICH08IS PLICA. PLICA POLONICA. 421
land in which the disease is endemic. The perusal of the
accounts of the disease given by various authors, incline me to
believe that the pathological state of the hair is similar to that
which I have described to exist in trichosis fiirfuracea. That
the hair is in fact in a state oi granular degeneration^ the granules
being turgid with a viscous sanguineous fluid, and probably
larger than those of trichosis furftu*acea. If this belief should
prove to be true, the causes of the disease and its treatment
vrill cease to present any points of real difficulty.
In plica, the scalp is inflamed and excessively tender ; the
hairs are swollen and imperfectly formed ; they are tinged with
a viscous and reddish-coloured fluid, and the hair-foUicles
secrete an abundance of this fluid, which agglutinates the hairs,
and by desiccation unites ihem into a solid mass. The tender-
ness of the scalp in these cases is so excessive, that the bare
touch of a single hair excites pain, and when cut across, the
reddish fluid with which the hairs are surcharged oozes from
the divided extremity. This appearance, together with the
extreme sensibility, has given rise to the supposition of their
being sarcofied, and pervaded vrith vessels and nerves. The
odour arising from a scalp so affected is described as being
exceedingly disgusting; excoriations of considerable extent are
frequently formed, and the matted hair becomes the resort of
countless pediculi. Plica is not confined to the scalp, but
afiects the hair on every region of the body; the nails of the
fingers and toes are also changed, becoming rough, fibrous, and
discoloured. Left to itself, the disease lasts for ten or twelve
months ; the symptoms then subside gradually, the hair returns
to its natural (Uameter, and the filthy mass is pushed by degrees
further and further from the surface, until it falls off* spon-
taneously, or is cut away by scissors.
The hair presents some modifications, in the manner of its
matting, which bear relation to its lengdi. Thus, in males who
wear the hair short, numerous locks are matted separately, con-
stituting the variety known as plica multiformis; at other times,
the matted hair forms a single coil, the plica caudiformis ; or,
again, it may constitute a large and irregular mass without
order in its m$itting, the usual character of the disease in
women.
Plica is accompanied and often preceded by severe febrile
symptoms, with pains in the head, lethargy, &c., and with
troublesome pruritus.
Several authors have asserted, that in the majority of cases
the scalp is not afiected in plica, and that the alteration in the
hair occurs at a certain distance from the integument. This
assertion is incredible, and it seems more reasonable to con-
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422 DISEASES OF THE HAIRS AND HAIR-POLLICLES.
elude, that in the cases adduced in support of this statement,
the disease was advancing towards cure, and consequently that
the morbid mass of hair was removed bj growth from the
sur&ce of the scalp. A recent writer on this subject, Dr.
Bidder,* makes the following remarks: — ^'^ During the past
summer 1 remained for several weeks in a country where plica
polonica is frequent. The disease occurred only in a mild
form. In all the cases which I examined, about twenty in
number, I found the hair, for a distance varying from half an
inch to one inch from the scalp, perfectly natural ; one would
have believed that the disease had been removed from the head
by the growth of the hair. The scalp was perfectly normal,
being neither reddened, swollen, nor increased in sensibility, so
that disease of the hair would appear to be capable of existing
independently of disorder of the scalp in which the matrix is
embedded.
" I also had an opportunity of observing the process of sepa-
ration of the diseased from the sound hair. Two individiuds
presented themselves in whom the morbid mass had fallen by
spontaneous separation — a rare occurrence. Once alive to the
possibility of such a process, I soon discovered, in two cases, a
groove, as though made by a ligature around the cylinder of
the hair, and forming a perfect line of demarcation between the
healthy and diseased portion of the hair. In some hairs the
groove resembled a mere crack, in others it had proceeded so
far that the separation was nearly effected. In other oases I
was unable to discover the line of demarcatioiL^'
683. Causes. — The causes of plica are not well known ; it is
met with in the rich as well as in the poor, but is most pre-
valent in marshy districts, and upon the banks of rivers.
684. Treatment. — ^Little is known with regard to the treat-
ment of plica : it seems generally admitted that no attempt
should be made to cut the hair while in its morbid condition.
VT. DISEASES OF THE HAIR-FOLLICLES.
685. The hair-follicles and hairs are so intimately allied, the
latter being a product of the former, that it is difficult to under-
stand how disease can be present in one without at the same
time involving the other. Practically this difficulty is solved by
the fact, that the follicles may be deranged in their function
without any alteration being manifested in the structure of the
hair. But the reverse of this position is not equally true ; for
in that greater morbid change, which is the cause of alteration
• Mul]er*8 ArchiT., 1840.
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NilBCX>SIS FOLLICULORUM. 433
in the structture of the hair, the follicles suffer to a greater or
less extent Hence, whUe the designation '^diseases of the
hair-follicles'' must be regarded as applying solely to those
organs, ^^ diseases of the hairs" may be supposed to implicate the
follicles also. There is another point upon which some eluci-
dation is required: the term hair-follicle, when considered
pathologically, must be supposed to apply only to the free
portion of that canal, and to include the sebiferous ducts.
686. The diseases of the hair-follicles, which I have thought
worthy of separate consideration, are four in number, namely —
Narcosis foUiculorum,
Stearrhoea foUiculorum,
Inflammatio foUiculorum,
Favus.
NARCOSIS FOLLICULORUM.
687. There is a state of the sCalp which is exceedingly
common, occurring chiefly in women and children, and occa-
sionally in men; a state which I have long recognised as
depenmng on torpid action of the folUcles. In this disorder,
the scalp and hairs are found covered with a yellowish and
dirty-looking powder, composed of an admixture of granular
particles and fiirfuraceous scales. Masses of this granular
substance are coUected at the mouths of the follicles, while
others are threaded Uke beads upon the hairs. By brushing,
the skin may be completely cleansed of this pulverulent sub-
stance, but the granular particles stiU remain threaded on the
hairs, and adherent to them, at the mouths of the foUicles^ If
a hair be withdrawn, its foUicular portion wiU be seen to be
enclosed in a smaU sheath of desiccated epitheUum or sebaceous
substance, which extends almost to its root Moreover, the
root is slender and dry, and the entire hair looks parched and
starved.
The symptoms which denote the existence of this complaint
to the sufferer are the difficulty of cleansing the hair, a moderate
degree of itching, and particularly the falling of the hair, which
comes off in large quantity. The faUing of the hair is easily
explained ; the torpidity of action, which gives rise fo the pro-
duction of a dry sebaceous matter, and a dry and pulverulent
epitheUum foUiculi, extends its influence to the growing hair,
which is deprived of its moisture and of its hold upon the
foUicle, and therefore falls before the slightest force. Another
change depending on the same cause is not imfrequently
observed in this disease — ^namely, greyness of the hair.
688. When the torpor of the folUcles occurs upon the general
surface of the body, it interferes, more or less, with the growth
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424 DISEASES OF THE HAIRS AND HAIR-FOLLICLES.
of the haiiSf and is termed morbus pilaris. In this affection, the
hairs become imprisoned within the follicles by the formation
at the mouth of die latter of a small mass or film of hardened
sebaceous matter ; and as the hairs continue to grow in spite of
this impediment, they are gradually twisted into a spiral coil,
which may be seen at the mouths of the follicles. A number of
little pimply elevations are in this manner produced, each
elevation corresponding with a coiled hair, and if the apex of
the pimples be rubbed off, the twisted hair vrill at once be
exposed. This disorder is most frequently perceived on the
legs and thighs. Turner remarks, that in children it is often
met with on the back. It is attended with itching, and occa-
sionally with acute lancinating pains, comparable to the piercing
of the skin with a sharp needle.
STEARRHCEA FOLLICULORDM.
689. There is another morbid condition of the hair-follicles
which I have had occasion to distinguish ; it is one in which
the epithelial product of the follicle, and particularly the seba-
ceous substance, are altered in their nature, and spread out
upon the skin, so as to form a thin crust, which covers more or
less of the surface of the scalp. This crust presents some
variety in point of colour. It is often yellowish, and resembles
the film which drying-oil leaves after desiccation, and some-
times is greyish and greenish in its hue. Occasionally, this
state of the scalp is associated with narcosis, and then the hair
is dusty and sordid ; but, more frequently, there is no such
appearance.
The symptoms by which the patient discovers the presence
of disease are, itching, frequent, often intense and sometimes
constant, and fall of the hair.
INFLAMMATIO FOLLICDLORUM.
690. Inflammation of the hair-follicles is indicated by an ery-
thematous blush of redness of the skin, dryness, and the produc-
tion of a large quantity of furftiraceous scales. There is, besides,
consideraMe itching, and more or less decadence of the hair.
This condition of the follicles is not unfrequently the forerunner
of the two preceding affections, as, in respect of the latter, the
following case will demonstrate :
691. A naval medical oflicer, while serving in the West Indies
in 1838, suffered from an attack of erythematous patches upon
the crown of the head. They were attended with itching, and
by a copious fiirfuraceous desquamation, the itching being
much increased at night. In 1837, on his return to £nglan<^
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INFLAMMATIO FOLLICULORUM. 425
the disease presented occasional exacerbations, but never at any
time disappeared entirely. In 1838, while on the Pacific coast
of South America, frequently exposed to a tropical sun, and
undergoing considerable fatigue with copious perspirations, the
patches coalesced, and poured out " an unctuous exudation of a
dark reddish colour.^' At this time, also, the loosening and fall
of the hair, which has continued until the present time, was first
noticed. " Previously to my return to England in 1839," this
gentleman observes, " large sebaceous incrustations covered the
crown of the head in patches varying from the size of a sixpence
to a shilling ; the scales became thicker, attended with an ex-
ceedingly disagreeable feeling of heat and itching. They were
in a state of continual decadence and renovation. I had my head
shaved for two or three months, and while the hair remained
short, I was eflfectually relieved from the disease."
As soon as the hair was allowed to grow, the disease returned,
and in 1840, while stationed at the river Plata, he was again
shaved, and continued the practice for four months. In 1841,
whilst in China, he had recourse to shaving for the third time.
*^ During oiu: operations," he remarks, " in the Yeang-tse-keang,
the heat was most intense, the thermometer ranging from 90® to
95^ in the shade. I think the disease, at this time, attained its
greatest pitch of intensity, which I am induced to attribute to
the impaired state of the digestive frmctions, as I was confined
for months exclusively to the ship, and of course debarred all
suitable exercise. The scales at this time assumed a gummy
character, tenacious and soft ; the itching was particularly annoy-
ing, but was somewhat relieved. I passed eighteen months on
the East India station without any alteration in the character of
the complaint"
" During my stay in England in the winter of 1844-45, 1 tried
preparations of the nitrate of silver, iodine, dilute hydrocyanic
acid, and I persevered in the use of the tincture of iodine applied
locally during the voyage to Van Dieman's Land last year with-
out any benefit; and during my return I used most assiduously
the bichloride of mercury, which relieved the itching for a short
time."
^' I am unable to account for the commencement of the disease,
nor was I during its progress sensible that climate produced any
material alteration in its character. Heat and itching were the
usual concomitants, and they were at times so annoying that I
was obliged to apply soap and water frequently during the day,
which always afibrded me temporary relief. Stimulants always
increased the itching.
. " A deceased brotiier was similarly affected, but he never lost
his hair, and I am the only one of my family who has felt its
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426 DISEASES OF THE HAIRS AMD HAIR-FOLLICLES.
decadence although many of my progenitors have lived to a very
old age.*'
^^Notwithstanding the different remedies resorted to, the
disease assumed that inveterate form which you saw when I had
first the pleasure of consulting you in February last. Since I
have been under your treatment, the disease has gradually yielded
to the means you have employed. The patches, alter your
second application, sunk to the level of the surrounding integu-
ments, the squamss have not been reproduced to a hundredth
part the extent that they were before, die few remaining patches
have gradually lost their hardness and redness, and are now
resuming the character of healthy integument I feel that the
hair has been in a slight degree reproduced.**
692. Treatment. — The treatment of the three preceding forms
of disease consists in the emplojrment of moderately stimu-
lant remedies locally ; and for the most part tonic medicines
constitutionally. Of course, the common indications of disorder
of stomach, kidneys, or uterine function will not be passed over.
In the case of the naval surgeon reported above, (§ 691,) I found
it necessary to modify the action of the skin by blistering the sur-
face occasionally with the acetum cantharidis, and afterwards
employing the cantharidine pomatum. Indeed the latter prepa-
ration I find invaluable in this class of diseases. It should be
sufficiently strong to keep up a moderate action in the skin.
Another exceUent remedy is die emulsion of ammonia and olive
oil. In some instances a stimulating lotion may be preferred
to oleaginous remedies, but in this case the skin must be kept
moistened with cold cream or some simple pomatum.
FAVUS.
SjD. Kerion, Porrigo; Willan. Tinea maligna, Teignefatfeuae; Alibert
Porrigophjfte. Gruby.
693. Favus (Plate 8) is a chronic inflammation of the hair-
follicles associated with the production of a peculiar yellow sub-
stance which surrounds the cylinder of the hair, and is seen
through the epiderma as a minute circular spot, not raised above
the level of the skin. The yellow substance, after a short period,
escapes from the follicles upon the surface of the epiderma, and
desiccates into yeUow friable crusts, forming a distinct cup with
an inverted border, around the base of each hair. When a
number of these cups are aggregated together, they give rise to
an appearance somewhat resembling the cells of a honeycomb ;
hence the generic designation of this disease— ;/ari«. WTien the
disorder declines, the affected skin is left bald and smooth, but
if it continue unchecked, it gives rise to morbid alteration of all
the textures, down to the bones of the cranium, and is prolonged
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FAYUS OISPERSU8. 427
to an indefinite period. The ordinary seat of &yu8 is the scalp,
but it may extend thence to the face and neck, and, indeed, to
the entire body. The disease is contagious, and is communica-
ble by contact to any part of the skin. '
Favus presents two principal varieties bearing relation to
the mode of distribution of the disease among the follicles : in
one of these, individual follicles, dispersed at various distances,
are affected, favus dispersus; while in the other, a number of
contiguousfoUicles, forming a patch of moderate size and rounded
form, are diseased, the latter constituting the favus confertus.
FAVUS DISPERSUS.
Syn. Porrigo lupmota,
694. The occurrence of favus dispersus (Plate 8, r.) is first
indicated by the appearance of minute isolated points of a yellow
colour, around the cylinders of the hair, dispersed in various
situations on the scalp. These yellow points increase in size and
number, they are surrounded by redness of the integument, and
accompanied by considerable pruritus. The yellow substance
contained within the hair-follicles shortly escapes, and desiccates
into small, cup-shaped crusts, of a bright yellow colour, porous
and friable in texture, and having inverted borders. The crusts
increasing in size, frequently attain the diameter of several lines,
and acre closely adherent to the skin. When exposed for some
time to the action of the air, the crusts lose their yellow colour,
and become whitish ; they also become more brittle than at first,
and easily break. If left to themselves, they remain adherent to
the surface for months, and even years ; and fresh accumulations
from the hair-follicles go on producing additional crusts, until
the entire scalp becomes covered by one dense and uniform
crust But the crusts rarely reach the extent here described,
they soon give rise to considerable inflammation of the skin and
intense itching, and are torn or rubbed off in the efforts made by
the patient to relieve himself by scratching. Those parts of the
scalp which are free from favus, are also inflamed to a trifling
extent, and are covered by desquamated epiderma.
When the crusts collect to any considerable extent, the chronic
inflammation of the integument which is set up will continue
until the whole of the tissues of the scalp, down to the bones of
the cranium, are involved in the morbid action. The odour*
which emanates from the diseased mass is excessively digusting,
and unless attention be paid to cleanliness, pediculi are engen-
dered in vast numbers, and add still more to the irritation.
When the crusts in this latter case are removed, the surface of
* Alibert compares it to the urine of cats.
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428 DISEASES OF THE HAIRS AND HAIR-FOLLICLES.
the scalp will be found covered by ulcerations of yarious depth,
which pour out a quantity of red and foetid fluid. This fluid
desiccates into brownish irregular scabs, wholly dissimilar to
those produced by the yellow matter from the hair-foUicles.
The consequences of the morbid action here described are not
limited to the textures involved in the disease; subcutaneous
abscesses are frequently formed in various situations, and the
occipital and cervical glands not unfrequendy become congested
and enlarged.
When the resolution of the disease of the scalp is eflfected,
the scalp is left smooth, shining, uneven, and deprived of hair,
and the integument is much thinner than heretofore. It frequently
happens, that upon these bald spots the hair never again returns,
or if it be reproduced, it is thin and woolly, and altered in its
colour. In course of time, the hair regains more or less of its
natural appearance, and the scalp is restored to its wonted
thickness.
FAVUS CONFERTUS.
Sjn. Porrigo scutukUa conferta.
695. Favus confertus (Plate 8, s.) is distinguished from tiie
preceding by the appearance of the disease in the form of circular
disks and rings. It commences by erythematous patches of a
circular form, and attended with considerable itching ; upon these
patches the minute yellow spots characteristic of the disorder
are soon perceived in considerable numbers, and afiecting the
whole of the hairs included within their ares. The crust which
results from the escape of the yellow substance, from so large a
number of follicles, is irregular on its surface, of a greyish yellow,
in place of the bright yellow tint of the discreet variety, and
corresponds in extent with the area of the patch. The disks
increase in size by the extension of the morbid action to the fol-
licles situated immediately around their circumference, and in
this way they attain considerable size. When it happens, as is
usually the case, that several patches are developed in the first
instance, they meet each other in their circular grov?th, and the
scalp presents one extensive and irregular crust, bounded at its
circumference by an outiine formed of numerous curves, which
represent so many segments of circles of larger or smaller di-
ameter. The same remarkable appearance, traced in red lines,
is perceived on the surfeu^e of the scalp, when the crust is removed.
The crust in some instances becomes so extensive, as to cover
the entire scalp, and the hair is destroyed over the whole of this
surface, with the exception of a narrow margin around the cir-
cumference, so that the head, under such circumstances, presents
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FAVU8 C0NFERTU8. 429
a thick, incrusted case, bounded on all sides by a thin fringe of
hair.
When the crust is remoTcd the surface of the skin is red and
tumid, and numerous yellow points prove that the disease is not
yet extinct. Examination of the scalp also shows, that while
the circle of the original patches extends by its circumference,
the centre is almost deprived of hair, and the characteristic
yellow spots may yet be observed around the few remnants
that are left
696. Pathology. — The yellow substance which constitutes
the crusts of favus has been stated by recent investigators, to
be an organic growth of simple structure, and bearing a marked
resemblance to those inferior members of the yegetable kingdom,
denominated mould. The structure of these crusts appears
first to have attracted the attention of Remak, who had observed,
so early as 1836, their composition of "fungoid filaments.''
Professor Schoenlein, of Zurich, next brought tJbem into notice
in a paper in Mulleins Archiv. for 1839, on the Pathology of
the Impetigines, in which he makes no doubt of the fungous
nature of the substance, and he illustrates his communication by
a rude figure of the appearance which they presented in his
observations. In piursuance of Schoenlein's researches, they
were examined by Fuchs and Langenbeck, of Gottingen ; more
recendy they have been studied by Dr. Gruby, of Vienna, who
expresses himself to have been ignorant of the labours of Schoen-
lein. Dr. Gruby has, moreover, given a clear and lucid de-
scription of the growth, which he regards as a parasitic plant,
belonging to the genus mycodermis. The following is an ab-
stract of a paper from the pen of Dr. Gruby, on this subject,
in MtiUer's Archiv. for 1842.
" The cup-shaped crust of favus is situated upon a depression
of the derma, and is covered by a sheath of epiderma, which is
thickest on its concave, and diinnest on its convex surfstce.
Immediately within the epiderma is a thin layer of amorphous
substance, composed of minute molecules; this layer is aense,
of a sulphur-yellow colour, and forms a capsule, which is in
contact by its external surface with the epiderma, and by its
internal surface with a fungous growth. The parasitic growth
is attached by means of its roots to the yellow capsule, while its
stem and branches extend inwards towards the centre of the
capsule, and constitute the whitish-grey and porous contents of
the crust. The roots and branches of the mycoderm are smooth,
cylindrical, transparent tubuli, which divide dichotomously
from point to point The interior of the tubuli is filled with a
granular substance, and divided here and there by transverse
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430 DISEASES OF THE HAIRS AND HAIR-FOLLICLES.
septa. At the ends of the branches are situated the seeds of
the plant, which are of a yellowish- white colour, and either col-
lected into an irregular assemblage, or disposed in the form of
a garland. The diameter of the branches of the mjcodermis
IS Tinnr ^ t^ of a millimetre ; that of the molecules contained
within the tubuli, Tiroinr to y^ mm.; and that of the seeds,
shr to T^ T^^' ^^' ^niby has detected seeds in the follicles
of the hair, and impacted in the ducts of the sebiparous glands.^'
To ascertain the degree of contagious power of the mjcoder-
mis. Dr. Oruby inoculated various mammiferous animals, birds,
reptiles, and insects, but unsuccessfully ; he was equally unsuc-
cessful in his own person, but succeeded, after seventy-six
attempts, in reproducing the mycodermis in a cryptogamic
plant
Mr. Busk, in a paper entitled " Observations on Parasitical
Growths on Living Animals,'' in the Microscopic Journal, (No.
10,) has given a figure of the mycodermis. He represents the
branches as consisting of a series of oblong cells connected by
their extremities.
However closely the fungous growth here described may
resemble a plant, its vegetable nature is very fax from being
established. The simplest forms of animals are composed,
like the mycodermis, of cells, variously connected together; and
subsequent research may prove the growth under consideration
to be of a similar nature. To my mind there is nothing im-
probable in the supposition of the origin of tjie growth from
morbidly developed epidermal cells of the hair-folUde, or from
those of the sebaceous substance. In a preceding section of
this work, I have shown that the latter are susceptible of con-
siderable alteration, and that in this state they assume an
appearance widely different from that of their normal condition.
Mr. Busk also entertains doubts with regard to the vegetable
nature of the mycodermis, and deduces an opinion favourable
to his opinion, from the chemical analysis of die crusts of fetvos
given by Thenard, who found them composed of
Albiiiiien . . 70
Gelttine. . . 17
Phosphate of lime 5
Water and loss . S
100
Dr. Carpenter, in his " Principles of Physiology," (p. 458,)
speaking on the same subject, remarks — "It has been assumed
that the organization is vegetable, because it (mycodermis)
consists of a mass of cells capable of extending themselves by
the ordinary process of multiplication. But it must be remem*
bered that the vesicular organization is common to animals, as
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DIAGNOSIS OF FAVUS. 431
well as to plants, being the only fonn that manifests itself at
an early period of development in either kingdom, and remain-
ing throughout life in those parts which have not undergone a
metamorphosis for special purposes. Hence, to speak of por-
rigo favosa^ or any similar disease, as produced by the growth
of a vegetable widiin the animal body, appears to the author a
very arbitrary assumption ; the simple fact being, in regard to
this and many other structures of a low type, that they present
the simplest or most general kind of organization/'
697. Diagnosis. — The especial characters of favus — namely, on
the one hand, cup-shaped crusts of a bright yellow colour, and
dispersed; and on the other, circular crusts of a greyish-yellow,
surmounting disks bounded by newly-affected follicles in the
circumference, are signs by winch this disease may be immedi-
ately distinguished from all other disorders affecting the scalp.
When impetigo figurata is seated upon the head, it presents
to a superficial examination some of the characters of favus, but
a remarkable difference is discovered as soon as the appearances
are investigated. The eruptions of impetigo are true pustules ;
they are large as compared with the minute yeUow spots of
favus, are slightly raised above the surface, are situated upon an
inflamed integument, form crusts of great thickness, thinner
towards the edges, and of a yellowish-brown colour ; the exco-
riated surfetoes pour out an abundant secretion, which desiccates
into fresh crusts whenever the first are removed ; the hair-follicles
are unaffected, and the disease is not contagious. If, now, we
compare these characters with those of favus, we shall find
that the yellow points of the latter are not pustules, that the
viscous and semifluid substance which the hair-follicles contain
is not pus, that the yellow points never rise above the level of
the epiderma, that the inflammation of the adjoining skin is
very trifling, that the crusts are not thick, that they are thinner
in the centre than at the circumference, that they are of a bright
yellow, or greyish-yellow colour, that no secondary secretion
accompanies their fall, that the hair-follicles are the essential
seat of the disease, that the hairs are consequently destroyed,
and that the disease is highly contagious^
When favus occurs upon the surface of the body, unless it
have originated by direct contact, it will always be found asso-
ciated with a similar affection of the scalp. The same characters
which distinguish it in the latter situation, are also applicable
to its development in other parts.
Herpes circinnatus and lepra are so different in their nature
from &VUS, and present so few points of resemblance to that
disease, as to render a mistake between them almost impossible.
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432 DISEASES OF THE HAIRS AND HAIR-FOLLICLES.
698. Causes. — The cause of favus is a special contagion,
consisting, if the vegetable theory be correct, in the transmission
of the cells or germs of the mycodermis, by the winds or by
actual contact, to the hair-follicles of a sound person. The
disease is most easily excited in a weakly and unhealthy state
of the system, and particularly in children of a scrofulous
diathesis. When once established, it is highly contagious ; it
affects persons of all ages, of both sexes, and at all seasons of
the year, but is usually met with in children and young persons.
Various circumstances predispose to this affection — namely,
improper or deficient diet, want of ventilation, humid atmo-
sphere, confined and unhealthy localities, &c. When any one of
these causes is present in assemblies of children, as in public
schools, the disease spreads with extreme rapidity, attacking
the most delicate first, and then extending to the rest. The
most frequent mode of transmission is by the employment of
towels, combs, brushes, or by the use of hats or caps belonging
to affected persons. It has been observed, that children, who
have been for some time the subjects of favus, are frequently
stunted in growth, and inferior in power of intellect.
699. Prognosis. — Favus may sometimes get well spontaneously;
more frequently, however, if left to itself, it will last for years,
and give rise to the most disastrous consequences.
700. Treatment — The indications to be fulfilled in the treat-
ment of favus are four in number — namely, 1. To destroy the
vitality of the parasitic growth ; 2. To remove all local causes of
irritation ; 3. To remove all general sources of irritation ; 4. To
excite the diseased hair-follicles to healthy action, and prevent
the reproduction of the mycodermis.
1. The first indication is best fulfilled by impregnating the
crusts, and bathing the scalp with a moderately strong solution
of bichloride of mercury. This precaution, moreover, prevents
the extension of the disease through the medium of fragments
of the crusts,
2. The next care should be directed to the removal of all
local causes of irritation, among which the hair and crusts
occupy the first place. The removal of the hair may be
effected either by shaving, or with the scissors; but as the
former is sometimes an inconvenient and a painful process, the
latter may generally be preferred, and the more particularly, as
it is equally efiicacious. The scalp should then be thoroughly
washed with a plentiful supply of soap, and the crusts removed;
this is best effected by means of a local vapour-bath, applied
through the medium of a caoutchouc cap. Another mode
which may be put in practice when the vapour apparatus is not
at hand, is to lay a piece of folded lint wetted in a solution of
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TREATMENT OP FAVUS. 438
snbcafbonate of soda or potash upon the head, and cover it
with an oiled sUk or caoutchouc cap, which shoiQd include the
entire scalp. By means of this simple contrivance, the surface
is freed completely of its crusts in the course of twelve hours.
Another mode of effecting the same object I mention only to
condemn ; I allude to the clumsy practice of enveloping the
head in a poultice. When the crusts are wholly removed, the
scalp should be thoroughly washed night and morning with an
abundance of soap, and tiben carefully combed, the object of
the former process being to free the skin of any fresh favous
matter that may escape from the follicles, and of the latter, to
remove the hairs which have been loosened by the disease, and
which are now acting as excitants of increased irritation. In
the interim of the ablutions, it is desirable to keep the scalp
cool by means of evaporating lotions, so long as any heat of
surface or redness remain.
3. The third indication calls for a carefril examination into
the. state of health and constitution of the patient, and the
employment of remedies fitted to remove any symptoms of
disorder which may be present there. In certain cases,
laxatives, alteratives, or tonics, may be necessary to the perfect
cure of the disease. In cases where cerebral congestion is
apparent, I am in the habit of applying blisters behind the
ears, or inserting a seton into the nape of the neck.
4. The definition which I have given above of the fourth
indication — namely, that its object is '' to excite the disordered
follicles to healthy action," will at once suggest to the mind of
the practitioner various remedies, from among the class of
stimulants, which may be suited to the treatment of this disease,
while it will also serve to explain the meaning of the long
catalogue of therapeutic agents which have been vaunted from
time to time as specific cures, as well as the endless list of
nostrums recommended by empirics. The medicine which I
have found to be most valuable in favus, is iodine, either in the
form of vapour, and used twice in the day, or tincture of iodine
brushed upon the scalp three times a day, in the morning and
evening after each ablution. In the majority of cases, I have
succeeded in curing the disease by this plan. Next to iodine,
I prefer a spirituous solution of bichloride of mercury pencilled
on the patches. With this fluid, I have frequently succeeded in
checking the disease at once. On the trunk or limbs, the
solution of the bichloride of mercury, or of the nitrate of silver,
are very successful.
Other remedies which 1 have from time to time tried, or
have been recommended by practitioners, are, the ioduret of
F F
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434 DISEASES OF THE HAIRS AND HAIR-FOLLICLES.
sulphur,* in the fonn of ointment ; subnitrate of bismuth oint-
ment; chloruret of lime; sulphuret of potash, either alone or
combined with lime water; solutions of sulphate of idno and
copper; lotions of hydrocyanic, acetic, muriatic, and nitric
acid ; vapour of sulphur ; aoetum cantharidis ; tar ointment ;
spirit of turpentine; rue; hellebore; black pepper; staves-
acre, &c.
The celebrated treatment of the brothers Mahon is based
solely on the strict observance of the second and fourth indica-
tions above proposed. They, in the first instance, cut the hair
to the length of two inches, apply poultices to sofiten, and
thorough washing with soap to remove the crusts, and then
comb die hair repeatedly, in order to draw out aU the loosened
hairs. Buch, indeed, is their estimation of the importance of
this process, that they either perform it themselves, or see
it done with their own eyes. And, in many cases, there can
be no doubt that the continuance of these measures, with-
out any other therapeutic aid, would be sufficient for the
perfect cure of the disease. After this preparatory process is
accomplished, they rub daily into the scalp, for about a
fortnight, a strong stimulating application, under the name of a
depilatory ointment, and continue the washing and combing as
before. For the next three or four weeks, and until ^e cure is
established, this treatment is pursued with longer and longer
intervals, no day being permitted to pass over without a
thorough ablution. By the employment of such means, these
gentlemen have reaped extraordmary success, curing many
eases which had previously resisted every possible mode of
treatment, (saving, I opine, the rational one of cleanliness.)
Thus, from the year 1807 to 1813, nearly one thousand persons
were treated in this manner with success, the mean duration of
treatment being fifty-five days.
The Messrs. Mahon make a secret of their stimulating appli-
cation, their ^^wmimade eptkUoire^ as they call it, forcibly
reminding us of the old nurse of St. Pancras and Sir Astley
Cooper's mbseripiion. (§ 374.) But, fortunately, they cannot
deprive us of the power of reflecting on the sense and modus
operandi of their plan. Dr. Willis, the able translator of
Rayer, has the following judicious remariL on the treatment of
favus : — ** Any plan which combines the removal of the hair by
gentle means — ^that is to say, after it is already loosened from
the roots, with undeviating attention to cleanliness for about
two months, will be found generally to cure favus. I have seen
more than one case of this disease get well by the regular use of
* Recommended by Biett, 9lj- to 38s. to the ^j.
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TREATMENT OF FAVUS. 435
simple soap and Watdr, Ivith the elilplojrment of a small-toothed
comby nig^t and mornings for a month or six weehs. Patience^
perseTeranoe, and oleanliness^ are the sheet-anchors in all the
snocessfiil plans of treating this obstinate disease^ as they are
eyidently in that pursued by Messrs. MiAon.^
701« I shall here subjoin several formulae for the preparation
of depilatory unguents and powders, in order that my readers .
may judge of their probable effeets. It will, I think, at once be
adi^tted, that these substances can hare no power of descending
into the follicles, and destroying the hair in that situation, and
that consequently their title is at least a misnomer. They can
do little more than the razor to sound hair, and on the already
loosened and &lling hair of favus they can produce no useful
effeeti In truth, as I haye abore asserted, they can act merely
as stimulating applications to the skin, and are consequently
fitted to fiilfil die third indication of treatment above men-
tioned.
Depilatoiy oinimaU (Rayer).
Ok
Slaked lime, 5g.
Subcarbonate of soda, ^iij.
Hog's-lard, |ij.
M«
DepUaiory powder (Rayer).
Lime, |j.
Subcarbonate of potash, |ij.
Charcoal, in powder, 3 j.
M,
Depilatory powder (Plenck).
Ok
Lime, ^iss.
Solphnret of arsenic, 3J.
Starch, zz.
M.
702. The treatment recommended by Plumbe is too excellent
to be passed over without remark. Mr. Plumbe was firmly im-
pressed with the opinion of the older dermatologists, that the
hairs acted as sources of irritation to the inflamed follicles, and
were the principal agents in keeping up the disease. Hence, his
first attention was directed to the removal, with forceps, of all
the loosened hairs ; in the second place, he endeavourea to press
out of the follicles as much of the favous matter as he was able,
and washed it away; he then rubbed some finely-powdered
sulphate of copper into the scalp, and removed the excess with
water. The sidphate of copper he employed, with the double
motive of decomposing the infectious principle of the yellow
matter, and of lessening its quantity by constringing the vessels
" firom which it flows.** This plan, repeated a few times, he found
FF 2
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436 DISEASES OF THE HAIRS AND HAIR-FOLLICLES.
suooessiul in arresting the disease, and effecting a cure. The
desquamation of the affected parts of the scalp, and their redness,
passed away in a short space of time, and the hair began to
reappear in one, two, or three months. When the diseased scalp
was covered with crusts and concreted secretions, he commenced
his treatment with poultices and fomentations, and when the
skin was thickened and inflamed, he recommended cold bathing
and strapping with adhesiye plaster.
M. Devergie* has recently employed at St. Louis a solution
of nitrate of mercury in nitric acid, which he applies by means
of a camers-hair pencil. The crusts speedily become reddish-
yellow in colour, and fall at the end of five days, leaving the
scalp sound. Caustic solution of iodine he found equally suc-
cessful in two cases. The disease exhibited no disposition to
return after either mode of treatment
* Bulletin G^n^nde de Therapentiqae, Oct 1841.
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CHAPTER XVII.
SYPHILITIC ERUPTIONS.
703. Under the influence of constitutional syphilis, eruptions
ore developed on the skin, which may assume any one of the
elementary forms of inflammation of the derma, and of its glands
and follicles, which are characteristic of disease of this tissue.
Thus, of the group of congestive inflammations there is not un-
frequently met with a syphilitic roseola, syphilitic erythema,
and, occasionally, a syphilitic urticaria. Appertaining to the
group of efiusive inflammations is an eruption of vesicles, con-
stituting vesicular syphilis. Suppurative inflammation of the
derma ofiers several forms of pustular syphilis ; papular inflam*
mation of the derma, syphilitic papules and tubercles ; and
squamous inflammation of the derma, syphilitic lepra, and
psoriasis. Besides the preceding disorders, which have their
especial seat in the tissues of the derma, the sebiparous glands
with their efierent hair-follicles, become the subjects of syphilitio
acne, and the hair-follicles of that alteration which gives rise to
syphilitic alopecia.
704. Syphilitic cutaneous eruptions are sometimes developed
concurrendy with the primary signs, but more frequently are of
secondary origin, being associated vnth one or more of those
symptoms which are indicative of secondary syphilis, and occur-
ring after the lapse of a variable period of time, frequently of
several weeks, and even of months. For the most part they are
chronic in their character and progress, but, in some few
instances, are attended with symptoms of acute inflammation,
particularly when they belong to the congestive group, or are
produced simultaneously with the primary syphilitic affection.
Syphilitic cutaneous eruptions are developed most frequently
on Uiose parts of the body which are exposed to the influence of
the atmosphere, and in which the capillary circulation is conse-
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438 SYPHILITIC ERUPTIONS.
quently most active. Hence we find them oflten on the face, the
forehead, the neck, the wrists, and hands; and, next in frequency,
on the trunk of the body and extremities.
705. There are certain signs which distinguish syphilitic erup-
tions from all others, and may be regarded as pathognomonic ;
these are, a dulness and coppery hue in the tint of redness, or a
lividity in the colour of the patches ; a brownish or greenish stain
left upon the skin after their decline ; an earthy hue of the skin ;
sometimes a disagreeable odour of the perspiration ; and a circu-
larity in the form of the patch. These signs, conjoined with
their usual seat on the face and trunk, and especially their asso-
ciation with other symptoms of secondary syphilis, such as ulce-
ration, or thickening of the mucous membrane of the throat, iritis,
or periostitis, are sufficient to establish a correct diagnosis of
their nature. The crusts which succeed to the pustular forms of
syphilis are remarkable for their greenish or blackish hue, their
thickness and density. And the scales of the squamous affec-
tions are characterized by thinness, and by their dull and greyish
tint.
SYPHILITIC URTICARIA.
706. This eruption is a rare form of syphilitic cutaneous dis-
order, which bears some resemblance to urticaria, but is dis-
tinguished from the ordinary forms of that exanthem by the
padiognomonic characters of syphilitic disease. Alibert describes
syphilitic urticaria under the name of ^^syphilide pustaileuse
ortiee."*
SYPHILITIC ROSEOLA.
MacuUe sypMitic<B,
707. Syphilitic roseola is the most common form of congestive
syphilitic eruption. It resembles, in general characters, common
roseola, makes its appearance under an acute type, but soon
passes into the chronic form. This eruption is usually met with
in association with gonorrhoea, occasioncdly it occurs with primary
sores, and sometimes with secondary syphilis. It is developed
on the limbs and trunk, as well as on the hxie and forehead,
under the form of small, irregular, and rounded spots, of a cop-
pery red colour, which disappear incompletely under pressure
with the finger ; they are attended with more or less itching,
occur usually in considerable numbers, and are sometimes con-
fluent The spots make their appearance very suddenly, often
in the course of a single night ; they remain for a few days at
their height, and then fade gradually away, being followed by
* This is one of the many instances of the loose af^lication of the term pmtiilar,
which have been corrected b j WiUm 994 ^ d)«qp'^
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SYPHILITIC ROSBOLA. SYPHILITIC RUPIA. 439
slight desquamalioiiy and leaving behind them a greyish or livid
stain, which lasts for several months^
This affection is distinguished firom ordinary roseola by the
dulness and coppery hue of its patches, by the permanence of
the stains which succeed, and by the absence of febrile symptoms.
Moreover, the diagnosis is greatly assisted by the presence of
gonorrhoea or syphilis, either in the primary or secondary form.
There is some danger, at a cursory glance, of mistaking syphililio
spots for ephelis, but a more careful inspection wUl at once
d^et us to a ccNrrect diagnosis of the two diseases. In ephelis,
the patches are irregular in their form, large, disposed to com-
municate with each other, and occupy chiefly the front of the
chest and abdomen. Moreover, they are yellow in colour,
attended by considerable itching, and covered by desquamating
epiderma. The syphilitic spots, on the contrary, are rounded,
small, few in number, and frequently situated solely on the face
and forehead. The eoppery red or grey colour, again, the lesser
degree of itching, and the absence of desquamation, are patho^
gnomonic of syphilitic maculae.
VESICULAR SYPHILIS.
708. Bupia is not unfrequently met with as an accompani-
ment of secondary syphilis, and particularly when the disease
haa been of long duration, or when the eonatitntion is enfeebled
by the abuse of mercury, or by hygienic causes. Other forms of
vesicolaar disease consecutive on syphilis are rare. Gibert
remarks that he once saw an instance of pemphigoid syphilitic
eruption, and Biett haa recorded an excellent case in illustration
of syphilitic eczema.
Syphilitic rupia i^proaches in characters somewhat to rupia
prominens, but is distinguished from that affection by the copper-
coloured hue of the areola, the thick, greenish crusts formed on
the desiccation of the bulla, and the deep excavation, with per-
pendicular borders, and grey surfetee of the ulcer.
709. The vericles of cutaneous syphilis sometimes assume the
ordinary characters of herpes, at others those of eczema. They
appear for the most part in successive eruptions, and are distri^
bated irregularly upon all parts of the surface of the skin, being
surrounded by a disk of rednesa which presents the customary
copper-coloured hue of syphilitic cutaneous disease. After the
lapse of a few days, the fluid contained in some of the vesicles is
absorbed, while others burst, and form a thin and brownish
scale, which remains adherent for some time. The spots occu-
pied by the vesicles are marked on their decline by a discoloured
stain, resembling that which succeeds to odier syjdiilitic erup-
tions.
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440 SYPHILITIC ERUPTIONS.
Vesicular syphilis is generally preceded or accompanied by
ulceration of the mucous membrane of the fauces and pharynx,
and by other symptoms of constitutional disorder.
PUSTULAR SYPHILIS.
710. An eruption of pustules is not an unfrequent form of
secondary syphilis. The general characters of this eruption are,
its development at a variable period after the primary affection ;
its association with other indications of syphilitic disease; its
appearance under the form of pustules raised upon a hardened
base (tubercular pustules) ; or surrounded by an inflamed areola
(ecthymatous pustules) ; and the termination of the eruption,
either in a discoloured stain, a cicatrix, or an ulcer.
Pustular syphilis presents two principal varieties, the psydra-
cious or tubercular pustule, and the phlyzacious or ectiiymatous
pustule. But between these varieties there are numerous inter-
mediate degrees, both in respect of the severity of the eruption,
and of the modifications arising out of the particular state of
constitution of the patient.
(a.) Tubercular Pustules.
711. Tubercular pustules bear a marked similarity to acne,
being developed upon hardened bases, appearing frequently on
the face and forehead, and in their nuldest form being unaccom-
panied by surrounding inflammation. They are tardy in their
course, present tiie ordinary colour of syphilitic eruptions, and
appear in successive crops ; so that, at tiie same visit, they may
be seen at every stage of their progress to maturity. When tiiey
burst, the matter which they contain concretes and desiccates
into a thin, yellowish-brown, and very adherent crust, which
leaves at its fall a discoloured stain, and a small white and
circular cicatrix, with a pitted centre.
712. In a more severe form of this tubercular pustule, the
base is of larger size and more inflamed, and the pustule, at its
apex, contains a greater quantity of pus. The scabs which suc-
ceed are consequentiy of larger size, and of a dark brown and
blackish hue. In a patient, lately under treatment in the Middle-
sex Hospital, under tiie care of Mr. Amott, the crusts resulting
from tiiis form of pustular syphilis were tiiick and very adherent,
and of a dark-brown colour, approaching to black. They were
scattered over the entire face, and gave to the man's aspect a
singularly disagreeable character.
(b.) Ecthymatous Pustules,
713. Instead of the conical and tubercular base of tiie pre-
ceding variety, syphilitic pustules sometimes put on the charac-
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PUSTULAR SYPHILIS. SYPHILITIC ECTHYMA. 441
ters of ecthyma. The pustules are of larger size^ they are
flattened upon the surface, and sometimes even depressed ; they
are scarcely raised above the level of the surrounding skin ; they
contain a variable quantity of a whitish-yellow pus ; they have a
hard and inflamed base, are scattered over the 8ur£EU)e of the
entire body, but are most numerously developed on the face and
trunk. On the rupture and desiccation of the pustule, they
become covered by a thin, yellowish-brown crust, and leave
behind them a small cicatrix in the centre of a livid patch of a
coppery hue. Sometimes several of the pustules are confluent :
the crust which results is exceedingly thick and adherent, and
at its fall is frequently succeeded by an ulcer of considerable
extent.
714. The most common form of pustular syphilis (ecthyma
syphiliticum) is constituted by pustules, which are larger than
those of the preceding variety ; ihey are few in number, and dis-
preet, and in these latter characters approach still more closely
in resemblance to ecthyma. They are developed, without pain
or inflammation, chiefly on the limbs, and particularly on the
lower extremities. They make their appearance, with very
trifling pain, in the form of a livid-coloured spot, of about the
size of a sixpence. Upon this spot, in the course of a few days,
the epiderma is raised, by the efiUsion beneath it of a dusky
purulent fluid, and the pustule is surrounded by a large copper-
coloured and purplish areola. When the pustule bursts, its
contents desiccate into a hard, round, and blackish crust, bounded
by a circular groove. The crust is very closely adherent, re-
maining for a considerable length of time, and leaving at its
fsdl a deep, circular ulcer, with hard, livid edges, and a greyish
unhealthy surface, upon which a second crust speedily forms.
The ulcer has no disposition to enlarge, and when it heals, is
followed by a round and permanent cicatrix.
It is this form of pustule which is most frequently observed
in infants labouring under syphilitic disease. The pustules are
large, oval, flat, and superficial ; they are more or less nume-
rous, and are followed by blackish crusts, which leave unhealthy
ulcerations at their fall.
Syphilitic ecthyma is distinguished firom the common form of
that pustular afiection, by its thick, black, and adherent crusts ;
the boundary groove which encircles them ; the deep and exca-
vated circular ulcers by which they are succeeded; and the
depressed cicatrix left by the latter. The bright, purplish-red
areola of common ecthyma, again, is widely difierent from the
dull, coppery purple of the syphilitic variety.
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442 SYPHILITIC ERI7FTION8.
PAPULAR AND TUBERCULAR SYPHILIS.
715. Tbe papular eruption (Platk 5> c*) which sometkneg
accompanies or succeeds to syphilis, presents the general cha-
racters of lichen. It consists of small, hard, slightly prominent,
conical pimples, having a coppery hue, and surrounded here
and there by a purplish areola. They terminate for the most
part by resolution and desquamation ; in some few instances
the pimples ulcerate at the points, and become covered by thin,
brownish scales. The ulcerations are very rarely so extensive
as to give rise to the formation of cicatrices. Syphilitic lichen
presents itself in an acute and a chronic form.
In the acute form^ syphilitic lichen is the occasional conco*
mitant of gonorrhcea, and when it accompanies syphilis, is
usually a primary affection. The papule are exceedingly
numerous, covering the entire body, but especially the face, and
appearing almost simultaneously. They terminate, in a £bw days,
in resolution and desquamation, some few of the pimples occa*
sionaUy ulcerating superfi<»ally. Sj^hilitic lichen is attended
with considerable itching, but rarely with symptoms of constitn«*
tional disturbance ; when these occur, they are limited to s^e
degree of headache and feverishness, and disappear very speedily,
generally witii the primary symptoms which they accompany.
In the chronic variety of syphilitic lichen, the pimples are as
large as the diameter of a small pea ; they are flat, but little
raised above the surface, indolent, of a coppery hue, but without
any areola. They are frequently clustered togetiier in consider-
able numbers, but are unaccompanied by itching or other
sjrmptoms, local or generals They are exceedingly tardy i»
their progress, commendng in the first instance by small
yellawish spots, which gradually rise to the elevation of pimples,
and then subside, after an uncertain duration, with equal slow-
ness. When they have attained their complete development,
they become surmounted by small thin scales, which are quickly
reproduced as frequentiy as tiiey &11, or are rubbed off. These
papulae are developed chiefly upon the limbs, and sometimes
upon the forehead and scalp. They not unfrequently acooaq>«ay:
other syphilitic eruptions, particularly tiie pcmtular form.
The peculiar coppery hue of syphilitic lichen, and its general
distribution over the surfsu^e of the body, serve to distinguish it
from the non-s}rphi]itic form, which is nsually successive in its
eruption, and limited to a single region.
SYPHILITIC TURERCLES.
716. When papulae assume a large size, they are termed
tubercles; and tiiis form of syphilitic cutaneous disease is the
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SYPHILITIC LICHEN. STPHILITIO TUBERCLES. 44S
most Sequent of all the affections whidh aocompany the
secondaiT disorder. The syphilitic tubercles present certain
points of resemblance in their general characters— yiz., their
livid and coppery discoloration, their slow and indolent
course, and their occurrence, as a common seat, upon the face,
particularly on the forehead and nose ; but they also exhibit
considerable differences in relation to their size, their number,
their form, their arrangement, their progress, and their termi*
nation, which constitute so many varieties of the affection.
717. Thus in one variety* the tubercles are small, never
exceeding the bulk of a pea ; they are numerous, disposed in
the form of circular rings, flattened and surmounted by a small,
thin scale. Their usual seat is the forehead, the scalp, and
neck, and they leave behind them, on their decline, a livid red
stain.
When the small tubercles composing these circles are covered
v?ith scales, the affection bears some resemblance to a lepra
which has healed in the eentxe. But the distinction between
the two diseases is marked by the individuality and thinness of
the scales in comparison with those of lepra, their evident
connexion with distinct tubercles, and the syphilitic tint which
invests the latter.
718. In a second variety the tubercles are larger, arranged in
groups, or dispersed vrithout order upon the surface of the
skin; they axe irregular in their form, smooth and shining in
their aspect, unattended by pain, heat, or exfoliation, and rest
stationary for years. When partial in their distribution, their
common seat is the nose and dieeks.
719. In a third variety the tubercles are large, round, and
few in number, indolent, of a violet-red colour, and surrounded
by a copper-coloured areola. From time to time, one of the
tubercles becomes inflamed and painftQ, the surrounding skin
is congested, and assumes a purplish-red colour, and an ulcer
is established upon the summit of the elevation. The ulcer is
speedily covered by a thick dark-coloured crust. The ulcer
extends deeply ; other tubercles and other ulcerations form,
and run their separate course, the crusts falling at short
intervals, and being replaced by fresh crusts. Sometimes, by
the communication of several ulcerations, an irregular ulcer
of large size, and covered by a thick, greenish-black crust,
results. When these ulcers occur on the face, their most
frequent seat, a portion of the nose or of the lip may be
destroyed by their extension.
* Gibert terms this affection tubereuU$ herpeH/ormeSf from the resemblanee whicjh
thor dreles bear to herpes circinnatos.
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444 SYPHILITIC ERUPTIONS.
720. In a fourtli Yariety, ' the tubercles being the same in
general appearance, the uJcerations which ensue, instead of
increasing in depth, extend from the summit of the tubercles to
the surrounding skin, in cunred lines, which assimie a Yariely
of curious figures, being in one place serpentine, and in anodier
forming segments of circles, of greater or smaller diameter. It
is this Yariety which has been described by Alibert as the syphi-
Hde pustuleuse serpiaineuse ; the ulceration is superficial, and
coYcred by a thick, olaokish crust, and leaYcs, upon its healing,
a white seam-like cicatrix. The whole body is sometimes
coYered by these ulcerations and their consequent cicatrices.
When diese serpiginous ulcerations axe coYered with crusts,
they haYc an appearance somewhat resembling psoriasis gyrata ;
or of lepra in progress of cure, when its circles are broken at
one or more points ; but the examination of the disease at once
remoYes all similitude. The scales of psoriasis conceal a con-
gested and elcYated surface, and not a superficial ulcer. More-
OYcr, the colour of the syphilitic afiection is pathognomonic, as
are the seams and cicatrices which it leaYes behind.
721. In a fifth Yariety, the ulceration, instead of spreading to
the surrounding skin in the form of a tortuous band, is confined
to a narrow line, which crosses the tubercle, and cleaYCs it into
two portions. From this linear ulceration a quantity of pffensiYe
secretion is poured out, which concretes into a blacki^ crust
This form of tubercle occurs upon the face, and not unfirequently
upon the scrotum, and around the anus.
This tubercle, in its form and size, somewhat resembles the
elcYations of lepra guttata, which haYe lost their scales. But
the linear ulceration and die secretion which it pours out are
diagnostic of the syphilitic disease. Moreover, lepra guttata
is rarely CYcr seen upon the scrotum, while it is abundantly
distributed upon the rest of the body.
Tubercular eruptions are the most troublesome forms of cuta-
neous syphilitic disease, on account of the tendency which exists
to the formation of unhealthy and rebellious ulcerations.
SQUAMOUS SYPHILIS.
722. Syphilitic eruptions occurring at a longer or shorter
period after the primary symptoms, sometimes present the
character of squamous disease. The scales are thin and greyish
in their colour, and are developed on surfaces which are veiy
slightly raised, and of a copper-coloured tint These afiections
usually assume the appearance of lepra or psoriasis, they are
chronic in their course, and terminate by resolution and des-
quamation.
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SQUAMOUS SYPHILIS. LKFRA. PSORUSIS. 445
SYPHILITIC LEPRA.
723. In syphilitic lepra, which corresponds with the lepra
nigricans of Willan, the affected spots are of small size, varying
from a few lines to the diameter of a shilling. They are of a
dull greyish or blackish hue, darker in the centre than at the
circumference, and covered by thin, greyish, britde, slightly
adherent scales. Upon their decline, the elevations look
smooth and shining, and they leave behind them, at their dis-
iappearance, a livid or grey stain, which endures for a consider-
able time. The whole skin frequently presents a yellowish,
tawny hue, and yields a peculiarly disagreeable odour.
Sometimes the eruption consists of small roundish spots,
having the general characters of lepra guttata, but distinguished
from the sporadic form of that disease by the purplish and
copper-coloured hue of the elevations upon which Ae thin white
scales are developed, fiiett considers tfie presence of a narrow
white border of epiderma around each of these spots as patho-
gnomonic of syphilitic psoriasis.
The eruption is developed without pain or itching, or any
sjrmptom of constitutional disorder. It lasts usually from six
to eight weeks, and sometimes for a longer period.
SYPHILITIC PSORIASIS.
724. Sometimes the patches are of various size, and irregular
in their form, presenting the ordinary appearance of psoriasis.
They consist of smooth, shining, copper-coloured elevations,
very slightly raised above the surface, and covered with thin,
whitish, irregular scales/ The patches are in some situations
isolated and discreet; in others, they communicate, forming
patches of considerable extent. The intermediate skin is sallow,-
and more or less discoloured. This eruption is sometimes
limited to a single region of the body, while at other times it is
dispersed over die entire surface. Syphilitic psoriasis offers no
disposition to the formation of chaps and fissures, as occurs in
the sporadic disease.
Occasionally, syphilitic psoriasis appears in the palms of the
hands and soles of the feet, but is usually conjoined with the
development of the eruption in other parts of the body. In
these cases, the palms or soles are covered by a scaly incrust-
ation, consisting of dry and britde laminae, which conceal a
surface of a violet tint, and somewhat dense in texture, but not
elevated above its natural level.
The syphilitic squamous affections are not unfrequently
accompanied by pustular eruptions. They are difficult of
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446 SYPHILITIC SEUPTIOMS.
maDagementy and sometimes exceedingly obstinate under treat-
ment.
726. Treatment — When syphilitic eruptions put on the cha-
racters of acute inflammation, they must be treated by anti-phlo-
gistic remedies, both generally and locally* Under all circum-
stances, it is a point of importance to regulate the secretions at
the outset of ue treatment, and determine what organs are
chiefly disordered. Baths are valuable agents in the cure of
syphilitic cutaneous eruptions, by relieving cutaneous conges-
tion, and by difiusing over a larger surface the cutaneous deter-
mination. For the same reason, sudorifics have obtained con-
siderable reputation, and still continue to be employed as adju-
vantia with benefit to the disease, the most approved sudorincs
being guaiacum, sarsaparilla, and mezereum.
In cases where, instead of assuming an inflammatory type, the
powers of the constitution are reduced below their proper level.
It behoves us to have recourse to opiates, in large and repeated
doses, in order to subdue the morbid irritability of the nervous
system.
When the general indications presented by tiie particular
case before us are fulfilled, we may commence the curative
treatment, by prescribing some one of tiie numerous forms of
iodine. This medicine is invaluable in secondary syphilis,
and is regarded, with justice, as almost specific in its effects.
The formula to which 1 am disposed to give the preference,
is the iodide of {>ota8sium, in doses of three grains, three times
iMlay at first, and increasing them as the symptoms may in^
cate.
Next to iodine, the bichloride of mereury oonnts the greatest
number of advocates ; fiiett is strongly**in &vour of tiiid remedy,
which he prescribes according to the following formula :- —
ft
Bfckloride» gr« z(}«
Opium, fff. xz«
M.
Divide into thirty-six pills, and give one every morning,
increasing the dose by degrees, and discontinuing the medicine
firom time to time, in case the bowels may be too much affected.
By others, the medicine is preferred in solution, either with ot
without opium.
Compounds of iodine and mercury are also deserving of
trial in obstinate cases of syphilitic eruption. A compound
frequendy employed on the continent is the proto-ioduret of
mercury with guaiacum powder, in the form of pills. M. Gibert
has lately directed the attention of the Academy of Medi<»ne to
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TREATMENT OF STPHILITIC EBUPTIONS. 441'
a formula which he tenns syrup of ioduretted deuto-ioduret of
mercury, (sirop de deuto-iodnre-iodur^.) The formula for this
syrup is the following : —
Dento-iodoret of mercorj 1 part
lodaretof potassiom 50 parts.
Water 50 ^
DiMolTe, filter, and add of sunple ejnp 2400 ,»
The average dose is firom four to six drachms.
M. Qibert speaks very highly of this medicine, which agrees
with all kinds of subjects, adults, children, or the aged; healthy
or cachectic.
Rayer extols mercurial ointment administered internally
for a month or six weeks; he remarks that the absorption
of the mercury is more regular and continuous when this
remedy is used than when any other mercurial is employed.
Whenever any affection of the gums is apparent, he diminishes
the dose, or stops it for awhile, to resume as soon as the effect
has passed away. The formida approved by Rayer is that of
Sedillot — ^namely,
ft
Ung. meroariaL fort, x'^.
Sapoo. CastilieDsia, 9ij.
PoIt. et mncUaff. altKese, q. i.
M.
Make into thirty-six pills ; two or three to be taken daily. It
is highly probable that the oleaginous solution of mercury con-
veyed in this combination may offer a superiority of absorption
to other compounds.
Whatever the remedy may be that is selected, its action may
be increased by the administration, at the same time, of one of
the sudorific decoctions above recommended.
The local applications hold in the first rank, emollient baths;
these are usenu in all varieties of the disease, but especially in
the squamous affections, in which they should be rendered
alkaline.
Papulffi and tubercles may be stimulated to absorption by
means of an ointment of ioduret of mercury, or ioduret of
sulphur ; or if they be situated around the anus, or upon the
scrotum, by fumigations of cinnabar.
For ulcerations and abrasions of the surface, a weak nitric
acid lotion, with or without opium, is the best application ; or
to relieve pain, the hydrocyanic acid lotion.
For the squamous affections, I have found the blue pill in
small doses taken twice a-day, and until the gums are slightly
tender, a specific remedy.
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448 SYPHILITIC ERUPTIONS.
Case illustrative of Syphilitic Lepra.
726. Syphilitic lepra. — A young lady had been in excellent
health up to the time of her marriage, in March, 1845. In
June, she felt languid and ill, and lost her appetite. In July,
the languor and illness iilcreased, and in August she miscarried.
She then went to Ramsgate, her husband remaining in town,
and got quite well. Towards the end of September, a few
weeks after her return home, she again fell ill, and lost her
spirits. In October, she felt a soreness of her throat, and first
observed an eruption on her skin.
On the 15th of January, I saw this lady for the first time;
she was pale, her skin having a dirty, yellow hue, dejected,
weak, and obviously completely out of health. Her tongue was
white and coated, pulse small and languid, and bowels confined.
The patches of lepra which were scattered over her arms,
trunk, and particularly on the neck, face, and head, were of a
dull, red hue, scarcely raised above the level of the skin, and
■coated with thin and irregular scales. Two or three which had
subsided had left brownish yellow stains behind them.
I prescribed for her four grains of protochloride of mercury
with eight of compound extract of colocynth every third night;
and nitric and sidphiuic acids with infusion of calumba and
gentian three times a day ; with a gargle of infusion of roses,
alum, and tincture of myrrh.
January 29. Much improved in general health; no firesh
patches. On the mucous surface of the labia majora were
three leprous spots, slightly ulcerated, which I touched with
nitrate of silver. I discontinued the tonic and aperient medi-
cine, and ordered three grains of blue pill, with one of extract
of gentian and half a grain of extract of conium twice a day.
Februarj' 4. Repeated the application of nitrate of silver to
the superficial ulcerations on the vulva which were nearly
healed.
February 7. The eruption fast disappearing ; ulcerations on
vulva well; complexion natural, and appearance very much
improved. Complains of soreness of her gums. The mercury
was now discontinued ; her bowels were kept regulated for
a short time longer, and I directed her to continue the mineral
acids with bitter infusion for another fortnight, when her cure
was complete.
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CHAPTER XVIII.
HISTORY AND DESCRIPTION OF THE ITGH-
ANIMALOULE.
ACARUS SCABIEI.
727. A POPULAR knowledge of the existence of the itch-
animalcale is probably coeval with the first development of
scabies in the human race, since we find that the earliest writers
mention it as possessing a popular synonjrm. Our dictionaries
afford us similar information, and most observers have noticed
the fact that a living creature is commonly extracted from the
bodies of those affected, by members of their own class and by
fellow-sufferers.
728. The earliest scientific information relative to the itch-
animalcules that we find recorded, dates as far back as the time
of Aristotle, 350 years before the Christian era. For we are
informed by Moufet, in the commencement of his chapter, " De
syronibus, acaris, tineisque animalium,*' that Aristotle was
acquainted with these syrones — a statement which he precedes
by a reproof to Thomas a Veiga for making an assertion to the
contrary. For, says he, " Syronem antiquitate ignotum fiiisse
Tho. a Veiga falso memorat, nam ipsum axapihov Aristoteles
vocat. (5 Histor. Animal., cap. 32.)
729. That the itch-animalcule was well kown to the Greeks
may also be inferred firom the names siro and acarus by which
it is designated, for, according to Moufet, both of these terms
are derived firom the Greek language. " Syrones item dici
videntur, avo rou cwpJw e^iiv, quia tractim sub cute vepunV*
And again, he observes, " to 70^ axaqe^y teste Polluce et Sinda,
exiguum ilium dicitur, quod ab exiguitate non possumus xEi^ai,
id est, dividere."
730. The Arabians were also acquainted with the animalcule
o G
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450- HISTORY AND DESCRIPTION OF THE ITCH-ANIMALCULE.
at a very early period, for we find Abinzoar, in the twelfth
century, thus speaking of them : " Syrones Assoalat et Aisoab
dicti, sunt pedicelli subter manuum crurumque et pedum cutem
serpentes et pustulas ibidem exeitantes aqua plenas : tarn parva
animalcula, ut vix visu perspicaci discemi valeant."* But
Moufet expressly tells us that Abinzoar is the only one amongst
the ancient authors who shows any knowledge of scabies and of
the proper method of treating it, " Horum nullus antiquorum
meminit prseter Abinzoar qui morbum hunc yidit et curationem
ejus recte instituit"
731. By the Romans the itch-animalcule was named pedicellus;
and firom several quotations made by Moufet, we may leam that
the Roman physicians were well acquainted with it.
Scaliger, in his letter to Cardanus in 1557, remarks that die
acarus is globular in form, and so minute as to be scarcely per-
ceptible. The Turinians, he observes, called it scirroy and the
Gascons, brigarU. The little creature lives in canals which it
burrows in the epiderma, and when taken out and placed upon
the nail, exhibits a certain degree of movement, which is much
increased by the warmth of the sun. When crushed between
the nails, a slight noise is heard, and a small quantity of watery
fluid is perceived.t
H Gabucinus observes, " Ad nostra tempora quoddam supplicii
genus indomita fceditate pervenit^ in manibus exilis quidam
pedicellus, lente minor, sub cute serpit*'
Ingrassias, after referring to the statement of Abinzoar, ob-
serves, "Excoriata cute ubi minimus ille jonthus varulusve,
cujusdam sudaminis instar apparet, exeunt animalcula viva, tam
parvuncula ut vix possint videri."
JoBERTUS very aptly compares them with moles, but unfortu-
nately invalidates his testimony by supposing them to be the
hidden cause of porrigo, for, says he, '^ na^ountur ssepe in capite
et pilorum radices exedunt, quos Gr»ci rpixofi^rwsyrpixwr^CinLroLSy
(rnra;, rpixofiopovsy tineas peculiari nomine appellant'^
Aldroyandus, also, in 1596, draws attention to the minute
size of the pedicelloy its resort in burrows beneath the epiderma,
and its excitation of vesicles. He remarks, that we need sharp
eyes and a good light in order to perceive it
782. Moufet, in the famous work already referred to, the
" Theatrum Insectorum," which was published in 1634, by Sir
Theodore Mayeme, after the death of its author, but was com-
menced during the preceding century by Wotton, Gessner, and
Penn, gives the first account of the itch-animalcule published
by an English writer. In this volume we find recorded a very
* Moafet, Tbeatrum Insectomm, p. 266.
t Exercitmtio 194 ; de Sabtilibus ; nimL 7, 16d7.
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OBSERVATIONS OF MOUFET — HAUPTMANN. 451
complete description of the creature, and the most important
facts with regard to its habits are accurately noted. In truth
but little is known on this subject^ even at the present day, that
was not already pointed out by this distinguished writer. In
reference to their size and form, he observes, " Syronibus nulla
expressa forma (ut recte Scaliger notavit) preterquam globi:
vix oculis capitur magnitude tarn pusilla, ut non atomis constare
ipsum, sed unum esse ex atomis Epicurus dixerit** In another
place he remarks, ^' Animalculum est omnium minutissimum ;*'
its colour, ^^ est albicante, capite excepto ; proprius intuenti
nigricat, vel nigro parum rubet ;'^ and it moves briskly when
liberated from confinement, and stimulated by light and warmth.
^* Extractus acu et super ungue positus, movet se, si solis etiam
calore adjuvetur." He remarks upon the burrowing habits of
the creature, and upon the situation in which it is usually found,
^^ Ita sub cute habitat, ut aeiis cunictdis pruritum maximum loco
ingeneret ;" and again, '^ Mirum est quomodo tam pusilla bestiola
nullis quasi pedibus incedens, tam longos sub cuticul& sulcos
peragat. Hoc obiter est observandum, syrones istos non in ipsis
pustulis sed prope habitare.'' He, morever, rebuts the notion
of their being allied to pediculi, and defends Aristotle against
such an insinuation. " Neque syrones isti sunt de pediculorum
genere ut Johannes Langius ex Aristotele videtur asserere : nam
illi extra cutem vivunt, hi vero non : neque revera Aristoteles
alio quod sciam scripto inter pediculos acaros numeravit'' His
inference respecting their origin, drawn from their habitation,
savours rather of the times than of the truth. '^ lUorum quippe
proprium est non longe residere ab humore aqueo in vesicula
vel pustulfi, collecto : quo absumpto, vel exsiccato, brevi omnes
intereunt Unde colligimus, quemadmodum ex sero putrefexjto
exoriantur, sic eodem vicissim sustentantur.'' Moufet falls into
the pardonable error, since repeated by several modem authors,
especially by Linnaeus, of confounding the acarus scabiei with
the acarus domesticus. Thus, he remarks that the syrones are
produced in decayed cheese and wax, and when found in these
substances, as well as in leaves and dried wood, they are termed
nntesj **Bed in homine wheale wormes dicuntur, et Grermanice
738. In the year 1664, Augustus Hauptmakn, a Getman
physician, published a work on baths,* in which he speaks of
the Acari or Sirones which he found in persons affected with
scabies. These, he says, are in German called " Reitliesen ;"
they have six legs, and in appearance they resemble the mites
of old cheese. To Hauptmann belongs the credit of giving the
* Uhralten Wolkensteiniiclien V^armen Bad and Wa88er schatse, Sto. Dresden.
GO 2
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452 HISTORY AND DESCRIPTION OP THE ITCH-ANIMALCULE.
first figure of the animalcale ; which is referred to by Bonanni,
both in his own work and in his edition of Kircherius, in the
following terms : ^^ Monstrosam eorum £guram com permultis et
oblongis post tergom caudis depinget"
Haffenreffer, in 1660, also a German physician, alludes to
the acarus as a species of pediculus of yery minute size, breed-
ing between the epiderma and the derma.^
734. In 1682, a short notice of the animalcule, attributed to
Etmuller, is given in the first Tolume of the ^^ Acta Erudito-
rum Lipsi»."t In this account reference is made to Scaliger's
observation of its globular form, and to the opinion entertained
by Rohault]: of its back being covered with scales : ^^ Dorsum
sit squammosum sen squamis coopertum.** The author gives
the following description of them : ^^ Colore sunt albicante et
pedibus exceptis, qui proprius intuenti nigricare videntur, pedi-
bus sex instructi sunt, binis utrinque mox juxta caput positis,
quibus talparum ritu canaliculos sub cuticula agere, ut oblongos
non raro, quasi sulcos, trahere, simulque molestissimum pruritum
excitare videntur." The paper is illustrated with three figures,
drawn with an object-glass of low power ; they are somewhat
coarsely executed, but afibrd a tolerably fair representation of
the general characters of the animalcule.
736. During the following year — namely, in 1683, Giovanni
Cosimo fionomo published his letter to Redi,§ which was
translated into Latin by Lanzoni,|| in 1692. An abstract of this
letter was read before the Royal Society by Dr. Mead, and pub-
lished in the Philosophical TransactionsIT for 1702. Bonomo
gives a more perfect account of the acarus scabiei than had
hitherto existea. His attention was first dravm to the subject
by meeting with the popular name of the itch-animalcule in his
VocabuJario delTAcademia delta Crusca, followed by the accom-
panying explanation : — ^^ PelliceUo e un piccoHssimo Bacotino, il
quale si genera a Rognom, in peHe e rodendo cagiona urC acutissima
pizzicareJ*^ He then betook himself to researches with the view
of determining the truth of this definition, in which he was aided
by his fiiend Hyacintho Cestonio, who informed him that he had
seen ^^ muliercidas propriis e scabiosis filiolis acus extremitate,
nescio quid educere, quod in laeve manus poUicis ungue, alterius
manus poUicis ungue compressum, in ipsa compressione ali-
* No0odocbiam cutis afiPect^ Ulmae, 1660.
For September, 1682, p. 317.
Trac Physic., par. i., cap.' 21, 1798.
ObserrazioDi intomo a pelicelli del corpo nmano del. O. Cos. Bonomo, in una
letteraalFr. Redi.
n Obsenrationes circa humani Corporis Teredinem. In MiscelL Natur. Curios,
for 1692.
f Philosophical Transactions, toL xxiii, p. 1296, pi. 283.
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OBSERVATIONS OF fiONOMO— M0R6AGNI — BONANNI. 453
quern parvum sonum facere Yidetur, hoc autem educi a minutio-
ribus tuberculis scabiosis, perfecta nondum sanie scatentibus^
Tel ut vdcitant immaturis ; mutoa quod itidem charitate inter
remiges et mancipia Balnei Libumensis, si scabies infestaret
fieri, adnotavit" Having obtained one of the animalcules, Bo-
nomo examined it with the microscope, and '^ found it to be a
very minute living creature, in shape resembling a tortoise, of a
whitish coloiur, a little dark upon the back, with some thin and
long hairs, of nimble motion, with six feet, a sharp head, with
two little horns at the end of die snout"*
Bonomo gives two rude figures of the animalcule, which are
inferior to those in the ^' Acta Eruditorum," and must have been
observed with a bad microscope. He also delineates its " very
small and scarcely visible white egg," and stands alone in this
observation. Two remarks in Bonomo's letter are especially de-
serving of attention ; the first is, his comparison of ^e siro with
a little bladder of water ; and the second, his observation rela-
tive to their habitation in vesicles, ^' immaturis ;" both of which
are invaluable as aids in seeking for the animalcule.
736. MoRGAGNi, in his 55th Letter, book 4, contributes his
evidence to the existence of the itch-animalcule, and records a
case in which he saw the creature himself.
737. In 1691, Philip Bonanni, in his " Observationes circa
viventia quae in rebus non viventibus reperiuntur," as well as in
his edition of the " Rerum Naturalium" of Kircherius, refers to
the opinions of Bochartus, Kircherius, and Borellus. Kirche-
rius found these minute creatures, ^' candidi puncti similitudi-
nem," when examined with the microscope, to be " animalia pilosa
et prorsus urso similia." Borellus, he observes, "histriei
similia facit ;^ but this author, I am inclined to think, describes
the acarus domesticus, and not the acarus scabiei ; although he
was evidently acquainted with the latter, since, in his '^ Histo-
riarum et Observationum Medico Physicarum," under the title
of " Ulcera Pediculosa,"t he records an instance of vesicular
affection apparently identical with scabies. Bonanni gives four
figures of the animalcule, one firom Bonomo's letter, two fi'om
the Acta Eruditorum, and one of his own. Concerning the
latter he observes, ^' insectum hexapode, quod motu erat pigrum,
colore livido, et raris setosis villosum.^:): In size, it was about
equal to a grain of sand ; and he concludes his description with
the following question : — ^^ Unde nam istos animatorum semia-
tomos erupisse judicabimus ?" From the examination of his
figure, which is of large size, and exceedingly rude, and fi'om
his statement that four of the little animals were sent to him by
* PhiloBophieal Transactions, abridged, yoL y., p. 199.
fobs, 20. JFig. lU.
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454 HISTOEY AND DESCSIPTION OF THE ITCH- ANIMALCULE.
Baldigianus, a professor of mathematics in Borne, and who had
extracted them from the face of one of his scholars, it is quite
evident that they are pediculi pubis, and not acarL Bonanni
recopies the four figures from Kircherius.*
738. In 1744,t Baker, in a curious work, entitled the " Micro-
scope made easy,*" for the perusal of a copy of which I am in-
debted to my kind friend Dr. Grant, remarks — " The microscope
has discovered what, vrithout it, could scarcely have been ima-
gined, that the distemper we call the itch is owing to little
insects under the cuticula, whose continual bitings cause an
oozing of serum from the cutis, and produce those pustules and
watery bladders whereby this disease is known." He then
quotes the description of the animalcule, and the mode of finding
and extracting it, given by Bonomo, and copies the two figures
of this author, not forgetting the ovum.
789. In 1762, Casal, a Spanish physician, in a work, entitled
'^ Medical Researches on the Asturias,'' referring to the burrow-
ing and grubbing habits of the acari, remarks, ^^ Yocantur
aratores, et merito, arant enim semper inter cuticulam et cutem.**
740. In 1786, Dr. Wichi^ann, of Hanover, was induced to
verify the prevailing opinion of the existence of an animalcule
in connexion with scabies, and the results of his labours are
published in a volume entitled " jStiologU der Kraetze.^^i He
found the zoological characters of the animalcule undecided, and
the precise species infesting the skin in scabies undetermined.
" Thus," he remarks, " of many naturalists, to name only a few
of rank, Linnaeus has only tentacula ; Schsefier has antenruB pedi-
formes articulat(B; while Baron de Qeex expressly says, ihey
have no antennae, but two arms, with joints, which resemble those
of spiders, who have likewise no antennae." He alludes also to
the opinion of Linnaeus, that the acari farinae might be conveyed,
in the powder used in dressing children, to their skins, and there
colonized ; and he attributes to this error on the part of the great
naturalist the assertion made by Professor Murray,§ " that pre-
vious to any appearance of pustules, (in scabies,) ^ere is always
a foulness of the juices, and that when this foulness has got a
certain height, the acari of cheese or meal are induced to seek a
nidus in the skin." Dr. Wichmann refers also to the omission
of distinction of species by Pallas, || for that author remarks,
" Acarus scabiei, acaro farinae est consanguineus." De G^eer,
however, distinguishes the two species very accurately, for of
the acarus farinae he observes, ^^ Acarus oblongus albns, capite
* Fig. 95. t This in the date of the third edition.
t 8to, 1786 ; and London Medical Joarnal, toL ix., 1768, p. 28.
§ De Yermibas inLepra obviis. Gottingen, 1769, p. 9.
O Dissertatio de infe6ti« viyentibas, 1760, p. 2.
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OBaERVATIONS OF WICHMANN— DB. AI>AMfl, 4*J
rufescente, pedibus coniois erassioribus aequalibus ^ Q^d of tha
acarus scabiei, ^^ Acaru& subrotundus albus^ pedibus rufescen-
tibus brevibus ; posticis quataor «eta longissima^ plajiitis quatuor
anticis fistulatis oapitulo terminatiH/' The author points out the
vesicles as the seat of habitation of the animaloule, but he ob-
serveS) that '^ even before such a transparent vesicle is form^
we may often discover traces of the insect on the fingers or
hands, in a reddish streak or furrow," and '^ it is even more usual
to find it in these furrows than in the pustules lliemselves*" The
furrows he finds only on* the hands and fingers. Dr. Wichmann
gives two figures of it, as examined with an object-glass of high
power. These are very correct, and g^ve a better idea of d^
little creature, as seen by that instrument, than aaiy other de*
lineations published. Like his predecessors, he makes no
attempt to describe the zoological characters and structure of
the animalcule.
741. In 1805, Dr. Adams gives two excellent figures of the
itch-animalcule in a paper^ addressed to Sir Joseph Banks, and
read before the Boyal Society in the month of April of that year.
This paper is entided " An Account of the Aearus Siroy {Acarus
Exulcerans of LimuBUSy) by some considered as the Itch Ihsecty
The figures of the acarus which accompany this paper are supe*
rior to any that have been published either before or since, and
are sufficient to identify the animalcule completely with the
acarus scabiei. The author's observations were made in Madeira,
where, it would appear, the creature is extremely common, and
is called ogao, ougouy or ougam. Dr. Adams gives no zoolo-
gical description of the animalcule, but confines himself chiefly
to the disease engendered by its presence, and to the mode of
detecting the 09ao. In the latter art he was instructed by an old
woman, and he confesses himself to have been a dull scholar ;
but the results of his researches afford no better information than
that which I have already adverted to, as contained in the
Theatrum Insectorum of Moufet. The principal seat of the
animal, says Dr. Adams, is a '^ reddish elevation'' at t)^ end of
a ^^ somewhat knotty'' reddish line, extending firom the vesicles
for the distance of about a quarter of an inch. The author
attributes to the animalcule a ^^ power of leaping with a force not
less than a flea. Such was the case with one whilst I was ex-
amining it under a convex lens." In this he is entirely mis-
taken ; for the creature is deficient in the organization necessary
for such an effort, and its sudden disappearance firom the field
of his lens is rather to be ascribed to some untowaxd movement
occurring during the ac^ustment of his optical apparatus. Dr.
* Published in his work on Morbid Poisons, 4to, 1S07, p. 293.
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456 HISTORY AND DESCRIPTION OF THE ITCH-ANIMALCULE.
Adams expresses himself unwilling to accord to Bonomo all the
credit which that writer claims ; and in reference to the dis-
covery of the egg, he remarks — ^* Without suspecting the good
intention of this writer, you will readily admit tiie uncertain dis-
crimination of the egg of an insect, described by De Geer as
about the size of a nit, but which, on placing it under a micro-
scope, by the side of a nit, did not appear more than a fourth
part of its bulk. For myself, I never could discover what could
satisfactorily be called an egg/^
Hitherto Dr. Adams has spoken of the 09ao as being identical
with the itch-animalcule of Bonomo and other writers, but in
subsequent paragraphs he declares his belief that the disease
engendered by the ougoes, and that of the itch, are perfectly dis-
tinct, and he founds this opinion upon the following data : —
1. The disease of ou§oes is attended with considerable febrile
disturbance, and sometimes with severe local symptoms.
2. It is easily cured ; by extracting the animalcules, by the
white precipitate ointment, or by the use of sulphur internally.
3. It is liable to recur, from ihe development of undestroyed
ova, unless the remedies be continued for a month after the
apparent cure ; and even then, if the disease be cured in the
autumn, it is liable to return in the spring, because the animal-
cules remain torpid during the winter.
4. It is always attended with vesicles which possess great uni-
formity, and have each a red line ; whereas in itch the vesicles
are variable in size.
5. The natives of Madeira entertain a disgust for the itch,
which they call sama ; whereas the ou9oes give them no dis-
comfort.
6. The dictionaries of all languages are opposed to the simi-
larity of the affections, since they indicate a name for the animal-
cule distinct from that of the itch.
7. John Hunter could never discover the itch-animalcule.
Now all these objections, cogent as they may have appeared
to the author, must instantly fall to the ground the moment that
the animalcule is shown to be present in the itch, and to be the
real cause of that affection. Nor would it be difficult to prove,
seriatim, that each of the objections above cited is equally un-
founded. The figures appended to Dr. Adams^ paper are so
excellent, that I am inclined to assign to them a rank superior
to those of Wichmann, although the object of the two authors \s
widely different, and scarcely admits of comparison, for while
the figures of Adams are intended to trace form and general
character, in those of Wichmann there is a manifest endeavour
to exhibit texture.
742. The year 1812 witnessed the performance of a most re-
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OBSERVATIONS OF RENUCCI — ALBIN GRAS. 457
markable scene in the memoirs of the acaxus scabiei. M. GalI: s ,
Pharmacien of Saint Louis, tempted by a prize offered by an
unbeliever in the existence of the little animal, introduced the
gentle stranger to the wondering gaze of all the notabilities of
Paris. The Academy applauded, the crowns were paid, and
the pencil of the artist of the Mus6e Royale was called to per-
petuate the juggle. He drew to the life the common meal-mite !
(acarus farinsB.) It is needless to say, that the statements put
forth by M . Gal^s were, from beginning to end, a tissue of
deceptions, and to have written such stuff as that contained in
his paper is the best proof that he could never have seen the
animalcule. M. Patrix played pantaloon to M. Gal6s's clown.
743. The discovery of the treachery of M . Gal6s was not,
however, made for a considerable number of years, when, with
some difficulty, Raspail succeeded in proving the identity of the
insect of Gal6s with the acarus farinae. The consequence of
this exposure was universal distrust, and in this state the ques-
tion remained, until a young student from Corsica, M. Renucci,
in the year 1834, exhibited the veritable animalcule in the
clinical theatre of Alibert, and demonstrated the method of dis-
covering its lurking place in the epiderma.*
744. The subject was next taken up by M. Albin Gras, a
student of St. Louis, who has shown himself well qualified for
the undertaking. He published a small treatisef in the autumn
of 1834, in which he gives a good summary of the knowledge of
our ancestors relative to the animalcule, explains the manners
and habits of the little creature, and details some excellent ex-
periments made by himself, in reference to the mode of treat-
ment of the disease. The habits of the acarus, when placed
upon the skin, are detailed in § 486 of this volume, and M . Gras^
Experiments on the influence of medicinal agents on its vitality
are quoted in paragraph 398. After giving a description of the
animalcule inferior to that of M. Raspail, the author remarks,
" If we observe the mode of progression of the insect on
the epiderma, we may easily assure ourselves that it does not
bore its cuniculi in the manner of the mole, by means of its
anterior legs, — for the legs are not disposed to enable the crea-
ture to effect its object in this manner, — ^butit lifts the epiderma
by means of its flattened snout. The hairs upon its back aid it
in this operation, for being directed posteriorly, all return on
the part of the animal is rendered impossible.''
" In examining several sarcoptes beneath the microscope, we
* Some account of M. Renacci's mode of procedure will be found in the Gazette
des Hopitaux, and Gazette Medicale for 1834.
t Recherches 8ur rAcams ou Sarcopte de la Gale de l*homme. Par Albin
Gras. Paris, Octobre 11, 1834.
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458 HISTORY AND DESCRIPTION OP THE ITCH-ANIMALCULE.
frequently perceive them to lay several small, white, oblong, and
transparent eggs, the eggs, according to M. Duges, being one*
third the length of the animal.^ ^^ If we place an acarus on the
epiderma, we perceive it to dodge about here and there, follow-
ing by choice the course of the folds of the skin, and every now
and then fixing itself upon the epiderma, and raising the pos-
terior part of its body.**
745. In 1834, Raspail published his ^^ M^moire companUdf
sur rhistoire naturelle de Finsecte de la Gale," in which he
details the history of modem discovery in France relative to the
itch-animalcule — ^a narrative replete with misadventures, that
the perusal of Moufet would have effectually prevented. In
1831, he had seen and delineated the acari scabiei of the horse,
but it was not until three years afterwards that he was&rst
shown by Renucci the animalcule of the scabies of man. After
describing the epidermal cuniculi which are burrowed by the
creature, he observes that the precise seat of the acarus is in-
dicated by a white point His description of the animalcule is
the following. It is white, scarcely half a miUemetre in diameter,
head and feet reddish and transparent, and it is invested by a
covering which is hard, dense, and resisting. Its abdomen is flat
and smooth ; the dorsum presents three prominences, one, of
very large size, in the middle, one, next in size, over the abdo-
men, and one near the head. Along the lateral border of the
C!;eature, the dorsal and ventral surface join like the carapaxand
plastrum of a tortoise, and the resemblance to the shell of this
animal is increased by the projection of the head and anterior
legs from the space between the carapax and plastrum in front,
between which they appear capable of retraction. The head is
provided with two large eyes, placed laterally; it is surmounted
by four antennae, which are disposed in two rows, between the
eyes ; the trunk is folded beneath the head. The anterior leg$
have four joints, and a haunch-piece at the base of each ; they
are terminated by a stiff ambulacrum, furnished at its extremity
vrith a sucker. ThiQ posterior legs have the same number of pieces
as the anterior, but are not more than one-fourth their leng^
and scarcely project beyond the abdomen. Each leg is ter-
minated by a long hair in place of an ambulacrum. The anus
projects, more or less, from the posterior border of the carapax,
and is bounded by two short parallel hairs on each side. The
carapax and plastrum are homy in texture ; the former is sur-
mounted by stiff homy hairs, disposed in a certain order, two
rows passing backwards from the centre to each side of the
anus, and two forwards to each side of the head. The structure
of the carapax is reticular, the meshes extending transversely.
The figures accompanying this excellent description of the
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OBSERVATIONS OF RASPAIL — LINNiRUS. 459
animal do great injustioe to the text ; they are inferior to those
of Adams, and also to those of Wichmann, neither of which
appear to have been known to the author ; while he praises
very highly the figures of De Greer, which are inferior to both.
746. Besides the authors above referred to, some account of
the acarus scabiei will be found in Schenhius^ Obs. 676 ; in
Jtosenstein, on the diseases of children ; Pallas^ de infestis viven^
tibus, 1760; SauvageSy Maladies de laPeau; MUeellanea Curiosa^
1692 ; Anrudes des Sciences cf Observation^ vol. ii. p. 446, vol. iii.
p. 298, 1830 ; Lancette FrangaisCj Aout, 1831 ; Bulletin de
Tkerapeutique, voL vii ; Journal des Connaissances Medicales^
Septembre 15, 1834. And for the comparative history of the
animalcule, fValz, de la Gale de Mouton.
747. LiNNiEUS,irom an imperfect acquaintance with the acarus
scabiei, has been the cause of much of the confusion and obscu-
rity which have involved the history of this animalcule. He
places acarus in his order aptera^ and gives the following as the
characters of the genus:* —
Os proboscide carens, haustello vagina bivalvi, cylindrica,
palpis duobus compressis, aequalibus, haustelli longitudine.
OcuH duo ad latera capitis.
Pedes octo.
Tentacula duo, articulata, pediformia.t
In the first edition of the Fauna Suecica,^ Linnaeus describes
the animalcule under the specific designation of ^^ acarus huma-
nus subcutaneus.^^ In the second edition § he considers the
acarus humanus subcutaneus as belonging to the same species
vnth the flour-mite, cheese-mite, &c. ; and in the " Systema
Naturae" observes, " Inter sirones Farinae, Scabiei, Phthiseos,
Hemitritaei, vix etiamnum repereri alias differentias quam a loco
petitas;" while he admits the itch-animalcule as a new species,
under the name of " acarus exulcerans.^^ The specific characters
of tliese two species he thus indicates :|| —
^^ Acarus siro. — A. lateribus sublobatis,pedibusquatuor posticis
longissimis, femoribus capiteque ferrugineis ; abdomine setoso.
** /S. A. humanus subcutaneus,
^^ Habitat sub cute hominis scabiem caussans ubi vesiculam,
excitavit, parum recedit corporis rugis secutus, quiescit iterum
et tittilationem excitat; nudis oculis sub cuticida delitescens
observatur ab adsueto acu facile eximitur, ungui impositus vix
movetur, si vero oris calido halitu affletur a^phs in ungue cur-
sitat.
* Systema NatursB, 1767.
t Entomologia Fauns Soecics. Viller's Edition, 1789. t No. 1194.
§ Anno 1761. No. 1979.
II Fauna Suecica. £ditio altera, auctior, 1761, Nos, 1975, 1976.
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460 HISTORY AND DESCRIPTION OF THE ITCH-ANIMALCULE.
" Description — Minimus, magnitudine vix lendis subrotundus,
capite vix conspicuo, ore ut et pedibus niffis sive testaceis;
abdomen ovatum byalinum ; in dorso duplici linea lunari sea
pari linearum fuscarum recurvatarum notatum et quasi lobo
utrinque.
" Acartis exulcerans. — A. pedibus longissimis setaceis ; anticis
duobus brevibus.
^^ Habitat in scabie ferina, cujus caussa est.^^
In the " Entomologia Fauns Suecicae" of Linnaeus, edited by
Villers,* the editor retains the above " Description in connexion
with acarus siro, but the ^^ Habitat*^ he transfers to acarus exul-
eerans, commencing it thus — " Habitat in scabie ferina, sub cute
hominis," &c. To this he adds the observation of Fabricius —
** Acaro sirone minor et distinctus et forte acaro exulcerante non
diversus." Then follows the " * Descriptio.' A. albus, diaphanus ;
corpus rotundatum, scabrum, nigro non lineatum uti acarus siro.*^
The editor concludes with two remarks from his own pen : —
^^ Obs. ] . In Fauna Suecica, ed. 1, acarum farinae et scabiei sepe*
raverat Linnaeus, postea conjunxit, sed DD. Geoff., Fab., De
Geer, pro diversis speciebus rite habuerunt ; ergo vere distincti.
— Obs. 2. Scabie certe hie acarus caussa est."
In the 13th editionf of the " Systema Naturae," the acarus siro,
comprising the meal-mite, the cheese-mite, &c., is separated from
acarus scabiei, but the acarus exulcerans is still retained. The
specific characters of the acarus scabiei are thus stated : —
" Acarus scabiei. — A. albus, pedibus rufescentibus ; posteriori-
bus quatuor seta longissima.
^^ Habitat in ulceribus scabiosorum, cutis rugas sequendo pe-
netrans, titillationem excitans ; utrum causa, an potius, symp-
toma mali ? Sirone multo minor."
Of the acarus exulcerans, Linnaeus remarks —
^^ Habitat in ulceribus scabie ferina laborantium. An satis
distinctus ab A. scabiei ?"
In the '' Amoenitates Academicae"]: the following passages,
which are deserving of notice, occur. The first conveys the best
idea of the seat and appearance beneath the cuticle of the acarus
that I have met with in any writer ; and the latter puts forth the
unfortunate observation, which led Linnaeus so deeply into error
with regard to the classification of the itch-animalcule. Speak-
ing of tihe vesicles, the writer observes — " Panun vero ab ilia in
ruga cutis punctiun quoddam fuscum quod nondum in vesicular
se extulit, fit tamen duobus diebus progressis ; acus aculeo lens
minima eximitur, quae ungui imposita et halitu oris afflata, in
♦ Anno 1789. f Edited by Gmelin, anno 1788. Vol 5.
X Miracula Insectorum. By G. E. Ayelin. Upsal, 1752. AmcBiiltat Acad.,
ToL iii, p. 333.
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OBSERVATIONS OF DE GEER — FABRICIUS. 461
ungae cursitat. Oculis armatis iilterius appareat insectum hoo
octo habere pedes, setas quasdam in dorso et acarum esse jam
allatum.'* ** Si mater aut nutrix infantem farina cereali, in qua
aeari saepissime habitant, adsperserit, infans in ea parte primo et
toto tandem corpore scabie laboravit"
In Sweden, LinnsBUs remarks that the itch-animalcule is named
Klamask,
ScHAEFFER also describes the animalcule in his ^^ Elementa
EntomologiaB," in 1766.
748. Baron De Geer was thoroughly well acquainted with
the itch-animalcule, and has left an admirable description* of
the creature, as well as two excellent figures. The latter, how-
ever, are not equal to the description. He points out the error
of LinnsBUS with regard to classification, and expresses his
conviction of the identity of the acarus scabiei and exulcerans.
The specific characters of the acarus scabiei he describes as
follows : —
" Acarus subrotundus albus, pedibus rufescentibus brevibus ;
posticis quatuor seta longissima, plantis quatuor anticis fistulatis
capitulo terminatis."
The capitulum in this definition he speaks of as being " en
forme de vessie ;" and in reference to scabies he observes — " Ces
mittes sont meme Tunique cause de cette vilaine maladie."
749. FABRiciDS,t in his " Systema Entomologicae," places the
acarus in the order antliatOy which he characterizes as possessing
" OS, haustello, sine proboscide." The characters of the genus
he thus designates : —
'^Acarus, — Haustellum, vagina bivalvi, cylindrica; palpi duo
longitudine haustelli." To which, in the amended edition of
1794, he adds — " antennsB filiformes."
With regard to specific characters, Fabricius adopts the defi-
nitions of Linnaeus, and admits two species as inhabiting the
skin of man — ^namely, the acarus siro and the acarus exulcerans.
Of the former he remarks : —
^^ Habitat in caseo, farina diutius asservatis, cutem hominis
rugas secutus penetrat, yesiculam et titillationem excitat. Caus-
sam, nee symptoma morbi esse evincunt observata analo^a cum
Gallis contagium cura."
And of the latter: —
" Habitat in scabie ferina."
In the " Fauna GroBnlandica,"J the same author observes, vrith
regard to the acarus siro: —
* M^moire poor serrir k Thistoire des insectes. Vol. yii., 1778, p. 94, pi. 5.
fig*. 12—14.
J Johannes Christ Fabricius. Ed. 1775, p. 813.
Anno 1780, p. S21.
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462 HISTORY AND DESCRIPTION OF THE ITCH-ANIMALCULE.
^^ Habitat in Ye8icul4 scabiei Grroenlandorum, qui ilium acu
apte eximere scientes, mihi miranti, ut yivum animal inoedentem
ostenderunt En Groenlandos Entomologos.'' ^^Yarietatem
fEbrinro quidem etiam in farina mea vidi : an vero in Groenlandia
domi habeat^ incertus sum dum Oroenlandi farinaceis non uton-
tur." He remarks also, that in Greenland the animalcule is
named " Okok ;" and that in the natural history of Bomares, it
is termed ^Scab'-ormy
In the ^^Entomologia Systemica^emendata,^* Fabricius adopts
the opinion of De Geer with regard to the identity of the acarus
siro with the acarus domesticus, or cheese and meal mite, and
admits the itch-animalcule as a distinct species, with the foUow-
ing chracters : —
'^ Acarus scabiceu — Albus, pedibus rufescentibus, posticis qua-
tuor longissima.^
It is, he continues, ^' multo minor et distinctus ab acaro sirone.^
He observes also that this species corresponds with the acarus
exulcerans, and quotes a passage from Linnaeus to the same
eflPect
750. M ULLER, in his " Prodromus Zoologiae Danic»y''t adopts
the early classification of Linnaeus, considering the itch-animal-
cule under the designation of acarus siro. In Denmark, he
observes, the creature is called Krid-arm, Bmg-ormy and MeeUmid,
The latter term, which, translated, would be tneal-mitej indicates
the popular extension, or possibly the popular origin, of the
error of the great Swedish naturalist.
751. Latreille established the itch-animalcule as a new
genus under the name of Sarcaptes fiominisj with the following
description: — Body apterous; no distinction of head or seg-
ments ; manducating organ prominent, without apparent palpi ;
eight short legs. Subsequently, however, on the occasion of
the memorable juggle of GaUs, Latreille omitted the genus
altogether.
752. The existence of the acarus scabiei is without question ;
I have extracted as many as twenty from their retreat at a single
sitting. I have placed Uiem on a slide of glass, and seen them
run ; and after the business of the day has been over, I have
examined them with the microscope, and found them stiU active,
living for several hours after my examination. I have already
stated, that I regard them as the unique cause of scabies, and
as a necessary feature in the diagnosis of that disease.
When examined with the naked eye, the acarus looks white
and shining, globular in its form, and very aptly resembling the
little bladder of water of Bonomo. There is no difficulty in
* Anno 1794, vol. iy. f Otho Fridericos MuUer. Anno 1776.
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ORIGINAL OBSERVATIONS. 463
extracting the little animal ; the cuniculus is seen without diffi-
culty ; the end of the cuniculus is perceived to be a little raised,
while a greyish speck is seen beneath it. As soon as this little
eminence of epiderma is lifted, if the end of the needle or pin
with which the operation is performed be examined, the minute,
white, and shining globe will probably be observed attached to
the instrument If there be no such object, the point of the
needle placed again beneath the raised capsule of epiderma
will pretty certainly draw it forth. This facility of extracting
the little creature is due to its great power of clinging to any
object with which it comes in contact.
When the acarus is seen running upon the surfiEUse of a plate
of glass, it may be perceived that its anterior margin presents a
dusky tint of colour, and the examination of this part of the
creature with the microscope brings into view a head not unlike
that of a tortoise, and a pair of large and strong legs on each
side of the head. These organs are encased in a moderately
thick layer of chytine, and have consequently the reddish-brown
tint of tihe oases of certain insects, or of the bright part of a thin
layer of tortoiseshell. Proceeding with our examination, we per-
ceive the general outline of the animal to be subrotund, the
antero-posterior predominating very little over the transverse
diameter ; the anterior part of the creature being broad, and the
posterior somewhat narrower and semicircular. The ventral sur-
face of the acarus is flat, and occupied by the head and eight
legs ; the dorsal surface is arched and irregular, and covered by
numerous spines ; and projecting backwards from the posterior
segment of the animal are twelve hair-like filaments, some long
and others short.
753. With the view of determining the size of the acarus, I
measured ten specimens, and found ti^em vary between yj-7^ and
-^ of an inch in length, and between 7^ and ^ in breadth*
The following were the measurements of seven of tiiis number : —
Length. Breadth.
Tir
tU
Tk
5oTr
T+^
Th
^
T^
Length. Breadth.
WS Toff
Toir
tV
754. Examined with a quarter or eighth of an inch object-
glass, or with Powell's half-inch, the case of the body of the
acarus is seen to be composed of narrow plates, variously dis-
posed with regard to the axis of the animal, but chiefly trans-
versely, and resembling a coat of plate armour. The connecting
membrane of these plates permits of a certain degree of move-
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464 HISTORY AND DESCRIPTION OF THE ITCH- ANIMALCULE.
ment between them. The dorsum of the creature is convex, but
irregular, and exhibits upon its borders a tendency to division
into a thoracic and an abdominal segment, the former being
somewhat broader than the latter. Anteriorly the dorsal case
terminates in a sharp border, which is scolloped, and forms a
jutting roof of protection to the head, and to each of the four
anterior legs. Posteriorly, the case is somewhat deeply cleft,
forming a groove, which corresponds on the ventral surface with
the sexual and anal aperture.
The dorsal surface of the creature is covered with tubercles,
spines, and hairbearing tubercles, regularly, and very remarkably
disposed. The venter of the acanis is flat, and the abdominal
portion slightly convex. The posterior part of the latter is
grooved upon the middle line, and furnished with an anal and
sexual aperture, of considerable size.
The head is an oblong cylinder, more or less obtusely pointed
in front, flattened beneath, enlarging slightly laterally towards
the body of the creature, and implanted by its posterior end into
the angular interval left by the separation of the anterior pair of
legs. The lateral enlargement towards the root of the head is
the most suitable place for eyes ; but I have not as yet been able
to detect those organs. The head is surmounted by two rows of
stifi* hairs. The mouth is an oblong aperture situated upon the
under surface of the head, and becoming broad towards the root
of the latter. Its borders are furnished with a thick fringe of
mandibles, and the interior supplied at each side with a number
of strong maxillae. The head is capable of elongation or retrac-
tion beneath the dorsal plate or carapax.
The legs are eight in number, four being anterior and four
posterior; the anterior legs are large and powerful, the posterior
small. The anterior pair of legs are so large, so closely placed
to the head, and directed so immediately forwards, as to deserve
the appellation of arms. The next pair follow immediately on
the preceding, but are directed outwards. The legs are conical
in form, tapering, when extended, to an obtuse point, and com-
posed of a hip-piece and three circular segments. The hip-
pieces of the two anterior legs join at an obtuse angle, and form
the limit of the root of the head. The point of meeting of these
hip-pieces is the commencement of a sternal crest, which runs
backwards on the plastrum for a short distance, and terminates
by a rounded extremity. A similar crest is formed on each
side by the junction of the hip-pieces of the anterior and lateral
legs, the crest being directed backwards and inwards towards
the termination of flie sternal crest. Each of the annular seg-
ments of the anterior legs is frimished with three or four bristly
hairs, which stand out at right angles from the segment More-
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STRUCTURE OF THE ACARUS SCABIEI. 465
over, the extremity of each anterior leg is provided with a
tubular cylinder as long as the entire leg, and terminated at its
extremity by a foot divided on its sole into five lobes.
The head and four anterior legs are covered by a strong case
of chytine, which presents the ordinary colour of insect cases —
namely, a brownish red. The plastrum is slightly tinted with a
similar hue, but the three crests formed by die hip-pieces are,
in virtue of their thickness, of a deep colour. These are the
red lines of Gras, Raspail, and others. The posterior legs have
but a thin case of chytine, and are less deeply coloured. The
coloured covering of the head and legs contrasts very strongly
with the yellowish white of the body of the animal.
The posterior legs spring from the posterior part of the tho-
racic segment of the animal, two on each side; they are conical
in form, composed of three segments, and each leg is connected
to the body by means of a triangular and flattened hip-piece.
Each posterior leg is terminated by a rudimentary tarsus and
foot, and by a long membranous hair-like organ, which is directed
backwards.
I have already alluded to the cleft on the posterior part of the
abdominal segment of the animal, and the papilla which bounds
the anal opening posteriorly. A pair of hair-like filaments
surmounted on short tubercles are found on each side of this
opening, near the posterior margin of the abdomen. These four
filaments, with the four hair-like organs of the posterior legs,
and the four directed backwards from the lateral part of tiie
thoracic segment, form the twelve hair-like filaments which are
observed along the posterior margin of the animal. These
filaments, together with the hairs, spines, and tubercles situated
on the dorsum, serve most eflectually to prevent the retrogression
of the acarus along its cuniculus, while the anterior part of the
creature is equally well organized for advance.
I have not been able to distinguish any sexual difierences
between the animals I have examined. In a sketch before me
is drawn a conical projection in this region, but I have not as
yet seen that appearance repeated.
The ova I have seen, ana I have preserved a slide, on which
there are two of these bodies.
The internal organization of the animalcule is obscured by
the large collection of adipose cells which form its superficial
stratum.
H H
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466
HISTORY AND DESCRIPTION OF THE
STEATOZOON FOLLICULORUM.
755. In the course of some researches directed to the inves
tigation of the cause of acne, Dr. Gustav Simon, of Berlin,
discovered an animalcule in the sebaceous substance with which
the hair-follicles are so commonly filled, particularly on the face,
and gave it the designation, acarus foUiculorum,* Dr. Simon's
researches have hitherto been mrected principally to the
sebiparous glands of the nose, where he finds the parasite with
astonishing frequency, even in cases where the skin presents all
the characters of perfect health. Of living persons he detected
the animal in three out of ten men in die sebaceous matter
squeezed out by pressure from the follicles ; but in the dead he
discovered them in almost every individual examined, the only
exceptions out of ten bodies being two newly-born children.
The mode of examination in the case of the dead was by means
of thin sections. The animalcules embedded in the sebaceous
matter are found in the hair-follicles near to the outlet, their
long axis corresponding with that of the follicle, and their heads
being directed inwards ; in four instances, the head and part of
the body of the little creature were lodged in a sebiferous duct
In normal hair-follicles there are usually not more than one or
two of these parasites ; in rare instances, three or four ; but
where the sebaceous substance is concreted, their number varies
firom two to six ; in one case, he found as many as eleven, and
in another, thirteen. They are tardy in their movements, but
retain their vitality for a considerable length of time; thus Dr.
Simon has found diem moving after a confinement of eight and
twelve hours between two plates of glass, and in one body they
were found alive after the person had been dead for six days.
The animalcule presents several forms, which correspond with
stages of development In the most common form, the animal
* Muner*8 Archiv., 1842, p. 218. Ueber eioe in den kranken ond normalen
Haarsacken des Menschen lebende Milbe.
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STEATOZOON FOLLICULORUM.
467
varies from 0,085 to 0,125 of a line (German) in length, and
0,020 of a line (German) in breadth; it has an elongated figurej
a long thoracic portion, with four pairs of legs, and an abdomen
three times as long as the thorax, and tapering gradually to an
obtusely pointed extremity. The head consists of two large
palpi, and of a proboscis situated between the two. The palpi
are bi-jointed, and terminated by several small teeth-like pro-
cesses. The probosciSy which is capable of elongation and re-r
traction, resembles a long tube, upon which lies a triangular
organ, having its narrow base, directed towards the root of the
former, and extending by its apex almost to the extremity of the
proboscis. This triangular body consists of two bristles lying
Fig. 1 ♦
Fig. 2.
m
Fig. 3.
* Fig. 1. The steatozoon seen npon its Tentral snrfiice. The structare of the
head, feet, and plastrnm are shown, as well as the annulate character of the abdomen.
The figure is drawn to a scale of a line to the ^^ of an inch.
Fig. 2. The steatozoon viewed npon its dorsal aspect The head is retracted
within the thorax.
Fig. 3. The steatozoon viewed npon its lateral aspect The serration of the
abdominal segmenU is somewhat exaggerated in all the figures.
H H 2
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468 HISTORY AND DESCRIPTION OF THE
side by side. The head is continuous directly with the thorax,
without any precise line of demarcation. The legs are short,
conical, and composed of three segments, and upon the latter is
an appearance of plaits. The leg is terminated by three claws,
one long, and the other two short From the anterior part of the
basis of each leg a double line runs transversely inwards across
the under surfiEice of the thorax, towards the middle, where one
of the lines passes forwards and the other backwards, and they
scire together to form a central longitudinal double line. The
transverse lines are probably continued completely around the
thorax. The thorax is highest at about the middle, and broadest
at the point corresponding with the second pair of legs. The
abdomen is markea by a number of transverse lines produced
by a series of grooves or contractions, which give to the margin
of this part a resemblance to a file. The contents of the abdo-
men are granular, and similar to those of pigment cells, and
among these granules are several large transparent places of a
round, oval, and sometimes quadrate form, like globules of ofl.
The tail is free from granules.
A second form was remarkable from having the abdomen once
only, or one and a half times longer than the thorax. The ab-
domen is more or less obtusely pointed posteriorly, and marked
by the characteristic transverse lines.
In a third form, the abdomen is very short and acutely pointed.
The thorax is broad, and there are no transverse lines on the
abdomen.
In a fourth form, the whole animal is remarkable for its slender
figure ; the abdomen is very long ; there are only three pairs of
legs, no transverse lines on the abdomen, and its granular con-
tents are much more lightly tinted.
756. To what part of the animal kingdom does the parasite
belong? asks Dr. Simon, and this question he refers to an
eminent entomologist of Berlin, who returns him the following
answer : —
The animal is clearly not an Helminthus, but its entire organi*
zation, and especially the great distinctness of its different pairs
of legs, betoken it to belong to the great division, Insecta, of
LinnsBUS. Of this extensive group, the parasite before us ap-
pertains to the class Arachnida, for there is no separation be-
tween the head and the thorax, there are no antennaB, and it has
four pairs of legs ; and judging from the form of its mouth, it
should belong to the order Acarus. The proboscis is the under
Up lengthened out, a form which this organ assumes in all mites.
The two bristles lying on the proboscis are the mandibles, and
the pair of two-jointed organs lying by the side of the prob^^scis
are ^e maxillary palpi. The different forms in which the crea-
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STEATOZOON FOLLICULORUM. 469
ture has been seen axe stages of development. In the early
state of the mite, the presence of three pairs of legs is a common
character. The lengthened form here principally described is
the second stage of development, and those with shorter abdomi-
nal segments represent later periods. It is therefore probable,
that in the fully developed stage the abdomen is lost altogether,
and we are inclined to believe that this last stage is not as yet
known to observers. The distinctions of genus and sex are,
consequently, not yet practicable.
In general, such a metamorphosis as the one here described
does not occur in the mite, for these creatures retain the form,
even although an additional pair of legs have to be developed,
which they possessed on first breaking from the egg. But, on
the other hand, Hartig has observed and described in the mite
of the pine-gall {Oribala ffeniculatay Latreille), a metamorphosis
precisely analogous to that of the animalcule before us.
These animalcules cannot be metamorphosed into parasitic
mites, for the itch-mite and mange-mite have distinctly segmented
legs with ioint-lobes (Heftlappchen), and no metamorphosis,
since they issue from the egg already provided with four pairs of
legs. Earlier^ some relationship might have been inferred be-
tween this animalcule and the bird-mite (Dermanyssus), which,
in its young state, has only six legs; but the worm-like form of
our animalcule in its early stages, and the remarkable shortness
of its legs, render comparison between them impossible.
The animal found by Donne in the mucus of the vagina (Tri-
chomonas vaginalis), which this observer considers to belong to
the Infusoria, and, according to others, is more nearly related to
Acarus, diflfers in many points, according to Donne's description
and figure, from the acarus of the hair-foUicles. For instance, it
is often not more than double the size of a blood corpuscule,
and at most ^^ ^^ ^ ^^^^ long; it has around or elliptic shaped
body, with a whip-like appendage in front, and along one of its
sides several fine fibres.*
Agahi, as the animalcule of the hair-follicles has not yet, as
we conjecture, been seen in its perfect shape, it is possible, al-
though little probable, that this last stage of development may
correspond with some already known mite. In no case, how-
ever, could the animalcule, for the before-mentioned reasons,
become one of the ordinary parasites of the human skin; but
* Hie trichomonas TaginalU, vith which I am vdl aoqoainted, bears no i
blanee whatever to the steatoxoon follicolomm. The tncbomonas is a g^balar sac*
slightly drawn oat to a point at some one point of its periphery ; and having con-
nected with this point a flexible and mobile pedicle, which acts the part of a sncker.
The sac measores about ^^ of an inch in diameter. I haTe not seen Donnl's
figure.— E. W.
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470 HISTORY AND DESCRIPTION OF THE
this creature must present the remarkable peculiarity of living
within the human body in its young state, and in its perfect
state, of living external to it. Further researches may serve to
establish this question; in the meantime, however, I will
designate this animal, from its habitat in the hair-follicles, acarus
follicuhrum.
757. About six times have I seen, both in the comedones of
living persons and in the hair-foUicles of the dead, a heart-
shaped body, having a small process projecting from its broader
end. This body was somewhat longer than die breadth of the
animal, of a brownish colour, and appeared to be filled vnth a
granular substance. In the hair-follicles, it was always close to
the animalcule, but not connected with the latter. This observa-
tion, with the fact of the non-resemblance of the heart-shaped
body with any known human structure, gives strength to the
conjecture that it must bear some relation to the acarus. It
might, for example, be an egg-shell, out of which an embryo has
escaped.
In reference to the movements of the creature, I have been
able to make the following observations: — The palpi are capable
of being moved in different directions, of being drawn in, and
stretched out The latter movements are remarked also in the
proboscis, which is sometimes thrust beyond the palpi, and some-
times drawn back. The legs can also be moved in various
directions, and the creature is often seen to move them back-
wards and forwards like to a pendulum ; they can also be re-
tracted or stretched forth. The thorax and body admit of
being curved. Although the creature makes all diese move-
ments, it does not walk, but merely changes its position from
«ide to side ; once, indeed, I saw an acarus widk a distance
equal to his own length, but then it was along a hair, which he
closely grasped.
Dr. Simon remarks, that he saw the first and second described
forms most frequently, and the third and fourth forms— namely,
that with the short and pointed abdomen, and the slender
animal with three pairs of legs, only rarely; the former in the
proportion of ten per cent., and the latter of six per cent. But
be feels so convinced of the accuracy of his observation, that
he regards as the most positive of his data, the presence of six
legs only in some.
758. After perusing the account of the steatozoon folliculorum,
as ^ven by its discoverer, Dr. Simon, I determined to proceed
to a verification of his discoveries, and being provided with an
instrument probably superior to that employed by Dr. Simon,
I have succeeded in making out certain points of structure that
had escaped his observation.
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STEATOZOON FOLLICULORUM. 471
I was not long in obtaining subjects: almost every face that 1
met supplied me with abundjEtnce, and the difficulty seems to be,
not to find the creature, but to find any individual, with the ex-
ception, according to Dr. Simon, of newly-bom children, in
whom these animalcules do not exist It is by no means neces-
sary to commence our search by selecting an acne punctata, or
even a comedo; almost every collection of sebaceous substance
which can be squeezed forUi from the numberless cutaneous
apertures upon die nose, the forehead, the face, and probably
from other parts of the body, will furnish subjects. Moreover,
Dr. Simon has observed that the parasites are situated near the
mouth of the follicle, consequently that portion of sebaceous
substance which is squeezed out with the least force is the part
which is most likely to be inhabited by the acarus.
The steatozoon folliculorum would seem to give rise to no
uncomfortable effects by its presence, unless, perchance, it should
multiply to such an extent as to become a source of irritation to
the follicle — a supposition which Dr. Simon admits, for it is found
m persons whose skin is perfectly healthy and clear, and in whom
no signs of cutaneous irritation are present These animalcules
undoubtedly feed on the sebaceous substance in which they lie
embedded, and which is the cause of their existence. I have
commonly found two in the small mass of this substance expressed
by the fingers, often four and five, and, in one instance, eight,
closely connected together. Hitherto, I have confined my ex-
aminations to living persons, having levied for contributions
among my more intimate friends, and have not as yet had re-
course to a skin studded with acne.
In the course of my investigations, I have examined several
hundreds of these animalcules, and have seen all the forms de-
scribed by Dr. Simon ; I have also had the good fortune to
discover the embryo and the ovum. I cannot, however, agree
with Dr. Simon with regard to the phases of development, which
he imagines to indicate perfection of growth; on the contrary, I
am inclined to believe the most common to be the most mature
form, and the third or most perfect of Dr. Simon, an embryonic
form. The following are the extremes of measurement of the
perfect animal in firuotions of an English inch, according to
my examinations: —
Entire length. Length of abdomen, Breadih of^iorax,
TSTT T2T TVS
1 1 1
"BT "ilff TVS
The animal is divisible into a head, a thorax, and abdomen,
the whole of these parts being well and distinctly marked.
The head represents in form a truncated cone, flattened from
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472 HISTORY AND DESCRIPTION OF THE
above downwards, and directed obliquely downwards from the
anterior part of the trunk. It is composed of two large lateral
organs, termed by Simon maxillary palpi, and of an intermediate
triangular organ. The maxillary palpi constitute the most con- .
siderable proportion of the head. Each is composed of three
segments, and is furnished with a prehensile extremity, consisting
of three curved finger-like organs, or claws. The first segment
of the maxillary palpus is large and long, the two succeeding
segments are smaller, and in every respect resemble the segments
of which the legs are composed. Indeed, these maxillary palpi
perform the office of arms, the first segment being fixed, and the
next two bending downwards under the first, or being stretched
directly forwards. It is this flexion and extension of a jointed
organ that Dr. Simon mistook for extension and retraction.
Upon the under part of the first segment of the maxillary palpi
I have observed a circle, which appears to me to bear some re-
semblance to an eye; upon this point, however, I am not quite
satisfied.
The triangular organ^ which includes the mouth of the creature,
is composed of three elementary parts — namely: 1. Of a tri-
angular process, a prolongation of the membranous case of the
animal from the neck along the middle line of the upper surfEU^e
of the head, to the extremity of the latter, where it curves
downwards, and in the latter situation consists of two parallel
pieces placed side by side. 2. Of a funnel-shaped and tubular
organ, or sucker, occupying a central position with regard to all
the other cephalic organs. 3. Of another triangular narrow pro-
cess, situated upon die under part of the head, and composed of
two lateral pieces.
The head is connected to the anterior segment of the thorax
by a loose membrane, marked on its surface by tranverse lines,
which indicate its susceptibility of being tlurown into folds.
This membrane is intended to admit of the retraction and exten-
sion of the head, and by its means the entire head may be drawn
in and buried deeply beneath the level of the membranous fold
here described, so that the head is entirely lost to view, and the
animal looks decapitated, tlie fold of the cervical membrane
forming a perfectly straight border in front. This is a peculiarity
in the structure of the animal that has been passed over by Dr.
Simon ; he makes no allusion to any such power, and he un-
doubtedly would have done so had he observed it^ for the effect
of the retraction is too remarkable not to be instantly recognised.
In fact, when an animalcule is alternately retracting and extend-
ing its head, the impression on the eye of the observer is that of
a creature one while furnished with a well-defined head, and the
next instant decapitated back almost to the level of the anterior
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STEATOZOON FOLLICULORUM. 473
segment of the thorax. The appearance presented by the animal
during the retraction of its head is represented in the wood en-
graving, fig. 2.
The movements of the maxillary palpi are flexion of the
last two segments, the first segment appearing to be firmly con-
nected with its fellow of tlie opposite side, and being very limited
in its movement of flexion. The extension of these segments
upon the first has led Dr. Simon to infer that the palpus might
be pushed out, and the sudden disappearance of these two seg-
ments, by flexion underneath the first, has induced him further to
believe that they might also be retracted. It might be imagined
that when the creature is seen from its under surface, this error
would become immediately apparent; but that is not the case ;
for the fore-shortening exhibited in the latter view only tends to
increase the deception. The three finger-like claws at the extre-
mity of the palpus are also capable of motion, and grasp upon
any object within their reach. The triangular pieces, both of the
upper and lower part of the head, move upwards and downwards
on each other, and at the same time separate to a slight extent.
The thoraxy which is the broadest and thickest part of the
animal, and somewhat tun-shaped, is flattened on its under
surface. It is composed of four broad segments, which are free
and joined by a connecting membrane on the dorsum and sides
of the creature, but are continuous inferiorly with the broad and
strong plastrum which covers the whole injferior surface of the
thorax. The segments are somewhat convex in their antero-
posterior diameter, particularly at the upper part, so that the
outline of the chest in this situation has die appearance of being
slightly fluted. The anchylosis of the four segments composing
the plastrum is marked by four transverse markings, consisting
each of two ridges, which correspond peripherally with the inter-
spaces between the legs and centrally bifiurcate, one passing for-
wards to unite with the line in front, the other passing back, to
become continuous with that behind. The same arrangement
takes place on the opposite side, and a sternal line, consisting
of a double crest, is consequently formed. The ridges of the
plastnim here described being thicker than the rest of the cover-
ing of the animal, are strongly and characteristically marked.
The segmented structure of the thorax permits of a certain
degiee of movement in this part of the creature.
The legs, which are eight in number, are connected with the
sides of die plastrum, each segment of the thorax sustaining one
pair of these organs. They are conical in figure, the base of the
cone being broad, and its apex obtusely truncated, and furnished
with three finger-like claws. Each leg is composed of three
segments, of a proximal segment, which is large, and almost
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474 HISTORY AND DESCRIPTION OP THE
triangular in form, the base of the triangle (scalene) being di-
rected forwards, and two smaller, cylindrical segments, the distal
segment supporting the three finger-like organs above noted-
The legs are all of the same size.
The movements of the legs are a forward and a backward
movement, the two small segments forming an acute angle in
their bend forwards upon the proximal piece, and being extended
directly backwards when the extension is completed; so that,
when the creature advances its leg, and places it on a flat sur-
face, the two small segments are directed forwards, and, by their
underside, rest upon the ground, together with the foot, like the
long hind-foot of the rabbit; then, clutching upon some object
within reach, the segments are carried backwards, until they form
a straight line with the axis of the proximal piece. By this
movement, an enormous power of propulsion is gained by the
creature, and it moves forward with considerable force. Dr.
Simon remarks, that the animal performs a swimming movement
with its legs, but without making any advance. That observa-
tion may, I think, be explained, by its compression, however
slight, between two plates of glass; by the injury the animal has
received in being pressed firom the hair-follicle along with the
sebaceous substance ; and by the fact of the glass upon which it
attempts to walk affording no rough points to which it can attach
itsel£ The legs are very irregular in their movements.
The abdomen is somewhat variable in point of length, but
generally more than two or three times longer than the thorax.
It is flattened on its under surface, and convex above, and tapers
gradually firom its base to its extremity, where it terminates in a
rounded point. It is composed of a series of extremely narrow
annular segments, which overlap each other firom before back-
wards. When examined on either surface, the margins of these
segments present the appearance of a regular succession of
transverse lines, and when seen along the outline, they give to it
the character of a serrated edge. The extremity of the abdomen
is sometimes lengthened out into a small pointed process. The
aperture of the anus is seen upon the under surface of the abdo-
men, near its extremity.
The annulated structure of the abdomen which is here de-
scribed, permits it to move with considerable freedom, and to
curve in any direction.
Of the internal structure. Dr. Simon says nothing more than
that the abdomen is filled with granular contents, and exhibits
several large and irregular vesicles, which he compares to oil-
globides. The granular matter of Simon is cellular tissue in its
most simple form ; with a good object-glass, the cells are quite
distinct, and appear to be filled with adipose fluid. These cells
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8TEATOZOON FOLLICULORUM. 476
are variable in point of size, some being exceedingly minute,
and others of moderate bulk ; they are assembled in such con-
siderable number in the abdomen, as to give it a dark appear-
ance, and by forming a thin stratum upon the inner surface of
the integument, they obscure the alimentary canal. Sometimes
the cells are confined to the abdomen, but more frequently
they extend into the thorax, forming a narrow line, that may
be traced almost as far as the head. By cai'efiil examination, I
have succeeded in distinguishing the muscular fasciculi, which
move the legs, and a broad oesophagus. In the abdomen I
have traced also the outline of an alimentary canal, and have
seen it terminate by an infundibiliform extremity at the anus.
The transparent cell-like organs seen in the abdomen of the
perfect animal I regaid as dilatations or convolutions of the
alimentary canal ; and a dark brownish mass in the commence-
ment of the abdomen I consider to be the liver. I have been
unable to discover any sexual difierences in the numerous
examples which I have examined.
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INDEX.
rAOB
Abiic ZOAB, on the acuns seabiei . 450
Aoarus folUeulonim 466
... Boabiei 288
Aone 388
... indtirau 390
... punctata 300
... rosacea 891
... simplex 389
... syphilitica 440
... vulgaris 389
Acret, Mr., case of melanopathia . 328
Adams, Dr., on the acarus seabiei . 455
on scabies in Madeira . 209
Albinismus 332
Albinoes 332
Aldrovandus, on the acams seabiei 450
Alley, Dr., observations on hydrar-
g)Tia 202
Alopecia 403
accidentalis 404
circumscripta 404
congenita 404
... senilis 406
... syphilitica 437
Alphos 263
Amadou, in the treatment of corns 311
Anidrosis 344
Anthrakokali 214
Area 404
Arsenic, its therapeutic effects . . 213
Atheroma 387
Atonic ulcers 181
Bacchia 391
Baker, on the acarus seabiei . . 454
Baker's itch 272
Baldness 403
Basement membrane 16
Becqnerel and Bresohet's experi-
ments 41
Bichdt, on the abnormal situation
of hair 401
Blanching of the hair 412
Blactis, vide rubeola.
Bonanni, on the acarus seabiei • . 453
Bonomo, on the acarus seabiei . . 452
Borellus, on the acarus seabiei . . 453
Briquet, M., treatment of variola . 93
rAOB
Bryce, Dr., vaccination teat . . . 118
Bume, Dr., case of pemphigus . . 180
Burnt holes 189
Busk, Mr., researches on myooder-
nis 430
Calcareous miliary tubercles . . 886
CaUosities 306
Calvities 406
Canities 412
Cantharides, then^MUtie effecU of 218
Capillaries of the derma .... 4
Carpenter, Dr., opinion on the my-
codermis . • 430
Casal, on the acarus seabiei . . . 454
Ceeley, Mr., researches on vacci-
nation 103,122
Chaps, treatment of ..... . 167
Chicken-pox 98
Chloasma 335
Chromatogenous disorders . . . 326
Chromidrosis 347
Cingulum 190
Clavus 306
Cnidoftis 142
Cold affusion 71
Comedones 363
Commission of vaccine, report . . 121
Contagion, nature of 48
Contractile tissue of the sldn . . 3
Cooper, Mr. Bransby, case of rupia 186
Corium 1
Corns 306
... fibrous 3IW
... laminated 307
... soft 810
Comua 379
Corpus papiUare, vide papillary
layer.
Couperose 388
Cow-pox 101
CrusUlactea 226
Cryptogamia in favus 429
rupia 172
sycosis .... 394
Cuticle, anatomy of the . . . • 1, A
Cutis, anatomy of the 1
Cutis anserina 8
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INDEX.
477
9Aom
Dandroff 281,288
Dartre, vide herpes.
... cmsUMsee 222
... cnisuc^ flaTesoente . . 222
... omsUujee stalactiforme . . 224
... farfdracee 281
... sqaameuse 2Hd
... squameuse humide . . . 199
... squamease licbenoide . . 274
Deflaviuin pilorum 409
DepilatorieB 408,435
Derma, anatomy of the ... . 1
Dobson, Sir Biohard, treatment of
erysipelas 140
Donovan, Mr., on the liquor hydrio-
datis arsenid et hydrargyri . . 269
Dupnytren's pomade for the hair . 409
Ear-wax • . . . 88
Eochymoses 816
Ecthyma 231
acutam 282
cachectionm 283
chronicum 288
... infantUe 288
... luridum 288
syphiliticum 440
... vulgare 282
Eotrouo treatment of variola . . 91
Eczema 199
... auriculare 207
capitis 206
chronienm 205
... faciei 207
... impetiginodes 204
... mamillare 208
... mercuriale 202
... perineale 208
... rubrum 201
... simplex 200
... solare 211
... syphiliticum 489
... umbilicale 208
EUiotson, Dr., treatment of psoriasis 279
Encysted sebaceous tumours . . 887
Endeimic method of administering
medicines 86
EpheUs 383
... ignealis 834
... lentigo 884
... scorbutica 387
... umbrosa 384
Ephidrosis 889
Epiderma, anatomy of the . . . 1, 5
Erectile tumours 313
Erysipelas 180
capitis . ^ . . . . 134
erraticum 182
faciei 183
gangrenosum .... 136
mamnuB 184
VAOH
Erysipelas metastaticum .... 132
... miliare 138
oedematodes .... 138
phlegmonodes .... 184
... phlyotenodes .... 183
simplex .>.... 180
umbilicale 184
Erythema 157
chronicum 164
circinnatum 159
... fugax 158
ichorosum 202
intertrigo 161
... iris 160
... laBve 161
marginatum 159
mercuriale 202
nodosum 168
osdematosnm .... 161
papnlatum 162
paratrimma 162
tuberosum 168
Essera, vide urticaria.
Esthiomene 801
Etmnller, on the acams aeabiei . 452
Exanthema labiale 189
Exanthemata 44
Fabridus, on the acaras scabiei . 461
False measles 151
Favus 426
... confertus 428
... dispersus 427
Febris motbiUosa 50
Felting of the hair 410
Fiery spoto 164
Fish-skin disease 855
Follicular elevations 885
tumours 887
Fourcault, M., his experiments . 40
Freckles 334
FuligokaU 214
Oabucinus, on the acams scabiei . 450
Oale 288
Oalto, M., on the acaras scabiei . 457
Goose-skin, vide cutis anserina.
Oown, red 240
Grantham, Mr., treatment of erysi-
pelas , . . 138, 141
Gras, M. Albin, experiments with
the aearus scabiei .... 298, 297
Graves, Dr., treatment of psoriasis 279
Grayness of the hair 412
Gregory, Dr., case of petechial
cow-pox 115
Grocer^s itch ."* 211
Grubs 868
Graby, Dr., researches on the my-
codermis 429
... researches on sycosis . . 894
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478
INDEX.
rAoc
Gum, red 240
Haemidrosis 347
Haffenreffer, on the acarus scabiei 4d2
Hair, abnormal direction of . . . 410
... alteration of •colour of . . 410
... anatomy of 19
... augmented formation of . . 308
... chemical composition of . . 32
... colour of 24
... development of 31
... diminished formation of . . 403
... diseases of 415
... downy 23
... felting of the 410
... growth of the 27
Hair-follides, anatomy of . . . 26
diseases of . . . 422
inflammation of . . 424
Hall, Dr. Marshall, treatment of
nsBvi 310
Hauptmann^on the acams scabiei 451
Henderson, Dr., eases of molluscnm 376
Herpes 187
... auricularis 189
... circinnatns 193
... exedens 209
... furftiracens 281
circinnatns . . 264
... iris 193
... labialis 189
... miliaria 188
... nasalis 189
... palpebralis ' . . 189
... phlyctenodes 188
... praepntialis 189
... proserpens 191
... pudendaUs 190
... zoster 190
Higginbottom, Mr., treatment of
erysipelas 140
Hives 97
Horn-pox 99
Horns 879
Hydrargyria 202
febrilis 203
maligna 203
mitis 202
Hydroa 217
... febrile 189
latraleptic method of administer-
ing medicines 36
Ichthyosis 354
cornea 361
simplex 359
spinosa ..''.... 359
squamosa 855
Idrosis 339
... maligna 341
... simplex ....... 340
PASS
Ignis sacer 190
... Sancti Anthonii 130
Impetigo 222
... oi^iitis 226
erysipelatodes .... 225
... faciei 226
... flguraU 222
... scabida 225
... sparsa 225
Infection, nature of 48
Ingrassias, on the acams scabiei . 4.M)
Iodide of arsenic in lepra . . . 269
... biniodide of mercury in
lepra 268
... liqnor hydriodatiB arsenid
et hydrargyii in lepra • . 268
lonthos 388
Itch 288
... baker's 272
... grocers 211
Itch-animalcule 288
Jackson, Mr., case of melanopathia 330
Jacobovics, Dr., on molluscum . . 375
Jobertns, on the acams scabiei . . 450
Johnson, Dr. James, on lichen
tropicus 247
Kerion 426
Key, Mr., case of rapia .... 186
Lanugo 23
LatreiUe, on the acams scabiei . . 462
Legrand, M., treatment of Tariola . 94
Lentigo 334
Lepidosis 263
Lepra 263
... alphoides 265
... guUata 265
... mercurialis 202
... nigricans 266
... syphiUtica 266,444
... vulgaris ..... 264
Leuce 299
Leucopathia 331
Lichen 242
... agrius 249
... circumscriptua 244
... gyratus 245
... lividus 244
... pilaris 244
... simplex 243
... syphiliticus 442
... tropicus 246
... urticatus 245
Lichtenstein, Dr., experiments on
inoculation . ^ 128
Linnaeus, on the acarus scabiei . 459
Liquor hydriodatis arsenid et hy-
drargyri 269
Listen, Mr., treatment of eiysipdas 140
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INDEX,
479
rxoM
Lnimla 33
Lupus 299
... exedens 301
... nun exedens 299
... Torax 801
Lymphatic plexus of the derma . . 4
Macul© 326
... hepatic® 335
... syphiliticae 438
MahoB, MM., treatment of faTus . 434
Mandl's researches on the hair . . 27
Measles, vide rubeola.
Melanopathia 326
Melanosis, cells of ... * . . 12
Melasma 337
Meliceris 387
MeUtagra 222
Mentagra 393
Mentagrophyte 394
Mercurial eczema 202
Midivaine, Dr., treatment of variola 91
Miliaria 217
... alba 217
... rubra 217
Miliary eruption 217
... vesicles 217
Moles 313,330,399
Molluscum contagiosum .... 365
Morbilli, vide rubeola.
Morbilli confluentes, vide scarlatina.
Morbus pilaris 424
Mother's marks .... 313, 330, 399
Moufet, on the acarus scabiei . . 450
Mycodermis 429
NsBvi, pigmentary 330
... pilous 399
... vascular 313
NiBvus 313
araneus 314
arteriosus 313
fiammeus 313
... matemus 313
... venosns 313
Nails, anatomy of the 32
... chemical composition of the 34
Nail-follicles 33
Napthaline 270
Narcosis folliculorum 423
NetUerash 142
Nerves of the derma 4
NigriUes 326
Nirles 188
Noli me tangere 301
Nosophyta 395
Olliffe, Dr., treatment of variola 92
Olophlyctide, vide herpes.
Ophiasis 404
Oribata genieulata 469
PAOS
Osmidrosis 345
Oxide of silver stain . • . . . 337
Pachulosis 312
Paterson, Dr., cases of molluscum . 377
Pi4»ill» of the derma 3
Papillary layer of the derma ... 3
Papula, Willan's first order . . . 236
Pearly tubercles 385
Pemphigus 1 73
acutus « 174
..« apyreticus 174
..« chronious 176
conflnens 174
congenitus .... 174
contagiosus ... * 177
gangrenosus .... 183
indicus 178
infantilis 183
pyreticus 174
simultaneus .... 174
solitarius 174
suceessivus .... 174
syphiliticus .... 439
vulgaris 174
Pemphix, vitU pemphigus.
Pereira, Dr., case of melanopathia . 328
Perspiration 38
chemical composition of 41
coloured 347
disorders of ... . 339
morbid 42
PetechiflB 316
after vaccination ... 115
Phlyzacia. 221,231
Physiology of the sldn .... 34
Picton, Dr., treatment of variola . 93
Pigmentary n»vi 330
Pigment cells 12,15
Pilous nevi ,..-.... 399
Pimply diseases 236
Pityriasis 281
capitis 283
labiorum 283
nigra 337
oris 284
palmaris 284
palpebrarum 283
plantaris 284
preputialis 284
pudendalis 284
rubra 282
versicolor 335
vulgaris 282
Plica polonica 420
... candiformis 421
... multiformis 421
Plumbe, Mr., treatment of favus 435
Polya, Dr., on the anthrakokali . . 214
Pompholyx 173
benignus 174
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480
INDEX.
rAoc
Pompholyx diatinus 176
solitarias 174
PorcupiDe disease 359
Pores of the sndoiiferoiis dacts . . 17
Porrigo decalTEOS 404
... favosa 226
furfurans 416
... granulau 227
... lanralis 226
lapinosa 427
scutulata , 416
Porrigophvte 426
Prickly heat 246
.- Dr. Johnson's obser-
vations .... 247
Dr. Winterbottom's ob-
servations . . . 246
Prurigo 254
formicans 255
... mitis 254
podicis 256
pndendalis 257
scroti 257
senilis 256
Pniritns 254
... ani 322
general 321
praeputii 323
... pudendi 323
... scroti 323
... urethrflB 323
Psora, vide scabies.
Psoriasis 272
conflnens 272
... diffusa 272
discreta .' 265
guttata 265
gyrata 274
infantilis 274
inveterata 274
labialis 276
palmaris 276
palpebrarum 275
priBputialis 276
scrotalis ...... 276
... syphilitica ..... 445
unguium 277
vulgaris ..... 272
Psydracia 221, 222
Purpura 316
cacheotica 318
... febrilis 319
haemorrhagica .... 317
senilis 318
simplex 317
urticans 317
PnstulflB, Willan's fifth order . . 220
Pustule, definition of . . . . . 220
Raspail, on the acarus scabiei . . 458
^nucci, M., on the acarus scabiei 457
TACK
Bete Malpighianum, vide rete mu-
cosum.
Bete mucosum 1
Betro-vaccination 122
Bevacoination 118
Bingworm.
impetiginous .... 224
rainbow 193
vesicular 193
Boots, Dr., case of pemphigus . . 180
Boseola 152
... ©stiva 151
annulata 153
arthritica 155
autumnalis 153
... cholerica 155
... infantilis . . . . . . 152
... miliaria 154
... rheumatica. 155
... syphilitica 438
vaccina 154
... variolosa 153
Bose rash 151
Bubeola 50
maligna, vide rubeola nigra.
... nigra 55
... sine catarrho 54
sine exanthemate ... 54
... vulgaris 51
Bupia 181
... escharotica 183
... prominens 182
... simplex 181
... syphilitica 430
Scabies 288
... cachectica 288
... lymphatica 288
... papuliformis 288
... purulenta 289
Scaliger, on the acarus scabiei . . 450
Scall, crusted 222
... humid 190
... piq>ulon8 231
... vesicular 206
Scalp, diseases of the.
... alopecia 403
... canities 412
... eczema capitis 206
... erysipelas 134
... favns 426
... impetigo figurata .... 226
sparsa .... 227
... inflammatio foUicnlomm . 424
... lepra vulgaris 265
... narcosis folliculorum . . . 423
... pityriasis ciqiitis .... 283
... psoriasis vulgaris .... 272
... stearrhoea fbUiculomm . . 424
... trichosis fnrftiracea . . . 416
plica 420
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INDEX.
481
Scarlatina
anginosa
gravior, vitie maligna.
Iffivigata
maligna
milliformis ....
mitior, mde anginosa.
papulosa
phlyctfiBQosa ....
plana
pustulosa
simplex
sine angini, vide simplex.
sine erapdone . . .
sine exanthemate . .
vesicularis
Scarlet fever
Scbaeffer, on the acarus scabiei
Sebaceous accumnlations . . .
flux
secretion
alteration of
augmentation of
composition of
diminution of .
retention of
tubercles, miliary . .
tumours, encysted . .
small ....
Sebiferous ducts
Sebiparous glands
... diseases of . .
Serous cysts
Serres, Bretonneau, &VeIpeau, MM.,
treatment of variola ....
Sbingles
Simon, Dr. Gustav, on the acams
foUiculorum
Skin, sensibility of the ....
... absorbing power of the . .
Small-pox
inoculated
modified, vide varicella.
pathology of ... .
Soft corns
Spasmus peripbericus
Squamae, Willan's second order
Squamous diseases
Stearrhoea flavescens
folliculorum ....
nigricans
simplex
Steatoma
Steatozoon folliculorum ....
Strophulus
albidus
candidus
confertus
intertinctus ....
Tolaticus
Sudamina
PAOB
00
62
61
64
61
61
61
61
61
60
65
65
61
60
461
878
349
37
352
349
87
350
362
885
387
865
18
18
349
886
91
190
466
34
35
75
81
84
310
3
261
261
352
424
353
349
387
466
239
241
241
240
240
241
217
rAOB
Sudatoria 339
cases of, in the Hotel Dieu 342
maligna 841
miliaris 340
simplex 840
Sudoriparous glands 16
... disorders of . 839
Sunburn 333
Swine-pox 90
Sycosis 393
... contagiosum ..... 394
Syphilis, pi^ular 442
pustular 440
squamous 444
tubercular 442
vesicular 489
Syphilitic eruptions 487
acne 440
ecthyma 440
eczema 439
lepra 444
lichen 442
maculffi 438
papulsB 442
pemphigus 439
psoriasis 445
pustules 440
roseola 488
rupia 489
tubercles 442
urticaria 438
vesicles 489
Teleangiectasia 318
Tetter, vide herpes.
... crusted 222
... dry 272
... humid 199
Thomson, Mr. Hale, on albuminous
moUuscum 378
Tilesius, case of moUuscum . . 370
Tinea amientacea 206
... capitis 416
... favosa 426
... furfuracea 206,416
... granulata 227
... lactea 226
... maligna 426
... mucosa 226
... tondans 416
Tooth-rash 239, 240
Trichiasis 410
Trichogenous pomatums and re-
medies 400
Triohosis furfuracea 416
plica 420
poliosis 412^
Trichomonas vaginalis .... 469
Tubercles, syphilitic 442
Tubercules bigarres 356
I I
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482
INDEX.
VAOB
Tylosis 806
Tyria 404
Urticaria 142
ab ingestis 144
oonferta 145
evanida 14d
... febrilis 143
Persians 145
subcutanea ..... 145
syphilitica 438
tuberosa 146
Vaccinadon 112
tests 118
Vaccinella 114
Vaccinia . . 101
Vallecnla unguis 33
Varicella 94
cellulosa 06
coniformis 08
globularis 07
lentiformis, vi^ie vesicularis.
lymphatica, vide vesicularis.
papularis 09
sine varicelUs .... 09
umbilicated pustular . . 96
Terrucosa 09
vesicularis 98
Variola 75
... coherens 75
... confluens 75
... disoreta 75
... inoculated 81
... lymphatics 94
... modified, vi^e varicella.
PACK
Variola, pathology of 84
secondary 75
sine variolis 82
vaccina 101
VariolsB crystaliinae 94
pusillas 94
... vaccine 101
veminoss 99
verruoose 99
Varioloid, vide variceUa.
Variolo -vaccination 123
Varus 388
Vascular nievus 313
Velpean, treatment of erysipelas 141
Verruca 305
... achrocordon . . . .305,366
sessilis 305
Vigo plaster in variola .... 92
Vincent, Mr., treatment of herpes
prasputialis 199
Vitiligo 299
Warts . • 305
Weber's experiments 34
Wen 387
Wheale-worms 451
Wiohmann, on the acarus scabiei . 454
Williams, Dr. Robert, treatment of
erysipelas 137
Xero-derma 350
Zona 190
Zoster 190
... heipetica 190
... ignea 190
THE END.
T. C. Savill, Printer, 4, Chandot Street, Covent Garden.
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